RIISE Module 2; Implementation Strategies

Definitions and examples of key terminology

What are implementation strategies?

Methods or techniques used to enhance the adoption, implementation, sustainment, and scale-up of a program or practice

Types of strategies (overview) definition

Implementation strategies range from those that are very targeted and time-limited to more complicated and extensive processes with many moving parts. Many implementation experts differentiate between discrete strategies and multifaceted strategies. To be most impactful, strategies should be selected that target high-priority implementation determinants (i.e. barriers or facilitators)

Discrete strategies definition

single actions or processes

Multifaceted strategies definition

combination of multiple discrete strategies;

multiple implementation strategies delivered at the same time may accumulate, amplify, converge, or facilitate each other to maximize effects

Examples of discrete strategy

Example of multifaceted implementation strategy

Multiple implementation strategies delivered at the same time may accumulate, amplify, converge, or facilitate each other to maximize efforts.

Accumulation definition

strategies at different levels produce a cumulative impact on a common mediating pathway or set of mediating pathways

Amplification definition

One strategy increases the target audience’s receptivity to other strategies

Convergence definition

Strategies at different levels mutually reinforce each other by altering patterns of interaction among two or more target audiences

Facilitation definition

One strategy removes the barriers or facilitates the effect of other strategies

Two compilations that describe different discrete and multifaceted approaches

ERIC and SISTER (for schools)

ERIC defintion

Expert Recommendations for Implementing Change (ERIC) - a compilation of healthcare-sector recommendations to catalogue all known implantation strategies and work toward common definitions. In 2015, ERIC project identified 73 unique implementation strategies.

SISTER definition

School Implementation Strategies, Translating ERIC Resources (SISTER) - adapted ERIC compilation to align with school settings. Resulted in 75 school-adapted strategies.

SISTER categories

• use evaluative and iterative strategies

• adapt and tailor to context

• train and educate stakeholders

• engage consumers

• change infrastructure

• provide interactive assistance

• develop stakeholder interrelationships

• support clinicians

• utilize financial strategies

SISTER Go Zone Plot - definition and graphic

a rating activity to determine which strategies they felt were most feasible and important - Go Zone reflects those determined to be high on both dimensions

Matching implementation strategies to determinants

A critical step of selection process - see example of matching

Potential pitfalls and missteps in implementation strategy selection

• train and pray

  • training alone does not result in practice change

• one size fits all

  • insufficient customization of strategies is less effective than contextually-responsive approaches

• everything but the kitchen sink

  • over complicated strategies that try to do too much are more difficult to implement

• ISLAGIATT

  • it seemed like a good idea at the time; expensive approach to trial and error

CFIR-ERIC Matching tool definition and graphic

this tool supports the identification of strategies based on the barriers or facilitators they are likely to impact

ASPIRE definition

Adapting Strategies to Promote Implementation Reach and Equity is a three-step process for adapting equity-explicitly implementation strategies

ASPIRE Step 1

Identify the underlying assumptions

• How and why is the implementation strategy supposed to work and for whom?

• What would need to be true about the implementation strategy to promote equitable outcomes?

ASPIRE Step 2

Identify potential sources of disparities

• Who is involved in the implementation strategy?

• What resources are necessary to engage in the implementation strategy?

• What is the process for enacting the implementation strategy?

• What are the potential outcomes of the implementation strategy?

ASPIRE Step 3

Adapt the strategy to ensure that equity is considered and that it has explicit potential to reduce disparities

• The necessary people and actors involved

• The process or steps that need to be enacted

• The outcomes that need to be considered

3 Key steps in ASPIRE

1. Identify underlying assumptions

2. Identify potential sources of disparities

3. Adapt the strategy to ensure that it has the potential to reduce disparities

Consider equity during each of these steps to improve designing and tailoring of strategies (4 ways)

1. Identify who (individuals or professional groups) needs to do what differently in order for implementation to be improved

2. Using informal and formal theory frameworks, identify barriers and enablers that need to be resolved. Articulate a pathway for the targeted behavior change to occur. A variety of research methods, including literature reviews and local qualitative an quantitative data collection, should be used to support the development of the theory of change.

3. Select implementation strategies (behavior change techniques, modes of delivery) that might be effective, loyally relevant, acceptable and feasible to overcome identified barriers and enhance facilitators to change. Selection of strategies could be based on matrices recommended by determinant frameworks, empirical evidence, and engagement with end users.

4. Decide how change in implementation can be robustly and feasibly measured, including factors on the hypothesized causal pathway (mediators) and appropriate implementation outcomes

Implementation mechanism definition

the processes or events through which implementation strategies operate to bring about positive implementation outcomes

What does the specification of mechanisms allow for?

• Investigation of null effects

• Replication of positive findings

• Identification of which strategy components are inert or unnecessary

• Adaptation of strategies to fit new contexts

CPD Definition

Causal Pathway Diagrams (CPD) - a tool for guiding thinking and building collaborative understanding to avoid random acts of intervention

Similar to a logic model or a theory of change but less holistic with greater focus on =

• mechanisms of change (the rationale, or why the “stuff we do” is expected to make people use “the thing”)

• Possible barriers to the mechanisms

• Moderators of why the mechanism might or might not work

• Preconditions necessary for the mechanism working

CPD Flowchart

Intervention Mapping Defintion

another method for tailoring implementation strategies that uses a sequence of 5 tasks to support strategy

5 Tasks of Intervention Mapping

1. Task 1: Collect and analyze data

2. Task 2: State expected outcomes

3. Task 3: Generate themes and scope

4. Task 4: Refine structure

5. Task 5: Develop measures

Evidence for Effectiveness

Using implementation strategies improves whether an EBP is conducted or how well it is performed; three quarters of studies (77%) show that a more intensive implementation effort is more effective than a less intensive comparison

Big picture themes from PCORI

Patient-Centered Outcomes Research Institute provided key findings about implementation strategy effectiveness -

• Individual strategies vary widely in their frequency of use

• Implementation strategies demonstrate stronger effects on practice change (i.e. implementation outcomes) than on service recipient outcomes

• The evidence for specific implementation strategies is generally very limited

• Nearly all studies use educational meetings (i.e. training/PD) and distribution of educational materials

Impact of poor reporting

• It hinders efforts to systematically design and tailor implementation strategies

• It limits our ability to learn from negative and replicate positive findings

• It prevents the successful adaption of an adaptation of an implementation strategy developed in one setting to another

• It limits understanding of generalizability and the role of context in implementation

Name it, Define it, Specify it Graphic

Examples of links between determinants, implementation strategies, mechanisms and implementation outcomes

What are the results of poor tracking, specification, and reporting?

• Limits replication in science and practice

• Precludes answers to how and why strategies work

Developing and ___ implementation strategies are ___ to contemporary implementation research

testing, foundational

Strategies should be ___ based on their likelihood of impacting specific, _____

selected, prioritized barriers and facilitators

Research on the ___ of implementation strategies is ___, with the strongest evidence across ___and ___ settings for training/PD, coaching, distribution of educational materials, and audit and feedback

impact, still emerging, education, health

Understanding the ___ through which implementation strategies have their impact should drive their ___, ___, and ___

mechanisms, selection, operationalization, evaluation