Implementation Science: Research Priorities and Needs for the Field Ian D Graham PhD Vice President Canadian Institutes of Health Research Chicago, July 28 th 2009 Cross QUERI Working Group on Implementation Science
Dec 25, 2015
Implementation Science: Research Priorities and Needs for the Field
Ian D Graham PhDVice President
Canadian Institutes of Health ResearchChicago, July 28th 2009
Cross QUERI Working Group onImplementation Science
Working in a living Lab
You have a unique opportunity to not only improve health and quality of life of your clients but
also to
further implementation (KT) science
• This can be done through 3 general strategies:– Move forward through retrospection and reflection – Make your tacit knowledge explicit through rigorous and
“infectious” reflection and documentation – Use conceptual frameworks
Why use a conceptual framework?
“It can scarcely be denied that the supreme goal of all theory is to make the irreducible basic elements as simple and as few as possible without having to surrender the adequate representation of a single datum of experience.”
Albert Einstein
Why use a conceptual framework?
• as with other forms of science, the success of a field is dependent on its theoretical foundation
• getting research into practice requires a systematic effort as the process is complex and occurs in the face of competing organizational and practice priorities
• hence researchers need to analyze and synthesize both the empirical and the theoretical underpinnings to be able to look inside the implementation “black box”
Why use a conceptual framework?• theory can be the driver of comparable and consistent
measurement/evaluation of implementation objectives• important for researchers to evaluate the utility of their
chosen theory including its internal and external validity – which components are critical, how should they be weighted
• The existing body of evidence about the effectiveness of different interventions suggests their impact is variable and effect sizes are generally moderate – thus evidence alone cannot guide implementation efforts
• We undertook a critical analysis of conceptual models of implementation as a means of understanding the theoretical underpinnings of implementation or what we at CIHR call knowledge translation.
• They have the basic purpose of focusing, ruling some things in as relevant and ruling others out due to their lesser importance.
Change theories/models fall into two basic kinds: Classical - models that describe change, but were
not specifically designed to cause change (e.g.PARIHS Promoting Action on Research Implementation in Health Services; Diffusion of Innovations) Planned – models that are intended to be used to guide or cause change (QUERI framework is a quality
improvement PAT)
…about conceptual frameworks
about conceptual frameworks
• Many of the PATs propose similar steps – can see that the QUERI framework addresses the action categories – the implementation “steps”
• The PATs are varied in their consideration of implemenation “factors” (covered in so called “classical” theories (of which there are many))
• Besides these macro and meso-level theories ,there are also many theories dealing with behaviour at the individual as well as organizational level (see chapter by Wensing et al. in “From Evidence to Practice” in particular, and the entire book, in general)
MonitorMonitorKnowledgeKnowledge
UseUse
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UseUse
EvaluateEvaluateOutcomesOutcomes
AdaptAdaptKnowledgeKnowledge
to Local Contextto Local Context
AssessAssessBarriers/facilitatorsBarriers/facilitators
to to Knowledge UseKnowledge Use
Select, Tailor,Select, Tailor,ImplementImplement
InterventionsInterventions
Identify ProblemIdentify Problem
Identify, Review,Identify, Review,Select KnowledgeSelect Knowledge
Products/Products/ToolsTools
SynthesisSynthesis
Knowledge Knowledge InquiryInquiry
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KNOWLEDGE CREATIONKNOWLEDGE CREATION
from: Graham et al: Lost in Knowledge Translation: Time for a Map?
http://www.jcehp.com/vol26/2601graham2006.pdf
MonitorKnowledge
Use
SustainKnowledge
Use
EvaluateOutcomes
AdaptKnowledge
to Local Context
AssessBarriers/facilitators
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Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Products/Products/ToolsTools
SynthesisSynthesis
Knowledge Knowledge InquiryInquiry
Tailo
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Kno
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KNOWLEDGE CREATIONKNOWLEDGE CREATION
http://www.jcehp.com/vol26/2601graham2006.pdf
from: Graham et al:Lost in Knowledge Translation: Time for a Map?
Knowledge Inquiry
• studies using all types of study designs• primary research needs to be targeted to fill the known
gaps in our knowledge base • primary research needs to be solutions-based• Implementation Science:
– need research on effectiveness/impact of interventions and develop common methods of evaluation
• QUERI 4 Phase Pipeline: – Phase 1: single site pilot; – Phase 2: small scale/multi site implementation trial; – Phase 3: large scale/multi-region implementation trial; – Phase 4: system wide roll out
Products/Tools
Synthesis
Knowledge Inquiry
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Synthesis
• need for synthesis to determine what we already know (or should know if we were to summarize the existing knowledge)
• can take the form of systematic reviews, meta analyses, realist reviews, etc.
• need to determine where there is a strong evidence base and move that evidence into action
Products/Tools
Synthesis
Knowledge Inquiry
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Knowledge Products/Tools
• Algorithms• Decision rules• Decision aids• Guidelines• Measurement tools
Products/Tools
Synthesis
Knowledge Inquiry
Tailo
ring
Kno
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MonitorMonitorKnowledgeKnowledge
UseUse
SustainSustainKnowledgeKnowledge
UseUse
EvaluateEvaluateOutcomesOutcomes
AdaptAdaptKnowledgeKnowledge
to Local Contextto Local Context
AssessAssessBarriers/facilitatorsBarriers/facilitators
to to Knowledge UseKnowledge Use
Select, Tailor,Select, Tailor,ImplementImplement
InterventionsInterventions
Identify ProblemIdentify Problem
Identify, Review,Identify, Review,Select KnowledgeSelect Knowledge
Products/Products/ToolsTools
SynthesisSynthesis
Knowledge Knowledge InquiryInquiry
Tailo
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Kno
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KNOWLEDGE CREATIONKNOWLEDGE CREATION
Action Cycle(Application)
EITHER
Start with problem/issue concern and look for research to solve the problem
OR
Become aware of the research/guideline and assess whether current practice is in keeping with it
Identify Problem
Identify, Review,Select Knowledge
Tailo
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Kno
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Products/ Tools
Synthesis
Knowledge Inquiry
KNOWLEDGE CREATION
MonitorKnowledge
Use
SustainKnowledge
Use
EvaluateOutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
• To apply knowledge, one needs to contextualize or adapt it for local use– e.g. ADAPTE Collaboration (for guideline adaptation)
• How might the implementation plan need to be adapted for local use?
AdaptKnowledge to Local Context
SustainKnowledge
Use
Evaluateoutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Tailoring Knowledge
Products/
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Knowledge Inquiry
KNOW
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N
MonitorKnowledge
Use
• Assess barriers and supports related to:– the knowledge (e.g. guideline)– the potential adopters– the practice setting– the implementation plan
• What might be the individual, team, and organizational barriers to uptake?
• Can the development process anticipate the barriers to use and address any of them?
AssessBarriers/facilitators
toKnowledge Use
MonitorKnowledge
Use
SustainKnowledge
Use
Evaluateoutcomes
AdaptKnowledge
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AssessBarriers to
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Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Tailoring Knowledge
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ledge Inquiry
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• Based on the barriers and supports identified, select or tailor implementation interventions
• e.g. Cochrane’s Effective Practice and Organization of Care review group source of synthesized info on effectiveness of KT interventions
http://www.epoc.cochrane.org/en/index.html
Select, Tailor,Implement
InterventionsSustain
KnowledgeUse
Evaluateoutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
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Identify Problem
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Products/
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MonitorKnowledge
Use
• Assess the use or uptake of the knoweldge– Conceptual use (knowledge, attitudes, intentions) – Instrumental Use (behavioural), – symbolic knowledge use (to persuade)
• What “dose “ of the intervention is being delivered?
MonitorKnowledge
Use
MonitorKnowledge
Use
SustainKnowledge
Use
Evaluateoutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Tailoring Know
ledge
Products/ Tools
Synthesis
Knowledge Inquiry
KNOWLEDGE CREATION
• Determine impact of the intervention– Client health and other outcomes (eg. symptoms,
morbidity, HRQoL, mortality, satisfaction)– Provider outcomes (eg. satisfaction)– System/organization outcomes (eg. Wait times,
expenditures, readmissions)– Unintended impacts
EvaluateOutcomes
MonitorKnowledge
Use
SustainKnowledge
Use
EvaluateOutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
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• What is needed to sustain ongoing use?• What ongoing monitoring of knowledge use and
impacts needed?• How long are the skills/knowledge maintained?
SustainKnowledge
Use
MonitorKnowledge
Use
SustainKnowledge
Use
EvaluateOutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
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Interventions
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CIHR:Two kinds of KTCIHR:Two kinds of KT
End of grant KT
Integrated KT
The researcher develops and implements a plan for making knowledge users aware of the knowledge generated through a research project
Research approaches that engage potential knowledge-users as partners in the research process. requires a collaborative or participatory approach to research that is action oriented and is solutions and impact focused (Mode 2).
What is integrated KT?
• a way of doing research• collaborative, participatory, action-oriented, community
based research, co-production of knowledge, mode 2 knowledge production
• involves engaging and integrating knowledge users into the research process
• Knowledge users can be:– Policy- and decision-makers from the community to the
federal level, researchers, the public, industry, clinicians, the media
– Investigators from different disciplines, teams, countries
In addition, knowledge users and researchers (knowledge creators) can work together to:
shape the research questionsdecide on the methodology interpret the study findings and craft messaging
around themhelp with data collection and tools developmentmove the research results into practicewidespread dissemination and application
What is integrated KT?
IKT and QUERI
• QUERI’s action-oriented approach that meaningfully engages clinicians, managers, patients/clients, and researchers in research-driven initiatives to improve quality = IKT (Mode 2 knowledge production)
• IS research agenda:– What has been learned so far about IKT at QUERI?– What’s involved in doing QI this way?– How is it working (how effective is it)?– How can it work better?– Strategies and tools to engage knowledge users– Guidelines/criteria for good Mode 2 knowledge production
(IKT)
Step 1: Select conditions per patient populations associated with high risk of disease and/or disability and/or burden of illness for veterans
1A. Identify and prioritize (via a formal ranking procedure)1B. Identify high-priority clinical practices and outcomes
within a selected condition
Step 3: Measure and diagnose quality and performance gaps
3A. Measure existing practice patterns and outcomes across VA and identify variations from evidence-based practices ("quality/performance gaps")
3B. Identify determinants of current practices3C. Diagnose quality/performance gaps
Identify Problem
Identify, Review,Select Knowledge
Tailo
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Kno
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Products/ Tools
Synthesis
Knowledge Inquiry
KNOWLEDGE CREATION
MonitorKnowledge
Use
SustainKnowledge
Use
EvaluateOutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
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Step 2: Identify evidence-based guidelines, recommendations and best practices
2A. Identify evidence-based clinical practice guidelines2B. Identify evidence-based clinical recommendations2C. Identify evidence-based clinical practices
Identify Problem
Identify, Review,Select Knowledge
Tailo
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Kno
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Products/ Tools
Synthesis
Knowledge Inquiry
KNOWLEDGE CREATION
MonitorKnowledge
Use
SustainKnowledge
Use
EvaluateOutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
AdaptKnowledge to Local Context
SustainKnowledge
Use
Evaluateoutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Tailoring Knowledge
Products/
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Knowledge Inquiry
KNOW
LEDGE CREATIO
N
MonitorKnowledge
Use
Step 4: Implement improvement programs4A. Identify improvement/implementation strategies, programs and program components or tools
4B. Develop or adapt improvement/implementation 4B. Develop or adapt improvement/implementation strategies, programs and program components or strategies, programs and program components or toolstools
4C. Implement improvement/implementation strategies/programs to address quality gaps
AdaptKnowledge to Local Context
SustainKnowledge
Use
Evaluateoutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Tailoring Knowledge
Products/
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Knowledge Inquiry
KNOW
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N
MonitorKnowledge
Use
Step 4: Implement improvement programs
4B. Develop or adapt improvement/implementation 4B. Develop or adapt improvement/implementation strategies, programs and program components or strategies, programs and program components or toolstools•IS Research Agenda:IS Research Agenda:
•Most efficient and useful methods for adapting Most efficient and useful methods for adapting guidelines/research to settingsguidelines/research to settings•How to develop local capacity for adaptation and How to develop local capacity for adaptation and sustainable process for adaptationsustainable process for adaptation
Step 3: Measure and diagnose quality and performance gaps
3A. Measure existing practice patterns and outcomes across VA and identify variations from evidence-based practices ("quality/performance gaps")
3B. Identify determinants of current practices3C. Diagnose quality/performance gaps
3D. Identify barriers and facilitators to improvement3D. Identify barriers and facilitators to improvement
AssessBarriers/facilitators
toKnowledge Use
MonitorKnowledge
Use
SustainKnowledge
Use
Evaluateoutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Tailoring Knowledge
Products/
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Synthesis
Know
ledge Inquiry
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Step 3: Measure and diagnose quality and performance gaps
3D. Identify barriers and facilitators to improvement3D. Identify barriers and facilitators to improvement• IS research agenda:
– Determinants of research use (role of unit/org culture, leadership)– Taxonomy for barriers and facilitators (individual, team,
organizational)– Validated measures to identify barriers and facilitators– Most efficient methods of identifying barriers and facilitators (e.g.
surveys vs interviews vs key informants)
AssessBarriers/facilitators
toKnowledge Use
MonitorKnowledge
Use
SustainKnowledge
Use
Evaluateoutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Tailoring Knowledge
Products/
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Synthesis
Know
ledge Inquiry
KN
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Step 4: Implement improvement programs4A. Identify improvement/implementation
strategies, programs and program components or tools
4B. Develop or adapt improvement/implementation strategies, programs and program components or tools
4C. Implement improvement/implementation strategies/programs to address quality gaps
Select, Tailor,Implement
InterventionsSustain
KnowledgeUse
Evaluateoutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Tailoring K
nowledge
Products/
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Knowledge Inquiry
KNOW
LEDGE CREATIO
N
MonitorKnowledge
Use
Step 4: Implement improvement programs4A. Identify improvement/implementation strategies, programs and
program components or tools4C. Implement improvement/implementation strategies/programs to
address quality gaps
• IS research agenda:– Effectiveness of implementation strategies (what works
for whom, under what conditions, with what evidence (guidelines)?) Methods to determine dose of strategies
– Strategies directed at individuals (e.g. psychological) vs social setting/organization (e.g. sociological, organizational) (health system interventions key)
Select, Tailor,Implement
InterventionsSustain
KnowledgeUse
Evaluateoutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Tailoring K
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Knowledge Inquiry
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MonitorKnowledge
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Step 5/6: Evaluate improvement programs
5. Assess improvement program feasibility, 5. Assess improvement program feasibility, implementation and impacts on patient, family implementation and impacts on patient, family and healthcare system processes and outcomesand healthcare system processes and outcomes
6. Assess improvement program impacts on health related quality of life (HRQOL)
MonitorKnowledge
Use
MonitorKnowledge
Use
SustainKnowledge
Use
Evaluateoutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Tailoring Know
ledge
Products/ Tools
Synthesis
Knowledge Inquiry
KNOWLEDGE CREATION
Step 5/6: Evaluate improvement programs
5. Assess improvement program feasibility, implementation and impacts on patient, family and healthcare system processes and outcomes
6. Assess improvement program impacts on health related quality of life (HRQOL)
EvaluateOutcomes
MonitorKnowledge
Use
SustainKnowledge
Use
EvaluateOutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Tailoring Knowledge
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Step 5/6: Evaluate improvement programs
5. Assess improvement program feasibility, implementation and impacts on patient, family and healthcare system processes and outcomes
6. Assess improvement program impacts on health related quality of life (HRQOL)
• IS research agenda:– Validated measures of knowledge use and impact
EvaluateOutcomes
MonitorKnowledge
Use
SustainKnowledge
Use
EvaluateOutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Tailoring Knowledge
Pro
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• IS research agenda:– Determinants of sustained knowledge use
(organizational, team, individual)– Methods to measure ongoing use and impact– Sustainability of implementation strategies overtime
and their impact– Creating sustainable research use organizations and
cultures
SustainKnowledge
Use
MonitorKnowledge
Use
SustainKnowledge
Use
EvaluateOutcomes
AdaptKnowledge
to Local Context
AssessBarriers to
Knowledge Use
Select, Tailor,Implement
Interventions
Identify Problem
Identify, Review,Select Knowledge
Tailor
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How to move the implementation science research agenda forward
• You have the QUERI Framework (PAT) and QUERI Pipeline– Review and refine the frameworks– Consciously categorize all activities by these
frameworks to allow better understanding of projects
• You have selected a classical theory to define how you examine/approach the factors (PARIHS, for example)– Theory testing
How to move the implementation science research agenda forward
• Theories range from the simple to the complex• Not practical nor feasible to control and/or measure
every possible variable nor to test every construct or hypothesis
• Need to do enough ground work to understand the implementation specific context and to get a sense of what the key change objectives are important to the knowledge-users in that context
• Need to balance need for context-specific tailoring with need for replicability and commonality of measurement tools
How to move the implementation science research agenda forward
• View all QI efforts as opportunities to advance implementation science– Be reflective: document processes and
experiences (the science and the art)– What are you learning? – Turn tacit knowledge about implementation and
implementation research into explicit knowledge- i.e. how to conduct implementation research but also how to implement
How to move the implementation science research agenda forward
• Develop and test measures (barriers assessment, knowledge use, impact, sustainability)
• Encourage use of common measures (or batteries of measures) to allow comparison across studies
How to choose the appropriate intervention
• Link specific interventions to the barriers– This is an art, not a science – If barrier is knowledge or confidence, then self
efficacy theory can be used, if it is lack of awareness, then the transtheoretical model could be used etc. Test methods of tailoring strategies to barriers
– involving a large number of potential knowledge-users in this process could contribute to a successful intervention (but this is an empirical question )
How to choose the appropriate intervention
• Decide if you need a single or multiple/complex interventions
• With multiple interventions – are you targeting the same or different barriers?
• Are the interventions targeted to different levels: individual, team, organization?
How to move the implementation science research agenda forward
There are also many theories dealing with behaviour at the individual as well as organizational level (see chapter by Wensing et al. in “From Evidence to Practice” in particular, and the entire book, in general)
• Whenever you are combining the QUERI framework with other theories, consider documenting your experiences so as to advance understanding of how useful the model is and to provide information to others who are attempting a similar project– Have you been able to derive and test hypotheses and
propositions based on the theory?– Does it explain successes and failures?– Does it suggest or provide ways to measure/evaluate the
hypotheses?– Does it adequately capture the critical components (the
active ingredients) of the implementation process in your project?
Back to the idea of working in a living Lab
You have a unique opportunity to not only improve health and quality of life of your clients but also to
further implementation (KT) science
• This can be done through 3 general strategies:– Move forward through retrospection and reflection
– Make your tacit knowledge explicit through rigorous and “infectious” reflection and documentation
– Use conceptual frameworks
working in a living Lab
You have seen the handout with implementation science goals listed in recent publications
Think about how your work can push the implementation science (KT) agenda
Relationships seem to be a key driver of implementation efforts – can this be studied and documented as well practiced?
Context is seen as important: what are the key features to either sink an implementation effort or successfully launch one?
working in a living Lab
We need to be able to monitor knowledge use, evaluate outcomes and sustain change
To do this effectively, transparently and in a manner that is reproducible, we need appropriate measurement tools
It is not helpful if everyone makes up their own every time they need one
Identify (adapt or develop) and use psychometrically validated tools
working in a living LabSustainability is a key issue that needs basic research
(how is it defined, how often and under what circumstances does it happen) as well as enabling research (what can be done to ensure sustainability – in a variety of contexts and settings)
Think back to past implementation successes and failures: how can theory be harnessed to differentiate them?
As implementation scientists, we need to work reflexively: using what we know about knowledge translation to inform and guide our own work
working in a living Lab
• Capacity development– Implementation researchers– Among service providers to effectively
facilitate implementation
• Ensuring relevance with service providers- making QUERI indispensible
working in a living Lab
• QUERI is at the cutting edge of Implementation Science
• What does QUERI need to do to stay at the cutting edge in the future?
Thank you for your attentionMerci
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