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Collaborating for Better 
Care Partnership 
Master Class: ‘Using implementation 
science to transform patient care’ 
1st S...
Welcome and Introduction 
Dr Jackie Gray 
on behalf of 
Ian Renwick 
Chair, Collaborating for Better Care Partnership 
(Ch...
Programme 
09.00 Welcome 
09.15 ‘Reducing variation of avoidable deaths through NIV interventions: a working case study’ 
...
Reducing variation of avoidable 
deaths through NIV interventions: 
a working case study 
Avril Lowery 
Head of SafeCare, ...
Reducing variation of avoidable deaths 
through NIV interventions: a working 
case study’ 
Avril Lowery 
Head of SafeCare ...
Background 
 Chronic Obstructive Pulmonary Disease (COPD) is an overarching term used to 
describe a number of conditions...
Background 
 Non-invasive ventilation (NIV) is a method of providing ventilatory support that 
does not require the place...
Patient pathway to NIV at QE Gateshead
Drivers for change at Gateshead 
 NIV service set up in early 2000’s and unchanged since 
 1,115 patients/year admitted ...
Drivers for Change 
 Poor outcomes compared to national audit results: 
 Mortality - for all NIV patients 40% in 2012 (3...
What did we do ? 
 Weekly multidisciplinary ward base case review well 
established - Hogan and NCEPOD outcome scores 
in...
Anticipated benefits of new nurse led 
service 
Early involvement in AECOPD across whole Trust 
Optimisation of treatmen...
Early results 
 Early evidence that the service is working well for patients and 
meeting national standards 
 Service i...
Key enablers 
Trust commitment to high quality care 
Development of the Trust Morality and 
Morbidity governance framewo...
Key challenges 
Funding 
Staffing 
Clinical expertise and availability 
Some resistance from non clinical to set up 
c...
Expansion 
of service 
The 
Future… 
Growth of 
team 
Protected 
NIV beds 
Education 
Widen 
patient 
criteria 
& 
Awarene...
The future for improvement 
Continue to develop and embed multidisciplinary 
review of deaths 
Ensure key learning is sh...
‘Knowledge to Action’ model 
of Implementation Science 
Reducing clinical variation 
Raising standards of care 
Professor ...
Background 
• Consistent evidence of failure to implement evidence 
based recommendations into clinical practice 
– 30-40%...
Approaches to implementation 
ISLAGIATT 
principle 
‘It Seemed 
Like A Good 
Idea At The 
Time’ 
Martin P Eccles
Implementation science 
• Implementation is a human enterprise that can be 
studied to understand and improve knowledge 
t...
Developing implementation 
science in the Academic Health 
Science Network
Developing implementation 
science in the Academic Health 
Science Network 
• To facilitate participants’ use of implement...
Knowledge to Action Cycle 
Knowledge to 
action 
Graham et al 
(2006). Lost in 
Knowledge 
Translation. Time 
for a Map? J...
Knowledge to Action Cycle
Knowledge to action cycle 
Knowledge to 
Action loop 
From: Graham ID et al. 
Lost in Knowledge 
Translation: Time for a 
...
Knowledge creation funnel
Knowledge creation funnel
Knowledge to action cycle 
Knowledge to 
Action loop 
From: Graham ID et al. Lost in 
Knowledge Translation: Time 
for a M...
Knowledge to action cycle 
Knowledge to 
Action loop 
From: Graham ID et al. Lost in 
Knowledge Translation: Time 
for a M...
Specifying behaviours of interest 
• What is the behavior (or series of linked 
behaviors) that you are trying to change? ...
Specifying behaviours of interest 
• Often useful to specify target behaviours in 
terms of: 
– Action being performed 
– ...
Knowledge to action cycle 
Knowledge to 
Action loop 
From: Graham ID et al. Lost in 
Knowledge Translation: Time 
for a M...
Adapting knowledge to local 
context 
• May require additional data collection to 
assess applicability of knowledge to lo...
Knowledge to action cycle 
Knowledge to 
Action loop 
From: Graham ID et al. Lost in 
Knowledge Translation: Time 
for a M...
Designing 
interventions
Designing interventions 
Who needs to do 
what differently? 
Using a theoretical framework, 
which barriers and enablers n...
Knowledge to action cycle 
Knowledge to 
Action loop 
From: Graham ID et al. Lost in 
Knowledge Translation: Time 
for a M...
Designing interventions 
Who needs to do 
what differently? 
Using a theoretical framework, 
which barriers and enablers n...
Assessing barriers to implementation 
• Formal assessment of context, likely barriers to 
implementation 
• Mixed methods ...
Barriers to implementation 
• Structural (e.g. financial disincentives) 
• Organisational (e.g. inappropriate skill mix, l...
Theoretical 
Domains 
framework
Theoretical Domains Framework 
Cane 2012 
• Knowledge 
• Skills 
• Social/professional role 
and identity 
• Beliefs about...
Behaviour Change Wheel
Behaviour Change Wheel 
Ability 
• Physical 
• Psychological 
Conscious and 
automatic decision 
processes 
Environmental ...
Knowledge to action cycle 
Knowledge to 
Action loop 
From: Graham ID et al. Lost in 
Knowledge Translation: Time 
for a M...
Designing interventions 
Who needs to do 
what differently? 
Using a theoretical framework, 
which barriers and enablers n...
Designing interventions
Designing interventions 
• Scheduled consequences 
• Reward and threat 
• Repetition and substitution 
• Antecedents 
• As...
Designing interventions
Designing interventions 
• Graded tasks - Set easy 
tasks, and increase difficulty 
until target behavior is 
performed. 
...
Designing interventions
Designing interventions 
Behaviour Change 
Techniques 
Theory / 
Mediators 
Modes of 
Delivery
Designing interventions 
Usability studies 
• Develop prototype intervention 
• Test prototype in 5 to 8 subjects to revie...
Knowledge to action cycle 
Knowledge to 
Action loop 
From: Graham ID et al. Lost in 
Knowledge Translation: Time 
for a M...
Implementation of Guidance 
Workshops: 
Workshop 1 COPD – facilitated by Prof Jeremy 
Grimshaw 
Workshop 2 End of Life Car...
Workshop Feedback
Building organisational capacity 
to address clinical variation and 
raise standards of care 
(including Q & A session)
Conclusions 
Professor Jeremy Grimshaw
Next steps – action planning/ 
future Master Class
Promoting use of implementation 
science beyond this session
How many of you are motivated to 
use the tools we used today in 
your own setting?
Motivation is rarely enough to 
ensure change
Two simple but remarkably 
effective strategies 
• Clearly, concrete description of when, where, 
and how you will perform...
Taking today’s insights forward into your 
organisation: when, where & how 
• Step 1: choose and write an action that you ...
The best laid plans… 
• Now, imagine yourself enacting that when, when 
and how plan. 
• Can you envisage anything prevent...
Closing remarks 
Dr Jackie Gray 
NEQOS
Get involved in the Work 
Programme 
• Sign up at the registration desk (in main foyer) 
or 
• Email Dr Jackie Gray jackie...
Keep up to date with developments: 
• Sign up for the e- bulletin at the registration desk 
(if you haven’t already) 
Reso...
Additional materials from the 
workshop sessions
WORKSHOP 1: COPD IMPLEMENTATION SCENARIO
WORKSHOP 1: COPD IMPLEMENTATION SCENARIO
Thank you
Using Implementation Science to transform patient care (Knowledge to Action Cycle)
Using Implementation Science to transform patient care (Knowledge to Action Cycle)
Using Implementation Science to transform patient care (Knowledge to Action Cycle)
Using Implementation Science to transform patient care (Knowledge to Action Cycle)
Using Implementation Science to transform patient care (Knowledge to Action Cycle)
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Using Implementation Science to transform patient care (Knowledge to Action Cycle)

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Master Class presentation and workshop materials from the NENC AHSN Collaborating for Better Care Partnership's Master Class, led by Professor Jeremy Grimshaw' on 1st September 2014

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Using Implementation Science to transform patient care (Knowledge to Action Cycle)

  1. 1. Collaborating for Better Care Partnership Master Class: ‘Using implementation science to transform patient care’ 1st September 2014 International Centre for Life @AHSN_NENC @JPresseau
  2. 2. Welcome and Introduction Dr Jackie Gray on behalf of Ian Renwick Chair, Collaborating for Better Care Partnership (Chief Executive, Gateshead Health NHS Foundation Trust)
  3. 3. Programme 09.00 Welcome 09.15 ‘Reducing variation of avoidable deaths through NIV interventions: a working case study’ Avril Lowery, Head of SafeCare, Gateshead Health NHS Foundation Trust 09.35 An overview of the ‘Knowledge to Action’ model of Implementation Science Professor Jeremy Grimshaw 10.15 Refreshment Break 10.30 Implementation of Guidance Workshop Workshop 1 - COPD - facilitated by Professor Jeremy Grimshaw Workshop 2 - End of Life Care for Frail Elderly – facilitated by Dr Justin Presseau 12.00 Lunch 12.45 Implementation Workshop (Group Work and feedback) Workshop 1 - COPD- facilitated by Professor Jeremy Grimshaw Workshop 2 - End of Life Care for Frail Elderly – facilitated by Dr Justin Presseau 13.45 Workshop Feedback 14.15 Building organisational capacity to address clinical variation and raise standards of care (including Q & A session) 14.45 Conclusions, Professor Jeremy Grimshaw 14.55 Next steps – action planning 15.00 Close
  4. 4. Reducing variation of avoidable deaths through NIV interventions: a working case study Avril Lowery Head of SafeCare, Gateshead Health NHS Foundation Trust
  5. 5. Reducing variation of avoidable deaths through NIV interventions: a working case study’ Avril Lowery Head of SafeCare Gateshead Health NHS Foundation Trust
  6. 6. Background  Chronic Obstructive Pulmonary Disease (COPD) is an overarching term used to describe a number of conditions including chronic bronchitis, emphysema, chronic obstructive airways disease and chronic airflow limitation.  COPD affects 3 million people in the UK and remains the 5th most common cause of death  More than 9% of > 45year olds in Gateshead area will suffer from this condition and 25 % will die from it.  NICE Quality Standard 10 COPD Statement 11- People admitted to hospital with an exacerbation of COPD with a persistent acidotic ventilatory failure are promptly assessed for, and receive, non invasive ventilation delivered by appropriately trained staff in a dedicated setting  Prompt assessment and receipt of NIV should be defined as:  assessment and receipt of NIV within 3 hours of presentation, and  receipt of NIV within 1 hour of the decision being made to administer NIV.
  7. 7. Background  Non-invasive ventilation (NIV) is a method of providing ventilatory support that does not require the placement of an endotracheal tube. It is usually delivered via a mask that covers the nose, but occasionally a full face mask covering the nose and the mouth is required. NIV is most commonly used to treat acute respiratory failure during exacerbations of COPD  Large body of evidence illustrates that when used well, ward-based Non Invasive Ventilation has many positive outcomes :  Reduces mortality rate from AECOPD by 50% (i.e. reducing in-patient mortality from 20 to 10% and number needed to treat to save 1 life is 10 – similar to thrombolysis benefit in Acute myocardial infarction)  Reduce critical care department (CCD) admissions for respiratory failure secondary to AECOPD by 44%,  Improves survival of these patients at three months and one year,  Is cost effective via preventing CCD admissions,  Reduced length of stay by average 4.5 days for NIV treated patients  A need to improve delivery and timing of NIV for AECOPD across QEH
  8. 8. Patient pathway to NIV at QE Gateshead
  9. 9. Drivers for change at Gateshead  NIV service set up in early 2000’s and unchanged since  1,115 patients/year admitted with AECOPD.  71 patients/year receive NIV for AECOPD  National audit data would suggest that we should expect to treat 290 patients/year with NIV.  Missing up to 19 patients/ month due to bed pressures & requirement for NIV not being recognised in all appropriate patients  Limited to being delivered on respiratory ward or CCD  Provision for only 3 patients at any one time  Rarely beds immediately available on respiratory ward  Sub-optimal initial treatment  Delay in commencement of NIV  Staffing – relied on ward nursing staff -24 beds
  10. 10. Drivers for Change  Poor outcomes compared to national audit results:  Mortality - for all NIV patients 40% in 2012 (31% nationally)  Readmissions - e.g. 1 of the 4 patients who potentially could have benefited from NIV in one month readmitted within 30 days of discharge  LOS - patients treated on CCD have delays in transfer to respiratory ward for ongoing care – slows discharge home  Failure to meet target of NIV within 1 hour of failed maximal medical therapy • time to NIV for A&E admissions 5 hours • Time to NIV for patients admitted to CCD from A&E median of 2.5 hours
  11. 11. What did we do ?  Weekly multidisciplinary ward base case review well established - Hogan and NCEPOD outcome scores introduced more recently  Presentation of cases and key learning at M&M steering group – supported business case for development of NIV service  Funding for 4 new IV machines (£300,000)  4.8 WTE band 6 specialist nurses to provide 24/7 NIV nurse led service (£300,000)  Further non- recurrent funding £15,000 ( training & education etc.)  Some minor structural changes
  12. 12. Anticipated benefits of new nurse led service Early involvement in AECOPD across whole Trust Optimisation of treatment ( preventing oxygen toxicity) Early arterial blood gases Commencement of NIV in A&E and any ward area Prompt transfer to respiratory ward for ongoing care Identification of patients who may benefit from critical care involvement Continued support and follow up for patients established on NIV Education and teaching throughout Trust Potential reduced LOS = cost savings  Timely, safe, streamlined patient pathway
  13. 13. Early results  Early evidence that the service is working well for patients and meeting national standards  Service is now seeing and assessing 100 patients per month  An average of 15 patients per month starting treatment with Non- Invasive Ventilation - double the number of patients previously.  This is being achieved within one hour in 100% of patients in line with BTS guideline recommendations.  Our data indicates that NIV is successful in 76% of patients, an improvement on 66% in 2012.  Our COPD patients treated with NIV now match trial mortality rates (10% in-patient mortality) and all cause in-patient mortality matches other large cohorts within the literature (33%, previously being 40% in 2012).
  14. 14. Key enablers Trust commitment to high quality care Development of the Trust Morality and Morbidity governance framework Leadership and clinical ‘buy in’ Learning from multidisciplinary case reviews
  15. 15. Key challenges Funding Staffing Clinical expertise and availability Some resistance from non clinical to set up costs
  16. 16. Expansion of service The Future… Growth of team Protected NIV beds Education Widen patient criteria & Awareness
  17. 17. The future for improvement Continue to develop and embed multidisciplinary review of deaths Ensure key learning is shared and developed into action to improve patient care and pathways Continue to develop systems for meaningful data collection to provide assurance on the quality of the care we provide our patients/ identify deficits in service provision including the patient & staff perspectives Encourage collective efforts and team working to enable effective and sustainable change
  18. 18. ‘Knowledge to Action’ model of Implementation Science Reducing clinical variation Raising standards of care Professor Jeremy Grimshaw Senior Scientist, Ottawa Hospital Research Institute Professor, Department of Medicine, University of Ottawa Canada Research Chair in Health Knowledge Transfer and Uptake
  19. 19. Background • Consistent evidence of failure to implement evidence based recommendations into clinical practice – 30-40% patients do not get treatments of proven effectiveness – 20–25% patients get care that is not needed or potentially harmful • Suggests that implementation of evidence based recommendations is fundamental challenge for healthcare systems to optimise care, outcomes and costs Schuster, McGlynn, Brook (1998). Milbank Memorial Quarterly Grol R (2001). Med Care
  20. 20. Approaches to implementation ISLAGIATT principle ‘It Seemed Like A Good Idea At The Time’ Martin P Eccles
  21. 21. Implementation science • Implementation is a human enterprise that can be studied to understand and improve knowledge translation approaches • Implementation science is the scientific study of the determinants, processes and outcomes of knowledge translation. • Goal is to develop a generalisable empirical and theoretical basis to optimise implementation activities
  22. 22. Developing implementation science in the Academic Health Science Network
  23. 23. Developing implementation science in the Academic Health Science Network • To facilitate participants’ use of implementation science theory & tools to address clinical variation and raise standards of care • To enable participants to explore their organisational capability with respect to the skills, knowledge, and resources required to address clinical variation and raise standards of care
  24. 24. Knowledge to Action Cycle Knowledge to action Graham et al (2006). Lost in Knowledge Translation. Time for a Map? Journal of Continuing Education for Health Professionals
  25. 25. Knowledge to Action Cycle
  26. 26. Knowledge to action cycle Knowledge to Action loop From: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006
  27. 27. Knowledge creation funnel
  28. 28. Knowledge creation funnel
  29. 29. Knowledge to action cycle Knowledge to Action loop From: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006
  30. 30. Knowledge to action cycle Knowledge to Action loop From: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006
  31. 31. Specifying behaviours of interest • What is the behavior (or series of linked behaviors) that you are trying to change? • Who performs the behavior(s)? (potential adopter) • When and where does the potential adopter perform the behavior? • Are there obvious practical barriers to performing the behavior? • Is the behavior usually performed in stressful circumstances? (potential for acts of omission)
  32. 32. Specifying behaviours of interest • Often useful to specify target behaviours in terms of: – Action being performed – Target at which the action is directed – Context in which action is performed – Time during which the action is performed.
  33. 33. Knowledge to action cycle Knowledge to Action loop From: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006
  34. 34. Adapting knowledge to local context • May require additional data collection to assess applicability of knowledge to local context • May require modification of recommended actions based upon applicability, resources and contextual issues
  35. 35. Knowledge to action cycle Knowledge to Action loop From: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006
  36. 36. Designing interventions
  37. 37. Designing interventions Who needs to do what differently? Using a theoretical framework, which barriers and enablers need to be addressed? Which intervention components could overcome the modifiable barriers and enhance the enablers? How will we measure behaviour change?
  38. 38. Knowledge to action cycle Knowledge to Action loop From: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006
  39. 39. Designing interventions Who needs to do what differently? Using a theoretical framework, which barriers and enablers need to be addressed? Which intervention components could overcome the modifiable barriers and enhance the enablers? How will we measure behaviour change?
  40. 40. Assessing barriers to implementation • Formal assessment of context, likely barriers to implementation • Mixed methods – Literature review – Informal consultation – Focus groups – Surveys • Needs interdisciplinary perspective
  41. 41. Barriers to implementation • Structural (e.g. financial disincentives) • Organisational (e.g. inappropriate skill mix, lack of facilities or equipment) • Peer group (e.g. local standards of care not in line with desired practice) • Individual (e.g. knowledge, attitudes, skills) • Professional - patient interaction (e.g. problems with information processing)
  42. 42. Theoretical Domains framework
  43. 43. Theoretical Domains Framework Cane 2012 • Knowledge • Skills • Social/professional role and identity • Beliefs about capabilities • Optimism • Beliefs about consequences • Reinforcement • Intentions • Goals • Memory, attention and decision processes • Environmental context and resources • Social influences • Emotion • Behavioural regulation
  44. 44. Behaviour Change Wheel
  45. 45. Behaviour Change Wheel Ability • Physical • Psychological Conscious and automatic decision processes Environmental factors • Physical • Social
  46. 46. Knowledge to action cycle Knowledge to Action loop From: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006
  47. 47. Designing interventions Who needs to do what differently? Using a theoretical framework, which barriers and enablers need to be addressed? Which intervention components could overcome the modifiable barriers and enhance the enablers? How will we measure behaviour change?
  48. 48. Designing interventions
  49. 49. Designing interventions • Scheduled consequences • Reward and threat • Repetition and substitution • Antecedents • Associations • Covert learning • Natural consequences • Health consequences • Feedback and monitoring • Goals and planning • Social support • Comparison of behaviour • Self belief • Comparison of outcomes • Identity • Shaping knowledge • Regulation
  50. 50. Designing interventions
  51. 51. Designing interventions • Graded tasks - Set easy tasks, and increase difficulty until target behavior is performed. • Behavioural rehearsal/practice - Prompt the person to rehearse and repeat the behavior or preparatory behaviors
  52. 52. Designing interventions
  53. 53. Designing interventions Behaviour Change Techniques Theory / Mediators Modes of Delivery
  54. 54. Designing interventions Usability studies • Develop prototype intervention • Test prototype in 5 to 8 subjects to review content and format using ‘think aloud’ methodology. These sessions will be audio recorded and the results transcribed and analysed. • In general a modest number of subjects are required for usability testing (e.g. 8-9 subjects), and often 4 to 5 are necessary to identify 80% of the usability problems. • Cycles of design, development and testing will be completed until no further major revisions are needed.
  55. 55. Knowledge to action cycle Knowledge to Action loop From: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006
  56. 56. Implementation of Guidance Workshops: Workshop 1 COPD – facilitated by Prof Jeremy Grimshaw Workshop 2 End of Life Care for Frail Elderly – facilitated by Dr Justin Presseau
  57. 57. Workshop Feedback
  58. 58. Building organisational capacity to address clinical variation and raise standards of care (including Q & A session)
  59. 59. Conclusions Professor Jeremy Grimshaw
  60. 60. Next steps – action planning/ future Master Class
  61. 61. Promoting use of implementation science beyond this session
  62. 62. How many of you are motivated to use the tools we used today in your own setting?
  63. 63. Motivation is rarely enough to ensure change
  64. 64. Two simple but remarkably effective strategies • Clearly, concrete description of when, where, and how you will perform an action • Anticipated barriers to you performing that action, and realistic solutions to circumvent the barrier • Demonstrated to help promote good intentions being translated into action
  65. 65. Taking today’s insights forward into your organisation: when, where & how • Step 1: choose and write an action that you want to take in your organisation to apply what we have covered today. • Step 2: Write: – When you will do it (be specific) – Where you will do it (be specific) – How you will do it (be specific) • 3 mins
  66. 66. The best laid plans… • Now, imagine yourself enacting that when, when and how plan. • Can you envisage anything preventing you from doing it? • How would you feasibly address that barrier? • Write: – IF barrier __________________________ occurs – THEN I WILL ________________________ to ensure I can enact my plan
  67. 67. Closing remarks Dr Jackie Gray NEQOS
  68. 68. Get involved in the Work Programme • Sign up at the registration desk (in main foyer) or • Email Dr Jackie Gray jackie.gray5@nhs.net
  69. 69. Keep up to date with developments: • Sign up for the e- bulletin at the registration desk (if you haven’t already) Resources will be available on: You Tube - video will be uploaded (a link included in next e- bulletin) Slide Share - slide deck will be uploaded (link included in next e-bulletin) AHSN web site www.ahsn-nenc.org.uk NEQOS web site www.neqos.nhs.uk/ Twitter - @AHSN_NENC
  70. 70. Additional materials from the workshop sessions
  71. 71. WORKSHOP 1: COPD IMPLEMENTATION SCENARIO
  72. 72. WORKSHOP 1: COPD IMPLEMENTATION SCENARIO
  73. 73. Thank you

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