1. Using Facilitation to Implement Clinical Innovations: Conceptual Foundations, Evidence Base, and Applications October 3, 2017
JoAnn E. Kirchner, MD
Director VA Behavioral Health QUERI
Professor, Department of Psychiatry, UAMS
VA QUERI QUE

2. Acknowledgements: Mona Ritchie Jeff Smith Kathy Dollar Jeffery Pitcock James Townsend Geoff Curran Louise Parker John Fortney and many, many more

3. Overview: Implementation is Challenging
Conceptual Foundation of Facilitation
Evidence to Support Facilitation
What Makes a Good Facilitator
Assessing Facilitation
Advancing the Science of Facilitation

4. New Clinical Innovations are Challenging to Implement
~ Top down initiatives are not sufficient
~ Readiness to participate differs across facilities
~ Requires the participation of multiple stakeholder groups
~ Limited availability of providers to participate in implementation activities
~ Education alone is rarely sufficient

5. New Clinical Innovations are Challenging to Implement
~ Top down initiatives are not sufficient
~ Readiness to participate differs across facilities
~ Requires the participation of multiple stakeholder groups
~ Limited availability of providers to participate in implementation activities
~ Education alone is rarely sufficient

6. Recommendations from the COVES Study
Cost and Value of Evidence-based Solutions (COVES) Innovation: Mental health primary care integration (PCMHI) Implementation Strategy: EBQI
Kirchner, et al., 2012
VA QUERI MNT & MNT

7. Recommendations from the COVES Study
Essential to involve local site participants in implementation efforts to assure buy-in and customization

8. Medical Center Chief of Staff:
“There may be pitfalls that those who design the program from afar are unaware of …that are happening at the front line level and so if you don’t get the input locally, you might be lucky and everything will go fine but you also may be unwittingly setting yourself up for disaster.”

9. Recommendations from the COVES Study
~ Preparatory work, prior to implementation, is crucial for program success
~ Need to develop and recommend a structured sequence for rolling out new programs or practices
~ When scaling up implementation of evidence- based practices, there is the need for the allocation of additional organizational resources that directly support the implementation process

10. i-PARIHS Framework
Harvey & Kitson, 2015

11. i-PARIHS Framework Successful Implementation Context Innovation
Recipient

12. i-PARIHS Framework Facilitation Successful Implementation Context
Innovation
Recipient

13. Other Frameworks Facilitation Successful Implementation REP-F CFIR
PRISM

14. 7/23/2018
Facilitation
Process of interactive problem solving and support that occurs in a context of a recognized need for improvement and a supportive interpersonal relationship
Powell, et al., 2015
Kilbourne, Amy

15. Facilitation Multifaceted process
Bundles an integrated set of interventions and other strategies
Which is applied varies based on the needs of the implementation process
Dynamic in nature that involves interactive problem solving

16. The establishment of a supportive interpersonal relationship with stakeholders is critical to success

17. Evidence for Implementation Facilitation
VA SDP

18. Study Aims: IF in Primary Care Mental Health Integration (PCMHI)
Within the national VA implementation of PC-MHI: Test the effectiveness of the IF strategy versus standard national support alone, on extent of clinic-level outcomes, provider behavior change, and changes in Veterans' service utilization at sites unable to implement the program without assistance.

19. Study Aims: IF in Primary Care Mental Health Integration (PCMHI)
Within the national VA implementation of PC-MHI: Test the effectiveness of the IF strategy versus standard national support alone, on extent of clinic-level outcomes, provider behavior change, and changes in Veterans' service utilization at sites unable to implement the program without assistance.

20. Methods: IF in Primary Care Mental Health Integration (PCMHI)
~ Evaluation conducted separate from the IF intervention
~ Quasi-experimental, Hybrid Type III Design
~ Mixed methods
~ Sites were identified by network level leadership
~ Sites unable to implement PC-MHI without assistance
~ Consensus matching:
Eight VA primary care (PC) clinics to receive IF
Eight matched comparison clinics

21. Results: Reach
OR = 8.93 (2.99,26.61), p<0.001

22. Results: Reach
OR = 4.30 (1.90, 9.73), p<0.001

23. Results: Adoption
The histograms illustrate, in aggregate, the distribution of Primary Care Providers (PCPs) and the percentage of patients they referred to Primary Care-Mental Health Integration (PC-MHI) during (a) Late-Phase
Implementation .
Non-Implementation Facilitation (non-IF) sites had more PCPs referring no patients to PC-MHI and referred a lower proportion of patients overall during
both study phases compared to PCPs at Implementation Facilitation.
The second
Adoption measure that indicated a greater proportion of PCPs’
patients received initial referrals to PC-MHI at IF clinics
compared to non-IF clinics during both evaluation periods
% Providers OR = 7.12 (1.22, 41.57), p < 0.05
% Patients β = (0.012, 0.014), p < 0.001

24. Results: Adoption % Providers OR = 9.73 (1.95, 48.56), p < 0.05
% Patients β = (0.008, 0.037), p < 0.05

25. Evidence for Implementation Facilitation
Within VA:
PC-MHI (Kirchner, et al., 2014; Ritchie, et al., 2017)
Re-engaging Veterans in care (Kilbourne, et al., 2014)
Heart failure (Heidenreich, et al., 2015)
Brief CBT in primary care (Mignogna, et al., 2014)
Outside VA:
Preventive care (Baskerville et al., 2001)
Patient-centered medical home (Nutting, et al., 2010)
Pediatric hospital care (Ayieko, et al., 2011)
Improved diabetes care (Dickinson, et al., 2014)
2012 Practice facilitation systematic review (Baskerville, et al., 2012)

26. Or lack there off…… Nursing Home Care (Kinley, et al., 2014)
Primary Care (Hogg et al., 2002; Hogg, et al., 2008)
Stroke care (Williams L, et al., 2015)

27. Matthew J. Chinman, PhD
VISN 4 MIRECC, RAND Corporation
. Laura J. Damschroder, MS, MPH
HSR&D Center for Clinical Management Research,
Diabetes QUERI VA Ann Arbor Healthcare System
. JoAnn E. Kirchner, MD
Mental Health QUERI, Central Arkansas Veterans Healthcare System, University of Arkansas for Medical Sciences
. Monica M. Matthieu, PhD
Mental Health QUERI, Central Arkansas Veterans Healthcare System, Saint Louis University
. Byron J. Powell, PhD
Dept. of Health Policy and Management, Gillings School
of Global Public Health, University of North Carolina
. Enola K. Proctor, PhD
Washington University in St. Louis
. Jeffrey L. Smith
Mental Health QUERI,
Central Arkansas Veterans Healthcare System
. Thomas J. Waltz, PhD, PhD
Eastern Michigan University, HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System
Expert Recommendations for Implementing Change (ERIC) Investigative Team
Primary funding for this research was provided by the U.S. Department of Veterans Affairs
Veterans Health Administration’s Mental Health Quality Enhancement Research Initiative (QLP 55–025).

28. Implementation Facilitation: Is it a Strategy or a Process?
External and Internal Regional Facilitators were followed over a two and a half year period through:
Initial site visit and monthly debriefings
Semi-structured interviews midway through, and at the end of, the intervention
Documented their activities and the organizational contexts of clinics receiving implementation facilitation in detailed summary notes of debriefings and verbatim transcripts of interviews
Content analysis of this data
Ritchie, Implement Sci, 2016
VA SDP

29. Implementation Facilitation: Is it a Strategy or a Process?
ERIC Implementation Strategies
Assess for readiness and identify barriers and facilitators
Audit and provide feedback
Purposefully reexamine implementation
Develop and implement tools for quality monitoring
Develop a formal blueprint
Conduct a local needs assessment
Facilitation
Technical assistance
Tailor strategies
Promote adaptability
Use data experts
Organize clinician implementation team meetings
Conduct local consensus discussions
Use advisory boards and workgroups
Involve executive boards
Conduct ongoing training
Conduct educational meetings
Create a learning collaborative

30. Implementation Facilitation: Is it a Strategy or a Process?
ERIC Implementation Strategies
Assess for readiness and identify barriers and facilitators
Audit and provide feedback
Purposefully reexamine implementation
Develop and implement tools for quality monitoring
Develop a formal blueprint
Conduct a local needs assessment
Facilitation
Technical assistance
Tailor strategies
Promote adaptability
Use data experts
Organize clinician implementation team meetings
Conduct local consensus discussions
Use advisory boards and workgroups
Involve executive boards
Conduct ongoing training
Conduct educational meetings
Create a learning collaborative
FACILITATION TOOLBOX

31. What Makes a Good Facilitator?
Knowledge
Skills
Core Competencies
Characteristics

32. Knowledge
Other quality improvement and organizational change processes
Knowledge is knowing a tomato is a fruit;
wisdom is not putting it in a fruit salad. Miles Kington

33. Knowledge Implementation strategies When to use which tool
Facilitation
Clinical Innovation
Other quality improvement and organizational change processes
They may not speak your language, but it is critical that you speak theirs!

34. Skills
Ritchie, Dissertation, 2016

35. Core Competencies
Build relationships with and between others and create a supportive environment for change
Help change the system of care and the structure and processes that support it
Transfer knowledge and skills and create infrastructure support for ongoing learning
Plan and lead change efforts
Assess people, processes and outcomes and create infrastructure for program monitoring
Ritchie, Dissertation, 2016

36. Characteristics of a Good Facilitator
Ability to empathize and understand the needs of others
Genuine
Positive
Flexible/ able to adapt to rapidly changing situations
Responsive in a timely manner
Innovative and resourceful
Energetic and enthusiastic

37. How to become a good facilitator
Training opportunities and materials (Ritchie, Dollar, et al. 2016)
Seek a mentor (Ritchie, Dissertation, 2016)
Form a Community of Practice (McCullough, et al., 2017)

38. Documenting Facilitation Time and Activities
Why do it?
Inform budget impact analyses
Inform hiring decisions
Determine feasibility for spread
Inform interpretations of implementation success or failure
Identify areas for additional training or mentoring
Facilitators love documenting!

39. Documenting Facilitation Time and Activities
Domains to track
Date and time spent
Event type
Communication Type (phone, , in-person)
People involved in interaction
Facilitation activity
Notes on interaction

40. Documenting Facilitation Time and Activities
Timing of facilitation tracking
Document continuously?
More complete info, but can be time-intensive and burdensome
Document for time-limited intervals and extrapolate?
Not as complete, but not as burdensome either

41. Time-Motion Tracker: PCMHI Facilitation Project

42. Facilitator Time by Month
Ritchie, et al., 2017

43. Innovation Uptake over Time

44. Qualitative Methods Regular debriefing with facilitators
Interviews with stakeholders at all levels

45. Innovation Uptake over Time

46. Coming attractions Common measures (QUAN)
Common iPARIHS codes and definitions (QUAL)
IF Fidelity tool
IF Strategy Dimensions tool for planning, evaluation and reporting

47. Networks IF Learning Collaborative
Collaborations with Alison Kitson, Gill Harvey and others

48. References
Ayieko, P., S. Ntoburi, J. Wagai, C. Opondo, N. Opiyo, S. Migiro, A. Wamae, et al. “A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial.” PLoS Medicine 8, no. 4 (2011): e Baskerville, N. B., W. Hogg, and J. Lemelin. “Process Evaluation of a Tailored Multifaceted Approach to Changing Family Physician Practice Patterns Improving Preventive Care.” The Journal of Family Practice 50, no. 3 (2001): W doi:jfp_0301_02410 [pii]. Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med. 2012;10: Dickinson, W. P., L. M. Dickinson, P. A. Nutting, C. B. Emsermann, B. Tutt, B. F. Crabtree, L. Fisher, M. Harbrecht, A. Gottsman, and D. R. West. “Practice Facilitation to Improve Diabetes Care in Primary Care: A Report from the EPIC Randomized Clinical Trial.” Annals of Family Medicine 12, no. 1 (2014): 8–16. Harvey G, Kitson A, (Eds.). Implementing evidence-based practice in healthcare: A facilitation guide. London: Routledge, Heidenreich, P. A., A. Sahay, B. S. Mittman, N. Oliva, P. Gholami, J. S. Rumsfeld, and B. M. Massie. “Facilitation of a Multihospital Community of Practice to Increase Enrollment in the Hospital to Home National Quality Improvement Initiative.” Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources 41, no. 8 (2015): 361–69. Hogg, W., N. Baskerville, C. Nykiforuk, and D. Mallen. “Improved Preventive Care in Family Practices with Outreach Facilitation: Understanding Success and Failure.” Journal of Health Services Research & Policy 7, no. 4 (2002): 195–201. Hogg, W., J. Lemelin, I. D. Graham, J. Grimshaw, C. Martin, L. Moore, E. Soto, and K. O’Rourke. “Improving Prevention in Primary Care: Evaluating the Effectiveness of Outreach Facilitation.” Family Practice 25, no. 1 (2008): 40–48 Kilbourne A, Almirall D, Goodrich D et al. Enhancing outreach for persons with serious mental illness: 12-Month results from a cluster randomized trial of an adaptive implementation strategy. Implement Sci Kinley, J., L. Stone, M. Dewey, J. Levy, R. Stewart, P. McCrone, N. Sykes, P. Hansford, A. Begum, and J. Hockley. “The Effect of Using High Facilitation When Implementing the Gold Standards Framework in Care Homes Programme: A Cluster Randomised Controlled Trial.” Palliative Medicine 28, no. 9 (2014): 1099–1109. Kirchner JE, Parker LE, Bonner LM, Fickel JJ, Yano E, Ritchie MJ. Roles of managers, frontline staff and local champions in implementing quality improvement: stakeholders' perspectives. J Eval Clin Pract. 2012;18: Kirchner JE, Ritchie MJ, Pitcock JA, Parker LE, Curran GM, Fortney JC. Outcomes of a partnered facilitation strategy to implement primary care-mental health. J Gen Intern Med. 2014;29(Suppl 4):