December 2018 Bulletin
Welcome to Implementation in Action, a monthly bulletin for implementers and intermediary organizations who are seeking to apply implementation science in a thoughtful and systematic way. Implementation in Action includes an introduction to the theme, a Project Spotlight, and links to two resources, an older one and a new one.
Do you Have a process in place to pick implementation Strategies?
By Julia E Moore
Senior Director, The Center for Implementation
Implementation is challenging and almost never goes the way you plan it. Has your implementation effort hit a roadblock and you don’t know how to move forward? Have people immediately become resistant and you don’t know how to turn it around? Are you feeling overwhelmed by implementation and don’t know what to do next?
If you are struggling with any of these issues, you probably need a process model, which presents the steps or stages to implement evidence. Some process models help guide you to develop programs when you have an evidence-based practice and others help you implement evidence-based programs. While a process model doesn't address all of the uncertainty of implementation, it can provide some guiding steps to get you out of an implementation rut.
So what’s the difference between an evidence-based practice and an evidence-based program?
An evidence-based practice describes WHAT you want someone to do differently, hopefully clarifying WHO needs to change and WHAT changes they need to make.
An implementation strategy describes HOW a person/organization/system changes. It is about the strategies we use to change someone’s behaviour.
An evidence-based program includes both the evidence-based practice and the implementation strategies. The combination of these has been systematically evaluated and shown to produce desired outcomes.
Before you pick a process model, you need to figure out if you are working with an evidence-based practice or program. This is because some process models describe how to implement an evidence-based program, while others help you develop a program if you only have an evidence-based practice. If you're starting with an evidence-based practice, then you need to select implementation strategies before you start implementing – these will help you figure out how you will support behaviour change.
Knowledge to Action
The knowledge to action (KTA) is a process model that helps you select implementation strategies. One of the things that makes the KTA unique is that it begins with research evidence, the need to synthesize and translate that evidence – these are represented by the funnel in the middle of the cycle. This makes the KTA very well-suited to situations where you have a practice change you want to make – a clearly defined set of recommendations about how you want someone to do something differently, for example recommendations from an evidence-based guideline.
The KTA provides the steps to take this evidence-based practice and select implementation strategies that support the behaviour change you are looking for. Let’s think through some definitions to illustrate how the KTA can help.
As you work through the action cycle of the KTA (the ring around knowledge generation), you systematically assess barriers and facilitators to change at individual, organizational, and systems levels. You then select implementation strategies (i.e., how behaviour is changed) using behaviour change theory targeting the identified barriers and facilitators. Not only do the implementation strategies need to be theory-based, they should also have evidence supporting their effectiveness.
Many KT initiatives employ commonly used implementation strategies (e.g., education). However, education is only likely to change behaviour if the underlying barriers to change are related to knowledge. If motivation is a barrier, education as an implementation strategy is not likely to change underlying motivation and alternate or additional strategy will be required.
Let’s think through an example using what appears to be a relatively simple evidence-based practice (the WHAT) – healthcare workers should get a flu vaccine. One of the most commonly used strategies in this situation is to use reminders. Reminders are an effective implementation strategy, shown in systematic reviews to change behaviour; however, reminders are going to work best when memory is barrier. Do you think that memory is one of the biggest barriers to getting healthcare workers to get their flu vaccine? If it isn’t one of the primary barriers, then you will need other implementation strategies, one that tap into people’s beliefs and emotions.
What if I don’t have a clinical evidence-based practice?
Recently, I have had a lot of conversations with people who or not implementing evidence-based guidelines or programs, but are trying to internally change the way work is done within their organization. For example, they are trying to adopt an integrated KT approach, to co-created knowledge with end-users, or engage stakeholders and patients in the research process.
Is the KTA helpful in these situations? Absolutely.
Although figuring out how an organization could adopt a co-creation approach is not a classic implementation of evidence example, it is still a situation in which you are trying to change people‘s behaviour and do something differently - for researchers to co-create knowledge with end-users. Therefore, the KTA can be used internally to guide the process of how you will support people to change the way they work.
You begin by clearly defining the change you want, assessing whether that needs to be adopted to different contexts or stakeholder groups, and then spend time understanding individual and organizational barriers to making this change – co-creating knowledge. Once you understand those barriers and facilitators, you can strategically select implementation strategies using evidence to pick ones that are effective, and theory to link them to those underlying barriers and facilitators to change.
Summary and resources
As you plan for implementation, figure out whether you are working with an evidence-based practice or program (most people are working with evidence-based practices unless they pulled them off of registries of evidence based programs). If you have an evidence-based practice, then you need a process model to guide you through selecting implementation strategies based on evidence and theory. The KTA does exactly that.
To learn more about how to use the KTA in practice, check out the December Project Spotlight, where we hear from a national funder, the Strategic Policy Branch of Health Canada. The Strategic Policy Branch is five years into a journey of adopting knowledge translation, both internally and for organizations/projects they fund and has just launched a resource to help people apply the KTA to their projects.
Project Spotlight: Implementing the KNowledge to Action (KTA) model in Health Canada’s Strategic policy branch grants and contributions programs
By Diana Kaan & Louise Zitzelsberger
Senior Policy Analysts, Knowledge Translation Team, Strategic Policy Branch, Health Canada
Through its funding programs, Health Canada’s Strategic Policy Branch aims to improve the health care system and the health of Canadians. Funded organizations undertake projects in various policy areas, such as palliative care, patient safety, and e-health. In general, most organizations are engaged in the development, dissemination or implementation of knowledge (or some combination of these).
In 2013, we identified knowledge translation (KT) as a useful concept to support the uptake of project outputs, achieve and ideally sustain outcomes. This new approach focused on implementation whereas previously end-of-project dissemination had been the norm.
Our first task was to establish a theoretical foundation to ensure a common understanding of KT and its application. After adopting the definition of KT developed by CIHR, we turned our attention to choosing a model that could guide the newly-established KT initiative.
The Knowledge to Action (KTA) model (Graham, ID., et al. 2006) was chosen because it:
is grounded in evidence;
asserts the importance of evidence to guide implementation;
applies to the diversity of branch programs;
provides a user-friendly approach to KT; and
was already being used by CIHR, a fellow organization in the federal government’s Health Portfolio.
Since then we have applied the principles underpinning the KTA model toward the development of resources. For example, we created the Knowledge Translation Planner (also available in French). The KT Planner, which breaks down the phases in greater detail, presents many of the key planning steps that are familiar to organizations, such as identifying outcomes from the onset and establishing a need based on evidence. The KTA model goes beyond these and stresses both the barriers to, and catalysts of, knowledge use. The model also highlights the selection of evidence-based strategies that address barriers.
In future, we will continue to integrate the principles of the KTA model into new resources and processes, including training, funding solicitation documents (guide for applicants, proposal review criteria) and performance measurement.
Implementation Resources - December Picks
Classic Literature: Interactive Systems Framework for Dissemination and Implementation
This article introduces the Interactive Systems Framework (ISF), a framework that can help us think about the different system and groups involved in producing a change. Under-utilized in healthcare, this classic implementation article is a great resource to revisit.
New Literature: Institute for Healthcare Improvement Psychology of Change Framework
This new white paper presents interesting and innovative ways of rethinking intrinsic motivation, co-design, co-production, power dynamics and adaptive leadership to inspire change in a new way. It’s an amazing new resource that has consolidated a huge amount of research from diverse fields.