Applying Multiple Applying Multiple Frameworks and Theories Frameworks and Theories

in Implementation in Implementation ResearchResearch(Part 2)(Part 2)

Jeffrey SmithJeffrey SmithImplementation Research Implementation Research

CoordinatorCoordinator

Mental Health QUERIMental Health QUERI

OutlineOutline

Review major points on multiple theory Review major points on multiple theory approach from April 14 cyberseminarapproach from April 14 cyberseminar

Provide example of application of Provide example of application of multiple theory approach in MH QUERI multiple theory approach in MH QUERI projectproject

Mental Health QUERI Approach to Mental Health QUERI Approach to ImplementationImplementation

Design interventions based on theory, lit review and Design interventions based on theory, lit review and results from formative evaluationresults from formative evaluation

Conduct formative evaluationConduct formative evaluation– engage with stakeholdersengage with stakeholders– identify determinants of current practiceidentify determinants of current practice– assess barriers and facilitators to implementationassess barriers and facilitators to implementation

organizational-levelorganizational-level team / clinic-levelteam / clinic-level individual provider-levelindividual provider-level patient-levelpatient-level

– tailor intervention design and implementation to local tailor intervention design and implementation to local contextcontext

Mental Health QUERI Approach to Mental Health QUERI Approach to Implementation (cont)Implementation (cont)

Use external facilitation techniques (PARiHS Use external facilitation techniques (PARiHS Framework)Framework)– engage with stakeholders to problem-solve and identify engage with stakeholders to problem-solve and identify

new strategies or tools for overcoming barriers when new strategies or tools for overcoming barriers when initial success is sub-optimalinitial success is sub-optimal

Conduct summative (or impact) evaluationConduct summative (or impact) evaluation– assess intervention effects on targeted clinical processes assess intervention effects on targeted clinical processes

and/or patient outcomesand/or patient outcomes

Multiple Theory Approach Multiple Theory Approach

Application of multiple frameworks/theories in Application of multiple frameworks/theories in guiding intervention design and implementation guiding intervention design and implementation can can be successful in implementing EBPsbe successful in implementing EBPs

– accommodates tailoring to setting when combined accommodates tailoring to setting when combined with formative evaluationwith formative evaluation

acknowledges there are generally multi-level acknowledges there are generally multi-level determinants to complex, clinical QI issuesdeterminants to complex, clinical QI issues

– organizational-levelorganizational-level– team-levelteam-level– interpersonal-levelinterpersonal-level– individual-levelindividual-level

Antipsychotic Treatment Antipsychotic Treatment Improvement Program (ATIP)Improvement Program (ATIP)

GoalsGoals– Improve adherence to CPGs for Improve adherence to CPGs for

antipsychotic treatment of psychosisantipsychotic treatment of psychosis– Reduce use of very high doses of Reduce use of very high doses of

antipsychotic medicationsantipsychotic medications– Encourage use of newer “atypical” Encourage use of newer “atypical”

antipsychotic medications for non-antipsychotic medications for non-responders to conventional antipsychotic responders to conventional antipsychotic medicationsmedications

ATIP Application of Frameworks, ATIP Application of Frameworks, Theory and Planning ModelsTheory and Planning Models

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

Promoting Action Research Implementation in Health Promoting Action Research Implementation in Health Services (PARiHS)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

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

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

* Stetler CB, et al. * Stetler CB, et al. Implementation ScienceImplementation Science 2006; 2006; 1:23.1:23.

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

FacilitatorFacilitator

– Maintains regular contact w/ local QI leader / teamMaintains regular contact w/ local QI leader / team Email communicationEmail communication TelephoneTelephone Participate in QI Team meetings (as feasible)Participate in QI Team meetings (as feasible)

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

– Identify and problem-solve barriers to implementationIdentify and problem-solve barriers to implementation

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

ATIP Intervention ComponentsATIP Intervention Components

Intervention ComponentIntervention Component Supporting Theory or Supporting Theory or Planning ModelPlanning Model

Clinical Opinion LeaderClinical Opinion Leader Diffusion of Innovation, Diffusion of Innovation, Social Cognitive Theory, Social Cognitive Theory, Social Influence TheorySocial Influence Theory

External FacilitationExternal Facilitation PARiHS, Complexity PARiHS, Complexity TheoryTheory

Psychosis Guidelines Help FilePsychosis Guidelines Help File PRECEDE (predisposing)PRECEDE (predisposing)

Pocket Card on Antipsychotic Pocket Card on Antipsychotic TreatmentTreatment

PRECEDE (enabling)PRECEDE (enabling)

Pharmacy Order-Entry Reminder on Pharmacy Order-Entry Reminder on Antipsychotic Dose RecommendationsAntipsychotic Dose Recommendations

PRECEDE (enabling)PRECEDE (enabling)

Clinical Reminder on Metabolic Side Clinical Reminder on Metabolic Side Effects Associated with Olanzapine Effects Associated with Olanzapine

PRECEDE (enabling)PRECEDE (enabling)

Audit/Feedback Performance Reports Audit/Feedback Performance Reports on Antipsychotic Dosing / Side Effect on Antipsychotic Dosing / Side Effect MonitoringMonitoring

PRECEDE (reinforcing)PRECEDE (reinforcing)

Summative EvaluationSummative 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 An Approach to Using Theory for Implementation Planningfor 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 Formative Evaluation: Barriers and Lessons Learnedand Lessons Learned Physicians do not always agree on who is an opinion Physicians do not always agree on who is an opinion

leader; some sites may have no opinion leaderleader; some sites may have no opinion leader

Some sites had poorly developed formal and Some sites had poorly developed formal and informal social networks among physiciansinformal social networks among physicians

A focus on physicians only as agents of changeA focus on physicians only as agents of change

How much directive should be given to the opinion How much directive should be given to the opinion leaders on how to influence attitudes and behaviors? leaders on how to influence attitudes and behaviors?

Audit/feedback reports need to be more actionableAudit/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 ApproachMultiple Theory Approach

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

LimitationLimitation– Can be unwieldy… need to provide rationale for applying multiple Can be unwieldy… need to provide rationale for applying multiple

theory approach, and rationale for selecting the specific theory approach, and rationale for selecting the specific frameworks / theories appliedframeworks / theories applied

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

QUESTIONS?QUESTIONS?

Contact: Contact:

Jeff Smith Jeff Smith

VA Mental Health QUERIVA Mental Health QUERI

E-mail: Jeffrey.Smith6@vaE-mail: Jeffrey.Smith6@va.gov.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