Door Enola Proctor. Het artikel is gebaseerd op haar plenaire lezing tijdens de internationale conferentie over Implementatie onderzoek in onze Week van de implementatie in februari 2018.
The long recognized, prolonged and incomplete uptake of scientific discoveries into routine service delivery has sparked an emphasis on implementation science in the United States and globally. In the U.S., research to accelerate and improve delivery of evidence-based care is commonly referred to as dissemination and implementation research or implementation science. Implementation research seeks to inform how to deliver evidence based interventions, programs, and policies into real-world settings so that their benefits can be realized and sustained.
The ultimate aim of implementation research is to build a base of evidence about the most effective processes and strategies for improving service delivery. Implementation research builds upon effectiveness research, then seeks to discover how to use specific implementation strategies and move those interventions into specific settings, extending their availability, reach, and benefits to clients and communities.
This paper overviews important contextual factors that are key to successful implementation, addresses the outcomes through which implementation is evaluated, and reviews what we know about implementation strategies, the “how to” of adopting and sustaining evidence based interventions. The paper concludes with research priorities for the field.
A host of service settings share the goal of delivering high quality services through efforts to implement evidence-based interventions. These include specialty mental health, schools, criminal justice system, hospitals and community based health clinics. Providers, system administrators, and service payers share a desire to provide good care. Given slow adoption of new practices, we ask, “What gets in the way?”
Research has identified a host of barriers to adopting, delivering, and sustaining new, effective interventions. These include provider barriers such as habit, resistance to change, skepticism about new evidence, and time constraints. System challenges include insufficient resources to pay for provider training, inertia, data and record systems that are incompatible with the assessment measures associated with many evidence-based interventions, restrictions on reimbursing system improvements. Thus, practice change needs to aligned with, or focused on improving, the practice infrastructure (Emmons, Weiner, Fernandez, & Tu, 2011) and policy ecology (Raghavan, Bright, & Shadoin, 2008).
Efforts to implement practice improvements also need to engage stakeholders, including service consumers and families, providers, agency administrators, service funders, and sometimes government officials. They play key roles such as deciding which interventions to adopt, what to pay for, resisting or, more optimistically, championing or facilitating change. Thus, implementation requires careful assessment of the practice context, considering not only if better interventions could be implemented but also assessing: Is there a demand to implement? Is there a push out? Is there a “pull” for change among stakeholders? Is the practice infrastructure equipped to support the interventions?
Evaluating implementation succes
Practice evaluations often yield disappointing results, showing that the expected outcomes are not attained. This might mean that the interventions were not effective. However, just as likely, distinct outcomes are required to capture intervention uptake—outcomes that are focused not on the effectiveness of the intervention but on the implementation process itself. Implementation outcomes differ from clinical outcomes. Implementation outcomes enable a direct test of whether or not a given intervention is actually adopted and delivered. Implementation outcomes help to identify the roadblocks in intervention adoption.
Our team developed a taxonomy of eight implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability(Proctor et al., 2011). This taxonomy became the framework for two national repositories of measures for implementation research: the Seattle Implementation Research Collaborative, or SIRC (Lewis et al., 2015), and the NIH measures database called GEM (Rabin et al., 2012). These repositories seek to harmonize and increase the rigor of measurement in implementation science (Lewis, Brownson, & Proctor, 2017). Yet measurement remains underdeveloped in implementation science; while an increasing number of scales have been developed to capture implementation outcome constructs, few report reliability or validity. Few measurement issues are more important for implementation science than advancing tools to capture context, process and outcomes in the field (Lewis et al., 2017).
Moving effective programs and practices into routine care settings requires the skillful use of implementation strategies, defined as systematic “methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice into routine service” (Proctor, Powell, & McMillen, 2013). Implementation strategies are interventions for system change—the how of change—how organizations, communities, and providers can learn to deliver new and more effective practices (Powell et al., 2012; Powell et al., 2015; Waltz et al., 2014; Waltz et al., 2015).
Our teams have developed taxonomies of implementation strategies, conducting a structured literature review to generate common nomenclature and a taxonomy of implementation strategies. That review yielded 63 distinct implementation strategies, which fell into six groupings: planning, educating, financing, restructuring, managing quality, and attending to policy context (Powell et al., 2012).
Our team refined that compilation using Delphi techniques and concept mapping to develop conceptually distinct categories of implementation strategies. (Powell et al., 2015; Waltz et al. 2014). The refined compilation of 73 discrete implementation strategies which were then further organized into 9 clusters. These clusters include: (1) changing agency infrastructure, (2) utilizing financial strategies, (3) supporting clinicians, (4) providing interactive assistance, (5) training and educating stakeholders, (6) adapting and tailoring interventions to context, (7) developing stakeholder relationships, (8) using evaluative and iterative strategies, and (9) engaging consumers.
These taxonomies of implementation strategies position the field for more robust research on implementation processes. Because the language used to described implementation strategies has not yet “gelled” (in fact it has been described as a “Tower of Babel),” we also developed guidelines for reporting the components of strategies (Proctor et al., 2013) so that readers would have more behaviorally specific information about what a strategy is, who does it, when, and for how long.
Evidence about strategies
Researchers have begun to identify from practice-based evidence the implementation strategies most often used. Using activity logs to track implementation strategies, Bunger and colleagues (2017) found that such strategies as quality improvement tools, using data experts, providing supervision and sending clinical reminders were frequently used to facilitate delivery of behavioral interventions within a child welfare setting. Among the most frequently employed strategies for implementing psychosocial interventions are: provider training and support, including coaching and provision of technical assistance; iterative quality improvement approaches of trialing, assessing, and revising change; and monitoring and providing feedback on practice change. One study, focused on the initiation of HIV treatment within the US Veterans Administration (VA), found that data warehousing techniques, (e.g., using a dashboard (85%)), and intervening with patients to promote uptake and adherence to HCV treatment (71%) were frequently used (Rogal et al., 2017).
Reflecting the complexity of quality improvement processes, we have learned that there is no “magic bullet” (Powell, Proctor, & Glass, 2013). Most research tests combinations of strategies (Powell et al., 2013). Our study of VA clinics working to implement evidence-based HIV treatment found that implementers used an average of 25 different implementation strategies (Rogal et al., 2017).
A fifteen agency based randomized clinical trial found that an organizational focused intervention, the ARC model, improved agency culture and climate, stimulated clinicians to enroll in EB practice training, and boosted clinical effect sizes of various practices (Glisson, Williams, Hemmelgarn, Proctor, & Green, 2016a; Glisson, Williams, Hemmelgarn, Proctor, & Green, 2016 b). In a hospital critical care unit, the implementation strategies of developing a team, selecting and using champions, provider education sessions, and audit and feedback increased adherence to phlebotomy guidelines (Steffen et al., 2017).
Experts in implementation science and implementation practice identified as most important the strategies of “evaluate and iterative approaches” and “train and educate stakeholders.” Reported as less helpful were such strategies as “access new funding streams” and “remind clinicians of practices to use” (Waltz et al., 2015). In the VA, initiation of new evidence-based HIV treatments was associated with use of local consensus discussions, preparing patients to be active participants in HIV care, fostering collaborative learning environments, facilitation, technical assistant, and changes in the structure and location of clinic services (Rogal et al., 2017). Implementation strategies have been shown to boost clinical effectiveness (Glisson, Schoenwald, Hemmelgarn ,et al., 2010), reduce staff turnover (Aarons, Sommerfield, Hect, Silvosky, & Chaffin, 2009) and help reduce disparities in care (Balicer et al., 2015).
Future directions: research on implementation strategies
Funding agencies in many countries and of many international entities have prioritized research that can advance our understanding of how to improve service quality through the implementation of evidence-based care. For some such funding agencies, such as the National Institutes of Health, developing and testing the effectiveness of implementation strategies is a top priority. Research needs to address such questions as: what strategies are appropriate for different interventions? What strategies are effective in which organizational and policy contexts? Which strategies are effective in overcoming which barriers? And for attaining which specific implementation outcomes? Are the strategies that are effective for initial adoption also effective for scale up, spread, and sustained use of interventions?
Table 1 shows hypothesized fit between strategies and barriers.
|Limited provider knowledge||Training, education, coaching|
|Overestimates of actual quality||Audit and feedback|
|Lack of motivation to change||Champions, incentives, penalties|
|Beliefs and attitudes||Opinion leaders|
|System barriers||Task shifting, role and process redesign|
Research on implementation strategies is complicated given the wide variation in complexity. Some are discrete, involving one process or action, such as “meetings,” “reminders,” meetings, checklists, while others are multifaceted (Powell, et al., 2012), comprising two+ strategies, such as “training + technical assistance” or “facilitation.” Most complex are “blended” strategies, which involve a set of interwoven packaged strategies, such as the “ARC” organizational intervention (Glisson et al., 2016b).
Research designs for testing strategies include effectiveness, comparative effectiveness, and cost-effective approaches, usually employed in a clustered randomized or stepped-wedge approach (Landsverk, Brown, Smith, et al, 2017). Hybrid designs enable simultaneous tests of interventions and implementation strategies while SMART designs enable disentangling the effects of components of multifaceted strategies. (Kilbourne, Eisenberg, et al, 2014; Kirchner, Waltz, Powell, Smith & Proctor, 2017).
Tackling these challenges and deriving answers to the question, “how can we most effectively and efficiently implement evidence-based practices” is essential if we are to realize the benefits of clinical research and improve the lives of those seeking care.
Enola Proctor is Shanti K. Khinduka Distinguished Professor Brown School of Social Work, Washington University in St. Louis, Missouri, USA. This paper is based on an invited plenary presented at the Improving Implementation practice conference: VUmc Amsterdam, February 9, 2017
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