demystifying knowledge transfer- an introduction to implementation science master class (newcastle...
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Powerpoint presentation from 'Demystifying Knowledge Transfer: an introduction to Implementation Science' - 28th May 2014. Facilitated by Professor Jeremy Grimshaw and Dr Justin PresseauTRANSCRIPT
Collaborating for Better Care
PartnershipMaster Class: ‘Demystifying Knowledge Transfer’:
Implementing Evidence Based Guidance
An introduction to Implementation Science
28th May 2014
International Centre for Life
@AHSN_NENC@JPresseau
Welcome and Introduction
Professor Paula Whitty
Director of NEQOS & Acting NENC AHSN
Knowledge & Information Programme lead
Programme10.10 Session 1: Implementing evidence based guidance11.00 Session 2: Case studies (working in pairs-followed by group feedback)11.30 Coffee & biscuits11.45 Session 3a: Behavioural approaches to implementing evidence based guidance
Identifying barriers and modifiable determinants12.15 Sessions 3b: Identifying barriers and modifiable determinants of implementation
Neighbour discussion (15 mins) plus some feedback time (15 mins). Jeremy/Justin barrier assessment in case studies
13.15 Lunch14.00 Session 4: Behavioural approaches to implementing evidence based guidance
Designing implementation programmes (Justin and Jeremy)Case studiesNeighbour discussion (15 mins) plus some feedback time (15 mins)
15.15 Coffee15.30 Session 5: Implementation design in case studies (Justin and Jeremy)16.00 Summary, conclusions and group discussion - Jeremy16.20 Concluding remarks - Paula/Jackie16.30 Close
Greetings from Ottawa
Greetings from Newcastle
Session 1: Implementing
Evidence Based Guidance
Prof Jeremy Grimshaw
Dr Justin Presseau
Session 1
Core concepts
Knowledge creation funnel
Background
‘All breakthrough, no follow through’Woolf (2006) Washington Post op ed
Much of the US $100 billion/year worldwide investment in biomedical and health research is wasted because of dissemination and implementation failures
Background
Institute of Medicine; Clinical Research Roundtable, Sung et al. JAMA 289:1278,2003
Background
Why do we need to think about implementation?• Consistent evidence of failure to translate
research findings into clinical practice– 30-40% patients do not get treatments of proven
effectiveness– 20–25% patients get care that is not needed or
potentially harmfulSchuster, McGlynn, Brook (1998). Milbank Memorial Quarterly
Grol R (2001). Med Care
• Suggests that implementation of evidence based care is fundamental challenge for healthcare systems to optimisecare, outcomes and costs
How do healthcare organisations currently address
quality challenges?
Issue guidance
Internal solutions
ISLAGIATT principle
Martin P Eccles
‘It Seemed Like A Good Idea At The Time’
Designing interventions
If you have a hammer, everything looks like nail
External
solutions
External solutions
External solutions
Throw everything at the problem!
16 28 46 63 56 N =
Absolute effect size
Number of interventions in treatment group
>4 4 3 2 1
80%
60%
40%
20%
0%
-20%
-40%
-60%
-80%
Grimshaw et al (2004) Health Technology Assessment
To date, many organisational responses to poor implementation have failed to achieve optimal
care despite considerable investments
Most approaches to changing clinical practice are more often based on beliefs than on scientific
evidence
‘Evidence based medicine should be complemented by evidence based implementation’
Grol (1997). British Medical Journal
Could we do better?
Undoubtedly
Implementing evidence based
practices
• Implementation is about ensuring that stakeholders are aware of and use research evidence to inform their decision making and actions to improve processes and outcomes of care
Implementing evidence based
practices
• Successful implementation depends upon:
– Internal knowledge (eg performance data, tacit knowledge of how organisation (and individuals) work)
– External knowledge (eg clinical and implementation science)
– Behaviour and organisational change expertise
Implementing evidence based
practices
Quality by any means necessary suggests need to use all tools and levers at your disposal
Implementation Science
• Implementation is a human enterprise that can be studied to understand and improve implementation approaches
• Implementation science is the scientific study of the determinants, processes and outcomes of implementation.
• Goal is to develop a generalisable empirical and theoretical basis to optimise implementation activities
Implementation Science
applied health researchcapacity buildingco-optation - cooperation - competingdiffusion*dissemination* getting knowledge into practiceimpactImplementation*knowledge communicationknowledge cycleknowledge exchange knowledge managementknowledge translation
knowledge mobilization knowledge transfer linkage and exchangepopularization of research, research into practiceresearch mediationresearch transferresearch translation science communication teaching“third mission” translational research transmission utilization
*cited most frequently
Implementation Science
Implementation Science
Implementation Science
Implementation science
• Implementation science is a research relatively new field in health research
• Inherently interdisciplinary
• Wide range of disciplines need to be engaged
– Clinical
– Health services research
– Social sciences
– Design and engineering
– Informatics
– Methodologists
• Broad range of forms of enquiry needed
Implementation science• Knowledge synthesis (what care should we be providing, what do we
know about the effectiveness of different implementation approaches); • Research into the evolution of and critical discourse around research
evidence; • Research into knowledge retrieval, evaluation and knowledge
management infrastructure• Identification of implementation failures;• Development of methods to assess barriers and facilitators to
implementation;• Development of the methods for optimising implementation programs;• Evaluations of the effectiveness and efficiency of implementation
programs;• Sustainability and scalability of implementation programs;• Development of implementation science theory; and• Development of implementation science research methods.
Knowledge to action cycle
Knowledge to
action cycle
Graham et al (2006).
Lost in Knowledge
Translation. Time for
a Map? Journal of
Continuing Education
for Health
Professionals
Knowledge creation funnel
Potential barriers to evidence based practice –knowledge management
• Over 20,000 health journals published per year– Average time professionals have available to read = <1 hour/week
• Published research of variable quality and relevance– Research users (consumers, health care professionals, policy makers,
researchers) often poorly trained in critical appraisal skills
• Individual studies rarely by themselves provide sufficient evidence for policy or practice changes– Individual studies are often misleading
Don’t believe the hype: early highly
positive results often contradicted
• Analyzed 115 articles published in 1990-2003 in the 3 major general medical journals (NEJM, JAMA, Lancet) and specialty journals that had received over 1000 citations each by August 2004
• 49 reported evaluations of health care interventions; 45 claimed that the interventions were effective.
• By 2004 5/6 non randomised studies and 9/39 randomised trials were already contradicted or found to be exaggerated
Don’t believe the hype: early highly
positive results often contradicted
Ioannidis JP. JAMA 2005
Don’t generate the hype
• AHSC release average of 49 press releases annually
• 44% promoted animal or laboratory research
– 74% of these explicitly claimed relevance to human health.
• 47.5% were about primary human research
– 23% omitted study size
– 34% failed to quantify results
– 17% promoted studies with the strongest designs (randomized trials or meta-analyses)
– 40% reported results of weak designs (uncontrolled studies, small samples (30 participants), surrogate primary outcomes, or unpublished data) but 58% lacked relevant caution
Don’t generate the hype
Knowledge creation funnel
Systematic reviews are a generic methodology used to synthesise evidence from a broad range of research methods addressing different questions
Knowledge creation funnelThe steps involved in undertaking a systematic review include
– stating the objectives of the research
– defining eligibility criteria for studies to be included
– identifying (all) potentially eligible studies
– applying eligibility criteria
– assembling the most complete dataset feasible
– analysing this dataset, using statistical synthesis and sensitivity analyses, if appropriate and possible
– preparing a structured report of the research.
Systematic reviews are a generic methodology used to synthesise evidence from a broad range of research methods addressing different questions
– Effectiveness of health care interventions– Diagnostic and screening tests– Determinants of health– Aetiological epidemiological studies– Genetic epidemiological studies– Health system issues (eg quality of discharge coding)– Qualitative methods – consumers’ experiences of
health care
Knowledge creation funnel
Knowledge creation funnel
Clarke MJ, Hopewell S, Juszczak E, Eisinga A, Kjeldstrøm M. Compression stockings for preventing deep vein thrombosis in airline passengers. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004002.
Knowledge creation funnel
Knowledge creation funnel
Cochrane Effective Practice and
Organisation of Care (EPOC) Group
• Cochrane Effective Practice and Organisation of Care (EPOC) group undertakes systematic reviews of interventions to improve health care systems and health care delivery including:
– Professional interventions (e.g. continuing medical education, audit and feedback)
– Financial interventions (e.g. professional incentives)
– Organisational interventions (e.g. the expanded role of pharmacists)
– Regulatory interventions
Cochrane Effective Practice and
Organisation of Care (EPOC) GroupEPOC Progress to date
• 96 reviews, 1 overview, 36 protocols
• Professional interventions – Audit and feedback: effects on professional practice and health care
outcomes
– The effects of on-screen, point of care computer reminders on processes and outcomes of care
• Organisational interventions– The effectiveness of strategies to change organisational culture to
improve healthcare performance
– Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases
Cochrane Effective Practice and
Organisation of Care (EPOC) GroupEPOC Progress to date
• Financial interventions– The impact of user fees on access to health services in low- and
middle-income countries
– Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians
• Regulatory interventions – Effects of changes in the pre-licensure education of health workers on
health-worker supply
– Pharmaceutical policies: effects of cap and co-payment on rational drug use
Cochrane Effective Practice and
Organisation of Care (EPOC) Group
Intervention # of trials Median absolute
effect
Interquartile
range
Audit and feedback
(Ivers 2011)
140 +4.3% +0.5% - +16%
Educational meetings
(Forsetlund 2009)
81 +6% +3 – +15%
Financial incentives
(Scott 2011)
3 NA NA
Hand hygiene
(Gould 2010)
1 NA NA
Factors influencing effectiveness of
audit and feedbackIvers N et al. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Library 2012
– Larger effects were seen if:
• baseline compliance was low.
• the source was a supervisor or colleague
• it was provided more than once
• it was delivered in both verbal and written formats
• it included both explicit targets and an action plan
Summary
Knowledge creation funnel
• The results of individual studies need to be interpreted alongside the totality of evidence (ie systematic reviews)
• Emphasis on KT of individual studies may distract the stakeholder group (increasing the noise to signal)
– ‘Don’t believe the hype’
– ‘Don’t generate the hype’
• Substantial evidence of effectiveness of implementation interventions
• Average effects modest but considerable variation of observed effectssuggesting that intervention design features and contextual factors likely effect modifiers
• Key (research and service) challenge is how to optimise interventions and tailor intervention to context
Knowledge infrastructure
• Knowledge management is fundamental challenge for health care organisations wishing to use evidence
• There is a need to develop knowledge infrastructure (services and processes)– Knowledge intelligence services– Rapid synthesis services– Requirements for statement about evidence
considered in high level policy documents (eg senior management team submissions)
– ….
Is research working for you?
http://www.cfhi-fcass.ca/PublicationsAndResources/ResourcesAndTools/SelfAssessmentTool.aspx
Is research working for you?
1. Acquire1.1 Are we able to acquire research?1.2 Are we looking for research in the right places?
2. Assess2.1 Can we tell if the research is valid and of high quality?2.2 Can we tell if the research is relevant and applicable?
3. Adapt3.1 Can we summarize results in a user-friendly way
4. Apply4.1 Do we lead by example and show that we value research use?4.2 Do our decision making processes have a place for research?
Is research working for you?
Knowledge to action cycle
Knowledge to Action loopFrom: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006
Adapting knowledge to local context
• May require additional data collection to assess applicability of knowledge to local context
• May require modification of recommended actions based upon applicability, resources and contextual issues
Summary
• Implementation is about ensuring that stakeholders are aware of and use research evidence to inform their decision making and actions to improve processes and outcomes of care
• Implementation science is the scientific study of the determinants, processes and outcomes of implementation.
Summary
• Successful implementation depends upon:– Internal knowledge (eg performance data, tacit knowledge
of how organisation (and individuals) work)
– External knowledge (eg clinical and implementation science)
– Behaviour and organisational change expertise
• Adopting a systematic (theoretically informed) approach will likely enhance likelihood of successful implementation
• The knowledge to action cycle is a useful planning framework.
Session 2: Case Studies
How would you tackle this?
• Two scenarios: choose one scenario, then work in pairs at your tables– Hand hygiene
– Diabetes care
• Spend 15 minutes in pairs
• Feedback to your table for 5 minutes
• General thoughts from tables 10 minutes
Scenario 1Hand hygiene in hospital
staff• Healthcare-associated infections are
among top 10 causes of hospital deaths worldwide
• Hand hygiene (washing or disinfecting hands) is most effective and cost-effective prevention method
• Adherence to hand hygiene recommendations consistently below 50%
Scenario 2Diabetes care in primary care
2011-2012 National diabetes audit showed:- 66% of patients meet guideline-recommended
treatment targets HbA1c (<=58mmol/mol) - 47% had blood pressure < 140/80mmHg- 41% reaching cholesterol target of <4mmol/L- 22% meeting all three targets - Care process completion has plateaued
2011 National study of 99 practices showed:• 73% of patients received general education• 51% with BMI>30 received weight advice• 68% received self-management advice• 59% prescribed for HbA1c when above target• 40% prescribed when BP above target
How would you improve the implementation of hand hygiene
practices in hospital?
How would you improve the quality of diabetes care in primary care?
Spend 15 minutes in pairsFeedback to your table for 5 minutesGeneral thoughts from tables 10 minutes
Feedback
How would you improve the implementation of hand hygiene
practices in hospital?
How would you improve the quality of diabetes care in primary care?
Session 3a: Behavioural
approaches to implementing
evidence based guidance
Prof Jeremy Grimshaw
Dr Justin Presseau
Knowledge to action cycle
Knowledge to Action loopFrom: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006
Barriers to implementation• Structural (e.g. financial disincentives)
• Organisational (e.g. inappropriate skill mix, lack of facilities or equipment)
• Peer group (e.g. local standards of care not in line with desired practice)
• Individual (e.g. knowledge, attitudes, skills)
• Professional - patient interaction (e.g. problems with information processing)
A behaviour change approach to
implementation science
• Behaviour change approaches apply to any level: from individuals to groups to organisations– Diagnosis:
• Who needs to do what, differently?
• What is preventing them from doing so
– Intervention: • Help them change what they do to promote
implementation
Identifying behaviours of interest
• What is the behavior (or series of linked behaviors) that you are trying to change?
• Who performs the behavior(s)? (potential adopter)
• When and where does the potential adopter perform the behavior?
• Are there obvious practical barriers to performing the behavior?
• Is the behavior usually performed in stressful circumstances? (potential for acts of omission)
Identifying whose behaviour(s)
need to change
• Often useful to specify target behaviours in terms of:– Actor performing the behaviour– Action being performed– Target at which the action is directed– Context in which action is performed– Time during which the action is performed.
• Provides clarity regarding what to change
Why use theory?• An organized, heuristic, coherent, and systematic
articulation of a set of statements related to significant questions that are communicated in a meaningful whole for the purpose of providing a generalisable form of understanding.
Meleis AI: Theoretical nursing. Development and progress
• It describes observations, summarizes current evidence, proposes explanations, and yields testable hypotheses.
• It represents aspects of reality that are discovered or invented for describing, explaining, predicting and controlling a phenomenon
The Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG). (2006) Imp Sci
Assessing barriers to
implementation
Why use theory?
• Interventions are likely to be more effective if they target determinants of behaviour
• Theoretical frameworks facilitate accumulation and integration of evidence– across context, population and behaviour
– of effects and of causal mechanisms
• Allows refinement and development of theory and, hence, more effective interventions
Assessing barriers to
implementation
What levels of theory?• Ferlie and Shortell suggest four levels of interventions to
improve the quality of health care: – the individual health professional; – health care groups or teams; – organisations providing health care (e.g., NHS trusts); – the larger health care system or environment in which
individual organisations are embedded. • Different types of theory will be relevant to interventions
at different levelsFerlie, Shortell (2001). Milbank Quarterly
Assessing barriers to
implementation
Making sense of theory
• Multiple theories and frameworks of individual and organizational behaviourchange, often with conceptually overlapping constructs
• Two recent attempts to make theory more accessible
– Theoretical domains framework
– Behaviour change wheel
Theoretical domains framework
Theoretical domains framework
• Conceptual mapping of 128 explanatory constructs drawing on 33 psychological theories
• Identified 14 domains covering main known factors influencing behaviour and behaviourchange
Theoretical domains framework• Knowledge
– Aware of guidelines and evidence?
• Skills– Sufficient training in techniques required?
• Social/professional role and identity – Is the action part of what the actor sees as
‘typical’ of their profession?
• Beliefs about capabilities– Confident in capacity to do the behaviour?
What makes it easier or difficult?
• Optimism– Is the actor generally optimistic that doing
the behaviour will make a difference in the grand scheme of things?
• Beliefs about consequences– What the the benefits and negative aspects
of doing the behaviour?
• Reinforcement– Does the behaviour lead to any personal or
external reward when it is performed?
• Intentions – How motivated is the actor to do this?
• Goals– How much of a priority is this action
compared to other competing demands?
• Memory, attention and decision processes
– Does the actor ever forget? Are there reminders in place?
• Environmental context and resources – Are there sufficient resources to do the
behaviour? If not, what is missing?
• Social influences– Who influences the decision to perform the
behaviour?
• Emotion– Is performing the behaviour stressful?
• Behavioural regulation– What does the actor personally do to ensure
that they perform the behaviour?
Cane et al 2012 (Impl.Sci.)
Behaviour Change Wheel
From the TDF to COM-B
Michie, van Stralen, West (2011) Impl.Sci.
Ability• Physical • Psychological
Environmental factors • Physical• Social
Conscious and automatic decision processes
Physical: physical skillsPsychological: Knowledge, cognitive and interpersonal skills, memory/ attention/ decisions processes, behavioural regulation
Reflective: intention, goals, social/professional role and identity, beliefs about capabilities, beliefs about consequences, optimismAutomatic: reinforcement, emotions
Physical: Environmental context and resourcesSocial: Social influences
Linking the TDF to the COM-B Model
Michie, Atkins, West (2014)
Should we use the TDF or COM-B?
• COM-B highlights higher-level factors
• TDF provides a fine-grained analysis that can be aggregated to the COM-B level
Summary so far
Whatever the level of granularity of the assessment, theory provides a way to assess barriers to implementation that provides…
– Common language for building cumulative knowledge-base to learn from past successes (and failures)
– Move beyond trial and error and ISLAGIATT
– Provides a basis for designing targeted interventions optimised to address identified barriers to improve care
Sessions 3b: Identifying barriers
and modifiable determinants of
implementation
Professor Jeremy Grimshaw
Dr Justin Presseau
• Neighbour discussion (15 min) Feedback time (15 min)
• Barrier assessment in case studies
Small group exercise
• Diagnosing the implementation problem
1. Whose behaviour needs to change?
2. Which behaviour(s)/actions do they need to change?
3. What are the barriers stopping them?
• Using COM-B or TDF as your framework for assessing barriers
Scenario 1Hand hygiene in
hospital staff
Scenario 2Diabetes care in
primary care
In pairs, discuss the following
1. What is the specific behaviour in terms of:ACTION: the specific behaviour(s)ACTOR(s): the person(s) whose behaviour needs to changeTARGET: details of the recipient of the action CONTEXT: where is the action performed?TIME: When is the action performed
2. Using the TDF or COM-B, identify which barriers may stopping them
Spend 15 minutes in pairsFeedback to your table for 5 minutesGeneral thoughts from tables 10 minutes
With your neighbour: Choose a scenario:
OR
Small group exercise
• Feedback
• What are advantages and disadvantages of using the theoretical domains framework
Case study – physician hand hygiene
Theoretical domains framework –
physician hand hygiene example
Determinants of behaviour• Knowledge• Skills• Social/professional role and identity • Beliefs about capabilities• Optimism• Beliefs about consequences• Reinforcement• Intentions • Goals• Memory, attention and decision processes• Environmental context and resources • Social influences• Emotion• Behavioural regulation
Cane et al (2012)
Implementation Science
Knowledge
• I am (not) aware of hand hygiene guidelines and have (not) heard of the 4 moments of hand hygiene
• I am (not) aware of evidence linking hand hygiene to health care associated infections
• Education about hand hygiene ensures that I practice it consistently
Theoretical domains framework –
physician hand hygiene example
Beliefs about consequences
• Practicing hand hygiene reduces the transmission of infection
• While improper hand hygiene can contribute to infection, it is not the only factor that can do so
• Practicing hand hygiene gives patients confidence in their physician
Theoretical domains framework –
physician hand hygiene example
Beliefs about Capabilities
• Hand hygiene is easy to practice
• I am not confident that I am following hand hygiene guidelines when practicing hand hygiene
Theoretical domains framework –
physician hand hygiene example
Social influence
• Patients expectations do (not) influence me to perform hand hygiene
• If I see someone practicing hand hygiene, it influences me to do the same
• Team culture influences others hand hygiene practice
Theoretical domains framework –
physician hand hygiene example
Goals
• Hand hygiene is always a necessity
• Hand hygiene is not my highest priority in patient emergency situations
• Hand hygiene is one of many priorities that I have to balance every day
Theoretical domains framework –
physician hand hygiene example
Skills
• I do (not) consider hand hygiene a skill
• I have (not) had training in hand hygiene practice
• With repetition, hand hygiene practice becomes automatic
Theoretical domains framework –
physician hand hygiene example
Memory, attention, decision processes
• Hand hygiene is (not) an automatic process for me
• When not touching the patient or patient environment, hand hygiene is unnecessary
• Reminders are useful for my hand hygiene practice
• Easily visible hand hygiene stations make it easier to remember hand hygiene
Theoretical domains framework –
physician hand hygiene example
Social professional role and identity
• Hand hygiene is a standard part of my patient consultations
• My hand hygiene is in line with my peers
• Physician hand hygiene compliance is suboptimal
• It is my job to be a hand hygiene role model to the members of my team
Theoretical domains framework –
physician hand hygiene example
Environment
• Easy access to hand hygiene stations makes it easier to practice hand hygiene
• The location of hand hygiene stations is important in facilitating hand hygiene practice
• Practicing hand hygiene takes time
• When I am busy, I am less likely to comply with hand hygiene guidelines
Theoretical domains framework –
physician hand hygiene example
Environment - Nonparticipant Observation
• Observations made while on a Surgery and Medicine Unit confirmed what was said in the physician interviews:
– Alcohol dispensers are sometimes empty
– Alcohol dispensers blend in with the wall
– Beside alcohol bottle baskets are empty
Theoretical domains framework –
physician hand hygiene example
Case study:
the iQuaD example• Three dominant theories and approaches in implementation
science:– “If you build it they will come”: the structural approach to
behaviour change
– “There is no ‘I’ in team”: change involves exchanges and shared processes between individuals working in teams within organisations
– “Between the ears” : individuals’ perceptions, cognitions beliefs, schemas, cognitive associations about their behaviour
• Rarely ever considered alongside each other. Need for empirical comparison of theory for utility in implementation science
The improving Quality in Diabetes care (iQuaD) study1,2
Aim: investigate how effectively and consistently factors from predominant organisational and behaviour theories predict- multiple evidence-based clinical behaviors promoted in guidelines- same sample of clinicians, primary care diabetes management in the UK
Design: Predictive. Questionnaires sent at baseline and 12 months later to GPs and nurses in 99 practices across the UK
National study of primary care in the UK
1 Eccles et al (2011, Impl Sci); 2 Presseau et al (in press, Journal of Behavioral Medicine)
National study
• Outcomes: – Clinician-level: clinicians’ self-reported behaviour at 12 months follow-up
– Practice level: patient report of care received and patient medical records
• Recruitment and response rates1
– 12 months follow-up
• 427 (289 GPs, 138 nurses) returned questionnaire (51% response rate).
• Mean of 41 patients/practice responded to questionnaire
• Main Findings
• Gaps in quality of care across the behaviours1
• Theory-based factors that predicted high quality care2
1 Eccles et al (2011, Impl Sci); 2 Presseau et al (in press, Journal of Behavioral Medicine)
Prescribing ...
1. ...additional antihypertensive drugs for people with type 2 diabetes whose blood pressure (BP) is above a target of 140 mm Hg for Systolic BP or 80 mm Hg for Diastolic
2. ...additional therapy for the management of glycaemic control (HbA1c) for the management of HbA1c in people whose HbA1c is higher than 8.0%, despite maximum dosage of 2 oral hypoglycaemic drugs.
Providing advice about...
1. ... weight management to people with type 2 diabetes whose BMI is above a target of 30kg/m2, even following previous management.
2. ... self-management to people with type 2 diabetes.
3. ...general education about diabetes for people with type 2 diabetes.
Examining...
1. ...foot circulation & sensation in the feet of people with
type 2 diabetes.
Health professionals: 63%Patient Records: 40%
Health professionals: 69%Patient Records: 59%
Health professionals: 78%People with diabetes: 51%
Health professionals: 77%People with diabetes: 68%
Health professionals: 78%People with diabetes: 73%
Health professionals: 70%People with diabetes: 91%
Eccles et al (2011, Impl Sci)
National study: gaps in quality of care
Staffing ratios
Meetings
Appointment length
Admin support
Recall system
Insulin initiation
Dedicated diabetes clinic
Structured education
Access to specialist care
List size
IMD
National study: testing structural correlates
Procedural Justice
Relational Justice
Implementation Behaviour
Participative Safety
Support for Innovation Implementation Behaviour
Vision
Task Orientation
Altruism, Courtesy, Sportsmanship,
Conscientiousness, Civic Virtue
Implementation Behaviour
Organizational Citizenship Behaviours (Moorman, 1991)
Team Climate (Anderson & West, 1994)
Organizational Justice (Greenberg 1990)
Elovainio, Steen, Presseau, Francis et al. (2012) Family Practice.
R2adj = 0.01 (0.00, 0.03)
R2adj = 0.00 (0.00, 0.03)
Predicting 12m self-report (median, range):
R2adj = 0.00 (0.00, 0.00)
National study: testing team theories
Presseau, Johnston, Francis, Hrisos, Stamp, Steen, Hawthorne, Grimshaw, Elovainio, Hunter, Eccles (in press) Journal of Behavioral Medicine
Outcome Expectations
Self-efficacy
Proximal Goals
Implementation Behaviour
Attitude
Subjective Norm
PBC
Intention Implementation Behaviour
Anticipated Consequences
Evidence of habit
Implementation Behaviour
Action Planning
Coping Planning
Implementation Behaviour
Social Cognitive Theory
TPB
Learning Theory
Planning
R2adj = 0.15 (0.09, 0.50)
R2adj = 0.14 (0.09, 0.48)
Predicting 12m self-report (median, range):
R2adj = 0.15 (0.09, 0.50)
R2adj = 0.15 (0.07, 0.43)
National study: testing behaviour theories
• Constructs from Organizational Theories did not predict implementation-related behaviours
• Constructs from Behaviour Theories consistently predicted multiple behaviours and scores showed room for improvement:
– Social cognitive theory in particular, along with habit and post-intentional factors
• Testing different theories in the same sample across multiple behaviours provides empirical theory selection through internal replication– Can be used to design intervention to improve care by targeting
modifiable factors shown to consistently predict clinicians behaviour
National study: testing multiple theories
Analytical Effortful Resource intensive Slow, Low capacity Conscious, deliberate2
Perceptual and cued Minimal effort, resources Fast, High capacity Unconscious Automatic Default process Operates in parallel2
Clinician Behaviour
Reflective process1
Impulsive process1
1Strack & Deutch, 2004; 2Evans 2008
• Dual process approach provides an opportunity to jointly • Skilled decision-making involving behaviours with highly salient consequences
(reflective process)• Automatic responses to environmental cues in stable contexts (impulsive process)
• Dual process models suggest that behaviour is determined by two interacting process1
Towards a dual process model of clinician behaviour
Motivational Phase Volitional Phase
Clinician Behaviour
IntentionAction Planning
Coping Planning
Towards a dual process model of clinician behaviour
Automaticity
1Presseau, Johnston, Heponiemi, Elovainio, Francis, Eccles, et al (in press) Annals of Behavioral Medicine
Tested a dual process model predicting
• …six clinical behaviours in same sample
• Hypothesising differences relative importance of reflective and impulsive system depending on the behaviour
• Motivational process remain a key direct and indirectpredictor of clinician behaviour
• Volitional process help to explain how intentions are translated into behaviour for advising behaviours but not examining behaviours (unclear for prescribing)
• Automatic processes are involved in prescribing, examiningand advising behaviours, though not without the input of the reflective process
both reflective and automatic processes involved in predicting clinician behaviours
both could be targeted to promote the implementation of healthcare interventions
Summary so far
Michie, van Stralen, West (2011) Impl.Sci.
• Physical • Psychological
• Physical• Social
• Conscious • Automatic
Interpreting iQuaD findings
according to COM-B
Predictive
Session 4: Behavioural approaches to
implementing evidence based guidance
Designing implementation programmes
Dr Justin Presseau
Prof Jeremy Grimshaw
Knowledge to action cycle
Knowledge to Action loopFrom: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006
• Choice of implementation intervention should be based upon:– ‘Diagnostic’ assessment of barriers
– Understanding of mechanism of action of interventions
– Empirical evidence about effects of interventions
– Available resources
– Practicalities, logistics etc
Designing interventions
Designing interventions
Who needs to do what differently?
Using a theoretical framework, which barriers and enablers need
to be addressed?
Which intervention components could overcome the modifiable
barriers and enhance the enablers?
How will we measurebehaviour change?
Designing interventions
Designing interventions
Who needs to do what differently?
Using a theoretical framework, which barriers and enablers need to be addressed?
Which intervention components could overcome the modifiable barriers and enhance the enablers?
How will we measurebehaviour change?
• What is the behavior (or series of linked behaviors) that you are trying to change?
• Who performs the behavior(s)? (potential adopter)
• When and where does the potential adopter perform the behavior?
• Are there obvious practical barriers to performing the behavior?
• Is the behavior usually performed in stressful circumstances? (potential for acts of omission)
Designing interventions
Designing interventionsWho needs to do what differently?
Using a theoretical framework, which barriers and enablers need
to be addressed?
Which intervention components could overcome the modifiable barriers and enhance the enablers?
How will we measurebehaviour change?
• COM-B• TDF• Behaviour change
theory
Designing interventions
Who needs to do what differently?
Using a theoretical framework, which barriers and enablers need to be addressed?
Which intervention components could overcome the modifiable
barriers and enhance the enablers?
How will we measurebehaviour change?
Designing interventionsWe have found it useful to distinguish…
– What we are trying to change – Why are we trying to change it? (constructs: barriers
and enablers)– How are we going to change it, including
• Intervention functions and Behaviour change techniques
• Context: the mode of delivery (eg group meeting, DVD)
• Content: how the technique will be operationalised
Behaviour change wheel
Michie, van Stralen, West (2012)
Central: COM-B model of behaviour
• Intervention functions surround the COM-B
• Policy categories to support change
Behaviour change wheel: intervention
functionsIncrease knowledge and understanding
Use communication tools to provoke positive or negative emotions or behaviour
Develop an expectation that a reward will be provided for performance
Develop an expectation that performance will result in cost or punishment
Developing physical, cognitive or social skills
Reduce performance opportunities through rule-setting
Make a change to the external social or physical
context
Exposure to someone that one identifies with
to imitate
Facilitation beyond education, training and environmental
restructuring
COM-B TDF Intervention functions
Physical capability Physical skills Training
Psychological capability Knowledge Education
Cognitive and interpersonal skills
Training
Memory, attention and decision processes
Training; Environmental restructuring; Enablement
Behavioural regulation Education; Training; Modelling; Enablement
Capability
Michie, Atkins, West (2014), p113-114
From TDF, to COM-B to Intervention Functions
COM-B TDF Intervention functions
Physical opportunity Environmental context and resources
Training; Restriction; Environmental restructuring; Enablement
Social opportunity Social influences Restriction; Environmentalrestructuring; Modelling; Enablement
Michie, Atkins, West (2014), p113-114
Opportunity
From TDF, to COM-B to Intervention Functions
From TDF, to COM-B to Intervention Functions
COM-B TDF Intervention functions
Reflective motivation
Professional/social role and identity
Education; Persuasion; Modelling
Beliefs about capabilities Education; Persuasion; Modelling; Enablement
Optimism Education; Persuasion; Modelling; Enablement
Beliefs aboutconsequences
Education; Persuasion; Modelling
Intentions Education; Persuasion; Incentivisation; Coercion; Modelling
Goals Education; Persuasion; Incentivisation; Coercion; Modelling; Enablement
Automatic motivation
Reinforcement Training; Incentivisation; Coercion; Environmental restructuring
Emotion Persuasion; Incentivisation; Coercion; Modelling; Enablement
Michie, Atkins, West (2014), p113-114
Motivation
Links between COM-B and intervention functions
in the Behaviour Change Wheel
COM-B
Intervention functions
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Physical capability
Psychological capability
Physical opportunity
Social opportunity
Automatic motivation
Reflective motivationMichie, Atkins, West (2014, p116)
Designing interventions – from functions to
behaviour change techniques
Need greater clarity re: specific content of interventions to change behaviour- What does an ‘educational session’ involve? What does providing a new piece of guidance
involve? What does ‘we sent our GPs on a training day’ actually involve? What are the active ingredients of change?
- If we want to replicate and generalise efforts in implementation science, we need a shared understanding of the content of our interventions
Goals and PlanningGoal setting (behavior) OR Goal setting (outcome)Problem solvingAction planningReview behavior goal(s) OR Review outcome goal(s)Discrepancy between current behavior and goalBehavioral contractCommitment
Feedback and monitoringMonitoring of behaviour by others without feedbackFeedback on behaviour/outcomes of behaviourFeedback on outcomes of behaviourSelf-monitoring of behaviourSelf-monitoring of outcomes of behaviourMonitoring of outcome(s) of behaviour without feedbackBiofeedback
Social SupportSocial support (unspecified)Social support (practical)Social support (emotional)
Shaping KnowledgeInstruction on how to perform the behaviourInformation about AntecedentsRe-attributionBehavioural experiments
Natural ConsequencesInfo about health consequencesInfo about emotional consequences Info re social and environment consequencesSalience of consequencesMonitoring of emotional consequencesAnticipated regret
Comparison of behaviourDemonstration of the behaviourSocial comparisonInformation about others’ approval
AssociationsPrompts/cuesCue signalling rewardReduce prompts/cuesRemove access to the rewardRemove aversive stimulusSatiationExposureAssociative learning
Repetition and substitutionBehavioural practice/rehearsalBehaviour substitutionHabit formationHabit reversalOvercorrectionGeneralisation of target behaviourGraded tasksComparison of outcomesCredible sourcePros and consComparative imagining of future outcomes
Reward and threatIncentive (outcomeMaterial incentive (behaviour)Social incentiveNon-specific incentiveSelf-incentiveSelf-rewardReward (outcome)Material reward (behaviour)Non-specific rewardSocial rewardFuture punishment
RegulationConserving mental resourcesPharmacological supportReduce negative emotionsParadoxical instructions
AntecedentsAdding objects to the environmentRestructuring the physical environmentRestructuring the social environmentAvoidance/reducing exposure to cues for behaviourDistractionBody changes
IdentityIdentification of self as role modelFraming/reframingIncompatible beliefsValued self-identifyIdentity associated with changed behaviour
Scheduled consequencesBehaviour costPunishmentRemove rewardReward approximationRewarding completionSituation-specific rewardReward incompatible behaviourReward alternative behaviourReduce reward frequencyRemove punishment
Self-beliefVerbal persuasion about capabilityMental rehearsal of successful performFocus on past successSelf-talk
Covert learningImaginary punishmentImaginary rewardVicarious consequences
V1 Behaviour change techniques taxonomy (Michie et al 2013)
Examples of techniques w/ definitions
• Graded tasks: “Set easy-to-perform tasks, making them increasingly difficult, but achievable, until behaviour is performed”– Capability (Psychological) in COM-B – Beliefs about Capabilities in TDF
• Habit formation: “Prompt rehearsal and repetition of the behaviour in the same context repeatedly so that the context elicits the behaviour”– Motivation (automatic) in COM-B– Behavioural Regulation and Reinforcement in TDF
• Feedback on behaviour: “Monitor and provide informative or evaluatvefeedback on performance of the behaviour (e.g. form, frequency, duration, intensity)”– Motivation (reflective) in COM-B– Behaviour regulation in TDF
Not all techniques are useful, and many techniques are designed to address specific types of barriers
From behaviour change techniques to
theory-informed barriers
• Behaviour change techniques can be mapped onto the theory-based barriers and facilitators from the models covered
– Behaviour change theories
– TDF
– COM-B
• Behaviour change wheel (intervention functions)
Supporting change through policy
Michie, van Stralen, West (2012)
Policy initiatives can facilitate intervention functions impact on COM-B components
Policy categories
Intervention functions
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Communication/marketing
Guidelines
Fiscal measures
Regulation
Legislation
Environmental and social planning
Service provision
Links between policy categories and intervention
functions in the Behaviour Change Wheel
Michie, Atkins, West (2014, p138)
Optimising interventions
Usability studies
• Develop prototype intervention
• Test prototype in 5 to 8 subjects to review content and format using ‘think aloud’ methodology. These sessions will be audio recorded and the results transcribed and analysed.
• In general a modest number of subjects are required for usability testing (e.g. 8-9 subjects), and often 4 to 5 are necessary to identify 80% of the usability problems.
• Cycles of design, development and testing will be completed until no further major revisions are needed.
Case studies
• Neighbour discussion(15 min) Feedback time (10 min)
• Implementation design in case studies
Scenario 1Hand hygiene in
hospital staff
Scenario 2Diabetes care in
primary care
In pairs, discuss the following
Based on the barriers you identified using the TDF or COM-B, select…1. Potential intervention functions to target those barriers2. Potential policy categories that would support that intervention
function
Spend 15 minutes in pairsFeedback to your table for 5 minutesGeneral thoughts from tables 5 minutes
With your neighbour: Choose the same scenario
OR
Session 5: Behavioural approaches to
implementing evidence based guidance
Implementation design in case studies
Prof Jeremy Grimshaw
Dr Justin Presseau
Designing interventions
Case study of physician hand hygiene
Designing interventions
physician hand hygienePhysician need to practice hand hygiene routinely
Beliefs about consequences –failure to practice hand hygiene not necessarily associated with adverse event
Persuasion/social influence –information on hospital associated infections and negative associated consequences, emphasis on hand hygiene as a team level responsibility delivered to team session by social influential
Who needs to do what differently?
Using a theoretical framework, which barriers and enablers need
to be addressed?
Which intervention components could overcome the modifiable
barriers and enhance the enablers?
How will we measurebehaviour change?
Designing interventions
physician hand hygiene
Choice of implementation intervention should be based upon:
– ‘Diagnostic’ assessment of barriers
– Understanding of mechanism of action of interventions
– Empirical evidence about effects of interventions
– Available resources
– Practicalities, logistics etc
Designing interventions
physician hand hygiene
1. Initial sensitisation (residents)Intervention content: Refresher about: – the 4 moments of hand hygiene (knowledge) – what is the patient environment (knowledge)– TOH hand hygiene compliance and infection rates (beliefs about
consequences, social influences (priority for chief resident and hospital))
Proposed delivery for Medicine:– When: During Resident Orientation -1st day of block– What: 1-2 slides on hand hygiene to be developed by team and given to
Chief Resident– Who will deliver: Chief Resident at the beginning of the block
Designing interventions
physician hand hygiene
2. Reinforcement (residents, attending physicians)Intervention Content: Knowledge about:
– Infection rates, the 4 moments, the patient environment (exact content to be developed and will be clinically relevant) (knowledge)
– Add Glo Germ demonstration in one of these sessions to illustrate technique (booth after session for all to try if interested) (skills)
Proposed delivery for Medicine:– When: During Antibiotic Stewardship Rounds – a weekly pause of rounds
that lasts a few minutes (already in practice) (social influence)– What: A hand hygiene curriculum delivered weekly (~2min/session) X 4 (for
one block)– Who will deliver: Local experts/opinion leaders
3. Address environmental barriers (unit staff)
Intervention Content: – Ensure that hand hygiene resources are easily accessible and noticeable
(including systems to ensure hand hygiene resources are routinely replaced)
Proposed delivery for Medicine:– How: Will walk through the chosen unit(s)
– Who will deliver: Members of the study team
– Accountability – unit
Designing interventions
physician hand hygiene
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MedicineM1
MedicineM4
SurgeryM1
SurgeryM4
Resident Audit Scores % Change Between Pre and Post
Control Group
Intervention Group
Designing interventions
physician hand hygiene
Aim: Conduct a cluster-RCT to evaluate the effectiveness and costs of a
theory-based multiple behaviour change intervention targeting general practitioners (GPs) and nurses, to support improvement in the provision of high quality care for people with type 2 diabetes in the North East of England
AdvisingPrescribing Examining
Local example:
Prescribing ...
1. ...additional antihypertensive drugs for people with type 2 diabetes whose blood pressure (BP) is above a target of 140 mm Hg for Systolic BP or 80 mm Hg for Diastolic
2. ...additional therapy for the management of glycaemic control (HbA1c) for the management of HbA1c in people whose HbA1c is higher than 8.0%, despite maximum dosage of 2 oral hypoglycaemic drugs.
Providing advice about...
1. ... weight management to people with type 2 diabetes whose BMI is above a target of 30kg/m2, even following previous management.
2. ... self-management to people with type 2 diabetes.
3. ...general education about diabetes for people with type 2 diabetes.
Examining...
1. ...foot circulation & sensation in the feet of people with
type 2 diabetes.
Health professionals: 63%Patient Records: 40%
Health professionals: 69%Patient Records: 59%
Health professionals: 78%People with diabetes: 51%
Health professionals: 77%People with diabetes: 68%
Health professionals: 78%People with diabetes: 73%
Health professionals: 70%People with diabetes: 91%
Eccles et al (2011, Impl Sci)
Evidence from our previous national study: gaps in quality of care
Design: Cluster randomised controlled trial (stratified by practice size)
- Theory-based process evaluation - Interview based process evaluation- Fidelity of delivery- Cost analysis
Recipients: GPs, nurses, healthcare assistants delivering care to people with type 2
diabetes
Timeline:
– Intervention development from Sept 2012 to start of Sept 2013– Pilot May/June 2013– Recruitment began in March 2013– Intervention delivery started mid September 2013– Follow-up 12 months later
The IDEA trial
RecruitGPs,nurses,healthcareassistants
in44Practices
BaselineQuestionnaire
Randomisation(stratifiedbypracticesize)
InterventionPractices(22) ControlPractices(22)
DeliverIntervention
Interviews(4)
Follow-upquestionnaire
Outcomes(12monthslater)-Random100patientsperpractice(anonymouspostalquestionnaire)
-Patientcomputerrecords
The IDEA trial: flow chart
Outcome expectations
Self-efficacy
Proximal Goals
Automaticity
Goal conflict Goal Facilitation
Goal Priority
Action Planning
Coping Planning
- Based on findings from iQuaD1,2,3
- Social Cognitive Theory4 + volitional constructs5 + dual process model3,6
- Reciprocal determinism1 operationalised to involve environment factors:- Automaticity (automatic response to cues)3
- Competing behaviours (conflict, facilitation and priority)4,5
Behaviour
Eccles et al (2011); 2,3 Presseau et al (in pressa; in pressb) 4 Bandura (1998); 5 Sniehotta (2009), 6 Strack & Deutsch (2004); 7,8 Presseau et al (2009, 2011);
Logic model
Intervention content
1 BCTs from Michie et al (2013). ABM
Target Construct Behaviour Change Techniques1
Self-efficacy - Demonstration of the behaviour
(beliefs about
capabilities)- Social comparison
- Verbal persuasion of capability
- Behavioural practice/rehearsal
- Graded tasks
Outcome expectations - Information about health consequences
(beliefs about
consequences)- Credible source
Proximal goals
(Reflective motivation)
- Goal setting (behaviour)
- Discrepancy between current behaviour and goal
- Commitment
Action planning - Action planning
Coping planning - Problem solving
- Adding objects to the environment
Habit/Automaticity - Behavioural practice/rehearsal
(Automatic motivation) - Habit formation
- Action planning and problem solving
• Self-administered pre-intervention questionnaire
• Pre-reading, website and PDF-based
• Group-based workshop to each practice– PowerPoint slides– Participant Workbooks– Small group tasks– Video case studies
• DVD of materials during evaluation
• Self-administered post-intervention questionnaire
• DVD of materials after evaluation
Intervention Control
✓ ✓
✓
✓
✓
✓
✓
✓
Format
clinical expert
behaviour change expert
Intervention providers
44 GP practices in the North-east of England
Setting
Audio recorded sessions- Transcribed/coded for delivery of BCTs, by whom
Facilitator debrief questionnaires- Independently completed; reported delivery of BCTs;
coverage across 6 behaviours; intensity Participant feedback
- Write plans on feedback forms
Training sessions based on BCTs1) Facilitator handbook2) Within facilitator team: observe, coping planning 3) Within research team: practice/rehearsal 4) Feedback on to facilitator team after delivery
1 Bellg et al 2002
Fidelity of delivery
– Intervention may or may not be effective
– Process evaluation to understand mechanism of change
– Theory-based process evaluation1,2:• Pre/post theory-based questionnaires
• Test for change in targeted constructs between intervention and control
1,2 Grimshaw et al (2007; submitted) Implementation Science;
Outcome expectations
Self-efficacy
Proximal Goals
Automaticity
Goal conflict Goal Facilitation
Goal Priority
Action Planning
Coping Planning
Behaviour
Process evaluation (quantitative)
• Four practices randomly selected for follow-up interviews
– TDF based barriers and facilitators to engaging in the intervention sessions
– Participants: clinicians participating in the intervention, practice manager
Process evaluation (qualitative)
• Cost of delivering the intervention• Staff training (facilitators)
• Primary care costs
• Increases in standard materials used (e.g., leaflets)
• Time use in consultation
• Average cost per patient to the NHS for medication prescribed
• Costs of service usage by people with Type 2 diabetes
Cost analysis
Summary
• Designing interventions involves assessing barriers to change and identifying interventions that potentially address these
• Behavioural theories may be helpful to inform barrier assessment and intervention choice
• Intervention mapping is a technique for systematically considering barriers and potential interventions
Developing the field of
implementation science
• Implementation science is a relatively new field - few health researchers have been engaged in the field for more than 10 years
• Substantive level of research activity– Cochrane Effective Practice and Organisation of Care
(EPOC) group register includes over 6,000 RCTs and quasi experiments of interventions to improve health care delivery and health care services
• Increasing funding and reporting opportunities for knowledge translation research
• Move towards research programs and laboratories
Implementation Research Laboratories• Research teams integrated into healthcare systems
undertaking program(s) of research directly relevant to healthcare systems’ priorities
• Reduces problems relating to convening de novo research teams, seeking project by project funding, negotiating access with healthcare systems, conducting study, writing up (usually out of funding period)
• Opportunities for formal and informal linkages of mutual advantage to research team and healthcare system
• More explicitly recognise relatives roles and responsibilities of research team and healthcare system
Developing the field of
implementation science
Developing the field of implementation
science
Developing the field of implementation
science
Developing the field of
implementation science
www.implementationscience.com
Summary• Implementation science is a relatively new field
of health services research
• Rapid progress has been made but substantial challenges remain
• Opportunities to foster linkages between implementation service departments and implementation researchers to form implementation science laboratories and address I2 challenge
Discussion
• Based on the workshop today, what are your current views on:
– Value of behavioural approaches to implementing evidence based guidance?
– What would be needed to adopt these approaches in practice?
– Are there any additional approaches that might complement behavioural approaches?
Closing remarks
Professor Paula Whitty
Director of NEQOS & Acting NENC AHSN Knowledge & Information Programme lead
Dr. Jackie Gray
Medical Epidemiologist, NEQOS
Get involved in the Work
Programme
• Sign up at the registration desk (in main foyer)
or
• Email Dr Jackie Gray [email protected]
Keep up to date with developments:• Sign up for the e- bulletin at the registration desk (if you haven’t
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Resources will be available on:
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AHSN web site www.ahsn-nenc.org.uk
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Thank you