Module 5: Implementation Science

Clinical research

does it work?

Effectiveness research

Does it work in real-world settings?

Quality Improvement

How can we improve local performance?

Change Management

How do we guide people through change?

Implementation Science

• How do we get evidence adopted and sustained at scale?

• closing the research-to-practice gap

• maturation leading to expansion to field to include dissemination

• the how and why interventions work or fail in real-world settings

• broader focus on implementation rather than improvement

  • identifying barriers limiting the use of innovations

  • Developing implementation strategies to overcome challenges

• emphasis on implementation and delivery of intervention

Common drivers for pharmacy practice transformation

• clinical practice

• adaptive leadership

• change management

• implementation science

Evidence Based Medicine

• conscious, explicit judicious use of current best evidence in making decisions about individual patients

• introduced d/t lack of agreement on best practices in patient care

Why use implementation science in healthcare?

• improve quality

• control costs

• maximize value

Efficacy/Effectiveness

whether an intervention works

Goal of Implementation Science

create generalized knowledge that can be applied and replicated beyond individual contexts/systems under study

Quality Improvement

• goal: solve healthcare delivery problems in specific contexts

• focus on improvement

• emphasis on rapid cycle testing

Where do implementation science and quality improvement overlap?

• Methods

• rooted in similar approaches and principles

Evidence-Based Intervention

service or practice supported by evidence

Adoption

initial decision to use an intervention

Implementation

active integration into routine workflows

Sustainability

continues use after initial launch

Fidelity

delivering the intervention as intended

Implementation Outcomes

• effects of deliberate and purposeful actions taken to implement new treatments, practices, and services

• distinct from healthcare outcomes

• 3 functions:

  • indicators of implementation success

  • proximal indicators of implementation processes

  • necessary precursors to achieving traditional effectiveness outcomes

Implementation Science frameworks

• determinant

• process

• evaluation

Determinant framework

• understanding/explaining factors that influence implementation outcomes

• factors hypothesized/found to influence outcomes

  • barriers, enablers, facilitators

Process Frameworks

• translating research into practice

• specify steps/stages in process of translating research into practice

• goal: describe and guide process of transitioning from research into practice

Evaluation Framework

• evaluating the implementation of a new practice

• specify aspects of implementation that could be evaluated to determine if implementation is successful

CFIR

• most widely used framework for identifying barriers and facilitators

• why implementation succeeds or fails

• “why”

CFIR 5 Domains

• innovation characteristics

• outer setting

• inner setting

• individuals

• implementation process

RE-AIM Framework

• evaluation framework

• determine whether a program has meaningful impact

• did the program make a difference?

• “did it work?”

RE-AIM Acronym

• R: Reach

• E: Effectiveness

• A: Adoption

• I: Implementation

• M: Maintenance

EPIS Framework

• focuses on stage of implementation over time

• before, during, and after implementation

• “how?”

EPIS Stages

• E: Exploration

• P: Preparation

• I: Implementation

• S: Sustainment

8 Core Implementation Outcomes

• acceptability

• adoption

• appropriateness

• cost

• feasibility

• fidelity

• penetration

• sustainability

Selection of implementation outcomes depends on

• research questions of interest

• implementation stage

• relevance to stakeholders involved with implementation process

What is implementation science concerned with?

• who

• what

• how

• when

Implementation practice

• applying evidence-based knowledge/strategies to enhance quality of implementation

• focus on “doing” or “how-to”

Implementation research

focus on evaluating the most effective approaches for implementing an innovation

Efficacy

innovation works under ideal/controlled circumstances

Effectiveness

innovation works under controlled, but more routine, real-world conditions

Dissemination research

focus on spread and sustainability of knowledge about an intervention

Dissemination science

scientific application and study of targeted distribution of information and evidence to a specific public health or clinical practice audience using planned strategies

Effective interventions are

• well-implemented

• evidence-based

Seminal work has recently focused on

• defined implementation strategies

• operationalizing implementation outcomes

• outlining methodological approaches that are most appropriate for conducting implementation research

How to select framework

• guided by fit between the type of framework

• stakeholder’s underlying needs

AIF Framework

• conceptual and practical road map for implementers

• outline mechanisms and strategies needed to put into practice any innocation of known dimensions

• 5 core frameworks:

  • usable innovation

  • implementation stages

  • implementation drivers

  • implementation teams

  • improvement cycles

• rely on”formula for success” that suggests positive outcomes result from multiplying effects of effective innovation, implementation, and enabling contexts

• designed to operationalize the practices of implementation in real-world settings

Common assumptions of implementation frameworks

• recognize critical importance of context and multi-level influences on implementation

• needs and perspectives of all stakeholders should be considered

• use of active implementation design and facilitation

• implementation unfolds in stages

Most difficult stage of implementation

• post-implementation

  • expansion, sustainability, scaling

Acceptability

the perception among implementation stakeholders that a given innovation is agreeable, palatable, or satisfactory

Adoption

the intention, initial decision, or action to try or use an innovation

Appropriateness

the percieved fit, relevance, or compatibility of the innovation for a given practice setting, provider, or consumer, and/or percieved fit of the innovation to address a particular issue or problem

Cost

the cost impact (incremental or implementation cost) of an implementation effort

Feasibility

the degree to which an intervention was implemented as it was prescribed in the original protocol or as it was intended by the program developers

Penetration

the integration of an innovation within a service setting and its subsystems

Sustainability

the extend to which a newly implemented treatment is maintained or institutionalized within a service setting’s ongoing stable operations