Precision Tailoring of Implementation Strategies Predrag Pedja - - PowerPoint PPT Presentation

Precision Tailoring of Implementation Strategies

Predrag “Pedja” Klasnja Kaiser Permanente Washington Health Research Institute

How do we do better?

Implementation Strategy Optimization Goals

Develop blended strategies that only contain component strategies…

• That are likely to be effective for prioritized determinants
• For which all key preconditions are present
• That interact synergistically

Implementation Strategy Optimization Goals

Develop blended strategies that only contain component strategies…

• That are likely to be effective for prioritized determinants
• For which all key preconditions are present
• That interact synergistically

Causal Pathway Diagramming

Distal Outcomes

Implementation outcomes that the implementation effort, as a whole, is intended to influence. Distal outcome: high level of therapist use of CBT techniques (organizational level outcome)

Use of CBT

Target Determinants

Factors that prior work has identified as having an influence on desired distal outcomes

• Key targets for change by implementation strategies
• Each strategy should target at least one prioritized determinant

Example determinants:

• Participation in EBP initiatives

(individual level)

• Proficient culture (org level)

Use of CBT High participation in EBP initiatives

Candidate Strategy

A strategy being considered for inclusion in a blended package that we think—based on theory, prior work, etc.—might be effective at influencing a prioritized determinant Example : incentives for participation in EBP initiatives (org. level)

Use of CBT Higher participation in EBP initiatives Incentives for participation in EBP initiatives

Mechanism

Process through which the candidate strategy is hypothesized to affect its target determinant

• What steps need to take place for the strategy to influence the

determinant?

• How quickly/slowly would this process work?
• Is the mechanism likely to have a strong enough effect on the

determinant to make the use of strategy clinically meaningful? Example mechanism: operant conditioning / positive reinforcement (individual level)

Preconditions

Factors that are necessary (but possibly not sufficient) conditions for the strategy to work via postulated mechanism

• Can function at different levels (cognitive, organizational, etc.)
• Can vary from site to site

Examples:

• EBP initiatives are available for clinicians to attend (org level, broader

clinical environment)

• Incentives allowed in the organization (org level)
• EBP initiative participation can be monitored to enable incentive

disbursement (technological level)

Use of CBT Higher participation in EBP initiatives Incentives for participation in EBP initiatives Positive reinforcement EBP initiatives available for attending (…)

Proximal Outcomes

Observable, measurable, short-term changes that indicate that the strategy is having an impact

• Should be in the causal path to the target determinant
• Should provide evidence on the hypothesized mechanism

Example proximal outcome: registration for the next EBP initiative within 30 days of incentive payout (individual level)

Use of CBT Higher participation in EBP initiatives Incentives for participation in EBP initiatives Positive reinforcement EBP initiatives available for attending (…) EBP initiative registration

Effect moderators

Factors that can strengthen or diminish the effect of the strategy on its downstream outcomes. Moderators…

• May vary across individuals and/or sites
• Can help explain heterogeneity in outcomes
• Can guide strategy design

Example moderators:

• Perceived value of the incentive (cognitive [individual] level)
• Immediacy of incentive payout (technological/organizational level)
• Reinforcement schedule (strategy design)

Use of CBT Higher participation in EBP initiatives Incentives for participation in EBP initiatives Positive reinforcement EBP initiatives available for attending (…) EBP initiative registration Incentive Immediacy Perceived value

Other Considerations

• A single strategy may influence multiple determinants
• A single strategy may work through multiple mechanisms
• A single determinant may get influenced by multiple strategies (look

for synergies)

• incentives for EBP initiative participation may signal that proficiency is valued

(proficiency culture)

• Things can break in several places along the causal path. Proximal
• utcomes can help figure out where the process went wrong

Summary

Causal pathway diagrams can…

• Help articulate how an implementation strategy is thought to

influence its target determinants

• Act as checks on feasibility and likely magnitude of this influence
• Ensure that all necessary conditions for a strategy’s functioning are

present in the current clinical setting

• Point to important factors that should be addressed in strategy design
• Indicate constructs that should be measured to explain how well the

strategy worked (or didn’t work)