The Implementation of Evi

Based Practices: Applying a 

Commitment Framewo

Ann F. Chou, PhD, MPH, MA1,2,3

Thomas Vaughn, PhD

4

Kimberly McCoy, MS

5

Bradley Doebbeling, MD, MSc5,6

1College of Public Health & College of Medicine, University of Okla

of Excellence, VA Greater Los Angeles Healthcare System; 3 VAMC

City; 

4College of Public Health, University of Iowa; 5 Roudebush VA

Indianapolis; 

6School of Medicine, Indiana University
Evidence-based Practic

 Evidence-based practice:

 integrates clinical expertise with bes

available evidence from systematic rto make decisions concerning patien

 may be promoted using clinical prac

guidelines, defining standards of car
What is implementation

What is implementation

 The study of methods to prom

systematic uptake and consistenintegration of research findings evidence-based practices into ropractice. 
Barriers to Implementati

 Consistent delivery of guideline-ind

care remains a challenge:

 Lack of organizational support and r Provider resistance Lack of understanding of the implem

process
Why We Need Theory Why We Need Theory

 The implementation process is 

infrequently driven by theoreticaconstructs.

 Theories may help identify indiv

characteristics and organizationaconditions that facilitate effectivimplementation. 
Study Objectives

 Using VA’s roll-out of the Major Dep

Disorders Guidelines as an example, aims to: 

1. Test a theoretical framework that 

factors facilitating guideline implementation; 

2. Understand the effects of the int

implementation outcomes on propractice.
Major Depressive Disorder Scr

Major Depressive Disorder Scr

Guideline Guideline

 An initial screening for Major An initial screening for Major 

Depressive Disorder should be Depressive Disorder should be conducted annually for all prima

conducted annually for all prima

patients except those currently b

patients except those currently b

treated for depression. treated for depression.
Identifying a Framewor

Identifying a Framewor

 Goal setting and task performance: Goal setting and task performance:

 Assign specific goals that organizatio

Assign specific goals that organizatio

participants can meet and accept participants can meet and accept

 Involve all participants in defining go

Involve all participants in defining go

determining strategies to implement determining strategies to implement

 Provide feedback concerning goal att

Provide feedback concerning goal att

on both individual and organizationa

on both individual and organizationa
Conceptual Framework

Interactive Factor• Participation 

Externa• Team • Feedba

Internal factors• Expectancy• Self-efficacy 

Performance of Clinical Practice

Goal Commitment/Implementation outcomes:

Agreement with guidelineAdherence to guideline recommendations

Improved knowledge of evidence supporting best practiceDelivery of best practices

Cognitive 

Processing
Hypotheses 1: Implementa

Interactive Factor

H1: Participation 

Goal Commitment/Implementation outcom

Agreement with guidelineAdherence to guideline recommendations

Improved knowledge of evidence supporting best prDelivery of best practices

+
Hypotheses 2 and 3: Impleme

External factorsH2: Team H3: Feedback

+

Goal Commitment/Implementation outcom

Agreement with guidelineAdherence to guideline recommendations

Improved knowledge of evidence supporting best pDelivery of best practices
Hypotheses 4 and 5: Implemen

Internal factors

H4: Expectancy

H5: Self-efficacy

+

Goal Commitment/Implementation outcom

Agreement with guidelineAdherence to guideline recommendations

Improved knowledge of evidence supporting best pDelivery of best practices
Hypothesis 6: Performan

Hypothesis 6: Performan

Performance of Clinical 

Practice

+

Goal Commitment/Implementation outcom

Agreement with guidelineAdherence to guideline recommendations

Improved knowledge of evidence supporting best Delivery of best practices
Data Source: Provider Le

 Determinants of Clinical Practice G

Implementation Effectiveness Study

 Primary data collected to assess provider e

work conditions, attitudes and experience guideline implementation, culture, quality improvement efforts
Data Sources: Organizational 

 External Peer Review Program (

 Review of clinical records on achievin

depression screening for eligible patie

 American Hospital Association 

Annual Survey

 Hospital characteristics including size

Hospital characteristics including size

teaching status, rural/urban location teaching status, rural/urban location 
VA’s Quality Enhancement Re

Initiative (QUERI)

 The VA has recognized the adoption a

The VA has recognized the adoption a

implementation of evidence implementation of evidence

-based pra

based pra

its medical centers as an area for impro

its medical centers as an area for impro

 An example is QUERI, with the An example is QUERI, with the Missi

Miss

“enhance the quality and outcomes of 

enhance the quality and outcomes of 

health care by systematically implemen

health care by systematically implemen

clinical research findings and evidence clinical research findings and evidence

recommendations into routine clinical recommendations into routine clinical practice. practice.

”
QUERI

 It is a partnership of health serv

It is a partnership of health serv

researchers and clinical manager

researchers and clinical manager

 QUERI provides a unique oppo

QUERI provides a unique oppo

to understand guideline to understand guideline implementation. implementation.
Sampling Sampling

 Survey Recruitment

 National sample of VA providers from 1

hospitals, stratified by provider type (phynurse, nurse practitioners, physician assis

 Sample

 N= 2,438 VA providers Response rate= 58%
Sample Demographics

 Gender: 61.8% male Age: 47.8% over age 50 Professional Training:

 Physicians: 37.8% Nurse Practitioners: 13.0%  Nurses: 37.9% Physician Assistants: 6.7% Other: 6.1%
Methods: Understanding 

Implementation Proces

 Hierarchical Generalized Line

Hierarchical Generalized Line

Model (HGLM): Model (HGLM):

 Implementation Implementation outcome outcomex = f (exte

(exte

factors, internal factors, interactive 

factors, internal factors, interactive 

control) control)
Variable Construction Variable Construction

2

Very 

little

You adhere to the 

1

3

recommendations

Not at Some G

all

With regard to the Major Depressive Disorder gurecommendations, please indicate to what extent
Implementation Outcome Var

Implementation Outcome Var

 Agreement with guideline 

recommendations

 Adherence to guideline 

recommendations

 Improved knowledge of eviden

supporting best practices

 Delivery of best practices
Measures Measures

 Interactive Factor

 Clinicians have inp

guideline impleme

 Provider involvem

quality of care imp

 Culture emphasize

participative decisimaking

Interactive FactorH1: Participation
Measures 

 External Factor

 Providers receive 

individualized feedperformance

 Providers receive f

on organizational gadherence

 Team work exists f

guideline implemen

 Inter-departmental 

coordination

External factorsH2: TeamH3: Feedback
Measures Measures

 Internal Factors

 Providers believe 

improves perform

 Frequency of per

data distribution

 Access to 

information/literpoint of care

Internal factorsH4: ExpectancyH5: Self-efficacy 
Control Variables Control Variables

 Provider demographics Provider demographics 

 Age Gender

 Provider practice Provider practice 

 Years in practice Years in practice  Type of provider (physician, nurse Type of provider (physician, nurse 

practitioners, nurses, physician assista

practitioners, nurses, physician assista
Methods: Effects of Implemen

on Practice

 HGLM:

 Clinical performance = Clinical performance = f (4 intermed

(4 interme

implementation outcomes, control) implementation outcomes, control)
Measures Measures

 Dependent Variable: Achieving an 85

greater rate of appropriate depression sin eligible patients 

 Independent Variables: 

 Agreement with guideline implementati Guideline adherence Improved knowledge in best practices Delivery of best practice
Control Variables Control Variables

 Provider Level:

 Provider gender Number of years in practice

 Hospital Level:

 Bed size Teaching status of facility Urban location
Results: Interactive Fact

Intermediate Implementation Ou

Involved in improving 1.19 1.47** 1.65*** quality of careParticipative culture 1.19 0.92 1.18 Provider have input into 1.44* 1.84*** 1.50* guideline implementation

Improved 

knowledge

Guideline 

Adherence

Agreement 

with 

Guideline

**** p

≤0.0001 ***p

≤0.005 **p

≤0.01 *p

≤0.05 †p

≤0.10
Results: External Facto

Intermediate Implementation Ou

Team work in 2.02**** 1.30 1.92*** implementationInter-departmental 0.95 1.11 1.01 coordinationReceipt of feedback on 0.93 0.96 0.93 organizational adherence 

Agreement 

with 

Guideline

Receipt of individualized 1.21 1.37

* 1.34† 

feedback 

Improved 

knowledge

Guideline 

Adherence

**** p

≤0.0001 ***p

≤0.005 **p

≤0.01 *p

≤0.05 †p

≤0.10
Results: Internal Facto

Intermediate Implementation Ou

Self-efficacyExpectancy Frequency of performance 1.15*** 1.25  1.17** * data distributionReady access to 1.32* 1.11 1.14 information Feedback affects 1. 59*** 1.45* 1.52* performance

Improved 

knowledg

Guideline 

Adherence

Agreement 

with 

Guideline

**** p

≤0.0001 ***p

≤0.005 **p

≤0.01 *p

≤0.05 †p

≤0.10
Results: Performance

Guideline Adherence 1.7Guideline implementation enhanced delivery of 0.9best practiceGuideline implementation improved knowledge 1.0Agreement with Guideline implementation 0.8

Dependent 

≥85 % S

(O

Intermediate Implementation 

Outcomes

**** p

≤0.0001 ***p

≤0.005 **p

≤0.01 *p

≤0.05
Summary of Findings

H4: Expectancy of Success SuppoH5: Self-efficacy SuppoH2: Teamwork Partially SH6: Guideline implementation enhanced Partially Sdelivery of best practiceH3: Feedback Partially SH1: Participation Suppo

Hypothesis Hypothe
Conclusion

 Goal commitment framework can b

in understanding factors that facilitaimplementation and use of depressiguidelines. 

 Participation, performance feedback

teamwork, expectancy, and self efficto greater goal commitment, facilitaimplementation process.
Limitations

 Self-reported performance Lack of data to adjust for patient 

characteristics and utilization

 Single-operational measures as pro

for self-efficacy and expectancy

 Cross sectional data
Implications

 Understanding mechanisms through which 

improved implementation and care deliveroutcomes are achieved is important.

 This framework may be generalizable to o

settings and useful to study the implementother care models/innovations. 

 Instituting systems/programs to facilitate 

appropriate performance feedback and proparticipation in decision-making should enorganizational change and learning. 
Acknowledgements Acknowledgements

 Funded by the VA Health Servic

Research and Development QUEinitiative #CPI99-126 and CPI01

 The Veterans Research and Educ

Foundation of the Oklahoma Cit
Thank You Thank You

 Contact Information: 

Ann F. ChouEmail: ann-chou@ouhsc.eduTelephone: 405-271-2115 ext 4