1. Time and cost of “extreme” implementation facilitation to address challenging contexts
Mona J. Ritchie, PhD
Chuan-Fen Liu, PhD
James C. Townsend, DHSc
Jeffery A. Pitcock, MPH
JoAnn E. Kirchner, MD
September 10, 2017

2. Acknowledgements
VA Health Services Research & Development and VA Quality Enhancement Research Initiative Project SDP :
Blended Facilitation to Enhance PCMH Program Implementation (J. Kirchner, PI)

3. Overview
Background
Methods
Key Findings
Discussion
Implications

4. Background
Implementing evidence-based practices and programs is challenging*
Facilitation has been widely used as an implementation strategy to address challenges in clinical settings**
We know little about the cost of implementation facilitation (IF), but hypothesize that application of it is resource intensive, especially when:
The innovation is complex
The site is under-resourced
The context poorly supports change
*Greenhalgh et al. 2004; **Baskerville et al. 2012, Stetler et al. 2006

5. Blended Facilitation Project
We tested an implementation facilitation (IF) strategy within the context of a VA system-wide initiative to integrate mental health services in primary care settings using evidence-based care models*
The IF strategy consisted of:
An external facilitator (EF) and an internal regional facilitator (IRF) in each of 2 networks, and
A structured implementation process
*Kirchner et al. 2014

6. Facilitators applied the IF strategy:
In 8 primary care clinics identified by network mental health leadership as unlikely to be able to implement PCMHI programs without assistance
At all levels of the system (clinic, medical center, and network)
Over a 2 ½ year period
They incorporated a wide variety of discrete implementation strategies, tailoring them to site needs and resources.
Thus..... “Extreme Facilitation”

7. This presentation focuses on our assessment of:
Results of our test of the IF strategy showed that clinics receiving IF compared to those that received only national level support, had:
Significantly higher program reach and adoption and these differences were sustained 1 year later*
Improved PCMHI program uptake, quality, and adherence to evidence**
This presentation focuses on our assessment of:
the time facilitators and VA stakeholders spent on IF activities and
the organizational cost of IF.
*Kirchner et al. 2014; **Ritchie et al. 2017

8. Methods

9. Time study
Using structured spreadsheets, each week facilitators documented their time and:
Participating stakeholders
Clinics that benefited from IF
Types of activities
Descriptive analysis by calculating:
Number of persons involved in IF activities
Number of hours spent

10. Organizational cost
Obtained salary information for each participant from publicly available web portals
Calculated hourly rates for facilitators’ and stakeholders’ salary and benefits and multiplied rates by # of hours
Calculated program support assistant salary at 25% effort
Calculated travel costs
Cost of facilitators’ time in travel
Cost of travel expenses obtained from project records

11. Key Results

12. Facilitator time across networks
Network A
Network C
Facilitators
Hours
% Hours
External Facilitator (EF)
Activities
141
71%
122
50%
Travel 57
29%
121
EF Total
198
100%
243
Internal Regional Facilitators (IRF)
1,792
91%
1,169
81%
171 9%
273
19%
IRF Total
1,963
1,442
Total Hours
2,161
1,685
Note that EF devoted only 0.05 FTE to train both IRFs and support implementation at 8 PC clinics!
Note that IRF-A devoted more time to IF activities than IRF-C
Of the total hours IRFs spent on IF activities, 61% were in Network A and 39% in Network C
If the EF only worked with each clinic individually, we could say that the EF averaged 35 hours/clinic on IF activities in Network A and 31 hours/clinic in Network C

13. Facilitator time across clinics
Time spent on activities benefitting all 4 clinics in a network:
EF - similar in both networks (37% and 39%)
IRF-A: 24%; IRF-C: 56%
Network A: both the EF and IRF devoted relatively more time to clinic A2
Network C:
EF – more time on clinics C2 and C4
IRF more time on clinic C3

14. Facilitator time by activity
In both networks, the EF focused more on Problem identification/resolution and Preparation/planning
In Network A, the IRF focused more on Problem identification/resolution and Stakeholder engagement than the Network C IRF
In Network A compared to Network C, the EF focused more on Problem identification/resolution, Stakeholder engagement, and Training/mentoring the IRF
Both IRFs focused a significant amount of time on Preparation and planning
In Network C, the EF focused more on Assessment and
Preparation/planning
The Network C IRF focused more than the Network A IRF on learning activities

15. Facilitator time by month

16. Stakeholder time
Network A
Network C
Stakeholder type
Person counts
Person hours
Person Counts
Person Hours # %
Clinic 54
41%
565
44% 92
46%
571
42%
VAMC 46
35%
352
27% 85
43%
669
49%
Network 20
15%
302
24% 10 5% 70
National 7 36 3% 8 4% 42
Other experts 6 27 2% 4 12 1%
Total all
133
100%
1,281
199
1,363
Clinic stakeholder hours similar in A & C but counts higher in C
VAMC stakeholder hours and counts higher in C
Network stakeholder hours and counts higher in A
Overall, stakeholder hours similar in both networks - counts higher in C

17. Organizational cost
Network A EF & IRF Travel salary & expenses: $27,738
Network C EF & IRF Travel salary & expenses: $50,727

18. discussion

19. Discussion
Facilitating implementation of complex evidence-based programs in clinics with challenging contexts requires substantial resources
It is likely that such clinics need ongoing IF for an extended period of time although internal personnel, trained by experts can provide the majority of IF
Facilitators need a significant amount of preparation and planning time
In addition to site needs and challenges...
Larger system needs can impact time spent on particular activities
Competing demands can impact time spent on particular clinics
Characteristics of the facilitators themselves can impact the amount of time dedicated to sites, particular activities, and indeed the whole effort

20. Implications

21. Implications
As systems initiate enterprise-wide implementation efforts, it is essential that leadership:
Plan to provide support for sites that may be unable to implement without assistance
Encourage and provide time for stakeholders to participate
Take into account existing local leadership support or resistance and resources, expectations and characteristic of facilitators

22. Implications
Given the organizational cost, intensive IF strategies may not be practicable on a large scale:
Identify sites likely to benefit
Tailor IF intensity to local needs
Apply very intensive strategies only when most needed

23. Microsoft Engineering Excellence
Contact information
Mona J. Ritchie

24. References
Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med. 2012;10: Greenhalgh T, Robert G, MacFarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: Systematic review and recommendations. Milbank Q. 2004;82: 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): Ritchie MJ, Parker LE, Kirchner JE. Using implementation facilitation to foster clinical practice quality and adherence to evidence in challenged settings: a qualitative study. BMC Health Serv Res. 2017;17:294. Stetler CB, Legro MW, Rycroft-Malone J, Bowman C, Curran G, Guihan M, et al. Role of "external facilitation" in implementation of research findings: a qualitative evaluation of facilitation experiences in the Veterans Health Administration. Implement Sci. 2006;1:23. doi: /