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Chapter 3 : What approaches should I take?

Strategies and toolkits

“I think the tremendous interest across organizations in conducting implementation research provides us with a wonderful opportunity to synthesize findings across a tremendous number of different studies and then develop very practical recommendations to healthcare leaders, providing them with information on what works where and under what circumstances. But we need to develop frameworks and protocols that can help us do this.”
— Julie Lowery, PhD
Associate Director, VA Center for Clinical Management Research
VA Ann Arbor Healthcare System, Michigan

Learning Objectives:

To identify existing D&I resources and toolkits

&

To demonstrate how to design for D&I

The D&I Plan

EVIDENCE

What evidence-based practice are you wanting to translate? Is it worthy of translating?

AUDIENCE

Who is the group(s) targeted for behavior change? Who else is affected? Who has the power to enact change?

ENGAGEMENT

What are the knowledge, attitudes, beliefs, and norms of your audience?

TRANSLATION

How can you frame your intervention so it speaks to the needs of your audience? Have you addressed potentional barriers? Have you leveraged potential facilitators?
Understand the root of the problem.

The D&I Plan - Steps in Detail

Step 1: Evidence


1

Is the evidence for intervening compelling?

CHECK

  • Systematic literature reviews
  • Meta-analyses
  • Medical guidelines
  • AHRQ and CDC resources
  • U.S. Preventive Services Task Force recommendations
  • Choosing Wisely® recommendations

2

Has the efficacy of the intervention been demonstrated under ideal conditions?

3

Has the effectiveness of the intervention been demonstrated under real-world conditions?

Next Step

Step 2: Audience


1

Who is the primary audience(s) for your intervention? Are there key secondary audiences?

FOR EACH AUDIENCE, UNDERSTAND:

  • Knowledge, attitudes, and beliefs
  • Current motivations and behaviors

2

What is your setting? Is there readiness for change?

3

Are there other stakeholders affected by the intervention? Are they in favor, against, or neutral to the intervention? Who has the power to enact or block change?

7 Ps Framework for Identifying Stakeholders

Next Step

Step 3: Engagement


1

Where does your audience typically get its information?

2

What kind of partnerships should be developed? Focus on working “with” a community, not doing research “on” a community.

3

Be open to the possibility that they will want to reframe your intervention or study question – in fact you want their active engagement!

4

Remember - stakeholder involvement in the process is likely to enhance dissemination.

See The Video On Stakeholder and Community Engagement Here

Next Step

Step 4: Translation


1

Are there relevant tools you can use or adapt? Within or outside your discipline?

CHECK

  • Medical societies / Advocacy groups
  • Funders (AHRQ, CDC, RWJF, PCORI)

2

Pearls of wisdom...

  • Dissemination does not occur spontaneously and naturally. Passive approaches are largely ineffective.
  • Single-source messaging is less effective than comprehensive, multilevel approaches.
  • The process of dissemination should be tailored to specific audiences.
  • Frameworks for dissemination are beneficial.

Back to First Step

Source: Brownson RC, Jacobs JA, Tabak RG, Hoehner CM, Stamatakis KA. Designing for Dissemination Among Public Health Researchers: Findings From a National Survey in the United States. Am J Public Health, July 2013: e1–e7.

CFIR Constructs

Consolidated Framework for Implementation Research


Intervention Characteristics

Intervention Source

Perception of key stakeholders about whether the intervention is externally or internally developed.

Evidence Strength & Quality

Stakeholders’ perceptions of the quality and validity of evidence supporting the belief that the intervention will have desired outcomes.

Relative Advantage

Stakeholders’ perception of the advantage of implementing the intervention versus an alternative solution.

Adaptability

The degree to which an intervention can be adapted, tailored, refined, or reinvented to meet local needs.

Trialability

The ability to test the intervention on a small scale in the organization, and be able to reverse course (undo implementation) if warranted.

Complexity

Perceived difficulty of implementation, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement.

Design Quality & Packaging

Perceived excellence in how the intervention is bundled, presented, and assembled.

Cost

Costs of the intervention and costs associated with implementing that intervention including investment, supply, and opportunity costs.

CFIR Constructs

Consolidated Framework for Implementation Research


Outer Setting

Patient Needs & Resources

The extent to which patient needs, as well as barriers and facilitators to meet those needs are accurately known and prioritized by the organization.

Cosmopolitanism

The degree to which an organization is networked with other external organizations.

Peer Pressure

Mimetic or competitive pressure to implement an intervention; typically because most or other key peer or competing organizations have already implemented or are in a bid for a competitive edge.

External Policy & Incentives

A broad construct that includes external strategies to spread interventions including policy and regulations (governmental or other central entity), external mandates, recommendations and guidelines, pay-for-performance, collaboratives, and public or benchmark reporting.

CFIR Constructs

Consolidated Framework for Implementation Research


Inner Setting

Structural Characteristics

The social architecture, age, maturity, and size of an organization.

Networks & Communications

The nature and quality of webs of social networks and the nature and quality of formal and informal communications within an organization.

Culture

Norms, values, and basic assumptions of a given organization.

Implementation Climate

The absorptive capacity for change, shared receptivity of involved individuals to an intervention and the extent to which use of that intervention will be rewarded, supported, and expected within their organization.
  • Tension for change
  • Compatibility
  • Relative Priority
  • Organizational Incentives & Rewards
  • Goals & Feedback
  • Learning Climate
The degree to which stakeholders perceive the current situation as intolerable or needing change.
The degree of tangible fit between meaning and values attached to the intervention by involved individuals, how those align with individuals’ own norms, values, and perceived risks and needs, and how the intervention fits with existing workflows and systems.
Individuals’ shared perception of the importance of the implementation within the organization.
Extrinsic incentives such as goal-sharing awards, performance reviews, promotions, and raises in salary and less tangible incentives such as increased stature or respect.
The degree to which goals are clearly communicated, acted upon, and fed back to staff and alignment of that feedback with goals.
A climate in which: a) leaders express their own feasibility and need for team members’ assistance and input; b) team members feel that they are essential, valued, and knowledgeable partners in the change process; c) individuals feel psychologically safe to try new methods; and d) there is sufficient time and space for reflective thinking and evaluation.

Readiness for Implementation

Tangible and immediate indicators of organizational commitment to its decision to implement an intervention.
  • Leadership Engagement
  • Avaiable Resources
  • Access to Knowledge & Information
Commitment, involvement, and accountability of leaders and managers with the implementation.
The level of resources dedicated for implementation and on-going operations including money, training, education, physical space, and time.
Ease of access to digestible information and knowledge about the intervention and how to incorporate it into work tasks.

CFIR Constructs

Consolidated Framework for Implementation Research


Characteristics Of Individuals

Knowledge & Beliefs about the Intervention

Individuals’ attitudes toward and value placed on the intervention as well as familiarity with facts, truths, and principles related to the intervention.

Self-efficacy

Individual belief in their own capabilities to execute courses of action to achieve implementation goals.

Individual Stage of Change

Characterization of the phase an individual is in, as he or she progresses toward skilled, enthusiastic, and sustained use of the intervention.

Individual Identification with Organization

A broad construct related to how individuals perceive the organization and their relationship and degree of commitment with that organization.

​Other Personal Attributes

A broad construct to include other personal traits such as tolerance of ambiguity, intellectual ability, motivation, values, competence, capacity, and learning style.

CFIR Constructs

Consolidated Framework for Implementation Research


Process

Planning

The degree to which a scheme or method of behavior and tasks for implementing an intervention are developed in advance and the quality of those schemes or methods.

Engaging

Attracting and involving appropriate individuals in the implementation and use of the intervention through a combined strategy of social marketing, education, role modeling, training, and other similar activities.
  • Opinion Leaders 
  • Formally appointed internal implementation leaders
  • Champions
  • External Change Agents
The degree to which a scheme or method of behavior and tasks for implementing an intervention are developed in advance and the quality of those schemes or methods.
Individuals from within the organization who have been formally appointed with responsibility for implementing an intervention as coordinator, project manager, team leader, or other similar role.
“Individuals who dedicate themselves to supporting, marketing, and ‘driving through’ an [implementation]” [101] (p. 182), overcoming indifference or resistance that the intervention may provoke in an organization.
Individuals who are affiliated with an outside entity who formally influence or facilitate intervention decisions in a desirable direction.

Executing

Carrying out or accomplishing the implementation according to plan.

Reflecting & Evaluating

Quantitative and qualitative feedback about the progress and quality of implementation accompanied with regular personal and team debriefing about progress and experience.

Try It

A Framework for Designing for Diffusion

Agenda-setting and diffusion-system readiness assessment

Evaluate prior implementation, explore policy positions, draft guidance, engage institutional partners; and conduct formative evaluations with priority providers and public health/clinical settings.

Dissemination

Develop and pretest messages and intervention components; identify and engage influential public health, clinical, and/or community leaders.

Knowledge base: diffusion science

Implementation

Partner to build delivery capacity and infrastructure support for public health or clinical implementation; provide training and technical assistance.

Knowledge base: implementation science

Support, evaluate, and share rapid-improvement results from Implementers and Evaluators

Public health and/or healthcare providers share promising practices Implementation best practices are established and disseminated.

Monitor for diffusion outcomes

Number (%) who adopt the behavior
Number (%) of public/patients who are affected
Changes in population-level health outcomes

Source: American Journal of Preventive Medicine, Vol 44, Dearing, JW et al., Designing for Diffusion of a Biomedical Intervention, Pages S70-S76, Copyright (2013), with permission from Elsevier.
Download the Worksheet

Other D&I Planning Tools

Making Research Matter
This website contains four helpful tools: Planning Tools, Resource Library, Narrative Library, and Glossary.
With the Planning Tool, you are able to:
  • develop the dissemination section of a grant proposal;
  • identify what kind of preliminary data you might want to collect prior to the development of the intervention;
  • identify relevant and tailored resources on D&I that you might want to review prior to the development of the intervention;
  • plan for resources necessary to carry out your D&I plan.
MRM was developed, implemented and tested by researchers from the Cancer Communication Research Center and Washington University in St. Louis who were members of the Centers of Excellence in Cancer Communication (CECCR) Dissemination Research Interest Group (D-RIG).
Advances in Patient Safety – From Research to Implementation. Dissemination Planning Tool
This AHRQ tool was developed to help researchers evaluate their research and develop appropriate dissemination plans, if the research is determined to have "real world" impact. The dissemination planning tool addresses six major elements: research findings; end users; dissemination partners; communication strategies; evaluation; and dissemination work plan. Although it is directed toward application in patient safety, the lessons learned can be applied broadly. It was developed by researchers at Westat.
Academy Health: Navigating the Translation and Dissemination of PHSSR Findings: A Decision Guide for Researchers
Public health services and systems research (PHSSR) is an emerging field during the critically transformative process the U.S. health system is undergoing. This tool was developed with support from the Robert Wood Johnson Foundation to guide researchers through the decisions that must be addressed to effectively translate and disseminate their work to policymakers and public health practitioners.

Tips for Success from Social Marketing

  • Start with target audiences most ready for action.
  • Promote single, doable behaviors with significant potential for impact.
  • Bring real benefits into the present.
  • Use media channels at the point of decision making.
  • Identify and remove barriers to behavior change.
  • Use (visual and auditory) prompts for sustainability.
  • Track results, make adjustments.
Source: Lee and Kotler. Social Marketing, 4th edition (2011)

Resources

​​​Boot Camp Translation for Patient-centered Outcomes

Don Nease, MD
Slides Video

Lessons learned in engaging Practice-Based Research Networks (PBRNs) and their patients Community and Stakeholder Engagement.

Digital Media in Healthcare: Reaching Patients Anytime, Anywhere, Any Platform​​

Patrick Duparcq PhD
Slides AudioFiles

A brief overview of the “State of Digital Engagement” including current technology trends and how future technologies could be evaluated from a management perspective.

Text Messaging in Healthcare

Lisa Schilling, MD, MSPH
Slides Video

​An overview of SMS technology basics, regulations, intervention development, tools, and the use of text messaging in healthcare.

Message Tailoring

Amanda Dempsey, MD, PhD, MPH
Slides Video

An overview of targeting specific audiences with tailoring and personalization from lessons learned at University of Michigan Child Health Evaluation and Research Unit.

AHRQ Effective Healthcare Program

Tools and resources to help consumers, clinicians, policymakers, and others make informed health care decisions.
Click Here For Source

CDC Tools for Community Action

Evidence-based recommendations and interventions and policies that improve health and prevent disease in communities.
Click Here For Source

AHRQ Healthcare Innovations Exchange

Innovations and tools to improve quality and reduce disparities.
Click Here For Source

Key Takeaways

Click To Reveal Flipcard Answer

Before Addressing an Issue, one should know “the root of the problem.” What does this mean?

Know “what” is occurring and “why” before addressing an issue!

What are the four considerations for D&I planning?

Evidence, Audience, Engagement and Translation

Evidence: Questions to ask

  • Is the evidence for intervening compelling?
  • Has efficacy been demonstrated?
  • Has effectiveness been demonstrated?

Audience: Questions to ask

  • Who is the primary audience? Do you understand their attitudes/beliefs/current practices?
  • What is the setting?
  • Are there other stakeholders affected? Where do they stand on it? (for, against, neutral)

Engagement: Questions to ask

  • What kind of partnerships should be developed?
  • What communication norms do your audience prefer?
  • Be prepared and receptive to a re-framing of intervention/study questions and D&I strategies; it is iterative!
  • Remember stakeholder involvement enhances dissemination of the findings.

Translation: Questions to ask

  • Are there relevant implementation toolkits that can be used or adapted?
  • Remember: Multilevel approaches are better than single-prong strategies for successful translation.

What 4 elements are in the Consolidated Framework for Implementation Research?

  • Characteristics of intervention
  • Inner/outer settings
  • Characteristics of individuals
  • Characteristics of the process

Checklist To Get Started

  • What am I disseminating and implementing? Is it worthy of broad-scale adoption?

  • Who are my target audience(s) for behavior change? Do I understand their knowledge, attitudes, beliefs, and behaviors about what I want to disseminate and implement?

  • Who are other stakeholders affected by the implementation? What are their opinions – are they in favor, against, or neutral? How might this influence adoption among my target audience? How should I address this?

  • How does my target audience view what I want to disseminate and implement? Can I frame what I want to disseminate and implement so the value-added benefit is clear and persuasive?

  • What are potential barriers to adoption that I should address in the design of my translation plan? What are potential facilitators that I can leverage?

Read Chapter 4