Applying Multiple Frameworks and Theories in Implementation Research(Part 2)

Jeffrey Smith

Implementation Research Coordinator

Mental Health QUERI

Outline
        - Review major points on multiple theory approach from April 14  cyberseminar   
        - Provide example of application of multiple theory approach in MH QUERI project

Mental Health QUERI Approach to Implementation
        - Design interventions based on theory, lit review and results from formative evaluation  
        - Conduct formative evaluation

engage with stakeholders

identify determinants of current practice

assess barriers and facilitators to implementation

organizational-level

team / clinic-level

individual provider-level

patient-level

tailor intervention design and implementation to local context

there is a need, after a translation study, to have gained an understanding of the implementation efforts, potential causal events leading to change, and suggestive evidence re: the specific translation components and processes that appeared to most influence success. (adaptation of Altman)

Note:  this note is from the slide presentation by Cheryl Stetler to QUERI Translation Coordinators, February 2003

Mental Health QUERI Approach to Implementation (cont)
        - Use external facilitation techniques (PARiHS Framework)

engage with stakeholders to problem-solve and identify new strategies or tools for overcoming barriers when initial success is sub-optimal
        - Conduct summative (or impact) evaluation

assess intervention effects on targeted clinical processes and/or patient outcomes

there is a need, after a translation study, to have gained an understanding of the implementation efforts, potential causal events leading to change, and suggestive evidence re: the specific translation components and processes that appeared to most influence success. (adaptation of Altman)

Note:  this note is from the slide presentation by Cheryl Stetler to QUERI Translation Coordinators, February 2003

Multiple Theory Approach 
        -  Application of multiple frameworks/theories in   guiding intervention design and implementation can   be successful in implementing EBPs
        -  accommodates tailoring to setting when combined with formative evaluation  
        -  acknowledges there are generally multi-level determinants to complex, clinical QI issues
        -  organizational-level
        -  team-level
        -  interpersonal-level
        -  individual-level

Antipsychotic Treatment Improvement Program (ATIP)
        - Goals

Improve adherence to CPGs for antipsychotic treatment of psychosis

Reduce use of very high doses of antipsychotic medications

Encourage use of newer “atypical” antipsychotic medications for non-responders to conventional antipsychotic medications

ATIP Application of Frameworks, Theory and Planning Models
        - Diffusion of Innovation (Rogers), Social Cognitive Theory (Bandura), Social Influence Theory (Mittman) 

Utilize influential local clinician leaders (opinion leaders) to inform other clinical staff about evidence-based antipsychotic medication management, model-targeted prescribing behaviors, and motivate practice change
        - Complexity Theory

Initial conditions in HCOs are important in intervention planning, but HCOs are adaptive and change over time

Need mechanism for assisting clinical partners in modifying or adapting initial intervention strategy based on changing circumstances, initial success

ATIP Application of Frameworks, Theory and Planning Models (cont)
        - Promoting Action Research Implementation in Health Services (PARiHS)

Use external facilitation techniques to enable and assist clinical opinion leader with problem-solving; address challenges to intervention implementation
        - PRECEDE Planning Model   (Predisposing, Reinforcing, and Enabling Constructs   in Education Diagnosis and Evaluation)

Address predisposing factors (eg, knowledge, attitudes) that influence EBP adoption

Enable providers to follow guideline recommendations at the point of care

Apply social incentives through performance audit/feedback to reinforce providers’ implementation of EBPs

“Refined” Description of Facilitation Based on VA QUERI Experience*

Facilitation is a process of interactive problem-solving and support to meet specific implementation goals, which occurs in the context of a recognized need for improvement and a supportive interpersonal relationship.

* Stetler CB, et al. Implementation Science 2006; 1:23.

Operationalization of External Facilitation in MH QUERI (based on PARiHS)
        - Facilitator

Maintains regular contact w/ local QI leader / team

Email communication

Telephone

Participate in QI Team meetings (as feasible)

Assist in goal-setting; monitor implementation of project tools/strategies; performance on clinical QI goals

Identify and problem-solve barriers to implementation

Assist in adapting tools/strategies as needed or suggested by site partners to meet project goals

ATIP Intervention Components
| Intervention Component                                                              | Supporting Theory or Planning Model                                       |
|-------------------------------------------------------------------------------------|---------------------------------------------------------------------------|
| Clinical Opinion Leader                                                             | Diffusion of Innovation, Social Cognitive Theory, Social Influence Theory |
| External Facilitation                                                               | PARiHS, Complexity Theory                                                 |
| Psychosis Guidelines Help File                                                      | PRECEDE (predisposing)                                                    |
| Pocket Card on Antipsychotic Treatment                                              | PRECEDE (enabling)                                                        |
| Pharmacy Order-Entry Reminder on Antipsychotic Dose Recommendations                 | PRECEDE (enabling)                                                        |
| Clinical Reminder on Metabolic Side Effects Associated with Olanzapine              | PRECEDE (enabling)                                                        |
| Audit/Feedback Performance Reports on Antipsychotic Dosing / Side Effect Monitoring | PRECEDE (reinforcing)                                                     |

Summative Evaluation
        - ATIP intervention improved antipsychotic medication management in concordance with CPGs (results varied by site)  
        - Reduced pharmacy costs for antipsychotics (results varied by site)  
        - Participating clinicians reported positive experiences with ATIP educational materials and clinical support tools

An Approach to Using Theory for Implementation Planning

Select theory of planned behaviorchange

Assess fit with initial theory

Identify potential strategies for achieving change

Select interventionsthat fit with plannedstrategies (based on theory)

Identify interventiontools that fit bothstrategy and theory

Launch interventionusing identified toolsand strategies

Evaluate effectivenessof intervention,strategies, tools

From: Sales A, Smith JL, Curran G, Kochevar L. Models, strategies and tools: The role of theory in implementing evidence-based findings into health care practice.  Journal of General Internal Medicine 2006; 21:S43-49. 

Formative Evaluation: Barriers and Lessons Learned
        - Physicians do not always agree on who is an opinion leader; some sites may have no opinion leader  
        - Some sites had poorly developed formal and   informal social networks among physicians  
        - A focus on physicians only as agents of change  
        - How much directive should be given to the opinion leaders on how to influence attitudes and behaviors? 
        - Audit/feedback reports need to be more actionable

From: Curran GM, Thrush CR, Smith JL, et al. Jt Commission J Qual Safety 2005; 31(12):700-707.

Multiple Theory Approach 

Strengths
        -  useful in designing multifaceted interventions to influence   multi-level determinants of care (flexible)
        -  allows integration of theory, knowledge, methods from multiple   disciplines (multidisciplinary)

Limitation
        -  Can be unwieldy... need to provide rationale for applying multiple   theory approach, and rationale for selecting the specific frameworks / theories applied

Key Guidance on Evaluation
        -  combine with rigorous formative evaluation
        -  conduct summative (impact) evaluation to assess intervention effectiveness on key study outcomes
        -  confirm, refute or propose refinements to selected theory (or applied strategy based on selected theory) based on study findings

QUESTIONS?

Contact:  

Jeff Smith 

VA Mental Health QUERI

E-mail: Jeffrey.Smith6@va.gov

Developmental
        -  Identify determinants of current practice
        -  Identify potential barriers / facilitators
        -  Assess feasibility of proposed intervention
        -  Integrate findings into intervention design and refinement prior to implementation

Implementation-Focused
        -  Assess discrepancies between implementation plan and execution, exploring issues of fidelity, intensity, exposure
        -  Understand and document nature and implications of local adaptation

Progress-Focused
        -  Monitor impacts and indicators of progress toward project goals
        -  Use data to inform need for modifying or refining original strategy
        -  Provide positive reinforcement to high performers; negative reinforcement to low performers

Interpretive
        -  Assess intervention usefulness/value from stakeholder perspective
        -  Elicit stakeholder recommendations for further intervention refinements 
        - Assess satisfaction with intervention and implementation process 
        -  Identify additional barriers / facilitators

Stages of Formative Evaluation

Post-Implementation

Pre-Implementation

Implementation