Applying Multiple Frameworks and Theories in Implementation Research (Part 2)

1. Applying Multiple Frameworks and Theories in Implementation Research(Part 2) Jeffrey Smith Implementation Research Coordinator Mental Health QUERI

2. Outline • Review major points on multiple theory approach from April 14 cyberseminar • Provide example of application of multiple theory approach in MH QUERI project

3. Mental Health QUERI Approach to Implementation • Design interventions based on theory, lit review and results from formative evaluation • Conduct formative evaluation • engage with stakeholders • identify determinants of current practice • assess barriers and facilitators to implementation • organizational-level • team / clinic-level • individual provider-level • patient-level • tailor intervention design and implementation to local context

4. Mental Health QUERI Approach to Implementation (cont) • Use external facilitation techniques (PARiHS Framework) • engage with stakeholders to problem-solve and identify new strategies or tools for overcoming barriers when initial success is sub-optimal • Conduct summative (or impact) evaluation • assess intervention effects on targeted clinical processes and/or patient outcomes

5. Multiple Theory Approach Application of multiple frameworks/theories in guiding intervention design and implementation can be successful in implementing EBPs accommodates tailoring to setting when combined with formative evaluation acknowledges there are generally multi-level determinants to complex, clinical QI issues organizational-level team-level interpersonal-level individual-level

6. Antipsychotic Treatment Improvement Program (ATIP) • Goals • Improve adherence to CPGs for antipsychotic treatment of psychosis • Reduce use of very high doses of antipsychotic medications • Encourage use of newer “atypical” antipsychotic medications for non-responders to conventional antipsychotic medications

7. ATIP Application of Frameworks, Theory and Planning Models • Diffusion of Innovation (Rogers), Social Cognitive Theory (Bandura), Social Influence Theory (Mittman) • Utilize influential local clinician leaders (opinion leaders) to inform other clinical staff about evidence-based antipsychotic medication management, model-targeted prescribing behaviors, and motivate practice change • Complexity Theory • Initial conditions in HCOs are important in intervention planning, but HCOs are adaptive and change over time • Need mechanism for assisting clinical partners in modifying or adapting initial intervention strategy based on changing circumstances, initial success

8. ATIP Application of Frameworks, Theory and Planning Models (cont) • Promoting Action Research Implementation in Health Services (PARiHS) • Use external facilitation techniques to enable and assist clinical opinion leader with problem-solving; address challenges to intervention implementation • PRECEDE Planning Model (Predisposing, Reinforcing, and Enabling Constructs in Education Diagnosis and Evaluation) • Address predisposing factors (eg, knowledge, attitudes) that influence EBP adoption • Enable providers to follow guideline recommendations at the point of care • Apply social incentives through performance audit/feedback to reinforce providers’ implementation of EBPs

9. “Refined” Description of Facilitation Based on VA QUERI Experience* Facilitation is a process of interactive problem-solving and support to meet specific implementation goals, which occurs in the context of a recognized need for improvement and a supportive interpersonal relationship. * Stetler CB, et al. Implementation Science 2006; 1:23.

10. Operationalization of External Facilitation in MH QUERI (based on PARiHS) • Facilitator • Maintains regular contact w/ local QI leader / team • Email communication • Telephone • Participate in QI Team meetings (as feasible) • Assist in goal-setting; monitor implementation of project tools/strategies; performance on clinical QI goals • Identify and problem-solve barriers to implementation • Assist in adapting tools/strategies as needed or suggested by site partners to meet project goals

11. ATIP Intervention Components

12. Summative Evaluation • ATIP intervention improved antipsychotic medication management in concordance with CPGs (results varied by site) • Reduced pharmacy costs for antipsychotics (results varied by site) • Participating clinicians reported positive experiences with ATIP educational materials and clinical support tools

13. An Approach to Using Theory for Implementation Planning Select interventionsthat fit with plannedstrategies (based on theory) Select theory of planned behaviorchange Identify potential strategies for achieving change Assess fit with initial theory Evaluate effectivenessof intervention,strategies, tools Launch interventionusing identified toolsand strategies Identify interventiontools that fit bothstrategy and theory From: Sales A, Smith JL, Curran G, Kochevar L. Models, strategies and tools: The role of theory in implementing evidence-based findings into health care practice. Journal of General Internal Medicine 2006; 21:S43-49.

14. Formative Evaluation: Barriers and Lessons Learned • Physicians do not always agree on who is an opinion leader; some sites may have no opinion leader • Some sites had poorly developed formal and informal social networks among physicians • A focus on physicians only as agents of change • How much directive should be given to the opinion leaders on how to influence attitudes and behaviors? • Audit/feedback reports need to be more actionable From: Curran GM, Thrush CR, Smith JL, et al. Jt Commission J Qual Safety 2005; 31(12):700-707.

15. Strengths • useful in designing multifaceted interventions to influence multi-level determinants of care (flexible) • allows integration of theory, knowledge, methods from multiple disciplines (multidisciplinary) • Limitation • Can be unwieldy… need to provide rationale for applying multiple theory approach, and rationale for selecting the specific frameworks / theories applied • Key Guidance on Evaluation • combine with rigorous formative evaluation • conduct summative (impact) evaluation to assess intervention effectiveness on key study outcomes • confirm, refute or propose refinements to selected theory (or applied strategy based on selected theory) based on study findings Multiple Theory Approach

16. QUESTIONS? Contact: Jeff Smith VA Mental Health QUERI E-mail: Jeffrey.Smith6@va.gov

18. Stages of Formative Evaluation Pre-Implementation Post-Implementation Implementation • Interpretive • Assess intervention usefulness/value from stakeholder perspective • Elicit stakeholder recommendations for further intervention refinements • Assess satisfaction with intervention and implementation process • Identify additional barriers / facilitators • Implementation-Focused • Assess discrepancies between implementation plan and execution, exploring issues of fidelity, intensity, exposure • Understand and document nature and implications of local adaptation • Developmental • Identify determinants of current practice • Identify potential barriers / facilitators • Assess feasibility of proposed intervention • Integrate findings into intervention design and refinement prior to implementation • Progress-Focused • Monitor impacts and indicators of progress toward project goals • Use data to inform need for modifying or refining original strategy • Provide positive reinforcement to high performers; negative reinforcement to low performers