1. Choosing implementation strategies to address local contextual barriers
Laura J. Damschroder, VA Ann Arbor Healthcare System
Thomas J. Waltz, Eastern Michigan University
Brenton Abadie, Eastern Michigan University
Byron J. Powell, University North Carolina at Chapel Hill
SIRC Bi-annual Conference, Seattle WA
9 September 2017

2. Background
EBI
Implementation
What strategies work in which contexts to reliably implement evidence-based innovations (EBI)?
Implementing EBIs is a tall/challenging order. One survey of executives (n=3000) from around the world revealed unsurprising but nonetheless shocking rates of failed change for 2/3 of initiatives (Meaney and Pung (2008)). This may be higher when assessing longer term sustainability. We know that there are multiple paths to success … and to failure. We also know (or think we know) that different strategies work under different circumstances. E.g., reviews of Audit and Feedback highlight the need to understand why this strategy has high impact in some settings but no or even negative impact in others. Our “holy grail” question as implementation researchers is: What strategies reliably work in which contexts?

3. Background Implementation \Science
We wish for a straight path – a single answer – one strategy (or multicomponent strategy) to rule them all but…

4. Background Tailor strategies based on context Assess context
Implementation \Science
Background
Tailor strategies based on context
Assess context
Choose strategy(s)
In fact, we are guided by the theory that we must first understand context and then tailor strategies to context.

5. Assess Context: Consolidated Framework for Implementation Research (CFIR)

6. CFIR: 5 Domains, 39 constructs

7. CFIR: 5 Domains, 39 constructs

9. CFIR: 5 Domains, 39 constructs

10. CFIR: 5 Domains, 39 constructs

11. CFIR Article Published 2009

12. Strategies: Expert Recommendations for Implementing Change (ERIC)

13. Concept Mapping Results

14. List of 73 ERIC Implementation Strategies

15. List of 73 ERIC Implementation Strategies

16. List of 73 ERIC Implementation Strategies

17. List of 73 ERIC Implementation Strategies

18. List of 73 ERIC Implementation Strategies

19. N=2847 Combinations ERIC Strategies n=73 CFIR Constructs n=39
The number of combinations gets much more complicated if you look at all of the possible combinations of ERIC strategies (about 9.44*10^21 for each barrier!).

20. best address specific CFIR organizational barriers?
Specific Aim
Which strategies
best address specific CFIR
organizational barriers?

21. Contextual Barrier: No Reflecting & Evaluating
There is little or no quantitative and qualitative feedback about the progress and quality of implementation nor regular personal and team debriefing about progress and experience

22. Methods
Methods

23. Invitations sent via email
Participants
Known users of CFIR
First authors of articles citing 2009 CFIR article
Inquiries to CFIR research team
Participants in earlier user panel for www. CFIRGuide.org technical assistance website
Implementation research communication channels
National Implementation Research Network (NIRN)
Society of Implementation Research Collaboration (SIRC)
Implementation Network mailing list
Invitations sent via
N=435
Respondents
N=169 (39%)

24. Participant Characteristics
Implementation experts have knowledge and experience related to changing care practices, procedures...
How much of your employment is with the VA?
How much of your employment is dedicated to research?
Does your employment include any clinical responsibilities?
CHECK ALL THAT APPLY

25. Survey of Implementation Experts
Select and rank up to 7 strategies that best address barriers related to Reflecting & Evaluating:
♦ There is little or no quantitative and qualitative feedback about the progress and quality of implementation nor regular personal and team debriefing about progress and experience. ♦
Audit and provide feedback

26. Assignment of CFIR constructs
CFIR Construct Randomly Assigned
Select & rank up to 7 Best ERIC Strategies
Willing to do another?
YES
Average number of CFIR barriers completed per respondent:
6.1 (1-36) barriers
Measures of central tendency for the number of CFIR barriers participants responded to:
Mean: 6.09
Median: 5
Mode: 2
SD: 4.75
Range: 1 to 36
Closing Questions ON

27. Mapping Results
Mapping Results

28. Number of ERIC strategies endorsed by 1+ respondent
Average n=47 ERIC strategies / CFIR construct

29. 2847 ERIC X CFIR Possibilities
Bad news:
At least one respondent endorsed 64% (n=1832)
Good news:
Possible combos reduced by 36%
39 X 73 = 2847
1832 actual combinations endorsed by at least one respondent: 64%
Thus, 36% of combinations received 0 endorsements
“Icon array” or “pictograph”

30. ERIC strategies chosen: Reflecting & Evaluating n=25 (Normalized to n=20)
N=43 strategies endorsed
Long array-long tail

31. ERIC strategies chosen: Reflecting & Evaluating n=25 (Normalized to n=20)
Level 1
Level 2

32. Example: Majority-endorsed strategies for CFIR barrier
ERIC Strategy
Reflecting & Evaluating
Develop and implement tools for quality monitoring
Goals & Feedback
Audit and provide feedback
1.8% of 1832 endorsed combinations

33. ERIC Strategy CFIR Barrier
There is little or no quantitative and qualitative feedback about the progress and quality of implementation nor regular personal and team debriefing about progress and experience
Low
Reflecting & Evaluating
ERIC Strategy
Level 1 Recommendations
Level 2 Recommendations
Develop and implement tools for quality monitoring
Develop and organize quality monitoring systems
Facilitate relay of clinical data to providers
Audit and provide feedback
Obtain and use patients/consumers and family feedback
Organize clinician implementation team meetings
Purposely reexamine the implementation
Use data experts
Facilitation
Capture and share local knowledge

34. Number of Level 1 & 2 recommended strategies x CFIR barrier
21 (54%) CFIR constructs have between 1 and 3 Level 1 strategies
All constructs have between 6 to 15 strategies (Level 1 and Level 2 combined)
Lowest number: n=5 Level 2 strategies for Patient Needs & Resources, which also had 3 Level 1 strategies (n=8 total). This may be the construct with the strongest overall endorsement.
Highest number n=15 for Complexity, which had 0 Level 1 strategies; 48 total strategies endorsed by at least one respondent
Level 1
Level 2

35. Rationale for choosing “best strategies”

36. Tool for Selecting Strategies

37. Tool for Selecting Strategies
Level 1
Recommendations
Level 2
Recommendations

38. Conclusions
21 (54%) CFIR barriers have 1+ strategy endorsed by a majority of respondents
Wide diversity in recommended strategies
Even when specific to a CFIR barrier
Diverse sample  diverse settings  diverse recommendations?
Practical considerations drove decisions
Relevance
Improvement opportunity
Feasibility
An Excel® tool has been developed to provide listings of Level 1 & 2 ERIC strategies for user-specified CFIR barriers.

39. Thank you!
Contact
@LJDamschroder

40. Extras

41. 33 ERIC strategies endorsed by majority of respondents for 22 CFIR barriers
ERIC Strategy
Culture
Engage: Key Stakeholders
Identify and prepare champions
Engage: Champions
1.8% of 1832 endorsed combinations
Engage: Impl. Leaders
Engage: Opinion Leaders
Inform local opinion leaders

42. Organizational incentives & rewards
Alter incentive/allowance structures
Implementation Climate
Assess for readiness and identify barriers and facilitators
Alter incentive/allowance structures
Develop academic partnerships
33 ERIC strategies endorsed by majority of respondents for 22 CFIR barriers
Readiness for Implementation
Build a coalition
Conduct educational meetings
Cosmopolitanism
Promote network weaving
CFIR Barrier
ERIC Strategy
Engage: Patients
Intervene with patients/consumers to enhance uptake & adherence
Develop educational materials
Access to knowledge & Information
Distribute educational materials
Prepare patients/consumers to be active participants
Knowledge & Beliefs about the Intervention
Organize clinician implementation team meetings
Networks & Communication
Involve patients/consumers and family members
Patient Needs & Resources
1.8% of 1832 endorsed combinations
Learning Climate
Facilitation
Obtain and use patients/consumers and family feedback
Planning
Conduct educational meetings
Promote adaptability
Adaptability
Develop a formal implementation blueprint
Available Resources
Access new funding
Cost

43. Tool for Selecting Strategies