Enola
Proctor
Johns
Hopkins
February
24,
2014
1
Implementa)on
Strategies
&
Outcomes:
Advancing
the
science

Session
overview:
1. Implementa?on
science:
What
is
it?
2. Implementa?on
outcomes
&
strategies:
conceptual
&
methodological
challenges
3.
Where
are
we
going?
2

I.
What
is
it?
NIH
Defini?ons*
Dissemina?on
Research:
– study
of
how
&
when
research
evidence
spreads
throughout
agencies,
organiza?ons,
and
front
line
workers.
Implementa?on
Research:
– scien?fic
study
of
how
to
move
evidence-­‐based
interven?ons
into
healthcare
prac?ce
and
policy
**PAR13-­‐055
3

What
is
implementa?on
research?
“Research
to
inform
how
to
make
the
right
thing
to
do
the
easy
thing
to
do.”
-­‐Carolyn
Clancy,
Agency
for
Healthcare
Research
and
Quality
4

Implementa)on
research:
What
does
it
take?
Quality
gaps
to
address
Evidence-­‐based
interven?ons
The
“how:”
Implementa?on
strategies
The
“where:”
Context
Theory
Partnerships
Research
Methods
&
tools
5

Implementa?on
is
about
improving
care
The
care
that
“could
be”
vs
The
care
that
“is”
What
quality
gaps
are
of
concern?
6

Quality
gaps
•

Quality
of
mental
health
care
US
mental
health
care:
“D
grade”
(NAMI)
AHRQ:
Physical
healthcare
is
improving,
but
no
improvement
in
depression
care
(AHRQ’s
2010
Health
Care
Quality
Report)
Household
data:
<10%
of
the
U.S.
popula?on
with
a
serious
mental
disorder
receives
adequate
care
(Kessler
et
al,
2005)
Racial
dispari?es
in
care
8

Evidence
Based
interven?ons
Are
interven?ons
ready
for
D&I?
Balancing
Tx
discovery
v
Tx
roll
out
9

When
we
have
effec?ve
interven?ons,
it’s
?me
to
delivery
them
Professional
Associa?ons
10

Implementa)on
Outcomes
Feasibility
Fidelity
Penetra?on
Acceptability
Sustainability
Uptake
Costs
*IOM
Standards
of
Care
Conceptual
Model
for
Implementa)on
Research
What?
QIs
ESTs
How?
Implementa?on
Strategies
Implementa?on
Research
Methods
Service
Outcomes*
Efficiency
Safety
Effec?veness
Equity
Pa?ent-­‐
centeredness
Timeliness
Pa)ent
Outcomes
Clinical/health
status
Symptoms
Func?on
Sa?sfac?on
Proctor
et
al
2009
Admin.
&
Pol.
in
Mental
Health
Services
CONTEXT
CONTEXT
CONTEXT
CONTEXT
The
Usual
The
Core
of
Implementa)on
Science
11

Implementa?on
research
studies…
Key
variables:
behavior
of
healthcare
professionals
and
support
staff
healthcare
organiza?ons
(culture/
context)
healthcare
consumers
and
family
members
policymakers
in
context
as
key
variables
Key
outcomes:
sustainable
adop?on,
implementa?on
and
uptake
of
evidence-­‐based
interven?ons
12

Theories
Now:
Many
models!!!
109
iden?fied
models
How
to
choose?
Tabak,
Khoong,
Chambers,
&
Brownson
(2012),
Bridging
Research
and
Prac?ce:
Models
for
Dissemina?on
and
Implementa?on
Research,
J
Prev
Med,
43(3):337–350
13

Implementation Strategies:
Definition
Systematic intervention process to adopt and
integrate evidence-based healthcare
innovations into usual care *
Active ingredient in processes for
moving EST’s and QI’s into usual care
*Powell, McMillen, Proctor et al., Medical Care Research and Review, 2012
14

Implementa?on
Strategies
…………the
‘how
to’
component
of
changing
healthcare
prac?ce.
……….Key:
How
to
make
the
“right
thing
to
do”
the
“easy
thing
to
do…Carolyn
Clancy
15

Implementa?on
Strategies:
Complexity*
Discrete
• involve
one
process
or
ac?on,
such
as
“mee?ngs,”
“reminders”
Mul)faceted**
• uses
two
or
more
discrete
strategies,
such
as
“training
+
technical
assistance”
Blended
• several
discrete
strategies
are
interwoven
&
packaged
as
protocolized
or
branded
strategies,
such
as
“ARC,”
IHI
Framework
fro
Spread”
*Powell,
McMillen,
Proctor
et
al.,
2012
**
Grimshaw
et
al.,
2001,
Grol
&
Grimshaw,
2003
16

A
Compila?on
or
“menu”
68
strategies
grouped
by
six
key
processes*
*Powell,
McMillen,
Proctor
et
al.,
Medical
Care
Research
and
Review,
2012
17

Plan
Strategies
• Gather
informa?on
• Select
strategies
• Build
buy-­‐in
• Ini?ate
leadership
• Develop
rela?onships

Educate
Strategies
• Develop
materials
• Provider
training
• Inform
and
influence
stakeholders

Finance
Strategies
• Modify
incen?ves
for
clinicians,
consumers,
reduce
disincen?ves
• Facilitate
financial
support:
place
on
formularies

Restructure
strategies
• Revise
roles
• Create
new
teams
• Change
sites
• Change
record
systems
• Structure
communica?on
protocols

Quality
Management
Strategies
• Audit
and
provide
feedback
• Clinician
reminders
• Develop
T.A.
systems
• Conduct
cyclical
small
tests
of
change
• Checklists

Policy
Strategies
Licensure
Accredita?on
Cer?fica?on
Liability

Strategies:
What
do
we
know?
• Passive
dissemina?on
is
ineffec?ve
– E.g.
publishing
ar?cles,
issuing
a
memo,
“edict”
• Training
is
most
frequently
used
strategy
• Mul?-­‐component,
mul?level
are
more
effec?ve
24

Implementa?on
Strategies:
What
do
we
know?
Discrete:
checklists,
data
feedback,
reminders
Bundled
or
complex:
Organiza?onal
change
strategies:
– teamwork,
culture,
communica?on
– Ex:
ARC
Technological
strategies?
Training
strategies:
Provider
educa?on,
coaching
Support
strategies:
Supervision,
Site
level
support
and
monitoring
25

Implementa?on
Outcomes
Dis?nct
from
clinical
outcomes

Could
have
an
effec?ve
interven?on,
poorly
implemented

Could
have
an
ineffec?ve
treatment,
successfully
implemented
26

Implementa?on
Outcomes:
Key
Concepts
• Acceptability
• Adop?on
• Appropriateness
• Feasibility
• Fidelity
• Implementa?on
cost
• Penetra?on
• Sustainability
27

Implementa)on
Outcomes
Mul?ple
stakeholders
&
mul?ple
perspec?ves
• Service
consumers,
families,
providers,
administrators,
funders,
legislators
• Which
outcomes
mater
most
to
whom?
How
are
outcomes
related?
• This
informs
modeling
of
change
• IO
↔
IO
• IO
→service
system
and
clinical
outcomes
28

Measuring
Constructs
Developing
field
– Standard
measures
lacking
Common,
overlapping
constructs
Meta-­‐analysis
to
enhance
D&I
measures
inhibited
by:
– Weaknesses
in
informa?on
about
outcomes
– Use
of
dichotomous
measures
– Unit
of
analysis
29

Measurement:
Toward
Standardiza?on
&
Harmoniza?on
• Seatle
Implementa?on
Research
Conference
Measures
Project
– htp://www.seatleimplementa?on.org/sirc-­‐
projects/sirc-­‐measures-­‐project/
• Grid-­‐Enabled
Measures
developed
by
the
Na?onal
Cancer
Ins?tute
– htp://cancercontrol.cancer.gov/brp/gem.html
30

Implementa?on
Outcomes
Ques?on
from
the
field:
How
much
will
this
cost
and
what
kind
of
havoc
will
it
wreak?
Priority
outcomes:
•
incremental
cost
•
scale
up
&
spread
•
sustainability
31

Implementa?on
outcomes:
what
do
we
know?
• Fidelity
=
most
frequently
measured
outcome
• Provider
aytudes
frequently
assessed
• Implementa?on
outcomes
are
interac?ve:
– Effec?veness
greater
acceptability
– Cost
feasibility
• We
don’t
know
much
about:
– Sustainability
– Scale
up
and
spread
32

Which
implementa?on
outcomes
are
most
important
to
pursue?
Stakeholder
assessment
Who
are
they?
–
Payers,
Policy
makers
– Administrators
– Researchers
– Clients/
Pa?ents
,
Families
– Providers
(clinicians,
counselors,
M.D.’s,
nurses,
OT,
PT,
SW)
– Support
staff
(units,
labs,
medical
records)
– Supervisors,
training
teams
Where
are
they
re:
the
implementa?on?
33

Which
implementa?on
outcomes
are
most
important
to
pursue?
Push
&
pull

Is
there
a
demand
to
implement?

Is
there
a
push?

Is
there
a
pull?
34

Which
implementa?on
outcomes
are
most
important
to
pursue?
Contextual
assessment:
Barrier
assessment:
Prac?ce
change
needs
to
aligned
with
 Priori?es
and
trends
in
policy
ecology*
 Agency
infrastructure,
system
antecedents
**
 Capacity
*Raghavan,
2009
**
Emmons,
2013
35

Context:
Consolidated
Framework
for
Implementa?on
Research
(CFIR)
• Composed
of
5
major
domains:
– Interven?on
characteris?cs
– Outer
seyng
– Inner
seyng
– Characteris?cs
of
the
individuals
involved
– Process
of
implementa?on
Damschroder
L,
Aron
D,
Keith
R,
Kirsh
S,
Alexander
J,
Lowery
J.:
Fostering
implementa?on
of
health
services
research
findings
into
prac?ce:
a
consolidated
framework
for
advancing
implementa?on
science.
Implement
Sci
2009,
4(1):50.
36

Implementa?on
Context
Advancing
measurement
for
contextual
constructs
• Measures
exist
for
several
of
CFIR’s
constructs
• More
informa?on
on
the
Wiki:
htp://wiki.cfirwiki.net/index.php??tle=Main_Page
Understanding
how
to
fit
changing
EB
interven)ons
into
changing
context*
*
Dynamic
sustainability
framework,
Chambers
et
al.,
Implementa?on
Science,
2013
37

Implementa)on
Strategies:
How
to
select?
Evidence
of
effec)veness
and
fit
 Under
construc?on
Informed
by
context
assessment
 Inner
seyng
 Outer
seyng
 Interven?on
features
 Barriers
assessment
 Flotorp,
S.A
(2013)
A
checklist
for
iden?fying
determinants
of
prac?ce:
A
systema?c
review
and
synthesis
of
frameworks
and
taxonomies
of
factors
that
prevent
or
enable
improvements
in
healthcare
professional
prac?ce.
ImplementaDon
Science
8:35
38

Where
are
we
going?
Challenges
and
opportuniDes
in
implementaDon
science
39

Priority
area
#1:
Implementa)on
Strategies
Build
the
evidence
Empirical
tests
of
strategies
CER
Cost
effec?veness
Understanding
what
strategies
work,
for
which
EST’s,
in
which
seyngs
Developing
more
parsimonious
strategies:
which
components
have
which
effects?
Which
strategies
for
which
implementa?on
outcomes?
40

Implementa?on
Strategies:
How
to
select?
• Context
assessment:
– Barrier
iden?fica?on
– System
antecedents
*
– Root
cause
analysis
• Target
to
context
• Stakeholder
engagement
*Emmons,
K.
M.,
Weiner,
B.,
Fernandez
,
M.E.,
&
Tu,
S.
(2012),
Systems
Antecedents
for
Dissemina?on
and
Implementa?on
:
A
Review
and
Analysis
of
Measures,
Health
Educ
Behav
39:
87
**
Flotorp,
S.A.,
Oxman,
A.D.,
Krause,
J.
et
al.,
(2013),
A
checklist
for
iden?fying
determinants
of
prac?ce:
A
systema?c
review
and
synthesis
of
frameworks
and
taxonomies
of
factors
that
prevent
or
enable
improvements
in
healthcare
professional
prac?ce,
Implementa?on
Science,
8:35
41

Implementa?on
Strategies:
Specifica?on
&
repor?ng*
Implementa)on
strategies
carry
same
demands
as
interven)ons
• Opera?onal
defini?ons
• Protocols
&
manuals
• Fidelity
Define
strategies
conceptually,
opera)onally
42
DEBATE Open Access
Implementation strategies: recommendations for
specifying and reporting
Enola K Proctor1*
, Byron J Powell1
and J Curtis McMillen2
Abstract
Implementation strategies have unparalleled importance in implementation science, as they constitute the ‘how to’
Implementation
Science
Proctor et al. Implementation Science 2013, 8:139
http://www.implementationscience.com/content/8/1/139

Priority
area
II:
Implementa)on
Outcomes
Mul)ple
stakeholders
&
mul)ple
perspec)ves
• Which
outcomes
mater
most
to
whom?
• Ques?on
from
the
field:
How
much
will
this
cost
and
what
kind
of
havoc
will
it
wreak?
Priority
outcomes:
•
incremental
cost
•
scale
up
&
spread
•
sustainability
43

Priori?es
for
Sustainability
Research
• Sustainability
of
EBPs
when
contexts
change
• Adaptability/Evolu?on
of
EBPs
over
?me
• Scaling
up
prac?ces
across
health
plans,
systems,
and
networks
• Studying
De-­‐Implementa?on
44

Program
Sustainability
Assessment
Tool
45

Priority
area
III:
Capturing
complex
implementa)on
Reality
of
most
service
delivery:
Co-­‐occurring
condi)ons
→
Mul)ple
EBI’s
Evidence
evolves
→
con)nually
adopt
Limited
capacity
→
must
de-­‐adopt
Fit
to
local
context
→
adapta)on
Staff
turnover→
con)nual
training
46

Treatment
Evidence
Con)nues
to
Grow
What
strategies
can
enable
providers
&
organizaDons
to
implement
evolving
evidence?
47

Training:
Implementa)on
Research
Ins)tute
(IRI)
• Na?onal
faculty
&
scholars
• 2
yr.
program
for
IR
in
mental
health
• Funded
by
an
NIMH
R25
grant
(NIMH
-­‐
R25
MH080916-­‐03);
VA
&
NIDA
supplements
• Held
at
Brown
School
Washington
University
in
St.
Louis
48

Training:
IRI
fellows
at
Hopkins
49

Training:
Mentored
Training
for
Dissemina?on
&
Implementa?on
Research
in
Cancer
(MT-­‐DIRC)
Na?onal
faculty
&
fellows
2
yr.
program
of
summer
ins?tutes
Based
at
Washington
University
NCI
supported
12
fellows
per
year
Applica?ons
for
summer
2014
due
this
winter
Contact:
rbrownson@wustl.edu
50

Training:
Training
Ins?tute
for
Dissemina?on
&
Implementa?on
Research
in
Health
TIDIRH
NIH
wide
Housed:
UNC,
UCSF,
Washington
U,
Harvard
htp://ctsi.ucsf.edu/calendar/training/2012-­‐training-­‐ins?tute-­‐
dissemina?on-­‐and-­‐implementa?on-­‐research-­‐health-­‐?dirh
• Applica?ons
for
2014
due
this
winter
51

Support:
Na)onal
Ins)tute
of
Mental
Health
P30
MH068579
R25
MH080916
P30
DK092950
U54
CA155496
UL1
RR024992
(Clinical
and
Transla?onal
Science
Award,
CTSA)
Washington
University
Ins?tute
for
Public
Health
Brown
School
of
Social
Work
Conflicts:
none
52

53

QuesDons…
….????????
Enola
Proctor
ekp@wustl.edu
54