1. Applying Multiple Frameworks and Theories in Implementation Research Jeffrey Smith Implementation Research Coordinator Mental Health QUERI

2. “In theory there is no difference between theory and practice… in practice there is.” Yogi Berra

3. Mental Health QUERI Approach to Implementation Design interventions based on theory, lit review and results from formative evaluation Design interventions based on theory, lit review and results from formative evaluation Conduct formative evaluation Conduct formative evaluation –engage with stakeholders –identify determinants of current practice –assess barriers and facilitators to implementation organizational-level organizational-level team / clinic-level team / clinic-level individual provider-level individual provider-level patient-level patient-level –tailor intervention design and implementation to local context

4. Mental Health QUERI Approach to Implementation (cont) Use external facilitation techniques (PARiHS Framework) Use external facilitation techniques (PARiHS Framework) –engage with stakeholders to problem-solve and identify new strategies or tools for overcoming barriers when initial success is sub-optimal Conduct summative (or impact) evaluation Conduct summative (or impact) evaluation

5. An Approach to Using Theory for Implementation Planning Select framework / theory / model of planned behavior change Assess fit with initial theory Identify potential strategies for achieving change Select interventions that fit with planned strategies (based on theory) Identify intervention tools that fit both strategy and theory Launch intervention using identified tools and strategies Evaluate effectiveness of intervention, strategies, tools Adapted from: Sales A, Smith JL, Curran G, Kochevar L. Models, strategies and tools: The role of theory in implementing evidence-based findings into health care practice. Journal of General Internal Medicine 2006; 21:S43-49.

6. Implementation Science Frameworks and Theories (selected) Organizational / System Level Organizational / System Level –Consolidated Framework for Implementation Research (VA Diabetes QUERI) –Promoting Action on Research Implementation in Health Services (PARiHS) –Stetler Organizational Framework for Institutionalizing EBPs –Greenhalgh Model for Diffusing Innovations in HCOs –Ottawa Model of Research Use –Simpson Transfer Model –Complexity Theory

7. Implementation Science Frameworks and Theories (cont.) Interpersonal Level Interpersonal Level –Diffusion of Innovation (Rogers) –Social Influence Theory (Mittman) –Social Cognitive Theory… aka Social Learning Theory (Bandura) Individual Level Individual Level –Theory of Reasoned Action / Theory of Planned Behavior (Azjen & Fishbein) –Health Belief Model (Rosenstock) –Transtheoretical Model and Stages of Change (Prochaska & DiClemente)

8. Multiple theory approach Strengths – useful in designing multifaceted interventions to influence multi-level determinants of care (flexible) – allows integration of theory, knowledge, methods from multiple disciplines (multidisciplinary) Limitations – Can be unwieldy… need to provide rationale for applying multiple theory approach, and rationale for selecting the specific frameworks / theories applied Key Guidance on Evaluation – combine with rigorous formative evaluation – conduct summative (impact) evaluation to assess intervention effectiveness on key study outcomes – confirm, refute or propose refinements to selected theory(ies) based on study findings

9. Summary Application of multiple frameworks/theories in guiding intervention design and implementation can be successful in implementing EBPs Application of multiple frameworks/theories in guiding intervention design and implementation can be successful in implementing EBPs – accommodates tailoring to setting when combined with formative evaluation – example forthcoming (May 5 session) acknowledges there are generally multi-level determinants to complex, clinical QI issues acknowledges there are generally multi-level determinants to complex, clinical QI issues – organizational-level – team-level – interpersonal-level – individual-level

10. QUESTIONS? Contact: Jeff Smith VA Mental Health QUERI E-mail: Jeffrey.Smith6@va.gov