Implementation Research: Theoretical Frameworks Session II, Applying Specific Frameworks

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PARiHS FrameworkPromoting Action on Research
Implementation in Health Services
Philip M. Ullrich, Ph.D. Spinal Cord Injury
QUERI IRC Philip M. Ullrich, Ph.D. Spinal Cord
Injury QUERI IRC
Philip M. Ullrich, Ph.D. Spinal Cord Injury
QUERI IRC
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• PARiHS Framework History Features Proposed
  utility Application Example

Philip M. Ullrich, Ph.D. Spinal Cord Injury
QUERI IRC Philip M. Ullrich, Ph.D. Spinal Cord
Injury QUERI IRC
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PARiHS Origins

• Royal College of Nursing Institute, UK
• 1990s

• Contemporary models of the processes of
  implementing research into practice are
  inadequate.
• Unidimensional
• Non-interactive

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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.

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PARiHS Framework Elements

• Evidence.
• Context.
• Facilitation.

Weak to strong support for implementation
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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.

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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.

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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.

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PARiHS Framework Elements and Subelements

• Evidence.
• Research
• Clinical experience
• Patient experience
• Local knowledge
• Context.
• Culture
• Leadership
• Evaluation
• Facilitation.
• Characteristics
• Role
• Style

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PARiHS Framework

• Successful implementation is most likely to occur
  when
• Scientific evidence is viewed as sound and
  fitting with professional and patient beliefs.

1. The healthcare context is receptive to
   implementation in terms of supportive leadership,
   culture, and evaluative systems.

• There are appropriate mechanisms in place to
  facilitate implementation.

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PARiHS Framework developmental history

• 1998 - 2002. Development, conceptual analysis.

• 2001-2003. Empirical case studies.

• 2003 to present. Diagnostic/evaluative tool
  development.

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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.

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PARiHS Diagnostic and Evaluative utility?
PARiHS Diagnostic and Evaluative grid
Kitson et al., 2008.
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Summary
Summary
Summary
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.

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Why PARiHS Framework for Spinal Cord Injury
(SCI) QUERI?

• SCI system of care and targets for change
• Evidence
• Research
• Local
• Clinical
• Patient
• Context

Opportunities to work with other QUERI groups.
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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

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SCI PUMT Implementation

• 12 SCI centers randomized to receive one of two
  implementation strategies

1. Simple Local champion receives toolkit
   materials.

1. Enhanced PARIHS-informed external facilitation
   strategy.

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SCI PUMT Enhanced facilitation
Kitson et al., 2008.
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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.
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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.

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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.

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SCI PUMT Results

• Stay tuned!

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Applying Multiple Frameworks and Theories in
Implementation Research

• Jeffrey Smith
• Implementation Research Coordinator
• Mental Health QUERI

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• In theory there is no difference between theory
  and practice in practice there is.
• Yogi Berra

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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

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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

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An Approach to Using Theory for Implementation
Planning
Select framework / theory / model of planned
behavior change
Select interventionsthat fit with
plannedstrategies (based on theory)
Identify potential strategies for achieving
change
Assess fit with initial theory
Identify interventiontools that fit
bothstrategy and theory
Launch interventionusing identified toolsand
strategies
Evaluate effectivenessof intervention,strategies
, tools
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 21S43-49.
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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

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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)

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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

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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

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QUESTIONS?
Contact Jeff Smith VA Mental Health
QUERI E-mail Jeffrey.Smith6_at_va.gov