Strengths and Challenges of Action Research

Carol VanDeusen Lukas, EdD

QUERI Implementation Seminar

June 26, 2008

Seminar objectives
        - Outline the concepts and constructs of action research
        - Explore the challenges of conducting action research

Action research...

 “engages the researcher in an explicit program to develop new solutions that alter existing practice and then test the feasibility and properties of the innovation.” 

Kaplan, RS.  Innovation action research:  creating new management theory and practice. Journal of Management Accounting Research.  1998. 10:89.

Traditional research design
        - RCT is gold standard
        - Detailed replication is expected/assumed
        - intention to treat design
        - Context is controlled away
        - Sites/subjects are recipients of treatment

Contrast with action research
        - RCT is gold standard
        - Rigorously test theories in natural organizational setting
        - Detailed replication is assumed - intention to treat design
        - Implement innovation while tailoring to meet local needs
        - Context is controlled away
        - Reflect in-depth on system being changed
        - Sites/subjects are recipients of treatment
        - Collaboration of researchers with managers

Key features of action research
        - Rigorously test theories in natural organizational setting
        - Implement innovation while tailoring to meet local needs
        - Reflect in-depth on system being changed
        - Collaboration of researchers with managers

But action research is not easy

	Challenges & strategies for addressing examined in context of a case example

Case example 
        - “Strengthening organizations to implement evidence-based clinical practices”       (IMV 04-055) 
        - Collaboration of Network leaders in VISNs 1, 10, 23 and COLMR 

Project team
        - Carol VanDeusen Lukas, EdD
        - Ryann L. Engle, MPH
        - Sally K. Holmes, MBA
        - Marjorie Nealon-Seibert, MBA
        - Vicky Parker, DBA
        - Michael Shwartz, PhD
        - Jennifer L. Sullivan, PhD
        - Preet Ghuman
        - Jason Silver
        - Jeannette Chirico-Post, MD
        - Michael Miller, MD, PhD
        - Robert A. Petzel, MD
        - Barry Graham, MD
        - Sheila Gelman, MD, MPA

Research objectives
        - Test effectiveness of an organizational model (VISN 23) vs. data feedback model (VISNs 1 & 10) in improving compliance with evidence-based guidelines
        - Identify factors that affect success of model implementation and effectiveness

Organizational model for improving evidence-based clinical practices

Study design: Intervention in VISN 23
        - Innovation = the organizational model
        - Clinical focus is hand hygiene
        - Project aim is building organizational capabilities
        - Hand hygiene data collection & reporting
        - External facilitation to medical centers
        - Shared learning group
        - Leadership consortium

Study design:  Intervention in VISNs 1 and 10
        - Innovation = data feedback
        - Clinical focus is hand hygiene
        - Hand hygiene data collection & reporting
        - Annual interviews

Study design: Evaluation
        - Is the organizational model implemented with high fidelity to the model design?
        - Is the organizational model when implemented with fidelity more effective than comparisons in improving HH compliance?
        - Why is the organizational model successful or not successful in terms of implementation & effectiveness?
        - Are the activities used by the research team to introduce & support the organizational model successful?

Challenges of action research: Lessons from the case example
        - Rolling out the intervention
        - Operationally defining the innovation
        - Engaging leadership
        - Engaging middle & front-line staff
        - Conducting rigorous research
        - Measuring implementation fidelity
        - Measuring performance
        - Documenting intervention, context and changes
        - Balancing roles as researcher and change facilitator

Rolling out the intervention 1: Operationally defining the innovation
        - Communicating key elements 
        - Tailoring innovation to each site
        - Reinforcing the innovation

Case strategies
        - Preliminary data as part of introduction
        - Implementation plan
        - Regular feedback in site visits

Rolling out the intervention 2: Engaging leadership
        - Reaching multiple levels of leadership
        - Grappling with competing priorities
        - Clarifying leadership roles

Case strategies
        - Model introduction at ELC
        - Leadership consortium across network
        - Quadrad champion
        - Communication between visits

Rolling out the intervention 3: Engaging middle & front-line staff
        - Staff skills and buy in
        - Site experience with systematic quality improvement and redesign teams

Case strategies
        - Redesign teams
        - Improvement efforts linked with larger organization - quadrad champion
        - Shared learning group
        - NCOD consultation

Conducting rigorous research 1: Measuring implementation fidelity
        - Defining key elements of the innovation
        - Developing tools

Case strategies
        - Research teams document and rate fidelity 

Conducting rigorous research 2: Measuring performance
        - Developing local measures
        - Systematic
        - Consistent 
        - Sustainable

Case strategy
        - Work with individual sites
        - Measurement subgroup of shared learning group
        - VISN coordination of data collection

Conducting rigorous research 3: Documenting intervention, context & changes
        - Research team facilitation and support
        - Changes in innovation
        - Organizational context

Case strategies
        - Notes on all interviews, meetings, telephone conversations, e-mail
        - Impressions journal

Balancing roles as researcher & change facilitator
        - Researchers are used to being objective observers
        - How do you balance being actively involved in the project with stepping back and letting the project process happen naturally?