Implementing Evidence-Base Practices: Be An EBP Know-It-All!!

1. Implementing Evidence-Base Practices: Be An EBP Know-It-All!! Brandeis U / Suffolk U: Educational Forum Wayne Stelk, Ph.D., VP, Quality Management Massachusetts Behavioral Health Partnership September 28, 2005

2. Know: Your EBP Product

3. The Evidence Hierarchy • Randomized controlled studies • Scientifically sound experimental studies • Level I or Level II practice modified and applied to a different population or in a different setting • Sound research, with documentation of service procedures and positive outcomes • Practice not research-based or replicable

4. Practice GuidelineLower Fidelity Demands • Practice Guideline • A clinical intervention typically developed through a formal process, based on authoritative “consensus” about the clinical literature • Intervention specifications are recommended, but the specific application of the intervention for the patient is at the discretion of the clinician

5. Evidence-Base PracticeHigher Fidelity Demands • Clinical intervention based upon rigorous research that shows positive outcomes consistently in repeated research studies • The randomized clinical trial (RCT) is the “gold standard” of evidence • As “manualized” treatment, clinicians must strictly adhere to all clinical standards as developed in the research protocol (fidelity)

6. What is a “Treatment Effect”?

7. Common Factors vs Specific Effects

8. Know:Your Audience

9. How Innovative Are We?Practice Guideline Usage Survey of BH Practitioners (N = 114) • Heard about practice guidelines? • Psychiatrists: 94%; psychologists: 81%; social workers: 42% • Inclined to use practice guidelines? • Psychiatrists: 88%; psychologists: 55%; social workers: 81% • Aware of a particular guideline? • Psychiatrists: 88%; psychologists: 13%; social workers: 18% • Actually used a practice guideline? • Psychiatrists: 64%; psychologists: 6%; social workers: 18% • (Reference: Mullen and Bacon, 2005)

10. Clinician Characteristics/Effects(Mostly Ignored in Research Design) • Objective Characteristics • Age, sex, ethnicity, socioeconomic background • Cross-Situational Traits • Personality and coping patterns; emotional well-being; values, attitudes, beliefs; cultural attitudes • Therapy-Specific States • Professional training; therapeutic style; choice of treatment interventions • Clinician/Client Relationship • Therapeutic alliance; treatment expectations • (Reference: Wampold, 2001, p. 185)

11. Know: Your EBP Implementation Strategy

12. What is Innovation Diffusion? • Innovation = • An idea, practice, or object that is perceived as new to the individual or organization • Diffusion = • The communication of an innovation through certain channels over time among members of a social system • Innovation creates UNCERTAINTY • Diffusion strategies must overcome uncertainty

13. Crossing the Chasm

14. Factors Affecting Rates of Innovation Adoption • The attributes of the innovation (EBP) • (this factor explains 50% of the variance in the rate of adoption) • Adopter (clinician) characteristics • The communication channels (about which we don’t know much for clinicians) • The social culture and structure (agencies) • Extent of change agents’ promotion efforts

15. Factors Affecting Rate of Adoption • Relative advantage of the EBP • Cost, status, incentives, mandates • Compatibility (avoid “empty vessel” error) • Adopter values, beliefs, needs, professional training, indigenous knowledge • Complexity • Negatively related to rate of adoption • Triability • Positively related to rate of adoption • Observability • The more observable the results, the better the rate of adoption • Re-Invention • Positively related to rate of adoption (flies in the face of fidelity)

16. Stages in the Innovation-Decision Process(compared to Porchaska’s Stages-of-Change) • Knowledge Stage (Precontemplation) • Learn about requirements and necessary skills • Persuasion Stage (Contemplation) • Talk with others; form positive image; get peer support • Decision Stage (Preparation) • Seek additional information; try it out • Implementation Stage (Action) • Use innovation a regular basis • Confirmation Stage (Maintenance) • Weigh advantages and benefits of continued use

17. What Are the Elements of a Good Implementation Strategy? • Know that good EBP products will not sell themselves. • Simplistic EBP implementation plans are not useful, such as Plan-Do-Check-Act. • Implementation of EBPs is a complex task requiring: • Empirically-based planning; • A good product; • A good understanding of the adopter-clinician; • Clinician characteristics • Useful communication channels • A good understanding of organizational readiness for change; • A medium for implementing the EBP (who is the change agent?); and • Sufficient resources to build an EBP infrastructure to sustain and evaluate the new practices.

18. Final Thoughts • EBPs have traction in the public arena. • EBPs are stirring the pot in positive ways. • EBPs may not be the perfect solution, but they have much to offer. • We should be aware of both the upsides and downsides of EBPs. • We should be aware of the challenges (and costs) of implementation. • Massachusetts should be viewed as a leader in promoting and implementing EBPs.

19. References Mullen, E. J., & Bacon, W. (2004). Implementation of practice guidelines and evidence-based treatment: A survey of psychiatrists, psychologists, and social workers. In A. Roberts & K. Yeager (Eds.), Evidence-Based Practice Manual: Research and Outcome Measures in Health and human Services. New York: Oxford University Press. Rogers, E. (2003). Diffusion of Innovations (5th ed.). New York: Free Press. Wampold, B. E. (2001). The Great Psychotherapy Debate: Models, Methods, Findings. Mahway, NJ: Lawrence Erlbaum Associates.