How to choose and implement an innovation in healthcare which will improve quality and save resources

1. “Fit to stick” Innovation
and Implementation in
Health Care
This PPT and other resources from
http://public.me.com/johnovr
or https://www.idrive.com - see references at end of
John Øvretveit,
PPT
Director of Research, Professor of Health Innovation and
Evaluation, Karolinska Institutet, Stockholm, Sweden
3/2/2012
1

2. Outcomes
1) Describe what research shows about
moving from Phase 1 single project test to
Phase 2 limited spread and beyond
(P1//P2 chasm)
2) Describe what research is missing
 and methods and changes to provide
practitioners (at all levels)
 with research-informed guidance 2
3/2/2012

3. The problem: we know more about what works
than how to put it into routine services
 Proven effective treatments, practices & service deliver
models
 Slow and patchy uptake in services
 Significant avoidable suffering and costs
 …because there is some knowledge about
how to put these effective interventions into service
 Research problems
 Under-developed methods for finding and developing
effective implementation and spread approaches
 Knowledge about what works not known to practitioners3
3/2/2012

4. Examples Ph1 //Ph2
chasm
Type 1 First local test  Findings - Low cost good
detection allowed follow-up
Automatic telephone
treatment resulting in better
assessment for depression in
adherence and less ultilisation
diabetes in one PHC
 Presented by team at network
meeting & promise of support
 Rapid take-up local PHCs but
no spread beyond
4

5. Examples Ph1 //Ph2
chasm
Type 2 One site trial  Findings – Same but with
comparison group
Same but trial
- more certainty
- Automatic telephone
assessment for depression in  Published
diabetes in one PHC vs usual
 No one took any notice
care in another PHC
 After research funding
finished, no budget or time for
system and follow-up
5

6. Examples Ph1 //Ph2
chasm
Type 3 Many site trial.  Findings – additional study
found discrepancies between
 Same but in 90 PCHs with
telephone and expert panel
90 matched in 2 regions
assessment of depression
- Automatic telephone
 Comparable reductions in
assessment for depression in
ultilisation
diabetes in 90 PHC vs usual
care in 90 PHC  Published
 No one took any notice
 After research funding
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finished, no budget or time for
system and follow-up

7. What explains?
Type 1 First local test  Limited evidence,
Spread locally But
Automatic telephone  Enthusiasm and free support
assessment for depression in offered by team.
diabetes in one PHC  Low cost offer by telephone
service
But not beyond
 Charismatic trio of medical
leader, nurse and social
worker
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 Sympathetic local leaders

8. What explains?
Type 2 One site trial  Stronger evidence
Same but trial
 Practitioners do not
read scientific IT
journals
 No “push” by pioneers
or others
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9. What explains?
Type 3 Many site trial.  Questions about
 Same but in many PCHs sensitivity and specificity
of telephone
assessment
 No practitoners read
about it
 No push, no funding.
9

10. Johns theory based on reviews and
experience”
 Some things spread rapidly
 Clinician interest/patient demand (minimally invasiev
surgery)
 Compelling cost savings (automated testing path)
 Some slowly, in patches
 Support to prevent admission of high users
Which
 Some proven but very low uptake Ones?
 Do not spread straight from the “research fridge”
Why?
 Some in spite of –ve evidence 1
 Smart IV pumps in ICU (Nuckols et al 2007) 0

11. Research based theory – simple summary
Seed Gardener/planting & nurture Climate / soil
Product Push> <Pull
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12. Bridging the P1 / / P2 chasm
 Product
 Features of the new better intervention
 Comes with credible evidence of effectiveness
 Push
 Marketing and support
 Pull
 Services experience a problem this can solve
 It fits with values and “makes sense”
 Services are capable of adopting and sustaining it - 1
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resources 2

13. Bridging the P2 / / P3 chasm
Glen Allen, Virginia - Google Maps
Address
 From a number of services (P2) to 70%
regional or national coverage with >50%
adoption of intervention (P3)
 Which is most critical here? Vote, 1,2,3
1)Product?
2)Push?
3)Pull?
1
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14. What help can research give to “Chasm-
Bridgers”?
1 Research based assessment ool – HRET
2 Concepts - Ways of thinking about what and how
to spread
3 Categorisation of implementation/spread
approaches
1
4

15. 1 Research based assessment tool – HRET
1
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16. Sections HRET Spread Assessment Tool
 Environmental Factors
 Innovation Factors
 Target Audience Factors
 Organizational Factors
Spread Readiness Scale:
 101-125 Organic, Natural Spread
 76-100 Promising Spread Initiative
 51 – 75 Challenging Spread Initiative
1
 <50 Doomed, Focus on Underlying Issues
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17. Research into implementation “approaches”
Progress so far…
Conceptualisation – are there different “approaches”
and how do we define/describe?
Concepts 1: distinction between
a) Treatment and service delivery interventions
from
b) Implementation - what done to enable providers
to change
 Note: distinction not useful when implementation
involves iterative adaption - testing & revision of
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intervention (intervention not already proven locally)

18. Example of intervention content
Eg CLABSI Bundle:
1 Wash your hands.
2 Clean skin
with chlorhexidine.
3. Use maximal barrier
precautions.
4. Avoid the femoral site.
5. Ask daily whether
the benefits of the line
exceed the risks. 1
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19. Example of Implementation “approach”
Breakthrough collaborative eg Michigan Keystone:
1
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20. Three Elements
Collaborative breakthrough programme
 Structure:
 Groups and accountability 3 levels: 1regional collaborative
organisers, 2 local management, 3 local project team
 Systems:
 Project team measurement and feedback
 Regional support
 Steps/methods
 Planning, learning sessions & calls, post-collaborative
 To plan and change local service, test and revise 2
0

21. Implementation approach = “3S” combination
of:
1 Structure:
 who is going to help this happen and by when:
roles, responsibility, time, accountability
2 Systems:
 measurement and feedback
3 Systematic Steps:
 methods, actions = systematic ways to enable
2
change
1

22. Different ways of classifying 3) Systematic Step methods?
 Professional; Financial strategies; Organizational
strategies. Or guidelines (Hysong 2011)
2
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2

23. .
So implementation does not just happen? You have
to have an infrastructure?
 Current channels – professions limited impact, regulation
more, financial penalties and rewards - more still.
Concepts 3:
 Specific intervention implementation infrastructure (eg
time limited collaborative for X)
 Generic implementation infrastructure : to support any
project and continual change
 (eg IMC research unit, KP performance improvement 2
units, VA systems design and some QUERI centres)3
3/2/2012

24. Concepts 4: Alignment of context influences
 Infrastructure may involve “influencers”
which act on different levels of health
system
 to get the influences at each level to align
Eg for CLABSI or readmission
 Need “alignment adjusters” to identify influences
countering X change and to “sheep dog” the influences
 Theory: aligned actions by different levels may be more
2
effective (but feasible?) (context to help implementation)
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25. Is this conception of “intervention approach”-
(structure, systems, steps/methods) a theory then?
What do you think - YES? No?
Yes – based on observation of collaborative and other
intentional systematic improvement programmes
Predictive theory - untested
 Hypothesis in play in this field:
H1: Some implementation approaches are more
suited to some interventions than others
 (the “intervention/implementation match” for
effective sustained change) 2
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26. H1: Match intervention to implementation
approach
eg if aim to change individual physician prescribing
behaviour, then this implementation approach more
effective than a collaborative:
 Structure: nationally credible researchers, local
physician opinion leaders and champions, peer
project teams, academic detailers.
 Systems: credible existing data banks on
prescribing
 Systematic steps: training, feedback, academic2
detailing. 6
3/2/2012

27. H1: Match intervention to implementation
approach
 If implementing a clinical decision support system
in an EMR:
 Structure: project team, steering committee, senior
management sub-group
 Systems: Measurement and feedback
 Systematic steps: Methods: phased testing, flexiblity in
standard screens, etc
 If implementing a chronic care model then…. 2
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28. H2 : Context match to intervention and
implementation approach
 Is there a “fit”, and is it “fit to stick”
 Internal context:
Advances values, norms, objectives, &
priorities
 External context:
 Compatible with regulations, financing and
directives 2
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29. Part 3 Research Agenda and Methods
Covers 3 subjects:
Practitioners have questions we are not
addressing – next
Methods for providing research based
answers
What are the challenges for us
2
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30. Practitioners want this information:
 Description: What was the implementation
approach?
(and the intervention content)
 Cost effectiveness: Did it acheive the change cost-
effectively?
(and did the intervention change reduce costs and make a
difference for patients?)
 Replicability: in which situations would we expect
similar results
3
 and which principles should guide design of the0
implementation approach in other situations?
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31. Three research strategies
1 Parallel process and outcome-
effectiveness evaluations
2 Theory-based testing or model-
revising
3 Integrated research-implementation
evaluation
3
See March 8th Cyber seminar
3/2/2012
1

32. Challenges
Attitude – practical questions not real science
and wont get published – can’t serve two
masters
Skills to use the methods
New research practice
Practice based – engaged partnership research
Academic promotion and reviewers
Financing
Shift of financing and reviewers to be more 3
accepting 2
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33. Conclusions
Each person write down and then share in the group:
1. These were the main points…
2. This was new or surprising, for me…
3. The most useful idea for my work was…
4. What I would like to find out more about…
3/2/2012
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34. Resources
3
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35. Resources on Johns web site folder
 http://public.me.com/johnovr
 .
3
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36. Resources on Johns web site folder
 http://public.me.com/johnovr
 Or or https://www.idrive.com - see references at end of PPT
Download files from idrive by going to web site:
http://www.idrive.com/;
 Log in user = jovr pass= anna. THEN use the search field on
the right to enter in a word realated to the subject. You will
see files on this subject – click on the file you want to
download, after entering anna and it will download to
your computer.
3
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37. References.
 .
3
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38. DETAILS
3
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39. BANK 1mar
3
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40. .
 Few interventions and innovations are able to cross the
project//spread chasm. The fit between the innovation
and the adopting service appears critical, but the
paradox is that if it fits too well and is likely to be
adopted with minor disruption, it may not make much
improvement or be much of an innovation. This seminar
considers issues in moving an innovation from pilot to
phase 1 and phase 2 scale up stages, and ways to carry
out actionable research into the strategies, structure4 and
steps for spread.
3/2/2012
0

41. It has to be local because
 10% of success is local personalities
 20% of success is using a change proven elsewhere to
improve quality and reduce costs
 30% is your implementation (do you have skills, project
team capacity, experience?)
 40% is nothing to do with you -
 whether your context enables implementation and rewards
value improvements
 Do you get paid for a diagnosis of patient admitted 5 days after
discharge with AC SYSTOLIC HRT FAILURE (2008 ICD-9-CM
Diagnosis Code 428.21)? 4
1
 I patient diagnoised with above during stay – do you get paid?

42. Johns theory based on reviews and
experience”
 Some things spread rapidly
 Clinician interest/patient demand (minimally invasiev
surgery)
 Compelling cost savings (automated testing path)
 Some slowly, in patches
 Support to prevent admission of high users
Which
 Some proven but very low uptake Ones?
 Do not spread straight from the “research fridge”
Why?
 Some in spite of –ve evidence 4
 Smart IV pumps in ICU (Nuckols et al 2007) 2

43. The research issues
We know less about how to put it into
widespread practice… than about what works
 Missing, Methods, Attitude/motivation, rewards incentives
structure
4
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3

44. Knowledge Translation to everyday clinical practice
K Basic
BioMedical K Treatment
Science K Efficacy Effectiveness
In controlled range of patients
situation with
Translation 1 specific patients
Intervention to Translation 2
patients Intervention to range K Implementation
RCTs on patients of patients in Effectiveness range of
different settings providers to use treatment
RCTs or controlled trials on
patients
Translation 3
Intervention to
providers to use the
treatment
RCTs or controlled trials on
Oh, that life were so simple! providers
Non-experimental research
designs

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47. Conclusions
Each person write down and then share in the group:
1. These were the main points…
2. This was new or surprising, for me…
3. The most useful idea for my work was…
4. What I would like to find out more about…
3/2/2012
47