Distortion of implementation techniques in health care: the case of - - PowerPoint PPT Presentation

CLAHRC Greater Manchester

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Distortion of implementation techniques in health care: the case of “facilitation”

Paul Wilson on behalf of

Roman Kislov, John Humphreys and Gill Harvey

roman.kislov@manchester.ac.uk

CLAHRC Greater Manchester

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CLAHRC Greater Manchester

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Context

• NIHR CLAHRC Greater Manchester is a partnership between health

providers and commissioners and academics to improve the health

• f people in Greater Manchester and beyond through carrying out

research and putting it into practice.

• Work with healthcare staff to design a project to address known

underperformance against Quality and Outcomes Framework indicators for CKD. –Halve the gap between recorded and estimated prevalence on practice registers –75% of CKD patients to be tested for proteinuria and managed to NICE recommended blood pressure targets

CLAHRC Greater Manchester

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CLAHRC Greater Manchester

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Why facilitation?

• CLAHRC GM implementation approach

– Framed by Promoting Action of Research Implementation in Health Services (PARIHS) conceptual framework and the Model for Improvement

• PARIHS defines successful implementation as a function of the interplay

between Evidence, Context and Facilitation: SI = f (E,C,F)

• Facilitation:

– A role (facilitator) + a process (facilitation)

Improvement methods: Aims/goals Collaborative learning Local application (PDSA) Audit and feedback Benchmarking

CLAHRC Greater Manchester

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CLAHRC Greater Manchester

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CKD Improvement Project

• Internal facilitators (non-clinical and clinical)
• External support

– experienced facilitators – clinical/opinion leaders – academic guidance

• Changes in facilitation input and support over time

CLAHRC Greater Manchester

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CLAHRC Greater Manchester

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Project phases

PHASE 1

• 2 non-

clinical facilitators

• Programme

Manager

• Data analyst
• Clinical

leader

• Academic/

experienced facilitator

PHASE 2

• 1 non-

clinical facilitator

• 2 clinical

facilitators

• 2 managers
• Data analyst
• Clinical

leader

• Academic/

experienced facilitator

PHASE 3

• 2 non-

clinical facilitators

• 3 clinical

facilitators

• 3 managers
• Data analyst
• [All part-

time]

CLAHRC Greater Manchester

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CLAHRC Greater Manchester

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How did facilitation evolve?

Three interrelated and overlapping processes:

• 1. Prioritisation of (measurable) outcomes over

(interactive) process;

• 2. Reduction of (multiprofessional) team engagement;
• 3. Erosion of the designated facilitator role

CLAHRC Greater Manchester

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CLAHRC Greater Manchester

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Facilitation as a managerial technique

Enabling the learning processes Involvement

• f teams

Articulated goals The facilitator role Tools

‘Soft core’ ‘Hard periphery’

CLAHRC Greater Manchester

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CLAHRC Greater Manchester

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Distortion of facilitation

The facilitator role Enabling the learning processes Involvement

• f teams

Articulated goals Tools

• Privileging

some ‘core’ components

• ver the
• thers
• Replacing

‘core’ components by the ‘peripheral

• nes
• Facilitators

shifting from ‘enabling’ to ‘managing’ and ‘doing’

• Explicit

performance goals prioritised

• ver implicit

sustainability- related goals

• Learning

how to meet performance targets, rather than how to improve services

• Context

substantially limits the agency of facilitators

CLAHRC Greater Manchester

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CLAHRC Greater Manchester

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Implications for practice

• Revisiting the facilitation concept

– from individuals in facilitator roles to network of facilitators and facilitator development and support – differentiating facilitator role and scope according to context

• Revisiting the PARIHS framework

– from heuristic to integrated-PARIHS framework – explicit theoretical base – facilitation as the active element – operationalising the facilitation role and process

CLAHRC Greater Manchester

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The i-PARIHS framework

Novice facilitator Experienced facilitator Expert facilitator

Harvey et al. Implement Sci 2016; 11:33.