Implementation strategies

Implementation strategies
Dagu Implementation science workshop
Hawassa University, August 21-25, 2017
E-mail: anna.bergstrom@kbh.uu.se

What is an implementation
strategy?
Clinical intervention: The ‘what-to’
implement component, e.g.
exclusive breastfeeding
Implementation strategy: The
‘how-to’ implement component,
e.g. lecture, training, audit-
feedback etc.
The implementation strategy is essentially the
intervention tested in a implementation science

Implementation strategy
definition
“methods or techniques used to
enhance the adoption, implementation,
and sustainability of a clinical program
or practice”
Proctor et al, 2013

The problem
As far as optimizing quality and safety
of patient care is concerned, there is no
convincing evidence that any particular
strategy is more effective than another
in any particular situation.

Effective implementation
 Assessing the actual performance and
mapping the problems relating to the
practice change
 Analyzing the target group and the
setting: what factors are stimulating or
hampering the process of change?
 Formulating a concrete, well-developed
and attainable proposal for change with
clear targets including a description of
developed or selected strategies for
change.
Grol and Wensing, Improving Patient Care: The Implementation of Change in Health Care

Effective implementation cont.
 Developing and executing an
implementation plan containing
activities, tasks, time schedule and
clear roles
 Integrating the improvement within the
normal practice routines
 Evaluating and revising the plan:
continuous monitoring on the basis of
indicators
Grol and Wensing, Improving Patient Care: The Implementation of Change in Health Care

Phases of change
 Orientation: promote awareness, stimulate
interest and involvement
 Insight and understanding: create
understanding, develop insight into the own
routines
 Acceptance: develop positive attitude for
change, create positive intentions or
decisions to change
 Change: try out change in practice, confirm
benefit and value of change
 Maintenance: integrate new practice into
routines, embed new practice in the
organization

Effective Practice and
Organization of Care group
(EPOC) taxonomy
To undertake systematic reviews of
educational, behavioural, financial,
regulatory and organisational
interventions designed to improve health
professional practice and the
organisation of health care services.
http://epoc.cochrane.org/our-reviews

EPOC cont.
 Delivery arrangements: Changes in how, when and
where healthcare is organized and delivered, and who
delivers healthcare
 Financial arrangements: Changes in how funds are
collected, insurance schemes, how services are
purchased, and the use of targeted financial incentives
or disincentives
 Governance arrangements: Rules or processes that
affect the way in which powers are exercised,
particularly with regard to authority, accountability,
openness, participation, and coherence
 Implementation strategies: Interventions designed to
bring about changes in healthcare organizations, the
behaviour of healthcare professionals or the use of
health services by healthcare recipients
http://epoc.cochrane.org/epoc-taxonomy

EPOC – Implementation
strategies
 Interventions targeted at healthcare
organisations (n=3): Strategies to change
organisational culture
 Interventions targeted at healthcare
workers (n=33): Audit and feedback,
Clinical incident reporting, Continuous
quality improvement, Educational
meetings, Educational games, Inter-
professional education and reminders
 Interventions targeted at specific types of

An example: Interventions targeted at specific
types of practice, conditions or settings
Interventions that will increase and
sustain the uptake of vaccines in low- and
middle-income countries
Giving information about vaccination to parents and
community members, handing out specially designed
vaccination reminder cards, offering vaccines through
regular immunisation outreach with and without
household incentives (rewards), identifying
unvaccinated children through home visits and
referring them to health clinics, and integrating
vaccination services with other services may lead to
more children getting vaccinated. However, offering
parents money to vaccinate their children may not

Audit and Feedback
“Any summary of clinical performance of
health care over a specified period of time
given in written, electronic or verbal format”
Cochrane review Number of
trials
Median change on dichtomous
performance measures
Audit and feedback (Ivers, 2012) 108 +4.3%
Conclusion: Audit and feedback generally leads to
small but potentially important improvements in
professional practice. The effectiveness of audit and
feedback seems to depend on baseline performance
and how the feedback is provided. Future studies of
audit and feedback should directly compare different
ways of providing feedback.

Educational outreach visits
“Describe a personal visit by a trained
person to health professionals in their
own settings”Cochrane review Number
of trials
Median change on
dichtomous performance
measures
Educational outreach visits (O’Brien
2007)
34 +5%
Conclusion: Education outreach visits alone
or when combined with other interventions
have effects on prescribing that are relatively
consistent and small, but potentially
important. Their effects on other types of
professional performance vary from small to
modest improvements.

(Electronic) Reminders
Includes paper-base and computer-
based remindersCochrane review Number of
trials
Median change on dichtomous
performance measures
Electronic reminders (Arditi, 2012) 32 +7% (+4% if together with
other strategies)
Conclusion: There is moderate quality evidence that
computer-generated reminders delivered on paper to
healthcare professionals achieve moderate improvement in
process of care. Two characteristics emerged as significant
predictors of improvement: providing space on the
reminder for a response from the clinician and providing an
explanation of the reminder’s content or advice. The
heterogeneity of the reminder interventions included in this
review also suggests that reminders can improve care in
various settings under various conditions.

Financial incentives
Cochrane review Number of trials
Financial incentives (Flodgren,
2011)
32
“Financial incentives are sources of motivation
when an individual receives a monetary transfer
which is made conditional on acting in a particular
way”
Conclusion: Financial incentives may be
effective in changing healthcare professional
practice

Inter-professional education
”An intervention where the members of more
than one health or social care profession, or
both, learn interactively together, for the explicit
purpose of improving interprofessional
collaboration or the health/well being of
patients/clients, or both.”
Cochrane review Number of trials
Inter-professional education (Reeves
2013)
15
Conclusion: These studies reported some positive
outcomes, due to the small number of studies and
the heterogeneity of interventions and outcome
measures, it is not possible to draw generalisable
inferences about the key elements of IPE and its
effectiveness.

Which strategies work best?
Grol and Grimshaw, Lancet

Challenges relation to effect
measures
Use mass media
Use media to reach large numbers of people
to spread the word about the clinical
innovation
Distribute educational material
Distribute educational materials (including
guidelines, manuals, and toolkits) in person,
by mail, and/or electronically
Powell et al, 2015

Modifiable elements of audit
and feedback
 Content: Comparative or not, anonymous or
not?
 Intensity: Monthly, quarterly, semi-annually,
annually?
 Method of delivery: By post, peer, or non-
peer?
 Duration: Six months, one year, or two
years?
 Context: Primary care or secondary care?
288 combinations Eccles et al., 2006

Challenges relation to effect
measures
 Terms and definitions for implementation
strategies are inconsistent
 Inconsistent use of words (same word has
multiple meaning/different terms having the
same meaning)
 Description of implementation strategies
too often do not include sufficient detail to
enable either scientific or real-world
replication

Prerequisites to measuring
implementation strategies
Name and define the implementation
strategies in ways that are consistent
with the published literature, and
carefully specify the following elements:
 Actor: who enacts the strategy?
 Action(s): what are the specific
actions, steps, or processes that need
to be enacted?
 Action target: what constructs are
targeted? What is the unit of analysis?Proctor et al., 2013

Prerequisites to measuring
implementation strategies cont.
 Temporality: when is the strategy
used?
 Dose: what is the intensity?
 Implementation outcome: what
implementation outcome(s) are likely
to be affected by each strategy?
 Justification: what is the empirical,
theoretical, or pragmatic justification
for the choice of implementation
strategy? Proctor et al., 2013

Effective implementation of
improvements
 The cognitive approach - considering and
weighing rational arguments. Selected
strategy: Evidence-based medicine and
guidelines
 The motivational approach - driven by
internal motivation. Selected strategy:
Problem based learning
 The marketing approach - attractive
messages
Selected strategy: Needs analysis, using

Effective implementation of
improvements cont.
 Social interaction - learn and change by the
example
Selected strategies: opinion leaders,
outreach visits
 Management approach - poor quality care is
a ‘systems problem’. Selected strategies:
redesigning care processes, teambuilding
 Control and compulsion - the power of
external pressure. Selected strategies:
legislation, inspection, performance

Adopter categories
Time
Middle majority

Sub-groups response to
strategies
Innovators Middle
majority
Laggards
Motivatio
n to
change
Intrinsic, seeing
the advantages
Belonging to a
group, relation to
others
Extrinsic,
coercion,
economic
pressure
Effective
influence
Aimed at
cognition
Aimed at attitude Aimed at
behavior
Methods Good
information,
credible sources,
written methods
Personal
sources, opinion-
leaders, activities
with colleagues,
feedback from
Regulations and
agreements,
reward and
sanctions, help
with practical
Green et al 1989, Grol 1992. Rogers 200

The problem
As far as optimizing quality and safety
of patient care is concerned, there is
neither convincing evidence that any
particular strategy is more effective than
another in any particular situation…
…nor if it is better to use one or
multifaceted strategies

Tailoring
Strategies that are designed to achieve
desired changes in healthcare practice based
on an assessment of determinants of
healthcare practice.
Systematic tailoring entails three key steps:
 Identification of factors influencing of
healthcare practice
 Designing implementation strategies
appropriate to the identified factors
 Application and assessment of
implementation strategies that are tailored
to the identified factors.
Wensing M et al. Impl Sci 2011

Barriers and facilitators
Factors that might prevent or enable
improvements, including factors that can
be modified and non-modifiable factors
that can be used to target interventions
Oxman, 2011
 The innovation
 The users (‘different levels’)
 The practice setting (local context)
 The organization
 The outer context

The innovation
 Underlying
knowledge
sources
 Clarity
 Degree of fit with
existing practice
and values
(compatibility or
contestability)
 Degree of novelty
 Useability
 Relative
advantage
 Trialability
 Observable
results
Kitson and Harvey, 201

The users (recipients)
 Motivation
 Values and beliefs
 Goals
 Skills and
knowledge
 Time, resources
and support
 Local opinion
leaders
 Collaboration and
teamwork
 Existing networks
 Learning
environment
 Power and
authority
 Presence of
boundaries

Inner context (practice
setting)
 Formal and informal leadership
support
 Culture
 Past experience of innovation and
change
 Mechanisms for embedding change
 Evaluation and feedback processes

Inner context (organizational
level)
 Organisational priorities
 Leadership and senior management
support
 Culture
 Structure and systems
 History of innovation and change
 Absorptive capacity
 Learning networks

Outer context
 Organisational priorities
 Policy drivers and priorities
 Incentives and mandates
 Regulatory frameworks
 Environmental (in)stability
 Inter-organisational networks and
relationships

Known barriers and
facilitators
 Knowledge management (overload)
 Structural barriers (e.g. financial
disincentives),
 Organizational barriers (e.g.
inappropriate skill mix, lack of facilities
or equipment)
 Peer group barriers (e.g. local
standards of care not in line with
desired practice)
 Professional (e.g. knowledge,

How to identify these factors?
 Qualitative methods (interviews, focus
groups)
 Direct observations (NB: ethics!)
 Surveys
No standard approaches available yet
Grimshaw et al., 2012

Assignment (only a few
examples!)
 Could your study inform the selection of
implementation strategy/strategies?
 Are barriers and facilitating factors for selecting
implementation strategy something that would be of
interest to study in your PhD?
 Is adoption and maybe modification of
implementation strategies something that would be of
interest to study in your PhD?
 Would it make sense to investigate the characteristics
of the innovation, the recipients or the context in
which the OHEP is implemented?
 Could your study evaluate the effect of an (or a
package of!) implementation strategies?

Why what works where
Understanding ‘context’ is regarded as a
priority field in implementation science
including the need to systematically
study the attributes of context
influencing the implementation of
interventions.
Kanouse D, Int J Technol Assess Health Care, 1988
Siddiqi K, Int J Qual Health Care 2005
English M, Arch Dis Child, 2008
Dieleman M, Health Research Policy and Systems, 2009
McCoy D, International Health, 2010

Context
Assessment for
Community
Health
(COACH)
tool
Investigating why what
works where in low- and
middle-income settings

The COACH group
Bangladesh
Dr Anisur Rahman
Dr Jesmin Pervin
Vietnam
Associate Professor Dinh P. Hoa
Dr Nga Nguyen
Mr Duc Minh Duong
Nicaragua
Dr Elmer Zelaya Blandón
Uganda
Dr Peter Waiswa
South Africa
Professor Mark Tomlinson
Mrs. Sarah Skeen
Canada
Professor Carole A. Estabrooks
Associate Professor Janet Squires
Sweden
Professor Lars-Åke Persson (PI)
Dr Anna Bergström
Professor Lars Wallin
Professor Petter Gustavsson
Associate Professor Carina Källestål
Associate Professor Mats Målqvist
Dr Katarina Selling
Professor Stefan Peterson

Context
42
Global
National
Regional
Provincial
District
Health
centre/unit/community
The environment or setting in which the proposed
change is to be implemented.
Kitson A, Qual Health Care, 1998

COACH dimensions and definitions

e.g. Work culture
Please think about the unit where you work most of the time and say how much you
agree/disagree with the following statements:
Item
Strongly
Disagree
Disagree
Neither
Agree nor
Disagree
Agree
Strongly
Agree
30. My unit is willing to use new
healthcare practices such as
guidelines and recommendations.
31. My unit helps me to improve and
develop my skills.
32. I am encouraged to seek new
information on healthcare practices.
33. My unit works for the good of the
clients and puts their needs first.
34. Members of the unit feel
personally responsible for improving
healthcare services.
35. Members of the unit approach
clients with respect.
For health worker in a health facility the concept of: Unit means the ward or primary health care centre where you are
working most of the time. Client means the person seeking health services from this unit.
For community health workers: Unit means the group of colleagues and supervisors you are part of. Client means the
members of the community to whom you provide services to.

Conclusion
We foresee alternative ways of applying
the COACH tool:
 As means of characterizing context
ahead of implementing health
interventions – tailoring
 To deepen the understanding of the
outcomes of implementation efforts.
 To address and act on locally
identified shortcomings of the health
system

Van Woerkom taxonomy
Adapted from Woerkom 1990

Plas et al. taxonomy
 Strategies targeted at individuals (end
users): mass media, personal material,
large group meetings
 Strategies aimed at organizational
structures: Changes in skill mix, role
(revisions), physical environment
 Strategies aimed at work processes:
standardizing/ redesigning work processes
 Strategies aimed at organizational
processes: Changes in internal/external

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