1 / 34

Philip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRC Philip M. Ullrich, Ph.D.

PARiHS Framework Promoting Action on Research Implementation in Health Services. Philip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRC Philip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRC. Philip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRC.

rune
Download Presentation

Philip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRC Philip M. Ullrich, Ph.D.

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. PARiHS FrameworkPromoting Action on Research Implementation in Health Services Philip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRC Philip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRC Philip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRC

  2. PARiHS Framework: History Features Proposed utility Application Example Philip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRC Philip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRC

  3. PARiHS Origins • Royal College of Nursing Institute, UK • 1990s • Contemporary models of the processes of implementing research into practice are inadequate. • Unidimensional • Non-interactive

  4. PARiHS Framework developmental aims: • Accurately represent the complexities of implementation. • Useful for explaining variability in the success of implementation projects. • Useful for guiding clinicians charged with implementing research into practice.

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

  6. 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.

  7. 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.

  8. 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.

  9. PARiHS Framework: Elements and Subelements • Evidence. • Research • Clinical experience • Patient experience • Local knowledge • Context. • Culture • Leadership • Evaluation • Facilitation. • Characteristics • Role • Style

  10. PARiHS Framework Successful implementation is most likely to occur when: • Scientific evidence is viewed as sound and fitting with professional and patient beliefs. • The healthcare context is receptive to implementation in terms of supportive leadership, culture, and evaluative systems. • There are appropriate mechanisms in place to facilitate implementation.

  11. PARiHS Framework developmental history: • 1998 - 2002. Development, conceptual analysis. • 2001-2003. Empirical case studies. • 2003 to present. Diagnostic/evaluative tool development.

  12. PARiHS Frameworkcurrent knowledge base: • Numerous case reports available, in support of face validity and practical appeal. • One published instrument related to PARiHS. • Theoretical positions of the framework are still in development.

  13. PARiHS Diagnostic and Evaluative utility? PARiHS Diagnostic and Evaluative grid: Kitson et al., 2008.

  14. Summary: Summary: Summary: Summary: • PARiHS framework has long been the subject of theoretical development. • Exploratory work in applying PARiHS to implementation interventions is encouraging. • Empirical foundations for the framework have not developed at pace with theory.

  15. Why PARiHS Framework for Spinal Cord Injury(SCI) QUERI?: SCI system of care and targets for change • Evidence • Research • Local • Clinical • Patient • Context Opportunities to work with other QUERI groups.

  16. Implementation Project Example 1 • SCI Pressure Ulcer Management Tool (SCI PUMT) • Implement a toolkit designed to standardize monitoring of pressure ulcer healing in the VA SCI system of care. • PUMT: • Training tools (education protocol, CD, models) • Competency assessment

  17. SCI PUMT Implementation 12 SCI centers randomized to receive one of two implementation strategies: • Simple: Local “champion” receives toolkit materials. • Enhanced: PARIHS-informed external facilitation strategy.

  18. SCI PUMT Enhanced facilitation Kitson et al., 2008.

  19. SCI PUMT Enhanced Facilitation • Diagnostic Assessment. Measure factors important to implementation at all participating sites. Specifically, the diagnostic assessment will measure: EVIDENCE: Appraisals of 4 sources of evidence: (1) Published scientific evidence. (2) Clinical experience or professional knowledge. (3) Patient experiences and beliefs. (4) Evidence derived from local experiences. CONTEXT: Appraisals of 3 aspects of context (1) Organizational culture. (2) Leadership. (3) Evaluation.

  20. SCI PUMT Enhanced Facilitation • Diagnostic Assessment. Measures: Organizational Readiness for Change Assessment (ORCA) 1) Questionnaire, 3 scales: Evidence, Context, Facilitation. Structured Interviews Evidence, Context, Facilitation.

  21. SCI PUMT Enhanced Facilitation • Depends upon results of diagnostic. • AND Pre-diagnostic efforts • Evidence: • Presentations of empirical research by nursing leaders. • Context • Involving national and local SCI leadership. • Facilitation • Selecting and training nurse facilitators.

  22. SCI PUMT Results Stay tuned!

  23. Applying Multiple Frameworks and Theories in Implementation Research Jeffrey Smith Implementation Research Coordinator Mental Health QUERI

  24. “In theory there is no difference between theory and practice… in practice there is.” Yogi Berra

  25. 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

  26. 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

  27. An Approach to Using Theory for Implementation Planning Select framework / theory / model of planned behavior change Select interventionsthat fit with plannedstrategies (based on theory) 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 Adapted 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.

  28. Implementation Science Frameworks and Theories (selected) • Organizational / System Level • Consolidated Framework for Implementation Research (VA Diabetes QUERI) • Promoting Action on Research Implementation in Health Services (PARiHS) • Stetler Organizational Framework for Institutionalizing EBPs • Greenhalgh Model for Diffusing Innovations in HCOs • Ottawa Model of Research Use • Simpson Transfer Model • Complexity Theory

  29. Implementation Science Frameworks and Theories (cont.) • Interpersonal Level • Diffusion of Innovation (Rogers) • Social Influence Theory (Mittman) • Social Cognitive Theory… aka Social Learning Theory (Bandura) • Individual Level • Theory of Reasoned Action / Theory of Planned Behavior (Azjen & Fishbein) • Health Belief Model (Rosenstock) • Transtheoretical Model and Stages of Change (Prochaska & DiClemente)

  30. Multiple theory approach • Strengths • useful in designing multifaceted interventions to influence multi-level determinants of care (flexible) • allows integration of theory, knowledge, methods from multiple disciplines (multidisciplinary) • Limitations • 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(ies) based on study findings

  31. Summary 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 example forthcoming (May 5 session) acknowledges there are generally multi-level determinants to complex, clinical QI issues organizational-level team-level interpersonal-level individual-level

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

More Related