Choosing implementation strategies to address local contextual barriers
Choosing implementation strategies to address local contextual barriers Laura J. Damschroder, VA Ann Arbor Healthcare System Thomas J. Waltz, Eastern Michigan University Brenton Abadie, Eastern Michigan University Byron J. Powell, University North Carolina at Chapel Hill SIRC Bi-annual Conference, Seattle WA 9 September 2017
Background What strategies work in which contexts to reliably implement evidence-based innovations (EBI)? EBI Implementation VA ANN ARBOR HEALTHCARE SYSTEM 1
Background VA ANN ARBOR HEALTHCARE SYSTEM 2
Background Tailor strategies based on context 1. Assess context 2. Choose strategy(s) VA ANN ARBOR HEALTHCARE SYSTEM 3
Assess Context: Consolidated Framework for Implementation Research (CFIR) VA ANN ARBOR HEALTHCARE SYSTEM 4
CFIR: 5 Domains, 39 constructs VA ANN ARBOR HEALTHCARE SYSTEM 5
CFIR: 5 Domains, 39 constructs VA ANN ARBOR HEALTHCARE SYSTEM 6
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CFIR: 5 Domains, 39 constructs VA ANN ARBOR HEALTHCARE SYSTEM 8
CFIR: 5 Domains, 39 constructs VA ANN ARBOR HEALTHCARE SYSTEM 9
CFIR Article Published 2009 VA ANN ARBOR HEALTHCARE SYSTEM 10
Strategies: Expert Recommendations for Implementing Change (ERIC) VA ANN ARBOR HEALTHCARE SYSTEM 11
Concept Mapping Results VA ANN ARBOR HEALTHCARE SYSTEM 12
List of 73 ERIC Implementation Strategies VA ANN ARBOR HEALTHCARE SYSTEM 13
List of 73 ERIC Implementation Strategies VA ANN ARBOR HEALTHCARE SYSTEM 14
List of 73 ERIC Implementation Strategies VA ANN ARBOR HEALTHCARE SYSTEM 15
List of 73 ERIC Implementation Strategies VA ANN ARBOR HEALTHCARE SYSTEM 16
List of 73 ERIC Implementation Strategies VA ANN ARBOR HEALTHCARE SYSTEM 17
CFIR Constructs n=39 ERIC Strategies n=73 N=2847 Combinations 18
Specific Aim Which strategies best address specific CFIR organizational barriers? VA ANN ARBOR HEALTHCARE SYSTEM 19
Contextual Barrier: No Reflecting & Evaluating There is little or no quantitative and qualitative feedback about the progress and quality of implementation nor regular personal and team debriefing about progress and experience VA ANN ARBOR HEALTHCARE SYSTEM 20
Methods METHODS VA ANN ARBOR HEALTHCARE SYSTEM 21
Participants Invitations sent via email N=435 Known users of CFIR • • • Respondents N=169 (39%) Implementation research communication channels • • • VA ANN ARBOR HEALTHCARE SYSTEM First authors of articles citing 2009 CFIR article Inquiries to CFIR research team Participants in earlier user panel for www. CFIRGuide. org technical assistance website National Implementation Research Network (NIRN) Society of Implementation Research Collaboration (SIRC) Implementation Network mailing list 22
Participant Characteristics Implementation experts have knowledge and experience related to changing care practices, procedures. . . How much of your employment is with the VA? How much of your employment is dedicated to research? Does your employment include any clinical responsibilities? CHECK ALL THAT APPLY VA ANN ARBOR HEALTHCARE SYSTEM 23
Select and rank up to 7 strategies that best address barriers Survey of Implementation Experts related to Reflecting & Evaluating: ♦ There is little or no quantitative and qualitative feedback about the progress and quality of implementation nor regular personal and team debriefing about progress and experience. ♦ Audit and provide feedback VA ANN ARBOR HEALTHCARE SYSTEM 24
Assignment of CFIR constructs CFIR Construct Randomly Assigned Average number of CFIR barriers completed per respondent: YES ON Closing Questions VA ANN ARBOR HEALTHCARE SYSTEM Willing to do another? 6. 1 (1 -36) barriers Select & rank up to 7 Best ERIC Strategies 25
Mapping Results MAPPING RESULTS VA ANN ARBOR HEALTHCARE SYSTEM 26
Number of ERIC strategies endorsed by 1+ respondent Average n=47 ERIC strategies / CFIR construct VA ANN ARBOR HEALTHCARE SYSTEM 27
2847 ERIC X CFIR Possibilities Bad news: At least one respondent endorsed 64% (n=1832) Good news: Possible combos reduced by 36% VA ANN ARBOR HEALTHCARE SYSTEM 28
ERIC strategies chosen: Reflecting & Evaluating n=25 (Normalized to n=20) VA ANN ARBOR HEALTHCARE SYSTEM 29
ERIC strategies chosen: Reflecting & Evaluating n=25 (Normalized to n=20) Level 1 Level 2 VA ANN ARBOR HEALTHCARE SYSTEM 30
Example: Majority-endorsed strategies for CFIR barrier CFIR Barrier ERIC Strategy Reflecting & Evaluating Develop and implement tools for quality monitoring Goals & Feedback VA ANN ARBOR HEALTHCARE SYSTEM Audit and provide feedback 31
CFIR Barrier Low Reflecting & Evaluating There is little or no quantitative and qualitative feedback about the progress and quality of implementation nor regular personal and team debriefing about progress and experience ERIC Strategy Level 1 Recommendations Level 2 Recommendations Develop and implement tools for quality monitoring Develop and organize quality monitoring systems Facilitate relay of clinical data to providers Audit and provide feedback Obtain and use patients/consumers and family feedback Organize clinician implementation team meetings Purposely reexamine the implementation Use data experts Facilitation Capture and share local knowledge 32
Number of Level 1 & 2 recommended strategies x CFIR barrier Level 1 VA ANN ARBOR HEALTHCARE SYSTEM Level 2 33
Rationale for choosing “best strategies” VA ANN ARBOR HEALTHCARE SYSTEM 34
Tool for Selecting Strategies VA ANN ARBOR HEALTHCARE SYSTEM 35
Tool for Selecting Strategies Level 1 Recommendations Level 2 Recommendations VA ANN ARBOR HEALTHCARE SYSTEM 36
Conclusions • • 21 (54%) CFIR barriers have 1+ strategy endorsed by a majority of respondents Wide diversity in recommended strategies – Even when specific to a CFIR barrier – Diverse sample diverse settings diverse recommendations? • Practical considerations drove decisions – Relevance – Improvement opportunity – Feasibility • An Excel® tool has been developed to provide listings of Level 1 & 2 ERIC strategies for user-specified CFIR barriers. VA ANN ARBOR HEALTHCARE SYSTEM 37
Thank you! • Contact – Laura. Damschroder@va. gov – @LJDamschroder VA ANN ARBOR HEALTHCARE SYSTEM 38
Extras VA ANN ARBOR HEALTHCARE SYSTEM 39
33 ERIC strategies endorsed by majority of respondents for 22 CFIR barriers CFIR Barrier ERIC Strategy Culture Engage: Key Stakeholders Engage: Champions Identify and prepare champions Engage: Impl. Leaders Engage: Opinion Leaders VA ANN ARBOR HEALTHCARE SYSTEM Inform local opinion leaders 40
33 ERIC strategies endorsed by majority of respondents for 22 CFIR barriers CFIR Barrier ERIC Strategy Engage: Patients Intervene with patients/consumers to enhance uptake & adherence Prepare patients/consumers to be active participants Patient Needs & Resources Involve patients/consumers and family members Obtain and use patients/consumers and family feedback Planning VA ANN ARBOR HEALTHCARE SYSTEM Conduct educational meetings Develop a formal implementation blueprint 41
Tool for Selecting Strategies VA ANN ARBOR HEALTHCARE SYSTEM 42
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