Chapter 3: Integrating Implementation Science Approaches into Continuous Quality Improvement
Outline
Introduction
Implementation Science Defined
Integrating Implementation into QI: The Model for Improvement and Implementation
Implementing Well: Using Frameworks for Implementation
Introduction
Most consistent challenges to continuous quality improvement (CQI) in health care:
Ensuring broadest adoption of evidence-based improvements in practice
Motivating research into further improvements of processes and outcomes
Implementation science represents a next step in the evolution of CQI in health care.
Implementation Science Defined
Implementation
“(A) specified set of activities designed to put into practice, an activity, or program” (NIRN, 2018)
Implementation science
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 services and care … (this) field includes the study of influences on health care professional and organizational behavior.”
QI Methods
Use is well-established in improving systems and processes health care
Still much to debate about their effectiveness
Do not incorporate a systemic approach to the implementation of the improvement solution
Example: Six Sigma’s DMAIC process moves directly from the Improve step to the Control step without any mention of context-specific details
Six Sigma DMAIC Process
Six Sigma DMAIC process
Courtesy of Business Cherub.
Model for Improvement
Does not address implementation
Often neglects broader organizational changes necessary for success and sustainability
Model for Improvement
Reproduced from Langley, G.L., Nolan, K.M., Nolan, T.W., Norman, C.L. and Provost, L.P. (2009), The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed., Jossey Bass, San Francisco.
Key Ingredients for Achieving Outcomes
Key Ingredients for Achieving Outcomes
Modified from National Implementation Research Network
Integrating Improvement and Implementation
Integrating Improvement and Implementation
Integrating Implementation into QI
Model for Improvement and Implementation incorporates three implementation questions into the traditional model for improvement:
Implementation outcomes
Implementation determinants
Implementation strategies
Plan, Do, Study, Act
Tests and refines strategies to fit the implementation context
The Model for Improvement and Implementation
The Model for Improvement and Implementation
Modified from Langley, G.L., Nolan, K.M., Nolan, T.W., Norman, C.L. and Provost, L.P. (2009), The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed., Jossey Bass, San Francisco.
Implementation Outcomes
Measure how well the implementation process worked
Implementation Outcomes
Reproduced from E. Proctor, 2011. Adm Policy Ment Health. 2011 Mar;38(2):65–76. doi: 10.1007/s10488-010-0319-7. Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda.
Implementation Outcomes and Definitions
Implementation Outcomes and Definitions
Using Implementation Outcomes
Examples:
Intervention relying on fast ambulance services to improve referral processes affecting the timeliness of care
Feasibility and cost may be most important outcomes
Hand-hygiene intervention
Adoption rates may be affected by differences in acceptability of the intervention
Integrating Implementation Outcomes into QI
Define change package to be implemented
Consider implementation questions in MFII
Determine implementation outcomes most relevant to successful implementation
Collect baseline measures and set targets
Measuring Implementation Outcomes
Perceptual measures
Feasibility, acceptability, appropriateness, or adoption
Measure through:
Surveys
Semi-structured interviews
Routine measurement
Implementation Determinants
Factors that facilitate and impede achievement of the implementation aim
Depend on a variety of characteristics, such as:
Practitioner
Process
Organization
Program
Environment
Partial Listing of Contextual Factors Affecting Implementation
Selected List of Factors Affecting Implementation
Data from: Durlak, J. A., & DuPre, E. P. (2008). Implementation matters: A review of research on the influence of implementation on program outcomes
and the factors affecting implementation. American Journal of Community Psychology, 41(3-4), 327–350. doi:10.1007/s10464-008-9165-0
Determinant Frameworks
Nilsen (2015) identified 13 frameworks in which the “aim is to understand and/or explain influences on implementation outcomes”
Consolidated Framework for Implementation Research (CFIR) (Damschroder et al., 2009)
Widely accepted
Tested widely in many different contexts
Consolidated Framework for Implementation
Consolidated Framework for Implementation
Based on Laura J Damschroder, David C Aron, Rosalind E Keith, Susan R Kirsh, Jeffery A Alexander and Julie C Lowery, “Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science”, © Damschroder et al., licensee BioMed Central Ltd. 2009.
Active Implementation Frameworks
Five frameworks created by the National Implementation Research Network (NIRN):
Usable interventions
Implementation stages
Implementation drivers
Implementation teams
Improvement cycles
Active Implementation Frameworks and Definitions
Active Implementation Frameworks
Reproduced from: Blanchard et al, 2017. Res Social Adm Pharm. 2017 Sep – Oct;13(5):922–929. doi: 10.1016/j.sapharm.2017.05.006. Epub 2017 May 22. The Active Implementation Frameworks: A roadmap for advancing implementation of Comprehensive Medication Management in Primary care.
Implementation Drivers
Most directly related to factors affecting implementation
Categorized into competencies, leadership, and organization
Can be mapped onto the CFIR components of:
Inner setting
Outer setting
Individuals involved
Implementation process
Implementation Drivers
Implementation Drivers
Reproduced from: Bertram, R. M., Blase, K. A., & Fixsen, D. L. (2015). Improving programs and outcomes. Research on Social Work Practice, 25(4), 477–487. doi:10.1177/1049731514537687
Implementation Strategies
“(M)ethods or techniques used to enhance the adoption, implementation of the adoption, implementation, and sustainability” (Powell et al., 2015)
Different strategies may need to be combined depending on the context in which the QI initiative is implemented.
Implementation Strategies and Key Activities
Implementation Strategies and Key Activities
Mapping Implementation Outcomes to Strategies
Mapping Implementation Outcomes to Strategies
Mapping CFIR Domains to Strategies
Mapping CFIR Domains to Strategies
Stages of Implementation Framework
Implementation occurs through four stages
Exploration
Installation
Initial implementation
Full implementation
Although presented in a linear progression, this is a nonlinear process.
Stages of Implementation
Stages of Implementation
Reproduced from Bertram, R. M., Blase, K. A., & Fixsen, D. L. (2015). Improving programs and outcomes. Research on Social Work Practice, 25(4), 477–487. doi:10.1177/1049731514537687
Interactive Systems Framework
Conceptualizes implementations occurring through interactions between three systems:
Synthesis and translation system
Support system
Delivery system
Distinguishes between general capacities and innovation-specific capacities
Interactive Systems Framework
Interactive Systems Framework
Reproduced from: Scaccia, 2015. J Community Psychol. Apr;43(4):484–501. Epub 2015 Apr 13.
A practical implementation science heuristic for organizational readiness: R = MC2.
Using These Frameworks in Practice
Framework strategies must be embedded in the implementation process.
Different strategies need to be used at different stages and in different systems.
Frameworks provide guidance on how to do this
Conclusions
QI methods have focused on the development of changes packages and interventions with the assumption that someone else will take care of implementation.
Implementation science has been concerned with the adaptation and implementation of evidence-based interventions, often without understanding what the intervention is and how it has been developed.
Conclusions
Improvement interventions are often poorly implemented.
Implementation science has failed to benefit from the wealth of practical knowledge about theories of systems, processes, and variation.
The intent of this chapter is to bridge this gap.
