IMPROVEMENT ? How do improvement science and implementation science - - PowerPoint PPT Presentation

Rohit Ramaswamy, PhD, MPH Associate Professor Public Health Leadership/Maternal and Child Health University of North Carolina, Chapel Hill

IMPROVING IMPLEMENTATION OR IMPLEMENTING IMPROVEMENT ?

How do improvement science and implementation science contribute to quality and effectiveness in health care?

Abe Wandersman, PhD Professor

• Dept. of Psychology

University of South Carolina

• Big picture issue
• Evidence Based Interventions are necessary but not

sufficient for outcomes

• Bridging research and practice
• The Interactive Systems Framework (ISF)
• Readiness
• Evidence Based System for Innovation Support (EBSIS)
• Integrating Improvement and Implementation: Ghana case

study

OVERVIEW

IMPLEMENTATION AND IMPROVEMENT SCIENCES – CONNECTED BY A COMMON GOAL

IMPLEMENTATION SCIENCE IMPROVEMENT SCIENCE

GOOD AND SUSTAINED OUTCOMES

CONTINUALLY IMPROVE IMPLEMENTATION QUALITY IMPLEMENT WHAT YOU IMPROVE WITH QUALITY

IMPROVING IMPLEMENTATION QUALITY

• CQI embedded into common implementation frameworks

Quality Implementation Framework Getting to Outcomes NIRN Active Implementation

IMPLEMENTING WHAT IS IMPROVED

• 1. No tools to guide the actual

process of implementation.

• 2. No formal approach that

facilitates adoption of improvement solutions

• 3. No formal method and tools

to adapt improvement solutions to other situations and contexts.

E vidence Based Interventions are Necessary But Not Sufficient for Outcomes

Replication worked (at first)

But Not at Scale

RESEARCH PRACTICE

BR BRIDGING R RESE SEARCH AN AND PR PRACTI TICE

*WHERE DO EVIDENCE BASED PRACTICES COME

FROM AND WHERE DO THEY GO *RESEARCH TO PRACTICE MODELS *THE INTERACTIVE SYSTEMS FRAMEWORK FOR DISSEMINATION AND IMPLEMENTATION (ISF)

2.With an emphasis

• n risk and

protective factors, review relevant information—both from fields outside prevention and from existing preventive intervention research programs

RISK AND PROTECTIVE FACTORS

• 3. Design,

conduct, and analyze pilot studies and confirmatory and replication trials

• f the preventive

intervention program EFFICACY TRIALS

• 4. Design,

conduct, and analyze large- scale trails of the preventive intervention program EFFECTIVENESS TRIALS

• 5. Facilitate

large-scale implementation and ongoing evaluation of the preventive intervention program in the community PRACTICE

• 1. Identity

problem or disorder(s) and review information to determine its extent EPIDEMIOLOGY

Feedback Loop

FIGURE 1.1 The preventive intervention research cycle. Preventive intervention research is represented in boxes three and four. Note that although information from many different fields in health research, represented in the first and second boxes, is necessary to the cycle depicted here, it is the review of this information, rather than the

• riginal studies, that is considered to be part of the preventive intervention research cycle. Likewise, for the fifth

box, it is the facilitation by the investigator of the shift from research project to community service program with

• ngoing evaluation, rather than the service program itself, that is part of the preventive intervention research cycle.

Although only one feedback loop is represented here, the exchange of knowledge among researchers and between researchers and community practitioners occurs throughout the cycle.

Distilling the Information— Synthesis & Translation System Supporting the Work—Support System Putting It Into Practice— Delivery System

Synthesis

General Capacity Building Innovation-Specific Capacity Building

General Capacity Use

Innovation-Specific Capacity Use

Macro Policy Climate Funding Existing Research and Theory Translation

Interactive Systems Framework for Dissemination and Implementation

Delivery System

General Capacity

General Capacities

Types of General Capacities (non-exhaustive) Authors

Culture

Drzensky et al., 2012; Glisson, 2007; Glisson & Schoenwald, 2005; Hemmelgarn et al., 2006

Climate

Aarons et al., 2011; Beidas et al., 2013; Damschroder et al., 2009; Glisson, 2007; Greenhalgh et al., 2004, Hall & Hord, 2010; Lehman et al., 2002

Organizational Innovativeness

Damschroder et al., 2009; Fetterman & Wandersman, 2005; Greenhalgh et al., 2004; Klein & Knight, 2005; Rafferty et al., 2013; Rogers, 2003

Resource Utilization

Armstrong et al., 2006; Greenhalgh et al., 2004; Klein et al., 2001; Rogers, 2003; Simpson, 2002

Leadership

Aarons & Sommerfield, 2012; Becan, Knight, & Flynn, 2012; Beidas et al., 2013; Fixsen et al., 2005; Grant, 2013; Rafferty et al., 2013; Simpson et al., 2002

Structure

Damschroder et al., 2009; Flaspohler et al., 2008; Greenhalgh et al., 2004, Lehman et al., 2002; Rafferty et al., 2013; Rogers, 2003

Staff Capacity

Flaspohler et al., 2008; McShane & Van Glinow, 2009; Simpson et al., 2002

GC Components are “Normal”

High Medium Low

Leadership

Interactive Systems Framework for Dissemination and Implementation

Delivery System

General Capacity Innovation- Specific Capacity

An Innovation

• Any policy,

program, or process that is new to a setting

Innovation-Specific Capacities

Types of Innovation-Specific Capacities; (non-exhaustive) Authors

Innovation-Specific knowledge, skills, and abilities

Wandersman, Chien, & Katz, 2012; Fixsen et al., 2005; Greenhalgh et al., 2004; Simpson, 2002

Program Champion

Atkins et al., 2008; Damshroder et al., 2009; Greenhalgh et al., 2004; Gladwell, 2002; Grant, 2013; Rafferty et al., 2013; Rogers, 2003

Specific Implementation Supports

Aarons et al., 2011; Beidas et al., 2013; Damshroder et al., 2009; Fetterman & Wandersman, 2005; Greenhalgh et al., 2004; Hall & Hord, 2010; Rogers, 2003; Schoenwald & Hoagwood, 2001; Weiner et al., 2008.

Interorganizational Relationships

Aarons et al., 2011; Flaspohler et al., 2004; Powell et al., 2012

Interactive Systems Framework for Dissemination and Implementation

Delivery System

General Capacity Innovation- Specific Capacity

Motivation

Motivation for Innovation

Types of Motivations (non-exhaustive) Authors

Relative Advantage

Armenakis et al., 1993; Damschroder et al., 2009; Hall & Hord, 2010; Rafferty et al., 2013; Rogers, 2003; Weiner, 2009

Compatibility

Chinman et al., 2004; Durlak & Dupre, 2008; Fetterman & Wandersman, 2005; Greenhalgh et al., 2004; Rogers, 2003; Simpson, 2002

Complexity

Damschroder & Hagedorn, 2011; Fixsen et al., 2005; Greenhalgh et al., 2004; Meyers, Durlak & Wandersman, 2012; Wandersman et al., 2008.

Trialability

Armenakis et al., 1993; Greenhalgh et al., 2004; Rapkin et al., 2012; Rogers, 2003

Observability

Beutler, 2001; Chinman et al., 2004; Damschroder et al., 2009; Ford et al., 2008; Rossi, Lipsey, & Freeman, 2004

Priority

Armenakis & Harris, 2009; Greenhalgh et al., 2004; Flaspohler et al., 2008

A Heuristic

Readinessi =

Motivationi x General Capacity x Innovation-Specific Capacityi

R = MC

2

Interactive Systems Framework for Dissemination and Implementation

Delivery System

General Capacity Innovation- Specific Capacity

Motivation Support System

General Capacity Innovation- Specific Capacity

Motivation

Readiness Building Strategies

Buildi ding R ng Readi diness ness

Broad Strategies

Ways to support an Innovation

Evidence-Based System for Innovation Support (EBSIS)

(Wandersman, Chien, & Katz, 2012)

Tools Training

Technical Assistance Quality Assurance/ Quality Improvement

Testing out systems to help assess and develop readiness and capability: Building Readiness Through an Evidence-Based System for Implementation Support (EBSIS)

Initial Readiness

• General

Capacities

• Innovation-

Specific Capacities

• Motivation

Readiness Outcomes Improved:

• General

Capacity

• Innovation
• Specific

Capacity

• Motivation

Relationships

Training

Quality Assurance Quality Improvement

Tools

Technical Assistance

IMPLEM EMEN ENTATION

Definition of Quality Implementation

We define quality implementation as putting an innovation into practice in a way that meets the necessary standards to achieve the innovation's desired outcomes

SYNTHESIS OF IMPLEMENTATION FRAMEWORKS

Meyers, Durlak & Wandersman 2012

• Review of implementation frameworks
• Implementation Action strategies used in

Iiterature · Action steps for implementing technologies, practices, and/or processes in organizations and/or communities

• 25 frameworks were retained (e.g., framework

by Dean Fixsen and colleagues)

Synthesis Methodology

· Quantitative and qualitative articles were retained

• Peer-reviewed publications, book chapters,

dissertations, or non-peer-reviewed monographs

• Articles which were retained had to include

an implementation framework

What is Practical Implementation Science? A user-friendly translationof the results of implementation science

Quality Implementation Tool (QIT)

• User-friendly translation of the quality implementation

framework

• QIT can be applied to:
• Planning for implementation
• Thinking through implementation dimensions a priori can

help systematize implementation

• Monitoring implementation

·Use of the checklist during implementation can inform needs for mid-course correction

• Evaluating implementation

·Checklist can be used for retrospective evaluation of implementation in relation to outcomes

QIT Components

• 1. Develop an implementation team
• 2. Foster supportive organizational climate and conditions
• 3. Develop an implementation plan
• 4. Receive training and technical assistance
• 5. Practitioner-developer collaboration in implementation
• 6. Evaluate aspects of implementation

Each component is broken down into concrete act ion steps

Component 1: Develop an Implementation Team

Action Steps: 1. Decide on structure of team overseeing implementation 2. Identify an implementation team leader 3. Identify and recruit content area specialists as team members 4. Identify and recruit other agencies and/or community members as team members 5. Assign team members documented roles, processes, and responsibilities

an

An Example using the QIT in bringing an innovation to scale

Q

Challenges to implementing 1TW01 with quality

• 1TW01 is a district level innovation

·Quality implementation at multiple sites

• 38 different schools
• district uses a site-based management system, so schools

have autonomy and district has less influence over local decisions

• Need to provide professional development and support to a

diverse set of teachers, all with varying levels of capacity ·Schools varied in level of "buy - in"

• Different types of resistance across schools

·Significant technical issues, including infrastructure differences across schools

Dealing with challenges

Used the QIT to help the district plan for and monitor implementation Representatives from schools and district came together to talk about how they can support implementation at the school-level The end result was a specific task list

• f what needed to be done and by when.

QIT is helping us navigate the layers of work - layers that take planning, and implementation down to the school and classroom level and layers that break large tasks into even smaller tasks with specific responsibi Iities"

• Dr. Debbie Hamm, Chief Information

Officer

1TW01 was the "skunk on the table" for middle schools

Variabi Iity in the implementation of 1TW01 (e.g. different devices, professional development) posed unique challenges in bringing quality implementation to scale

"The tool allows potentially dysfunctional relationships to step back, take a deep breath, and apply clear and structured logical steps to working through a challenge ... The OIT tool seems to position the elements of the project (and the challenges) externally in a way that the key team members can see through the hype and work in logical ways that lead to better outcomes. Also, many times in education ...we begin with the end-game in mind and struggle to work backwards to force the end game - sometimes with incorrect practices -- without any structured guide to step through sequentially. The OIT helps people to "face the brutal facts". It is effective in taking complex and potentially convoluted projects and converting the variables to their lowest common denominator."

• Tom Cranmer, Executive Director of IT services

I

' 1

I

a

Get to t to th this!! !!

• Durlak, J. A., & Dupre, E. P

. (2008). Implementation matters: A review of research on the influence of implementation on progam

• utcomes and the factors affecting the implementation. American

Journal of Community Psychology, 41, 327-350.

• Gottfredson, D. C. & Gottfredson, G. D. (2002). Quality of School

Based Prevention Programs: Results from a National Survey. Journal

• f Research in Crime and Delinquency, 39, 1, 3-35.
• Meyers DC, Katz J, Chien V, Wandersman A, Scaccia JP, & Wright A.

(2012). Practical implementation science: developing and piloting the quality implementation tool.American Journal of Community Psychology, 50(3-4), 481-96.

• Meyers, D.C., Durlak, J.A.,& Wandersman A. (2012). The qua Iity

implementation framework: a synthesis of critical steps in the implementation process. American Journal of Community Psychology, 50(3-4), 462-480.

• U.S. Department of Education, Office of Planning, Evaluation

and Policy Development, Pol icy and Program Studies Service (2011). Prevalence and Implementation Fidelity of Research-Based Prevention Programs in Public Schools: Final Report, Washington, D C

References

IMPLEMENTATION AND IMPROVEMENT SCIENCES – CONNECTED BY A COMMON GOAL

IMPLEMENTATION SCIENCE IMPROVEMENT SCIENCE

GOOD AND SUSTAINED OUTCOMES

CONTINUALLY IMPROVE IMPLEMENTATION QUALITY IMPLEMENT WHAT YOU IMPROVE WITH QUALITY

INTEGRATING IMPLEMENTATION AND IMPROVEMENT - GHANA CASE STUDY

• Ghana has implemented interventions

to promote access, increasing facility based deliveries.

• But the question is: what happens

when the patient gets to the hospital?

• MMR has not been reduced

significantly in tertiary hospitals

• Ghana has emphasized access, without

addressing quality of care within institutions

THE CONTEXT

• Ridge Regional Hospital

(RRH) is an obstetric referral center in Accra

• Almost 10,000 births per

year

• 6 labor and 2 delivery

beds

• Operating theatre 200m

away

• 1 consultant OB
• 4 medical
• fficers/residents
• 3-4 midwives/shift

THE HISTORY

• Volunteer medical team from

UNC, Duke and Wake Forest Universities working at hospital from 2007-2012

• Improved clinical staff capacity,

provided equipment and supplies

• Dramatic impact on outcomes
• Volumes and case complexity

increased

• System strengthening project

started in 2013

• Focus on 5 regional hospitals
• Systematic approach to systems

change through QI methods.

MATERNAL MORTALITY AT RIDGE HOSPITAL

Deliveries and MMR - Ridge Hospital: 2007 to 2014

MORTALITY DUE TO MOST COMMON COMPLICATIONS

Pre-eclampsia Hemorrhage Year Total Deliveries Prevalence (%) Case Fatality Rate (%) Prevalence (%) Case Fatality Rate (%) 2007 6049 5.3 3.1 0.8 14.8 2008 7465 7.9 1.3 1.3 5.1 2009 8230 12.1 1.1 3.9 1.9 2010 8133 12.8 1.1 4.2 2.0 2011 9357 14.5 1.1* 5.2 1.6# 2012 11032 16.3 1.0 7.2 1.9 2013 7591 16.1 0.6 5.5 2.1 2014 9113 15.5 1.2 6.0 1.8

Represent 56% and 60% of all deaths in 2007 and 2014

MORTALITY AUDIT 2014 – AVOIDABLE FACTORS

FACTOR CATEGORY Inadequate dose of ketanine Clinical Delay in getting basic labs Operational Unavailability of size 18 cannula Operational Failure of adequate monitoring Leadership Delay in ANC referral Operational Delay in labs Operational Delay in seeking health care Operational Administration of wrong medication Clinical Temporary failure of oxygen system Operational Risk factor of anaemia not identified Clinical Not diagnosing pelvic absess Clinical No funds for blood Operational Senior person not called on time Leadership Unavailability of blood Operational Should involve physicians earlier Leadership Discharged too early Leadership

IMPLEMENTATION MODEL Clinical Excellence Leadership Excellence Operational Excellence

Integrated Systems Strengthening Approach

io

Synthesis & Translation System – What practices are important for this setting?

Support System – How do we promote capability in these practices Delivery System – How do we ensure change is occurring?

Synthesis General Capacity Building Innovation-Specific Capacity Building General Capacity Use Innovation-Specific Capacity Use

Macro Policy Climate Funding Existing Research and Theory

Translation

USING THE INTERACTIVE SYSTEMS FRAMEWORK

Initial Readiness

• General

Capacities

• Innovation-

Specific Capacities

• Motivation

Readiness Outcomes Improved:

• General

Capacity

• Innovation
• Specific

Capacity

• Motivation

Relationships

Training

Quality Assurance Quality Improvement

Tools

Technical Assistance

Performance Gaps

BUILDING THE SUPPORT SYSTEM

IMPROVING IMPLEMENTATION QUALITY - PDSA

• Identify areas where

implementation needs to be improved

• Launch local quality

improvement projects led by clinical champions

• Use PDSA model for rapid

improvements

IMPROVING IMPLEMENTATION - TRIAGE

RED YELLOW GREEN

Eclampsia/seizure Sickle cell not in crisis Generalized complaints Hemorrhage/heavy vaginal bleeding Decreased or no fetal movement Normal labor Antepartum/postpartum hemorrhage Multiple pregnancy in labor Coma/unconscious Preterm labor Abnormal vital signs Preterm rupture of membranes Sickle cell crisis Stable/managed hypertension 2 or more previous c/s in active labor Previous c/s Diabetic HIV Positive

TRIAGE PROTOCOL

% of s shifts w ts wher here w wrist t band use w e was monitored

10 20 30 40 50 60 70 80 90 100

%

IMPROVEMENT CYCLE 1 – BAND MONITORING

% of pa patien ents w ts with w h wristbands s

10 20 30 40 50 60 70 80 90 100

%

IMPROVEMENT CYCLE 2 – BANDING COMPLIANCE

Audit 10 patients wrist band + folder combinations per week

Total patient wrist band + folder combinations Correct Incorrect 535 495 (93%) 40 (7%)

IMPROVEMENT CYCLE 3 – BANDING QUALITY

Working diagnosis and Plan - Triage Admission Form Audit 2013 - 2014

10 20 30 40 50 60 70 80 90 100 Working diagnosis made Plan made Dec-13 Q1 2014 Q2 2014 Q3 2014 Q4 2014

%

IMPROVEMENT CYCLE 4 – BANDING USE

IMPLEMENTING IMPROVEMENTS - NICU HAND HYGIENE

• 21 beds
• Census audit conducted

from Dec 9, 2014 - 176 days have been audited

• The peak number of

babies was 50

• Cot sharing occurred on

86% of days

CLOSING OPERATIONAL GAPS – QI PROJECTS

• Led by QI Leaders
• Focus on cross-

departmental projects

• Use Six Sigma

methodology

• Emphasis on
• perational issues

• Hand hygiene training presentation (with post test)
• Visual reminders posted throughout NICU
• Weekly reinforcement messages on hand hygiene topic

areas during staff meetings

• Additional hand towels supplied to NICU

IMPROVEMENT ACTIVITIES

#1 Needs/ Resources/ Readiness

#2 Goals & Objectives #3 Best Practices #4 Fit #5 Capacities #6 Plan #7 Process Evaluation #8 Outcome Evaluation #9 Improve / CQI #10 Sustain

RESULTS

USING AN IMPLEMENTATION APPROACH

DESIGNING SOLUTIONS FOR FIT

• Involving staff team in

improvement design

• Including NICU

specific images

• Redesigning language
• f training materials
• Using local voices to

record training video

BUILDING CAPACITY

• Multiple training

sessions

• Weekly reminders in

staff meetings

• Use of clinical

champions for support and reinforcement

• Multiple presentations
• Building monitoring

capacity

PLANNING FOR IMPLEMENTATION

• Clear plan with

timelines

• Involvement of

multiple stakeholders at various points in implementation

• Clear roles and

responsibilities

• Ongoing monitoring

• Big picture issue
• Evidence Based Interventions are necessary but not

sufficient for outcomes

• Bridging research and practice
• The Interactive Systems Framework (ISF)
• Readiness
• Evidence Based System for Innovation Support (EBSIS)
• Integrating Improvement and Implementation: Ghana case

study

SUMMARY

CONCLUSION

“An integration of systematic implementation with quality improvement approaches is likely to enhance the quality of healthcare delivery by increasing the ability of practitioners to improve as well as to implement well” – Wandersman, Alia, Cook and Ramaswamy (2015)