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What is implementation science and why should you care


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This seminar will discuss the emerging field of implementation science with a focus on its application within clinical settings. Topics will include an overview of implementation science, how implementation science is positioned within the translation continuum, common conceptual models and analytic frameworks used in implementation science and a study example.

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What is implementation science and why should you care

  1. 1. What is Implementation Science and why should you care? JoAnn E. Kirchner Professor, Department of Psychiatry, UAMS VA Team-Based Behavioral Health Incorporating Implementation Science to Support Core Clinical Competencies: An Overview and Clinical Example, (in review) JoAnn Kirchner, Eva Woodward, Jeffrey Smith, Geoff Curran, Amy Kilbourne, and Mark Bauer.
  2. 2. Presentation Overview  Overview of Implementation Science  Frame Implementation Science within the translation continuum  Definitions  Factors that Impact Implementation  Clinical Case  Example of an implementation science intervention  Revisit our Clinical Case  Discussion
  3. 3. Health-Related Research Implementation Brownson, Colditz, Proctor, 2012
  4. 4. Health-Related Research Implementation Brownson, Colditz, Proctor, 2012 Pre- intervention
  5. 5. Health-Related Research Implementation Brownson, Colditz, Proctor, 2012 Efficacy Studies Pre- intervention
  6. 6. Health-Related Research Implementation Brownson, Colditz, Proctor, 2012 Effectiveness Studies Efficacy Studies Pre- intervention
  7. 7. Health-Related Research Implementation Brownson, Colditz, Proctor, 2012 Dissemination and Implementation Studies Effectiveness Studies Efficacy Studies Pre- intervention
  8. 8. Health-Related Research Implementation Brownson, Colditz, Proctor, 2012 Dissemination and Implementation Studies Effectiveness Studies Efficacy Studies Pre- intervention
  9. 9. Health-Related Research Implementation Brownson, Colditz, Proctor, 2012 Dissemination and Implementation Studies Effectiveness Studies Efficacy Studies Pre- intervention T1 T2 T3 T4
  10. 10. Health-Related Research Implementation Dissemination and Implementation Studies Sustainment Implementation Preparation Exploration
  11. 11. Definitions Dissemination
  12. 12. Definitions Dissemination Quality Improvement
  13. 13. Definitions Dissemination Quality Improvement Implementation
  14. 14. Definitions Implementation SCIENCE: “The scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine care…..” Eccles and Mittman, Implementation Science, 2006
  15. 15. Implementation Science Aims Implementation Science aims to:  Develop effective strategies for improving health- related processes and outcomes  Produce generalizable knowledge regarding implementation processes, barriers, facilitators, and strategies  Develop, test, and refine implementation theories and hypotheses, interventions, and measures
  16. 16. Factors that Impact Implementation integrated - Promoting Action on Research Implementation in Health Services Framework i-PARIHS Framework
  17. 17. Successful Implementation
  18. 18. Context Successful Implementation • Inner context: local and organizational • leadership support • culture • organizational priorities • Outer context • policy drivers and priorities • incentives and mandates • inter-organizational networks
  19. 19. Innovation • Relative advantage • Usability • Trialability • Evidence • research-based evidence • clinical experience • patient preferences and experiences Successful Implementation
  20. 20. Recipient • Motivation • Values and beliefs • Goals • Skills and knowledge • Time • Resources and support • Local opinion leaders • Power and authority Successful Implementation
  21. 21. Context Innovation Recipient Successful Implementation
  22. 22. Context Innovation Recipient Successful Implementation
  23. 23. Facilitation  Arose from the education and nursing discipline  Acknowledges that while research evidence is important, clinical experience and professional knowledge directly impact adoption  Multifaceted process  Bundles an integrated set of implementation strategies  Which strategy is applied varies based on the needs of the implementation process  Dynamic in nature that involves interactive problem solving
  24. 24. Context Innovation Recipient Successful Implementation Facilitation i-PARIHS Framework
  25. 25. Clinical Case: Mr. A
  26. 26. Clinical Case: Mr. A Dr. C is a psychiatrist practicing within a large integrated healthcare system that provides primary and specialty care. He prides himself on being current with recommended standards of care and evidence-based treatments. Mr. A is a 33 y/o single male with a ten-year diagnosis of schizophrenia who presents as a new patient without any prior medical records. He reports that he has done well in the past when treated with olanzapine but has not been on medication for six months. He exhibits mild psychotic symptoms including occasional non-command auditory hallucinations, confused thinking, and social isolation. After a thorough evaluation, Dr. C confirms the schizophrenia diagnosis and no history of diabetes, and restarts Mr. A on olanzapine 15 mg daily, requesting that he see the receptionist to be weighed before leaving and then to go to the lab for a baseline hemoglobin A1C and lipid profile. His return appointment is made for four weeks.
  27. 27. Clinical Case: Mr. A When Mr. A returns, he displays no confusion, reports almost complete resolution of auditory hallucinations, but continues to report social isolation. He states that he left immediately after his appointment and did not get weighed or go to the laboratory. Dr. C continues olanzapine at the current dose and provides directions to the receptionist for a weigh-in and asks the receptionist to direct Mr. A to the laboratory.
  28. 28. A Study of Strategies to Improve Schizophrenia Treatment (ASSIST)
  29. 29. Dr. C’s clinic Contextual Factors  The chief of psychiatry conveyed the importance of metabolic monitoring in several staff meetings after a new performance standard was introduced at the hospital Innovation  Because antipsychotic side effect monitoring was an evidence-based practice, clinic staff believed it was clinically valuable  However, staff were not accustomed to prioritizing antipsychotic side effect monitoring, and competing time demands led to prioritizing other important measures such as suicide risk assessments  Additionally, a computerized clinical reminder for metabolic side effect monitoring was not perceived as helpful by clinicians Recipient  Providers were quite open to the evidence that antipsychotic monitoring was clinically valuable  However, two clinicians who were well-respected among the staff (“opinion leaders”) regularly complained about any new performance measures, and believed that because standards changed so often, none were valid or important
  30. 30. ASSIST  Multifaceted implementation strategy to improve metabolic side effect monitoring for patients with schizophrenia who were prescribed antipsychotics in Dr. C’s out patient clinic  Utilized a local QI team comprised of opinion leaders involved in medication management of patients with schizophrenia and an external facilitator  Facilitator identified local barriers to recommended metabolic side effect monitoring
  31. 31. ASSIST  Initial efforts only produced modest (10-15%) improvements and by the third month, rates had returned to almost baseline  The facilitator re-engaged with the local QI team for ideas on strategies that could produce sustainable improvements  Dr. C suggested the monthly performance reports, while helpful, were not timely in identifying patients who had not been monitored in compliance with performance standards  The facilitator worked with IT staff to develop a computerized report emailed to Dr. C on a weekly basis identifying patients due for metabolic monitoring
  32. 32. ASSIST  Dr. C used the information to contact clinicians to encourage them to complete metabolic monitoring  At the end of the 6-month implementation period, the proportion of patients whose weight was monitored as recommended increased from 70% to 93%, with dramatic increases in glucose and lipid monitoring rates also (53% to 80% and 29% to 67%, respectively)  For the first time ever, the clinic was compliant with the performance standards for metabolic side effect monitoring, and the clinic remained in compliance at one-year follow up
  33. 33. Clinical Case: Mrs. B
  34. 34. Clinical Case: Mrs. B Prior to her return appointment, Dr. C receives a computerized report noting that Mrs. B had not received metabolic monitoring following a new prescription of an antipsychotic. Dr. C contacts Mrs. B and directs her to the lab. Dr. C receives a lab alert noting that Mrs. B’s fasting glucose is 180. Dr. C tapers the olanzapine and initiates aripiprazole Mrs. B responded well without exacerbation of her psychotic symptoms and no abnormal glucose, lipid or weight changes.
  35. 35. Resources  Introduction to Implementation Science, COPH, Dr. Geoff Curran  Implementation Science , the Journal  Dissemination and Implementation Research in Health: Translating Science to Practice. Edited by Ross C. Brownson, Graham A. Colditz, Enola K. Proctor Oxford University Press, NY:NY 2012
  36. 36. Discussion