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

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

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

PARiHS FrameworkPARiHS Framework

Promoting Action on Research Promoting Action on Research Implementation in Health ServicesImplementation in Health Services

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

•PARiHS Framework:PARiHS Framework:

History History Features Features Proposed utility Proposed utility Application Example Application Example

PARiHS OriginsPARiHS Origins

Royal College of Nursing Institute, UKRoyal College of Nursing Institute, UK 1990s1990s Contemporary models of the processes of Contemporary models of the processes of

implementing research into practice are inadequate.implementing research into practice are inadequate. UnidimensionalUnidimensional Non-interactiveNon-interactive

PARiHS FrameworkPARiHS Framework developmental aims:developmental aims:

Accurately represent the complexities Accurately represent the complexities of implementation.of implementation.

Useful for guiding clinicians charged Useful for guiding clinicians charged with implementing research into with implementing research into practice.practice.

Useful for explaining variability in theUseful for explaining variability in the

success of implementation projects.success of implementation projects.

PARiHS Framework ElementsPARiHS Framework Elements

Evidence.Evidence.

Context.Context.

Facilitation.Facilitation.

Weak to strong support for implementationWeak to strong support for implementation

Evidence Sub-elements:Evidence Sub-elements: Research evidence.Research evidence.

Weak: Anecdotal evidence, descriptive.Weak: Anecdotal evidence, descriptive. Strong: RCTs, evidence-based guidelines.Strong: RCTs, evidence-based guidelines.

Clinical experience.Clinical experience. Weak: Expert opinion divided.Weak: Expert opinion divided. Strong : Consensus.Strong : Consensus.

Patient preferences and experiences.Patient preferences and experiences. Weak: Patients not involved.Weak: Patients not involved. Strong : Partnership with patients.Strong : Partnership with patients.

Local information.Local information.

Context Sub-elements:Context Sub-elements: Culture.Culture.

Weak: Task driven, low morale.Weak: Task driven, low morale. Strong : Learning organization, patient-centered.Strong : Learning organization, patient-centered.

Leadership.Leadership. Weak: Poor organization, diffuse roles.Weak: Poor organization, diffuse roles. Strong : Clear roles, effective organization.Strong : Clear roles, effective organization.

Evaluation.Evaluation. Weak: Absence of audit and feedbackWeak: Absence of audit and feedback Strong : Routine audit and feedback.Strong : Routine audit and feedback.

Facilitation Sub-elements:Facilitation Sub-elements:

Characteristics (of the facilitator).Characteristics (of the facilitator). Weak: Low respect, credibility, empathy.Weak: Low respect, credibility, empathy. Strong: High respect, credibility, empathy.Strong: High respect, credibility, empathy.

Role.Role. Weak: Lack of role clarity.Weak: Lack of role clarity. Strong: Clear roles.Strong: Clear roles.

Style.Style. Weak: Inflexible, sporadic.Weak: Inflexible, sporadic. Strong: Flexible, consistent.Strong: Flexible, consistent.

PARiHS Framework: PARiHS Framework: Elements and SubelementsElements and Subelements

EvidenceEvidence.. ResearchResearch Clinical experienceClinical experience Patient experiencePatient experience Local knowledgeLocal knowledge

ContextContext.. CultureCulture LeadershipLeadership EvaluationEvaluation

Facilitation.Facilitation. CharacteristicsCharacteristics RoleRole StyleStyle

PARiHS FrameworkPARiHS FrameworkSuccessful implementation is most likely to Successful implementation is most likely to

occur when:occur when:1.1. Scientific evidence is viewed as sound and Scientific evidence is viewed as sound and

fitting with professional and patient beliefs.fitting with professional and patient beliefs.

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

3.3. There are appropriate mechanisms in There are appropriate mechanisms in place to facilitate implementation.place to facilitate implementation.

PARiHS FrameworkPARiHS Framework developmental history:developmental history:

1998 - 2002. Development, conceptual 1998 - 2002. Development, conceptual analysis.analysis.

2003 to present. Diagnostic/evaluative tool 2003 to present. Diagnostic/evaluative tool development.development.

2001-2003. Empirical case studies.2001-2003. Empirical case studies.

PARiHS FrameworkPARiHS Framework current knowledge base:current knowledge base:

Numerous case reports available, in support Numerous case reports available, in support of face validity and practical appeal.of face validity and practical appeal.

Theoretical positions of the framework are Theoretical positions of the framework are still in development.still in development.

One published instrument related to PARiHS.One published instrument related to PARiHS.

PARiHS Diagnostic and PARiHS Diagnostic and Evaluative utility?Evaluative utility?

PARiHS Diagnostic and Evaluative grid:PARiHS Diagnostic and Evaluative grid:

Kitson et al., 2008.

SummarySummary::

PARiHS framework has long been the subject PARiHS framework has long been the subject of theoretical development.of theoretical development.

Empirical foundations for the framework Empirical foundations for the framework have not developed at pace with theory.have not developed at pace with theory.

Exploratory work in applying PARiHS to Exploratory work in applying PARiHS to implementation interventions is encouraging.implementation interventions is encouraging.

SummarySummary::SummarySummary::Summary:

CIPRS: Stetler & Damschroder Theoretical Frameworks

Using Theory for Implementation Using Theory for Implementation PlanningPlanning

Select theory of planned behaviorchange

Assess fit with initial theory

Identify potential strategies for achieving change

Select interventionsthat fit with plannedstrategies (based on theory)

Identify interventiontools that fit bothstrategy and theory

Launch interventionusing identified toolsand strategies

Evaluate effectivenessof intervention,strategies, tools

See references: Sales et al., 2006

CIPRS: Stetler & Damschroder Theoretical Frameworks

Selecting a Theory Selecting a Theory -- 11 Consider Context

Study characteristics Professional discipline/perspective Intervention characteristics Inner and outer setting Individuals involved Implementation process

Consider Level Individuals Teams Organization System

Why PARiHS FrameworkWhy PARiHS Framework for Spinal Cord Injury for Spinal Cord Injury

(SCI) QUERI?:(SCI) QUERI?:SCI system of care and targets for changeSCI system of care and targets for change

a.a. EvidenceEvidence ResearchResearch LocalLocal ClinicalClinical PatientPatient

b.b. ContextContext

Opportunities to work with other QUERI groups.Opportunities to work with other QUERI groups.

Implementation Project Implementation Project Example 1Example 1

SCI Pressure Ulcer Management SCI Pressure Ulcer Management Tool (SCI PUMT)Tool (SCI PUMT) Implement a toolkit designed to Implement a toolkit designed to

standardize monitoring of pressure standardize monitoring of pressure ulcer healing in the ulcer healing in the

VA SCI system of care. VA SCI system of care. PUMT:PUMT:

Training tools (education protocol, CD, Training tools (education protocol, CD, models)models)

Competency assessmentCompetency assessment

SCI PUMT SCI PUMT ImplementationImplementation

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

1.1. Simple: Local “champion” Simple: Local “champion” receives toolkit materials.receives toolkit materials.

2.2. Enhanced: PARIHS-informed Enhanced: PARIHS-informed external facilitation strategy. external facilitation strategy.

SCI PUMT Enhanced SCI PUMT Enhanced facilitationfacilitation

Kitson et al., 2008.

SCI PUMT Enhanced SCI PUMT Enhanced FacilitationFacilitation

Diagnostic AssessmentDiagnostic Assessment. . Measure factors important to implementation at all Measure factors important to implementation at all participating sites. Specifically, the diagnostic participating sites. Specifically, the diagnostic assessment will measure: assessment will measure: EVIDENCE: Appraisals of 4 sources of EVIDENCE: Appraisals of 4 sources of evidence: evidence:

(1) Published scientific evidence. (1) Published scientific evidence. (2) Clinical experience or (2) Clinical experience or

professional knowledge.professional knowledge.(3) Patient experiences and (3) Patient experiences and

beliefs.beliefs.(4) Evidence derived from local (4) Evidence derived from local

experiences.experiences.CONTEXT: Appraisals of 3 aspects of CONTEXT: Appraisals of 3 aspects of context context

(1) Organizational culture. (1) Organizational culture. (2) Leadership. (2) Leadership. (3) Evaluation.(3) Evaluation.

SCI PUMT SCI PUMT Enhanced FacilitationEnhanced Facilitation

Diagnostic AssessmentDiagnostic Assessment. .

Measures: Measures:

Organizational Readiness for Change Assessment (ORCA)Organizational Readiness for Change Assessment (ORCA)1) Questionnaire, 3 scales: 1) Questionnaire, 3 scales:

Evidence, Context, Facilitation. Evidence, Context, Facilitation.

Structured InterviewsStructured Interviews Evidence, Context, Facilitation. Evidence, Context, Facilitation.

Depends upon results of diagnostic.Depends upon results of diagnostic.

SCI PUMT SCI PUMT Enhanced FacilitationEnhanced Facilitation

ANDAND Pre-diagnostic efforts Pre-diagnostic efforts Evidence: Evidence:

Presentations of empirical research by nursing leaders.Presentations of empirical research by nursing leaders.

ContextContext Involving national and local SCI leadership.Involving national and local SCI leadership.

FacilitationFacilitation Selecting and training nurse facilitators.Selecting and training nurse facilitators.

Stay tuned!Stay tuned!

SCI PUMT ResultsSCI PUMT Results

Applying Multiple Applying Multiple Frameworks and Frameworks and

Theories in Theories in Implementation Implementation

ResearchResearchJeffrey SmithJeffrey SmithImplementation Research Implementation Research

CoordinatorCoordinator

Mental Health QUERIMental Health QUERI

““In theory there is no difference In theory there is no difference

between theory and practice… in between theory and practice… in

practice there is.”practice there is.”

Yogi BerraYogi Berra

Mental Health QUERI Approach to Mental Health QUERI Approach to ImplementationImplementation

Design interventions based on theory, lit review and Design interventions based on theory, lit review and results from formative evaluationresults from formative evaluation

Conduct formative evaluationConduct formative evaluation engage with stakeholdersengage with stakeholders identify determinants of current practiceidentify determinants of current practice assess barriers and facilitators to implementationassess barriers and facilitators to implementation

organizational-levelorganizational-level team / clinic-levelteam / clinic-level individual provider-levelindividual provider-level patient-levelpatient-level

tailor intervention design and implementation to local tailor intervention design and implementation to local contextcontext

Mental Health QUERI Approach to Mental Health QUERI Approach to Implementation (cont)Implementation (cont)

Use external facilitation techniques (PARiHS Use external facilitation techniques (PARiHS Framework)Framework) engage with stakeholders to problem-solve and identify engage with stakeholders to problem-solve and identify

new strategies or tools for overcoming barriers when new strategies or tools for overcoming barriers when initial success is sub-optimalinitial success is sub-optimal

Conduct summative (or impact) evaluationConduct summative (or impact) evaluation

An Approach to Using Theory for An Approach to Using Theory for Implementation PlanningImplementation Planning

Select framework / theory / model of planned behavior change

Assess fit with initial theory

Identify potential strategies for achieving change

Select interventionsthat fit with plannedstrategies (based on 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;

21:S43-49.

Implementation Science Implementation Science Frameworks and Theories Frameworks and Theories

(selected)(selected)

Organizational / System LevelOrganizational / System Level Consolidated Framework for Implementation Consolidated Framework for Implementation

Research Research (VA Diabetes QUERI)(VA Diabetes QUERI)

Promoting Action on Research Implementation in Promoting Action on Research Implementation in Health Services (PARiHS)Health Services (PARiHS)

Stetler Organizational Framework for Stetler Organizational Framework for Institutionalizing EBPsInstitutionalizing EBPs

Greenhalgh Model for Diffusing Innovations in HCOsGreenhalgh Model for Diffusing Innovations in HCOs Ottawa Model of Research UseOttawa Model of Research Use Simpson Transfer ModelSimpson Transfer Model Complexity TheoryComplexity Theory

Implementation Science Implementation Science Frameworks and Theories (cont.)Frameworks and Theories (cont.)

Interpersonal LevelInterpersonal Level Diffusion of Innovation (Rogers)Diffusion of Innovation (Rogers) Social Influence Theory (Mittman)Social Influence Theory (Mittman) Social Cognitive Theory… aka Social Learning Theory Social Cognitive Theory… aka Social Learning Theory

(Bandura)(Bandura)

Individual LevelIndividual Level Theory of Reasoned Action / Theory of Planned Theory of Reasoned Action / Theory of Planned

Behavior (Azjen & Fishbein)Behavior (Azjen & Fishbein) Health Belief Model (Rosenstock)Health Belief Model (Rosenstock) Transtheoretical Model and Stages of Change Transtheoretical Model and Stages of Change

(Prochaska & DiClemente)(Prochaska & DiClemente)

Multiple theory Multiple theory

approachapproach StrengthsStrengths

useful in designing multifaceted interventions to influence useful in designing multifaceted interventions to influence multi-level determinants of care (flexible)multi-level determinants of care (flexible) allows integration of theory, knowledge, methods from multiple allows integration of theory, knowledge, methods from multiple disciplines (multidisciplinary)disciplines (multidisciplinary)

LimitationsLimitations Can be unwieldy… need to provide rationale for applying Can be unwieldy… need to provide rationale for applying multiple multiple theory approach, and rationale for selecting the specific theory approach, and rationale for selecting the specific frameworks / theories appliedframeworks / theories applied

Key Guidance on EvaluationKey Guidance on Evaluation combine with rigorous formative evaluationcombine with rigorous formative evaluation conduct summative (impact) evaluation to assess intervention conduct summative (impact) evaluation to assess intervention effectiveness on key study outcomeseffectiveness on key study outcomes confirm, refute or propose refinements to selected theory(ies) confirm, refute or propose refinements to selected theory(ies) based on study findingsbased on study findings

Summary Summary

Application of multiple frameworks/theories in Application of multiple frameworks/theories in guiding intervention design and implementation guiding intervention design and implementation

can can be successful in implementing EBPsbe successful in implementing EBPs

accommodates tailoring to setting when combined accommodates tailoring to setting when combined with formative evaluationwith formative evaluation example forthcoming (May 5 session)example forthcoming (May 5 session)

acknowledges there are generally multi-level acknowledges there are generally multi-level determinants to complex, clinical QI issuesdeterminants to complex, clinical QI issues organizational-levelorganizational-level team-levelteam-level interpersonal-levelinterpersonal-level individual-levelindividual-level

QUESTIONS?QUESTIONS?

Contact: Contact:

Jeff Smith Jeff Smith

VA Mental Health QUERIVA Mental Health QUERI

E-mail: Jeffrey.Smith6@vaE-mail: [email protected]