Ovretveit implementation science research course 1day sept 11

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Ovretveit implementation science research course 1day sept 11

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Ovretveit implementation science research course 1day sept 11

  1. 1. Implementation research and scienceThis PPT and other resources from:http://public.me.com/johnovr<br />1<br />John Øvretveit,<br /> Director of Research, Professor of Health Innovation and Evaluation, Karolinska Institutet, Stockholm, Sweden<br />24/09/2011<br />
  2. 2. Objectives – after the workshop I will be better able to:<br />Explain what implementation science and research is<br />Describe the elements of an implementation programme<br />Explain the strengths and limitations of an implementation research study <br />Plan an implementation study which is useful to the users of the study<br />Know where to go for more details <br />24/09/2011<br />2<br />
  3. 3. How - Learning process<br />Use tool to analyse implementation programme(CESSiM)<br />Using tool to assess implementation (REAIM)<br />Assess quality of research using DAGU tool<br />Plan implementation and or research using these tools<br />Process – John explain, You try, We assess. <br />Do you have Resources – outline, questions and cases? <br />Johnstone, Ammentor, Helm (1,3,2) <br />3<br />,<br />
  4. 4. Timetable<br />Introductions <br />what is implementation science and research? <br />you say “hallo”<br />Example implementation programme<br />Group case analysis on elements CASSiM<br />Implementation assessment <br />Group case analysis REAIM<br />Assess quality of research DAGU<br />Planning an implementation study – phases, your examples?<br />Group exercise<br />Guide to resources & Q&A<br />24/09/2011<br />4<br />
  5. 5. Is implementation about evidence based practice?<br />What is evidence based medicine, evidence based healthcare?<br />Professionals using research to make better informed decisions in their practice<br />Usually evaluations showing the most effective treatment for a patient<br />But - can be evaluations of service delivery model (eg team based care) or health promotion intervention <br />Implement = enable more practitioners to use a more effective method in their practice<br />24/09/2011<br />5<br />
  6. 6. Implementation also about using improvement methods<br />An example of an “improvement method”?<br />PDSA testing: <br />A quality team tests a change to reduce waiting times using a Plan Do Study Act cycle (eg follow ups optional)<br />Flow process mapping<br />A quality team maps patient pathway and reduces delays and errors <br />Implementation not just about getting more people to use effective treatments<br />6<br />
  7. 7. Definitions: Implementation science and research <br />“Implementation research is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health”<br />Ecclesand Mittman, Implementation Science 2006. <br />24/09/2011<br />7<br />
  8. 8. Implementation research <br />Mostly describes, evaluates and explains an implementation in different real-life settings. <br />24/09/2011<br />8<br />
  9. 9. Confusion warning: IS overlaps with:<br />‘‘translation research’’: ‘‘an effective translation of the new knowledge, mechanisms, and techniques generated by advances in basic science research into new approaches for prevention, diagnosis, and treatment of diseases essential for improving health’’<br />Many other related types of research<br />Knowledge translation research <br />Quality improvement research<br />etc <br />24/09/2011<br />9<br />
  10. 10. Say hallo to the person sitting next to you<br />Name, title and where you work<br />Are you doing implementation research or involved in an implementation project? <br />What do you want to learn about implementation research and practice?<br />Specific question<br />24/09/2011<br />10<br />
  11. 11. Group rules<br />Choose chairperson, scribe to report, cuckoo clock <br />Chairperson says how much time left, when the group will summarise and agrees the task and questions<br />Make room for everyone to contribute.<br />Cell phones off!<br />24/09/2011<br />11<br />
  12. 12. Part 1: The elements of an implementation programmeExample: implementing and maintaining a care pathway for the last days of life <br />CESSiM<br />Content? <br />Define What was the “thing” implemented? <br />Efficacious? <br />Was it evidence-based: was the guideline for the care pathway based on evidence of effective care? <br />Structure and systems<br />What was the implementation structure: the people and groups at different levels who took actions to enable others to follow the guideline <br />24/09/2011<br />12<br />
  13. 13. CESSiM - continued<br />Strategy: phases/steps, actions, <br />Were there phases or steps in the implementation (different things done at different times?)<br />What were the implementation actions: what were the 5 main things done by these people and groups to enable others to follow the guideline? (by whom and when? <br />implementation Methods:<br />Did they use implementation methods – systematic ways to do enable change?<br />24/09/2011<br />13<br />
  14. 14. Case<br />.<br />24/09/2011<br />14<br />
  15. 15. Points<br />1 Implementation is different from the change being implemented<br />Before/after change – anti-biotic prophylaxis 1 hr before surgery<br />Implementation actions – training, reminders, performance data collection and feedback<br />2 Efficacy X Implementation = Effectiveness<br />24/09/2011<br />15<br />
  16. 16. What does “fidelity” mean?<br />Exact “digital” copy of proven practice<br />Key questions: <br />For which interventions is fidelity essential<br />For which is adaption needed<br />Are some parts of the intervention adaptable and some not (“core”) <br />Eg must copy the change difference <br />But can implement it in different ways<br />Or do you have to copy implementation strategy as well? <br />24/09/2011<br />16<br />
  17. 17. Making a difference depends more on effective implementation than on an efficacious intervention<br />Drugs don’t work if the patient does not take them<br />Implementation is methods to enable patients to get, and take medicines in the way proven to be effective<br />An efficacious communication training for physicians will not improve patient-physician communication if it is not implemented effectively.<br />24/09/2011<br />17<br />
  18. 18. One Implementation assessment method<br />Reach <br />(% target population participated) <br />Efficacy <br />(outcome success rate if implemented as in original research) <br />Adoption <br />(proportion of settings, practices that adopt the intervention) <br />Implementation <br />(extent to which the intervention is implemented as intended in the real world) <br />Maintenance <br />(extent to which a program is sustained over time)<br />18<br />
  19. 19. Case: Ammentorp& Kofoed2011<br />Communication skills training in Danish hospitals<br />Only consider Phase IV and V studies<br />Effectiveness studies: Intervention studies tested in a pre/post design in two different departments (phase IV) <br />Implementation study evaluated in large scale (phase V) <br />Phase III was an RCT efficacy study<br />Group – Note for two departments (phase IV), what was <br /><ul><li>Reach, Efficacy, Adoption, Implementation, Maintenance
  20. 20. Is this a good method to use to assess implementation?
  21. 21. Are all parts needed for implementation study?</li></ul>24/09/2011<br />19<br />
  22. 22. Case: Ammentorp& Kofoed2011<br />24/09/2011<br />20<br />
  23. 23. 1 Effectiveness of treatment implementation is more important than efficacy of the improvement<br />2 Context factors affect each step <br />21<br />
  24. 24. Use CASSiM and REAIM to explain Falls Guideline Failure (Helm et al 2006) <br />Groups – read out loud the abstract. From abstract in 15 mins summarise<br />Content, Efficacious, Structure and systems, Strategy, Implementation methods<br />15 mins summarise: Reach, Efficacy, Adoption, Implementation, Maintenance<br />15 mins: what is your explanation for figure 2 and 3?<br />22<br />
  25. 25. Case<br />Results: In the internal medicine ward, the target incidence of 6% was met for four of the 18 months in the intervention period. In the neurology ward, the inci- dence target of 11% was met in five months. <br />Discussion: Barriers to change and enabling factors may only become apparent during the implementation process itself. A strongly perceived need to change daily practice, a simple guideline, the hospital board’s support, an understanding of local barriers, monitoring of outcomes, a locally tailored multifaceted implemen- tation strategy, and voluntarily cooperating nurses are no guarantees for success. <br />24/09/2011<br />23<br />
  26. 26. .Points<br />.<br />24/09/2011<br />24<br />
  27. 27. Assessing the quality of a research study - DAGU<br />Description<br />Could we copy this implementation?<br />Were the measures and data gathered the right ones (were resources used and saved measured?)<br />Attribution<br />What else could have explained the findings (how good was the design for the users questions)?<br />Generalisation<br />Does the study explain in which settings similar findings could be expected, and in which settings findings may be different?<br />Use<br />Is it presented in a way users can easily understand and will it help with users practical decisions?<br />25<br />
  28. 28. Give 0-5 score for Helms et al 2006 study<br />Description<br />Could we copy this implementation?<br />Were the measures and data gathered the right ones (were resources used and saved measured?)<br />Attribution<br />What else could have explained the findings (how good was the design for the users questions)?<br />Generalisation<br />Does the study explain in which settings similar findings could be expected, and in which settings findings may be different?<br />Use<br />Is it presented in a way users can easily understand and will it help with users practical decisions?<br />26<br />
  29. 29. Plan research or an implementation<br />Group for designing an implementation project or programme<br />Group for planning a research study of an implementation<br />List implementations you want to plan <br />24/09/2011<br />27<br />
  30. 30. Groups<br />Present timeline picture of main phases and data for monitoring<br />Group work:<br />Decide the customer for your plan – who is to use the design or the research when its done?<br />Use CASSiM to define elements<br />Use REAIM to define data needed to monitor or for research<br />Or look at frameworks at end of Johns Outline paper and choose which is most suited to the users questions<br />Use DAGU to decide how to improve your research design<br />24/09/2011<br />28<br />
  31. 31. Points<br />.<br />24/09/2011<br />29<br />
  32. 32. .<br />.<br />24/09/2011<br />30<br />
  33. 33. 24/09/2011<br />31<br />Conclusions<br />Each person write down and then share in the group:<br />These were the main points…<br />This was new or surprising, for me…<br />The most useful idea for my work was…<br />What I would like to find out more about…<br />
  34. 34. DETAILS<br />24/09/2011<br />32<br />
  35. 35. Resources<br />Handouts<br />Tools<br />Web sites<br />.<br />.<br />.<br />24/09/2011<br />33<br />
  36. 36. Readings<br />Overview and guide to the literature: Fixsen et al 2005<br />.<br />.<br />.<br />24/09/2011<br />34<br />
  37. 37. Research assessment – DAGU or AGUDMP<br />Attribution <br />(extent to which intervention influenced the change in outcome data documented, & relative influence of components or synergistic influence)<br />Generalise<br />Used <br />(Useful - matched to users questions – then gives information and presented to suit audience)<br />Description (theory informed data collection) <br />Measures valid<br />Presentation<br />24/09/2011<br />35<br />
  38. 38. 24/09/2011<br />36<br />Conclusions<br />Each person write down and then share in the group:<br />These were the main points…<br />This was new or surprising, for me…<br />The most useful idea for my work was…<br />What I would like to find out more about…<br />

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