THEORY AND IMPLEMENTA

INTERVENTION PLANNIN

Teresa M. Damush, Ph.D.

Imp e e tat o lementation Resea cr h Coo d at

r inat

VA Stroke QUERI Center

HSRD COE, Roudebush Roudebush VAMC, Indianapo

Indianapo

Laura Damschroder, MS, MPH, Christian H

Ph.D., Cheryl Stetler, Stetler, RN, Ph.D.
Audience Poll Question

• What exposure have you had to the

presentation for today?

– Attended the EIS training last July in Den– Listened Listened to the presentation presentation online– Reviewed only the slides online– This will be my first time hearing about i
Audience Poll Question

• Have you ever adapted or tailored an

intervention?

– Yes– No
Audience Poll Question

• How confident do you feel about cond

theory‐based implementation study?

– Not at all confident– Somewhat confident– Moderately Confident– Very confident– I’m ready to dive in!
Conducting Theory‐based

Implementation

Assess targeted 

EBP change and 

context

Select targeted 

theory(s) & provide 

rationale

Dev

imp

co te t 

A fit f

at o a e 

Assess fit of

findings with 

initial theory

Evaluate effectiveness Exe

imp

of implementation,

strategy

Adapted from: Sales A, Smith J, Curran G, Kochevar L: Models, strategies, and tools. Theory in implebased findings into health care practice. J Gen Intern Med 2006, 21 Suppl 2:S43-49.
Using Theory to Plan Implemen

Intervention

• There are no right or wrong theories

• There are better fitting fitting theories/mod

theories/mod

explain why a specific strategy or mec

causes the intended intended change

• The implementation strategy(s) may b

operationalized from the theoretical c

• To apply the better fitting fitting theory, you 

’ 

specify several key issues.

Note: Operational definition= a clear, concise detailed definition of a con

and actionable components so that all have the same understanding of h

practice and collect it or determine whether its correct or not.
What are the change object

object

• (1. Assess targeted EBP change and co• Implementation strategies attempt to 

the cause of the performance gap or s

failures

• What is expected to change in the

organization organization as a result of the interven

interven

• What are the persons in the organizat

expect de to learn or do as a result of t

intervention?
Who are the targets? targets?

(1. Assess targeted EBP change and context)Subgroups may require d ff i erent implementation strat• Front line clinicians engaged in specific task

– One group

– Interdisciplinary group – does strategy need to d

discipline?

• M li l u t p e Targets

– System

– Clinical Providers

– Patients

• Sublevels

– Groups of patients with specific characte
What is the Context/Nature o

Evidence Based Practice (EB

• (1. Assess t td arge ed EBP change and cont t) ex• tPA (tissue Plasminogen Activator) is a therap

a stroke patient patient within 3 hours of the acute s

event. A VA facility’s ability to administer ma

on its infrastructure.

• Hospital service infrastructure varies by

– ED capabilities– Access to neurol it og s 24/7– Knowledgeable and Prepared staff– Organization Organization policy – treat or transfer transfer– Stroke Service unit/Certified Stroke Center

– General medicine service
What is the mechanism/strate

which you expect the change to 

How do you expect to get fromCURRENT EBPPRACTICE I• Where are you now?• Where do you want to be?• Potential Barriers to change?• Possible facilitators to Change?

I 

=HOW to get to desired outcomes, EBP
LITERATURE REVIEW

• What do you know from the literature 

this change mechanism?

• What if any theories have been emplo

this type of change?

• Consider the strength of this evidence• What have others interested interested in this

mechanism/strategy previously used?

• How well has this mechanism/strategy

produced change?
(2) Select Targeted Targeted Theo

• Pre‐Implementation work may be part o

planning theory (e.g. PRECEDE/PROCEED 

• From our pre‐implementation work, we 

identify identify actionable actionable factors factors to target in th

intervention to evoke the planned chang

• R i ev ew the possible th i eor es and th i e r co

components

• What theory(s) best represents this mec

for change?
(2) Select targeted targeted theor

• Theory is applied to the components o

implementation intervention

• Identify potential determinants of beh

resistance resistance – Why do people behave as

observed in this setting?

• What intervention could effect desira

change?

Sales et al Models, Strategies, Tools, JGIM 2006 21:S43‐46
Providing Rationale for Select

Theory

• RATIONALE = Justification for selection 

operational definition of the concept as 

to your specific implementation progra

BehaviorDeterminant

Theory/Model

ImplementationProgramComponent

Rationale

PhysicianBehaviorChange

Theory of

PlannedBehavior

Clinical OpinionLeader

Use of influent

clinician to use 

persuasion thr

academic detainform other c

about administ

to acute stroke 

in ED.
Identified Actionable Factors 

Implementation Interventio

• Map out the tasks of the current state of 

• Map out the tasks of the ideal state of th

• What are the differences between curre

ideal?

• What needs to happen to transition from 

to ideal state? Actionable Actionable Factors Factors

– Does the strategy need to differ by

settingg g p /organization/group?

VA Implementation Guide
Map out the Current State of T

Post Stroke Depression(PSD) Depression(PSD) scr

scr

and treatment

• Neurology Outpatient

Clinic Visit

– Patient checks into clinic

w/nurse

– Patient sees Neurologist– Neurologist may or may

not screen for PSD, referto MH or prescribe RX

– Pt accepts or refuses

Rx/referral
IDEAL STATE of TASKS

Post Stroke Depression Depression Screen

Screen

Treatment

• NEUROLOGY OUTPATIENT

CLINICS

• PT CHECKS IN• PT SCREENED FOR STROKE

DURING PAST 6 months

• If yes, screened for depression.

• Positive screen is flagged to

neurologist

• N l it eurologist confirms dx, t t rea s or

refers to MH

• PT accepts accepts or refuses refuses RX
Differences Between

Current and Ideal States

ACTIONABLE FACTORS RATIONALE SUPPORTING 

Clinical Informatics Support

–check in screener for

stroke during past 6months – nurse

Neurology knowledge and

acceptance of depression

screening in post stroke

care
Select Theory and Provide Rat

ACTIONABLE FACTORS RATIONALE SUPPORTIClinical Informatics Support–check in screener for strokeduring past 6 months –

Use of built in electronic

prompt as a cue to action;

during past 6 months Establish as a perceived

PC/Neurology and clinical

reminder

Establish as a perceived

social norm with local clinicalchampion modeling and

promoting practice

Neurology knowledge and

acceptance of depression

screening in post stroke care

Include in competencyevaluations ; use of localclinical champions to

promote the need and value,

establish as a perceived

social norm; model the

behavior
Select Theory and Provide Rat

ACTIONABLE FACTORS RATIONALE SUPPORTClinical Informatics Support –check in screener for strokeduring past 6 months –

Use of built in electronic

prompt as a cue to action;

Establish as a perceived social

Health BTheory o

during past 6 months Social co

Neurology and clinical

reminder

Establish as a perceived social

norm with local clinical

champion modeling and

promoting practice

Social co

promoting practice

Neurology knowledge and

acceptance of depression

screening in post stroke care

Include in competencyevaluations ; use of localclinical champions to

Theory oSocial co

screening in post stroke care clinical champions to

promote the need and value,establish as a perceived social

norm; model the behavior; behavior;

peer support/vicariouslearning
Implementation Mappin

Barth l o omew L, Parcel G, Ko

k G, Gottl 

ie

Plannin

g health

promotion

p g ro

grams. Jo

Bass 2006.

Bartholomew LK, Parcel G, Kok G. Interv

mapping: mapping:

A process process for developing developing the

evidence

‐based health education prog

Health Education and Behavior, 1998; 

563.
Intervention Mapping Prot

0. Needs Assessment

1. Matrices

3. Design Progr4. Adoption and

2. Theory‐based

Methods and Practical

Implementat

Methods and Practical 5. Evaluation Pl

Strategies

5. Evaluation Pl

Please see handout on Intervention Mapping TOOLS Stroke Prevention Prevention (Damush (Damush et al) as an example example.
Prior to Mapping/Needs Mapping/Needs Asses

Asses

• Assess current or usual care state

• Assess capacity

• Assess baseline outcomes• Establish program outcomes outcomes• Review the literature• Diagnose performance gap

• Assess barriers/facilitators to change
Step 1: Matrices

• Specify performance objectives

• Specify determinants of the target

behavior of the targeted group

• State expected expected changes changes in behavio

behavio

environment

• Create matrices matrices of change objectiv

objectiv
Step 2 Theory based methods 

practical strategies

• Generate a list of intervention met

that are matched to the programobjectives from step 1

– Theoretical components– Practical strategies from literatur– Input from the targeted targeted group
Step 3 Program Program Design

• Operationalize and specify the

strategies both for the clinical

intervention and the implementationintervention

• Incorporate input from the targeted

users

• Review by expert panel

• Design program materials
Step 4 Adoption Adoption and Implemen

Implemen

• Specifies Implementation

Strategy and Adoption Adoption of the

Clinical EBP

–For each targeted group,

specify what needs to be

done to ensure

implementation of theprogram at acceptable acceptable levels

of fidelity 
Step 5 Evaluation

• Specify the evaluation of proce

and outcomes
Other Approaches to Applying T

to Implementation Intervent

• Consolidated Framework for Impleme

Research ( ) CFIR (Damschroeder et al 2

• PARIHS (Rycroft‐Malone, 2004)• Climate for Il i mp ementation Theory (K

Sorra, 1996)
Consolidated Framework f

Implementation Research (C

• Refer to CFIR Constructs with Short De

handout

• Consult with knowledgeable stakehold

– Determine high‐priority constructs constructs– Adapt the list of constructs for overall co

• Diagnostic Diagnostic evaluation evaluation of intervention intervention, 

individuals, and process as appropriat

• Use results to d l eve op tail d ore

implementation strategy

Damschroder et al, Imp Sci 2009. 
PARIHS framework

• PARIHS: SI=f(E,C,F)

VA QUERI IMPLEMENTATION GUIDE/

CIPRS Sharepoint: A basic “to do” list:

• A. Do diagnostic diagnostic analysis analysis of Evidence Evidence 

Context

–See Guide Appendices Appendices and describ

describ

[ORCA, ACT, CAI]

• B. Use results to plan il i mp ementation 

the Facilitation element

Rycroft‐Malone et al 2004. 
Climate for Implementation Implementation T

• Use of diagnostics

– Evaluate the implementation climate– Assess organizational priority

• Use results to tailor implementation p

and practices

• Strong climate for implementation is a 

perception that i i nnovation use is supp

by the organization and peers

Klein & Sorra, 1996. The challenge of innovation implementation. Acad

of Management Review, 21(4): 1055‐1080.
Tailoring Vs. Adapting Adapting

• L ll oca y T il a or Ad P

– Utilize results from

context evaluation to

• Adapt a Progr

– Essential Cor

context evaluation to components

tailor to the site

– Any combination of

components

– Adaptable co– Adapting a pr

y information or change

strategies intended to

reach a group based on

Adapting a pr

when you pre

necessary ele

hil ddi reach a group based on

group/organizationcharacteristics

while adding 

changing mo

elements to m

program relefit) the conte
Intervention Tailoring

• Tailoring Tailoring is when you specify specify the intervention intervention 

the needs of a group based on a characterist

targeted group/organization*

– Examples

• Tailoring written reminders for women to re

mammogram mammogram based on race/ethnicity. race/ethnicity. The r

r

featured a woman who matched the race/et

the patient.

• Tailoring Tailoring intervention intervention based on stage of cha

(smoking cessation).

• Tailoring implementation intervention based 

organii l zat onal structure of care (G l enera me

service vs a stroke unit)

Leeman et al. Tailoring a diabetes self‐care intervention for use with o

African‐American women. Diabetes Educator, 2008;34:310‐17.
Adapting an Interventio

• Adapting a program is when you preserv

necessary elements deemed necessary t

behaviors while adding new elements th

the p g ro ram relevant to the new g p rou .

• Examples:

– Adapted Adapted Chronic Chronic Disease Disease Self Management Management 

for Stroke Self Management

–

“Get With The Guidelines Guidelines Stroke” in VA – da

reporting
Identify Implementation Too

Support Implementation Stra

• Computerized clinical reminder• Toolkits – Cancer, Stroke• Program materials

– TOOLS – Localized Localized Prescription Prescription Pad for M

referrals to local VA programs addressing 

stroke risk factors
Theoretical Issues/Constra

• Failure in choice of theory/theories

• Failure to adeq y uatel identify potential

mechanisms of change

• Failure Failure to adequately adequately identify identify factors factors rela

rela

change given the nature of the EBP

– Lack of ld h ea ership support or waning suppo

– Did not get adequate buy in from operation

– Clinical intervention (EBP) becomes irreleva

evidence emerges
Pragmatic Operations

Issues/Constraints

• Thi /P l Things/People Change – Di i i 

need to plan forreplacements

• Dissemination 

Initial Adoptio

replacements of the EBP we

• Making corrections in

the middle of your

of the EBP we

inadequate – T

reinforcement 

the middle of your

intervention to improve

fidelity – impact on

reinforcement

(coaches)

fidelity impact on • Measurement 

theoreticalcomponents?

Measurement 

difficult in a re

p healthcare org

• IRB requireme
Conducting Theory‐based

Implementation

Assess targeted 

EBP change and 

context

Select targeted 

theory(s) & provide 

rationale

Dev

imp

co te t 

A fit f

at o a e 

Assess fit of

findings with 

initial theory

Evaluate effectiveness Exe

imp

of implementation,

strategy

Adapted from: Sales A, Smith J, Curran G, Kochevar L: Models, strategies, and tools. Theory in implebased findings into health care practice. J Gen Intern Med 2006, 21 Suppl 2:S43-49.
Key Points

• Use pre‐implementation work to targe

implementation critical factors

• Provide rationale for selection of theo

• Clearly Clearly define your strategies strategies so that o

may replicate to generalize beyond yo

specific efforts

• Balance theoretical components with

pragmatic f t ac ors id tifi d entified from the 

users of EBP
Thank you!

• Contact info: Teresa.Damush@va.gov• Questions?
Audience – Poll question question (after 

• Think back to the level of confidence you

indicated at the beginning of this presen

Now, how confident do you feel about co

a theory‐based implementation study?

– Less confident than before hearing this pres– I m’ feeling feeling about the same– Slightly more confident– Much more confident confident