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Implementation Research_ Theoretical Frameworks Session II

VIEWS: 4 PAGES: 34

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									        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.
                         Philip M. Ullrich, Ph.D.
                    Spinal Cord Injury QUERI IRC
Spinal Cord Injury QUERI IRC
•PARiHS Framework:

History
Features
Proposed utility
Philip M. Ullrich, Ph.D.
Application Example
Spinal Cord Injury QUERI IRC
Philip M. Ullrich, Ph.D.
Spinal Cord Injury QUERI IRC
            PARiHS Origins
   Royal College of Nursing Institute, UK
   1990s
   Contemporary models of the processes
    of implementing research into practice
    are inadequate.
     Unidimensional
     Non-interactive
          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.
 PARiHS Framework Elements

   Evidence.

   Context.

   Facilitation.

Weak to strong support for implementation
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.
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.
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.
       PARiHS Framework:
    Elements and Subelements
   Evidence.
       Research
       Clinical experience
       Patient experience
       Local knowledge
   Context.
       Culture
       Leadership
       Evaluation
   Facilitation.
       Characteristics
       Role
       Style
          PARiHS Framework
Successful implementation is most likely
  to occur when:
  1.   Scientific evidence is viewed as sound
       and fitting with professional and patient
       beliefs.
  2.   The healthcare context is receptive to
       implementation in terms of supportive
       leadership, culture, and evaluative
       systems.
  3.   There are appropriate mechanisms in
       place to facilitate implementation.
          PARiHS Framework
         developmental history:
   1998 - 2002. Development, conceptual
    analysis.

   2001-2003. Empirical case studies.



   2003 to present. Diagnostic/evaluative tool
    development.
          PARiHS Framework
        current 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.
      PARiHS Diagnostic and
        Evaluative utility?
PARiHS Diagnostic and Evaluative grid:




                                    Kitson et al.,
                                    2008.
                 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.
              Using Theory for Implementation
              Planning
         Select theory of                             Identify potential                   Select interventions
         planned behavior                             strategies for                       that fit with planned
         change                                       achieving change                     strategies
                                                                                           (based on theory)


         Assess fit with
         initial theory




         Evaluate effectiveness                       Launch intervention                  Identify intervention
         of intervention,                             using identified tools               tools that fit both
         strategies, tools                            and strategies                       strategy and theory


CIPRS: Stetler & Damschroder Theoretical Frameworks                            See references: Sales et al., 2006
              Selecting a Theory - 1
                     Consider Context
                             Study characteristics
                             Professional discipline/perspective
                             Intervention characteristics
                             Inner and outer setting
                             Individuals involved
                             Implementation process
                     Consider Level
                             Individuals
                             Teams
                             Organization
                             System


CIPRS: Stetler & Damschroder Theoretical Frameworks
           Why PARiHS Framework
            for Spinal Cord Injury
                (SCI) QUERI?:
SCI system of care and targets for change
  a.   Evidence
          Research
          Local
          Clinical
          Patient
  b.   Context

Opportunities to work with other QUERI groups.
    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
     SCI PUMT Implementation
12 SCI centers randomized to receive one of
    two implementation strategies:
1.   Simple: Local “champion” receives toolkit
     materials.
2.   Enhanced: PARIHS-informed external
     facilitation strategy.
SCI PUMT Enhanced facilitation




                        Kitson et al.,
                        2008.
    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.
                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.
                 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.
SCI PUMT Results



   Stay tuned!
   Applying Multiple
    Frameworks and
      Theories in
Implementation Research
        Jeffrey Smith
   Implementation Research Coordinator
         Mental Health QUERI
“In theory there is no difference between
  theory and practice… in practice there is.”
                                    Yogi Berra
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
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
          An Approach to Using Theory for
             Implementation Planning

Select framework /                         Identify potential                       Select interventions
theory / model of                          strategies for                           that fit with planned
planned behavior                           achieving change                         strategies
change                                                                              (based on theory)


Assess fit with
initial theory




Evaluate effectiveness                     Launch intervention                      Identify intervention
of intervention,                           using identified tools                   tools that fit both
strategies, tools                          and strategies                           strategy 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.
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
    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)
         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
                        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
        QUESTIONS?

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

								
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