Session 4: Frameworks used in Clinical Settings, Part 2

1. Session 4: Frameworks used in Clinical Settings, Part 2 Janet Myers, PhD, MPH Janet.Myers@ucsf.edu 415-597-8168 Session 2 ● September 27, 2012

2. Session 4 Overview • Review the rationale for frameworks • Fidelity Frameworks • Fidelity of Implementation • Framework for Implementation Fidelity • PARIHS Framework • Promoting Action on Research Implementation in Health Services • ORCA Framework • Organizational Readiness to Change • Frameworks exercise

3. Review – Why frameworks? Planning: To guide the selection and tailoring of programs or interventions. Implementation: To understand program “theory,” which can improve implementation Can guide timing/stages of implementation Evaluation: As a guide to evaluation Suggest formative evaluation/diagnostic analysis Guide the development of hypotheses to test. Facilitate interpretation of process and outcomes and the relationship between the two

4. FOI: Fidelity of Implementation To explain the degree to which evidence-based interventions succeed or fail. FOI occurs between context and program effectiveness

5. Framework for Implementation Fidelity Carroll et al “A conceptual framework for implementation fidelity” Implementation Science 2007 2:40.

6. SmartSTEPS ATSM Model

7. Conceptual Framework for Evaluating Intervention Fidelity of SMARTsteps

8. PARIHS

9. PARiHS Framework Elements • Evidence. • Context. • Facilitation. Weak to strong support for implementation

10. Evidence Sub-elements: • Research evidence. • Weak: Anecdotal evidence, descriptive. • Strong: RCTs, evidence-based guidelines. • Clinical experience. • Weak: Expert opinion divided. • Strong : Consensus. • Patient preferences and experiences. • Weak: Patients not involved. • Strong : Partnership with patients. • Local information.

11. Context Sub-elements: • Culture. • Weak: Task driven, low morale. • Strong : Learning organization, patient-centered. • Leadership. • Weak: Poor organization, diffuse roles. • Strong : Clear roles, effective organization. • Evaluation. • Weak: Absence of audit and feedback • Strong : Routine audit and feedback.

12. Facilitation Sub-elements: • Characteristics (of the facilitator). • Weak: Low respect, credibility, empathy. • Strong: High respect, credibility, empathy. • Role. • Weak: Lack of role clarity. • Strong: Clear roles. • Style. • Weak: Inflexible, sporadic. • Strong: Flexible, consistent.

13. PARiHS Framework: Elements and Sub-elements • Evidence. • Research • Clinical experience • Patient experience • Local knowledge • Context. • Culture • Leadership • Evaluation • Facilitation. • Characteristics • Role • Style

14. PARIHS Causal Pathways (from Kitson et al)

15. Limitations Used post-hoc Study designs: Only cross-sectional or retrospective Lack of conceptual clarity

16. ORCA Assesses 3 major scales corresponding to the core elements of PARIHS Evidence: published research, professional knowledge/competence, patient prefs, local context Context: Org culture, leadership, evaluation/feedback. Facilitation: Internal and external factors

17. Table 2: Planned Data Collection for each element of the Conceptual Framework (PARIHS) and Fidelity of Implementation (FOI)