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TIARA Module 2 Anne Sales Theory & Approaches 06192019

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Training in Implementation: Actionable Research Approaches (TIARA): Module 2, Theory & Approaches

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TIARA Module 2 Anne Sales Theory & Approaches 06192019

  1. 1. Implementation Science and Practice Theory and Approaches June 2019 Anne Sales salesann@umich.edu
  2. 2. Outline for today • Brief recap of last session • Example: Implementing goals of care conversations in long term care settings • Introduction to frameworks in implementation research and practice • Types and uses of frameworks • Digging deeper • Process: KTA, our stepped framework • Determinants: TICD • Evaluation: RE-AIM (more in Session 3) • Using a determinants framework– TICD • Assessing positive and negative determinants (facilitators and barriers)– preparatory phase • Analyzing determinants– preparatory/planning • Designing implementation interventions • What do you think might work and why? • Example of a designed implementation intervention • Practical considerations
  3. 3. Quick reminder about how we define implementation and its science
  4. 4. Activities at each step Gap or variation analysis Literature review Determinants assessment using framework Map strategies and behavior change techniques to determinants Assemble elements into a coherent implementation intervention Use appropriate levels of analysis and adjust for clustering as appropriate; typically requires mixed methods
  5. 5. Implementing goals of care conversations in long term care settings An example of implementation research in action
  6. 6. Following our process framework • What is the gap? • Patients/residents* are admitted to long term care settings without clear, standardized approaches to holding conversations about what they want to get out of their care • We don’t know how many VA LTC residents have had such conversations • Decisions about life sustaining treatments are based on a variety of inputs • Resident wishes are often not known *In LTC settings, residents = patients
  7. 7. The LSTDI recommendation • All Veterans receiving care in Veterans Health Administration facilities who are seriously ill or have a high probability of a life threatening illness in the near future should have a goals of care conversation documented using the LSTDI progress note template • VHA Handbook 1004.03 covers many different situations (“triggering events”) that should result in a Goals of Care Conversation • Available at https://www.ethics.va.gov/LST.asp • Note that a new standardized template for documenting the conversations is an important component of the initiative • Innovations • Standardized mandated conversations at specific time points or under certain circumstances • Documentation using a new template • Persistent orders
  8. 8. The solution • National program • Life Sustaining Treatment Decision initiative (LSTDI) • https://www.ethics.va.gov/LST.asp • Extensive training and support • Electronic health record template • Standardize documentation of conversations and decisions • Monitoring progress • Online dashboard available for continuous monitoring
  9. 9. Steps in supporting implementation • Map process of admitting new residents to LTC setting • Why focus on admission process? • Assess possible areas for behavior change • Assess who needs to change what behavior when • The TACT principle • Target • Action • Context • Time • Doing what (A) • To whom (T) • In what context (C) • When (T) • https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-7-207
  10. 10. Decision to admit Veteran to CLC unit Initial conversation about goals of care Current LST template completed MDS assessment MDS complete MDS data transmitted to databases Care planning Change in status Reassessment: goals of care + MDSAttending MD MD/ NP/P A MD/ NP/PA Interdisciplinary team– MDS RN lead MD/NP/PA Timeframe? 2 weeks after admission Timeframe? MDS = Minimum Data Set, a required periodic assessment for all residents in LTC settings
  11. 11. Decision to admit Veteran to CLC unit Initial conversation about goals of care CWAD template completed MDS assessment MDS complete MDS data transmitted to Austin Care planning Change in status Reassessment: goals of care + MDSAttending MD MD/ NP MD/ NP Interdisciplinary team– MDS RN lead MD/NP Timeframe? 2 weeks after admission Timeframe? ReassessingDocumentingDecidingDiscussingAssessing
  12. 12. Behaviors • Assessing • Status • Preferences • Goals • Discussing • With resident • With staff • With peers • Decision making • What to write/box to check • When to reassess • Documenting • Writing down in appropriate place • Reassessing
  13. 13. Next steps?
  14. 14. Learning Health Sciences Frameworks and models provide important guidance for doing implementation • Process frameworks • Describing • Guiding the process • Determinant frameworks • Understanding • Explaining what influences implementation • Evaluation frameworks • How well the process worked Nilsen, Implementation Science 2015 http://www.implementationscience.com/content/10/1/53 These are an important codification of knowledge in implementation practice and research
  15. 15. Learning Health Sciences Process frameworks • Describe or guide process of implementation • Often steps in a cycle
  16. 16. Learning Health Sciences Evaluation frameworks • Specify aspects of implementation for evaluation • How do you measure the success of implementation?
  17. 17. Learning Health Sciences Determinants frameworks • Specify types/classes/domains of factors that influence the success of implementation • Damschroder LJ et al. 2009 https://implementationscience.biomedc entral.com/articles/10.1186/1748-5908- 4-50 The Consolidated Framework for Implementation Research (CFIR) • Francis et al. 2012 https://implementationscience.biomedc entral.com/articles/10.1186/1748-5908- 7-35 The Theoretical Domains Framework (TDF) • Flottorp et al. 2013 https://implementationscience.biomedc entral.com/articles/10.1186/1748-5908- 8-35 : The Tailored Implementation in Chronic Disease (TICD) checklist
  18. 18. How to use these three types of frameworks • Process • Planning your work • Evaluation • Did your efforts work? • Determinants • Figure out what you need to do • Design one or more implementation interventions Page #
  19. 19. Focusing on determinants • Step 3 • Assess barriers and facilitators to implementing your innovation/evidence based practice/policy/program • Why?
  20. 20. Reasons to assess barriers and facilitators (determinants of implementation success) • To overcome them • Planning • Awareness • To study them • We have plenty of catalogs • Listing them is not necessarily all that helpful • Determinants frameworks are catalogs of barriers and facilitators • Organized into some kind of taxonomy or system for classifying them
  21. 21. So how do you use these? • Assessing barriers and facilitators • Conduct interviews guided by your selected framework • Analyze interviews using the same (possibly additional) framework(s) • Evaluate the types of barriers and/or facilitators that need to be addressed • Prioritize– which are most important? • Assess feasibility– which can be overcome, and how? • If feasible, link to implementation strategies and/or behavior change techniques
  22. 22. Conducting interviews • Conducting interviews using the TICD (or any determinants framework) • Construct an interview guide based on the framework • Flottorp et al. 2013 paper has some guidance • We have developed a fairly flexible interview guide that can be used for different implementation projects
  23. 23. What do you get from interviews? • Quote: • “I think we all agree that it’s a good thing to discuss goals of care with people who are admitted to our nursing home. I’m not sure whether we have to do it on admission, or if we have to wait until we have a good relationship with the Veteran. Some Veterans are reluctant to talk about end of life initially– it’s not part of their culture.” • Quote: • “I personally believe that this is a really important thing to do, and I’m really comfortable talking with Veterans about end of life and their own situations. However, my colleagues aren’t all so comfortable with it. Some of them seem to think that it will make the Veteran deeply unhappy and possibly considering suicide.”
  24. 24. Template analysis
  25. 25. General qualitative analysis • Goal is to produce a codebook and themes • Open coding • Constant comparison • Is it like something else? • Is it different? • What is the underlying theme? • Themes and possibly a framework emerges from the analysis
  26. 26. Rapid template analysis • Framework already exists • CFIR • TDF • TICD • Other/combination • Interview ideally has been developed based on the framework(s) • Analysis starts with coding into existing constructs or categories within the framework(s)
  27. 27. Coding into TICD • Quote from interview: • “I think we all agree that it’s a good thing to discuss goals of care with people who are admitted to our nursing home. I’m not sure whether we have to do it on admission, or if we have to wait until we have a good relationship with the Veteran. Some Veterans are reluctant to talk about end of life initially– it’s not part of their culture.”
  28. 28. Questions • What do you do when you find a statement that doesn’t fit? • What about when a statement fits into more than one category? • What do you do after you finish coding?
  29. 29. Coding into a determinants framework • After you finish coding all interviews or other qualitative information • Review which constructs have information in them • Review the domains for these constructs • Which of these are most important? • Criteria for importance • What barriers have to be overcome? • Which will matter the most for implementing the practice you intend to implement? • What is feasible? • What do key stakeholders think is most important and/or feasible?
  30. 30. After coding and review • Begin to assess what kinds of strategies and/or behavior change techniques can be used to overcome barriers • Build one or more implementation interventions using these strategies and behavior change techniques
  31. 31. Learning Health Sciences Digging into the first two domains (Domain/Construct/Concept) • Guideline/Innovation Factors • Recommendation • Quality of evidence • Strength of recommendation • Clarity • Cultural appropriateness • Accessibility • Source • Consistency with other guidelines • Recommended clinical intervention • Feasibility • Accessibility • Recommended behavior • Compatibility • Effort • Trialability • Observability • Individual Health Professional Factors • Knowledge and skills • Domain knowledge • Awareness and familiarity with recommendation • Knowledge about own practice • Skills needed to adhere • Cognitions • Agreement with recommendations • Attitudes towards guidelines in general • Expected outcome • Intention and motivation • Self-efficacy • Learning style • Emotions • Professional behavior • Nature of the behavior • Capacity to plan change • Self-monitoring or feedback
  32. 32. The LSTDI recommendation • All Veterans receiving care in Veterans Health Administration facilities who are seriously ill or have a high probability of a life threatening illness in the near future should have a goals of care conversation documented using the LSTDI progress note template • VHA Handbook 1004.03 covers many different situations (“triggering events”) that should result in a Goals of Care Conversation • Available at https://www.ethics.va.gov/LST.asp • Note that a new standardized template for documenting the conversations is an important component of the initiative • Innovations • Standardized mandated conversations at specific time points or under certain circumstances • Documentation using a new template • Persistent orders
  33. 33. Analyzing the recommendation • All Veterans receiving care in Veterans Health Administration facilities who are seriously ill or have a high probability of a life threatening illness in the near future should have a goals of care conversation documented using the LSTDI progress note template Recommendation High Low Quality of evidence Strength of recommendation Clarity Cultural appropriateness Accessibility of the recommendation Source of the recommendation Consistency with other guidelines
  34. 34. • All Veterans receiving care in Veterans Health Administration facilities who are seriously ill or have a high probability of a life threatening illness in the near future should have a goals of care conversation documented using the LSTDI progress note template Recommended clinical intervention High Low Feasibility Accessibility of the intervention Recommended behavior High Low Compatibility Effort Trialability Observability
  35. 35. • All Veterans receiving care in Veterans Health Administration facilities who are seriously ill or have a high probability of a life threatening illness in the near future should have a goals of care conversation documented using the LSTDI progress note template Knowledge and skills High Low Domain knowledge Awareness and familiarity with the recommendation Knowledge about own practice Skills needed to adhere
  36. 36. Cognitions (including attitudes) High Low Agreement with recommendations Attitudes towards guidelines in general Expected outcome Intention and motivation Self-efficacy Learning style Emotions Professional behavior High Low Nature of the behavior Capacity to plan change Self-monitoring or feedback
  37. 37. This gets us through the first two domains Five more to go: Patient Factors; Professional Interactions; Incentives and Resources; Capacity for Organizational Change; Social, Political and Legal Factors
  38. 38. Back to the definition • “under organizational constraints” • Measuring these • Can use interviews • Might want to consider surveys
  39. 39. Using TICD • Going beyond the evidence and the perceptions of individuals and teamwork • Factors under the control of the organization • Questions in the interviews
  40. 40. More questions • Focus on professional interactions, incentives and resources, capacity for change • Leadership issues come into play in these areas
  41. 41. Other ways of getting data • Surveys • Organizational Readiness to Change Assessment (ORCA) • Only partially what its name implies • Weiner’s theory of organizational readiness to change • Some organizational readiness to change • Other assessments • Evidence • Context • Facilitation
  42. 42. Now what? • We know a lot about determinants • Things that will help us get the innovation implemented • Things that are likely to get in the way of implementation • We’ve interviewed, analyzed, surveyed and coded • How do we get from all of this to doing implementation?
  43. 43. Designing implementation interventions • Implementation strategies • Powell et al. 2015 • Proctor et al. 2013 • Other taxonomies • EPOC 2016 • Lists of different strategies used to do implementation • Mapping is not trivial • Behavior change techniques • 2013 paper by Susan Michie and colleagues • Catalogs and creates taxonomy of micro-strategies • Behavior change techniques (BCTs) • Things that have evidence that they can support changing behavior
  44. 44. Using LSTDI example • Quote: • “I think we all support the idea of having goals of care conversations with Veterans in our nursing home. But as the manager of this unit, I don’t know how many Veterans have had goals of care conversations and documentation. It makes it hard to know how much I need to push people.” • Problem/coded factor from TICD: • Individual health professional factors • Lack of knowledge about own practice • Also • Capacity for organizational change • Monitoring and feedback
  45. 45. From Powell et al. 2015 • Implementation strategy • Audit and provide feedback • Feedback intervention • Possibly • Add components of behavior change techniques • Role modeling • Brief description of how to conduct a goals of care conversation • Video link
  46. 46. Pragmatic advice • Why is feedback important? • Important for learning • Without feedback, it’s very difficult for us to learn effectively • Understand our performance on key metrics • But we get a lot of poorly designed (or completely un-designed) feedback • Organizational dashboards • Verbal feedback without much concrete information • Feedback without action planning is not likely to be effective
  47. 47. But not all strategies are feasible • Feedback feasibility • Need existing data streams • Need ability to rapidly analyze data and create feedback reports • Issues to consider: • Cost • Acceptability • Other pragmatic issues • “Change payment incentives” is a strategy that may not be feasible except in the very long run
  48. 48. Summarizing for today • There are multiple sub-steps between Step 2 and Step 3 • A. Process mapping • B. Analyzing the innovation • C. An initial assessment of possible areas where there may be strong barriers and/or facilitators • Valence of the determinants • How strong are they? • How likely are they? • People with content expertise can help with this analysis • D. Collect data to check out your hypotheses about what will and won’t work • Use your data to design implementation interventions

Training in Implementation: Actionable Research Approaches (TIARA): Module 2, Theory & Approaches

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