“Fit to stick”

Spreading effective interventio

healthcare

This PPT and other resources from This PPT and other resources from

http://public.me.com/johnovr

or h // id i https://www.idrive.com ‐ see references at e

John Øvretveit,

Director of Research, Professor of Health Innovation and 

3/13/2012 

Evaluation, Karolinska Institutet, Stockholm, Sweden
Outcomes – you are better ab

1)Describe what research shows about moving from project or guidelines....to Phase 2 limited spread (P1//P2 chasm) ...and be

yond 

2) Describe the missing research and methods...to hel

pp ( ) ractitioners 

(at all levels

)

....with research-informed guidance

• . 

3/13/2012
Outline

1 The problem

– Crossing the project/guideline-to-spread chasm

2 R h d id h l “ 2 Research and guidance to help “bridgers”3 Research needed

– Implementation science and spread to answ

questions

3/13/2012
The problem: we know more about what 

than about how to enable ordinary servicethan about how to enable ordinary service

• Proven effective treatments, practices & serv

mod l e s

– Slow and patchy uptake in services– Significant avoidable suffering and costs 

we know this because there is knowledge about howe know this because there is knowledge about ho

effective interventions into service The 
Research problems

• Knowledge about what works not know

by practitioners

• Under-developed methods for finding a

d l i ff ti i l t ti deve

lop

ing effective 

imp

lemen

t

ation an

approaches. 

• Not a research priority• A i d d d hi Att

itu

de an

d rewar

ds to researc

h

into 

implementation and spread

3/13/2012
Examples P1 //P2 c

Type 1: First local test of

 Findings - Low co

detection, allowed 

test ofAutomatic telephone 

fd i i

treatment, resultinadherence and les

assessment 

for 

depress

ion 

in db 

diabetes in one PHC 

 Presente

d

by team 

meeting with prom

 Rapid take Rapid take

-up in l

up in l

no spread beyond
Examples Ph1 //Ph2 

Type 2 One-site trialTi l l d

 Findings – Sam

comparison gro

Tr

i

a

l eva

luate

d

- Automatic telephone 

comparison gro

- more certa

assessment for depression P bli h din diabetes in one PHC 



P

ubli

s

h

e

d

 No one took an

- vs usual care in another 

PHC

 After research f

finished, no bu

for this system up 
Examples Ph1 //Ph2 

Type 3 Many-site trial

 Findings – addition

discrepancies betw

.

• 90 PCHs with 90 matched 

expert panel assessdepression

 But comparable red

• Automatic telephone 

assessment for depression in 

diabetes in 90 PHC

But comparable red

ultilisation (why?)

 Again, published diabetes in 90 PHC

..vs usual care in 90 PHC

 No one took any no After research fund

budget or time for sfollow-up 
These not real examples - characteris

wh t i ht h

a

t might b td e expec

t

e

d

Poll –

This fits with my experience and und t di f th lit t f ll 

ders

tandi

n

g o

f the litera

ture 

for all 

“types”

1Yes, 2 No, 3 Partial fi

t
What explains?

Type 1 First local test S d l ll

 Limited evidence, Spread locally

Automatic telephone assessment f d i i di b t i

Limited evidence,

But Enthusiasm and fre

for depression in diabetes in one 

PHC 

But not beyond

Enthusiasm and fre

by team.

 Low cost offer by t

But not beyondWhy not?

 Charismatic trio of 

nurse and social wo

 Sympathetic local l
What explains?

Type 2 One site trialSame findings but trial

 Stronger evid

Same findings, but trial  Practitioners 

scientific IT j

 No “push” by 

others. 

 No infrastruct

spread
What explains?

Type 3 Many site trial.

 Questions abo

and specificity 

• Same but in many PCHs

and specificity 

telephone asse

 No practitoner

it

N h f 

 No push, no fu
What explains?

Summary 

– Why the spread chasm?

Why do you expect auto

 Doubts about “wou

setting”?

 No infrastructure / 

- Why do you expect autospread for all proven or 

promising?

 No infrastructure /  No push,  The chasm between 

services

• Questions about sensitivity and 

specificity of telephone assessment?

à Might spread in 

infrastructure an

à No cross system 

• But no practitioners read about 

it anyway 

à No cross system 

 No funding
Real example of chasm from Guideline to Wid

• 1. Awareness of guideline• 2. Agreement with guideline• 3. Ad ti op on

– decide to follow guidelines for some patie

• 4. Adherence

– Follow guidelines guidelines at appropriate appropriate times for 

• Would concepts apply to patient’s tr

adherence?
From guidelines to patient benefit: “

. 12% agree/adopt gap 

20% / d t B t 20% agree

/

a

dop

t

B

e

ta 

Blockers 

4% hl t l 4

o

% c

h

oles

terol

8o% adopt 20% adhere chronic heart failure

3/13/2012 Why gap
John’s observations: from reviews and e

• Some things spread rapidly rapidly

– Clinician interest/patient demand (minim

surgery

)

– Compelling cost savings (automated testin

• Some slowly, in patches

– Support Support to prevent prevent admission admission of high use

• Some proven but very low uptake

–Do not spread straight from the “research 

• Some in spite of

–ve evidence 

Some in spite of ve evidence

– Smart IV pumps in ICU (Nuckols et al 2007
Research based theory – simple sum

Seed Gardener/planting & nurture Clim

Bridging implementers 1 Suppor

2 L l 

Their actions and plan 2 Local o

features s

3 Wider en

3/13/2012 Product Push> <P

3 Wider en
• Product Bridging the P1 / / P2 chasm

– F t f th b tt i t ti Fea

tures o

f the new 

b

etter 

i

n

tervention

– Comes with credible evidence of effectiveness

• Push

– Individual implementers and plan

• Pull

– Service experience a problem this can solve– It fits with values and “makes sense”– Services are ca

p pg g able of ado

ptin

g and sustainin

g it –r

– Environment not hostile, may be helpful

• Other factors for P2 to P3 60% services? Other factors for P2 to P3 60% services?
All bridges are local – but need support and 

environment – the 10

-20

-30

-40 princ

40 princ

• 10% of success is local personalities• 20% of success is using

a change proven else

improve quality and reduce costs

– – credible

& experience advice

• 30% is your implementation implementation (do you have sk

sk

team capacity, experience?)

• BUT 40

% is nothing nothing to do with you

‐

whether your context enables implementation and value improvements

3/13/2012
Second Bridge? The P2 / / P3 

• From a number of services (P2) to 70% 

or nati l i h 50% iona

l coverage w

i

t

h >50% ad i opt

io

intervention (P3)

• Which is most critical here? Vote for on

1)Product Yes/No?2)Push Yes/No

?

3)Pull Yes/No?

3/13/2012
Part 2: What help can research give to 

Bridgers”?

Role model “Evel

‐Knieval researcher

‐

entrepreneurs

” “don

’

t ta

k

e no

”

From pilot, across the chasm....to widespread adoption

Eric Coleman (Transitions)Peter Pronovost (CLABSI)

Lisa Rubenstein (Depression care in PHC)

Steve Asch (Chronic Heart Failure

, HIV AIDS)

Leaders important but not the only ingredientShould not depend only on unusual leaders
Part 2: What help can research give 

“Chasm-Bridgers”?

1 Research basedassessment tool – HRET2 Concepts ‐ Ways of

thinking about what and

how to spread

3 Categorisation of

implementation/spreadapproaches4 I l t ti mplementation science
1 Research based assessment to
Sections HRET Spread Assessm

• Innovation Factors• Target A dience A

udience Factors Factors

• Organizational Factors

• Environmental Factors

Spread Readiness Scale:

• 101

‐125 Or

ganic, Natural

Sprea

d

• 76

‐100 Promising Spread Initiative

• 51 – 75 Challenging Spread Initiative

• <50 Doomed, Focus on Underlying Underlying Issues

2011 Health Research

& Educational Trust Contact:SteveHinesatshines3@aha.org 
Research into implementation “app

Pro

gress so 

far...Conceptualisa

Are there different “approaches” and how do we def

Concepts 1: distinction between

a) Treatment and service delivery interventions

from (Product or content)

b) Implementation ‐ what done to enable providers t

• Note: distinction not useful when implementation 

iterative adaption ‐ testing

& revision of interventio

(intervention not already proven locally)
Example of intervention “product” or “

Eg CLABSI Bundle:1 W h as your h d an s.

2 Clean skin

with chl h d or exidine.

3. Use maximal barrier

precautions.

4. Avoid the femoral site.

5. Ask daily whether whether

the benefits of the line

exceed the risks.
Example of one “Implementation Ap

Breakthrough collaborative method eg MichigKeystone:

3/13/2012
Four elements necessary for intentiona

Illustrated Illustrated on a Collaborative Collaborative breakthrough breakthrough pr

pr

• Finance – to pay for the below. Pay for collab

Organisers Organisers, project project team time etc.

• Structure:

– Groups and accountability accountability 3 levels: levels: 1regional 1regional co

co

organisers, 2 local management, 3 local project 

• Systems:

– Project team measurement and feedback– Regional support

• Steps/methods

– Planning, learning sessions & calls, post‐collabo– To plan and change local service, test and revise
Implementation approach = The 

combination of:

1 Finance – sources (1 to start and, 2 re‐fsustain from savings or ops bd ) u get2 Structure:

– who is going to help this happen, and by w

responsibility, time, accountability accountability

3 Systems:

–measurement and feedback

4 Syste at c m i Steps:

–methods, actions = systematic ways to en
Is this conception of “intervention approach”

Structure, Systems, S / h d) Steps/methods) a theo

What do you think ‐ YES? No?Yes – based on observation observation of collaborative collaborative an

intentional systematic improvement programm

Predictive theory – untestedH1: Some implementation approaches are mor

some interventions than others 

3/13/2012
H1: Match intervention to implementatio

eg if aim to change individual physician pbehaviour, then this implementation approach may effective than a collaborative:• Finance: operations investment and support

• Structure: nationally credible researchers, local phy

leaders and champions, peer project teams, academ

• Systems: credible existing data banks on prescribin

of relating to units or physicians for feedback or pa

• Systematic steps: training, feedback, academic deta

3/13/2012
Different approach if implementing 

d ii ec s on support system within an 

• Finance: operations investment and support• Structure: project team, user steering comm

management sub‐group

• Systems: Project management, EMR capable 

CDS, updating content of CDS

• Systematic steps: Methods: phased testing, 

standard screens, etc

If implementing a chronic care implementing a chronic care model or falls p

model or falls p

then.... 
H2 : Context match to both interven

implementation approach

• Is there a Is there a “fit”, and is it and is it “fit to stick fit to stick”• Internal context: 

Advances values, norms, objectives, & 

• Et l t t External context:

–Comp g, 

atible with regulations, financin

directives

3/13/2012
Conclusions

1 “Not fit to implement implement, because because innovation innovation n

• John argued for testing through spreading, once pr

concept

2 For it to be implemented implemented and sustained sustained it ha

context

• intervention intervention will be rejected rejected by local and ext

ext

environment, unless these changed.

The GIP guide: “Goldilocks Goldilocks Implementation Implementation Pr

Pr

improvement has to be different, but not too‐

be implemented,‐ unless major push, and changes to pull 
Part 3 Research Agenda and Meth

Implementation science Implementation science

Covers 4 subjects:1. Why implementation research is i2. Practitioners have questions we a

addressin

g

3. Methods for providing research b

answers

4

. What are the challenges for us What are the challenges for us

3/13/2012
.

Why implementation infrastructure neededDo current current channels channels work? – professions professions limit

limit

regulation more, financial penalties and rewa

still.C t oncep s 3:

• Specific intervention implementation infrast

time limited collaborative for X)

• Generic implementation infrastructure : to s

project and continual change

• (eg IMC research research unit, KP performance performance impr

impr

units, VA systems design and some QUERI ce

3/13/2012
Knowledge Translation to everyday clinical prac

K Basic

BioMedicalScience K Efficacy

In controlled

K Treatment

Effectiveness

range of patients

Translation 1Intervention to

In controlled

situation with

specific patients

range of patients

Intervention to Translation 2

patients

RCTs on patients

Translation 2Intervention to range

of patients in

different settings

K ImEffec

different settings provid

RCTs or controlled trials on

patients Translatio

Intervent

provid

Intervent

providers 

treatmen

RCTs or cont

Where is most research focused?

providersNon‐experim

designs Would more research on T3 pay back?
“Implementation” defined bro

Steps in implementation pathway: intermediate outcomes

% imm

.50% of services decide to adopt 5

50% of clinicians in this service prescribe appropriately (accept adopt)

2

appropriately (accept, adopt)50% patients collect prescription and start 150% adhere correctl

y 6

50% actually benefit 3After 6 months adhere and benefit After

6 months adhere and benefit 1

After 2 years? Likely impact on stroke and heart attack

?

3/13/2012 

Likely impact on stroke and heart attack

?

(Based on Glasgow 2010)
Why implementation research is im

If you were a social venture capitalist with 100If you were a social venture capitalist with 100

you put it in better drug treatment research 

...or implementation research? or implementation research?• Knowledge about effective interventions to 

pati d ii ents and organisations

...could help others implement proven be

practices or delivery models

• The p p ,

otential of implementation research, a

showing in some projects

What are the questions this research needs to aWhat are the questions this research needs to a
Descision‐makers/implementers qu

• How certain does the evidence of effectivene

certain does the evidence of effectivene

be before spread? (internal validity). Too ear

• L l oca appli bilit cability (t l ex ernal validit ) y pati t 

ents

– What do we have to do to copy this? (research d

• Time and money costs, and savings?• Can research research help spread proven interventio

interventio

• Test interventions locally?

= Build scientific knowledge of implementatiospread not just efficacy efficacy

3/13/2012
Practitioners want this inform

• Description: What was the implementation a

: What was the implementation a

(and the intervention content)

• C t ff ti Did it Cost effectiveness: Did it achieve th h 

e c ange 

effectively?

(and did the intervention change then reduce costs difference for patients?)

• Replicability: in which situations would we e

similar results? 

....and which principles should guide design oimplementation approach in other situations?

3/13/2012
Three research strategies

1 P ll l arall

e

l process and t ou

tcomeeffectiveness evaluations

2 Theory 2 Theory

-based testing or model based testing or model

-r

r

3 Integrated research research

‐implementa

implementa

evaluationSee March 8 See March

8th Cyber seminar Cyber seminar

3/13/2012
One research agenda 

1 Describe Describe different different successful successful and unsuccessful unsuccessful spre

spre

• using the spread approach framework: finance, str

s

ystems and ste

p /s

/actions

• Is there

a local to national spread chasm P2

> P3 a

2 Test hypothesis hypothesis different different categories categories of intervention

intervention

different spread strategies to be successful

Possible categories

• Provider Provider behaviour behaviour change (care practice) practice) (simple (simple 

• Service delivery model

• ICT intervention intervention in

a service service

• Method intervention 

3/13/2012
Summary

“Performance gap can be narrowed by implknowledge about effective treatments and cmodels”

• Uncertainties: cost‐effectiveness and reproducibility• Constrained by lack of research informed guidance a

implementation.

• Cost of operating operating new model is one thing – cost of im

im

is another – when is payback and for whom?

• Research on implementation and spread, if informed 

give guidance for decision‐makers

• Use theory suited to intervention and research users 

•

3/13/2012
Research Challenges

Attitude – practical questions not real science and wopublished 

– can’t serve two masters

Academic promotion and reviewersSkills to use the methods Skills to use the methodsNew research practice 

Practice based Practice based

– engaged partnership research engaged partnership research

Financing Shif f fi i d i b i Shift o

f financ

ing an

d rev

iewers to 

be more accept

ing

Do we have the skills and will to innovate? 

3/13/2012
“approaches”

& issues in “transfer” to other setting ( 

external 

Why 

• Actionable research,y 

 wanted by decision mak

significantly reduce patient suffering and cos

• Final frontier of Final frontier of the “translation pipeline translation pipeline , ” le

understood, and where non-experimental me

better match to questions. better match to questions.

• Exciting rapidly developing field with innov

research methods research methods – join the pioneers on the f

join the pioneers on the f

3/13/2012
Resources on Johns web site f

• http:// / public.me.com

/johnovr

• Or

Download files from idrive by going to web sithttp://www idrive com/; http://www.idrive.com/;

• Log in user

= jovr pass= anna. THEN use the 

on the right to enter in

a word realated to th

You will see files on this subject – click on th

want to download, after entering anna an

download to your computer.

3/13/2012
Conclusions

1. Main points...2. Thi i i f his was new or surprising, for me...3. The most useful idea for my work was...4. What I would like to find out more abou3/13/2012 
Recommended spread research refere

“presenters notes” view on PPT b“presenters notes” view on PPT b

Richard Della Penna1, Helene Martel2, Esther

B Neuwirth*2, J

Marta I Filipski2, Jennifer Green4 and Jim Bellows2 Rapid spre

change:

a case study in inpatient palliative care BMC Health S

Research 2009, 9:245

Greenhalgh,

T Robert,

G Bate

P Kyriakidou O Macfarlane

F Ho

Good Ideas:

A

s

ystematic review of the literature on diffusion, 

and sustainability of innovations in health service delivery and London: UK National Co

‐ordinating Centre for NHS Service De

Organisation, 2004.

Nolan K, Schall MW, Erb F, Nolan T. Using

a framework for spre

patient access in the Veterans Health Administration. Jt Comm 

Saf. 2005 Jun;31(6):339

‐47.

3/13/2012
Recommended spread references – 

research

-based guidance based guidance

• Supporting Spread: Lessons from the California Improvement Network 2011 w

Supporting Spread: Lessons from the California Improvement Network 2011 www

McCannon C.J., Schall M.W., Perla R.J.: Planning for Scale:

A Guide for Designing La

Improvement Initiatives. IHI Innovation Series white paper. Cambridge, MA: Institu

Improvement, 2008. http://www.ihi.org/IHI/Results/WhitePapers/PlanningforScal

accessed Mar. 26, 2009).

Massoud M.R., et al.:

A Framework for Spread: From Local Improvements to System

Innovation Series white paper. Institute for Healthcare Improvement; 2006.

http:// http://www.ihi.org www.ihi.org/IHI/Results/ /IHI/Results/ WhitePapers WhitePapers

/ AFrameworkforSpreadWhitePaper.

AFrameworkforSpreadWhitePaper.

26, 2009).

Pryor D.B., et al.: The clinical transformation of Ascension Health: Eliminating all p

deaths. Jt Comm J Qual Patient Saf 32:299–308, Jun. 2006.

Brach C, Lenfestey N, Roussel A, Amoozegar J, Sorensen A. Will It Work Here?

A De

to Adopting Innovations. Prepared by RTI International under Contract No. 233‐02Healthcare Research and Quality (AHRQ) Publication No. 08‐0051. Rockville, MD: A

2008.

3/13/2012
3/13/2012
Different ways of classifying the 3) Systematic Ste

• Professional; Financial strategies; strategies; Organizati

Organizati

strategies. Or guidelines (Hysong 2011)

3/13/2012
Concepts : Alignment of context inf

• Infrastructure may involve “influenc

which act from and on different different lev

health system

• to get the influences at each level to 

Eg for CLABSI or readmission readmission

• Need “alignment adjusters” to identify influe

countering countering X change and to “sheep dog” the 

• Theory: aligned actions by different levels m

effective effective (but feasible?) feasible?) (context (context to help

implementation) 

3/13/2012
Question: You are a social venture ca

You have $100m for cardiovascular cardiovascular 

Will it do more good for patients if used to deeffective implementation

o

f

known

effective

cardiovascular treatments,

...or to d l eve op more

effective treatments

?

• New treatments? Yes?• Effective implementation? (including patient

adherence!) Yes

• If providers use known effective CV treatme

more, will this do more good than 10% more 

CV

drug

th ? erapy

? N ?o

? Y ? es

?
Simmons & Shiffman 2006 “Elements of scaling‐up” fr

3/13/2012 
3/13/2012 
3/13/2012 
.

• Research methods technology develope

hammer

• Does not work on screws Does not work on screws

• Can you invent a screwdriver to meet ne• Will doing so pay off?• N b ill Not now, but soon will

3/13/2012
Is your intervention intervention a CSI

Multiple actions• By different actors

• At different times

In a changing environment/context• With impacts which act back on the actionsA tc ors it t n erpret the i t ti n ervention conceptActors influence to change actions by feedbac

others experience

Implementation affected by power groups & h

interpret the intervention or actions

3/13/2012