July 2019 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 overview of the issue's theme, a Project Spotlight, and links to two resources - one from the foundational literature on the topic and another more recently published resource.
HIRING: Implementation Evaluator (Part-time)
The Center for Implementation is excited to share that we are looking to hire a part-time Implementation Evaluator (10 hours a week). This position is open to PhD students who are looking to gain experience that will set the course for a non-academic career.
For more information, click here.
Free mini-Course is wrapping up - only one week left!
Last month we launched our first ever online mini-course, Inspiring Change: Creating impact with evidence-based implementation. Since the launch, over 1300 people have registered for the course!
The course is designed for professionals responsible for creating change - the people leading change efforts within their organizations and communities.
This course is available for free until August 3rd.
CLICK HERE to sign up (it’s free) – you can launch into the modules right away!
Please forward this email to anyone you think would be interested.
Many people have requested a certificate of completion. To receive the certificate of completion that you must complete all sections to the very last module and on that module press continue and complete on the top right hand corner. Otherwise, it says that you have only completed 95% of the course. Once you have completed until the end, please email Shubi Ahmed (Shubi.Ahmed@thecenterforimplementation.com) and he will provide you a certificate of completion by August 10, 2019. You must request a certificate to receive one.
Do barriers and facilitators assessments have to be resource-intensive?
Senior Director, The Center for Implementation
Lately, one of the most common questions I get is: how do I assess barriers and facilitators, especially if I have limited resources?
It seems as though many people applying implementation science in practice have bought into the importance of assessing barriers and facilitators. They see the benefits of having a process model like the Knowledge to Action, they plan to use a theory of change, and they understand the value of assessing barriers and facilitators, but they get stuck on logistics. This is particularly true when working on a project that has limited resources.
Luckily there are very practical, inexpensive, and relatively quick ways that you can assess barriers and facilitators.
Assessing barriers and facilitators to select implementation strategies: the ideal scenario
First let’s start with an ideal situation. If I had unlimited time and resources, I would have a very comprehensive 4 step process to understand the barriers and facilitators.
I would review the literature to find existing studies that assess barriers and facilitators to either the specific practice change or a similar practice change. I would then pull the relevant barriers and facilitators from the literature. These barriers and facilitators would provide a starting place to understand the local level barriers and facilitators.
Next I would conduct interviews or focus groups, sharing the already identified barriers and facilitators and ask probing questions to get deeper into root causes and very unique barriers specific to that context.
After surveys and interviews, I might do observations, watching the people who are expected to change and making note of barriers and facilitators that people may not realize influence their behavior (e.g., workflows). The reality is humans are not great at understanding why we do and don’t do things, so asking us why we made a change or didn’t make a change is not always the best way to get at the true causes of our behavior.
After all of that, I may realize I have so many barriers and facilitators that I might want to prioritize them, or at least get a sense of which ones are most important in this context, so you might conduct a survey.
There are similar examples in the published literature, like the one by Atkins and colleagues.
Unfortunately almost no practical implementation project has the time and resources to do such a comprehensive barriers and facilitators assessment. So where does that leave you?
Barriers and facilitators: the quick and low-resource way
The literature is often the easiest and fastest way to get information about barriers and facilitators. There are so many studies out there assessing barriers and facilitators to change on a wide range of topics. While you may not be able to find a study that specifically looks at the barriers and facilitators to your exact practice change, chances are you can find things that are conceptually similar. Focus on the literature that looks at the same target population and/or the same or similar practices. But don’t forget to go to some of the more generic literature on barriers and facilitators. There are existing systematic reviews, like the review by Cabana and colleagues that has over 290 physician barriers and facilitators to guideline implementation. Chances are some of the barriers and facilitators you are facing are in that list.
Barriers and facilitators from the literature can provide a decent foundation understanding of potential barriers and facilitators. However, it is very important to get the perspective of the people who are being expected to change. If you have the time and resources to do formal interviews or focus groups, that’s great. If you don’t, through informal conversations you can gain very valuable information about what is really happening, and what factors are likely to hinder or support the implementation of the new practice.
Asking people questions directly can be hugely valuable, but there is one other method that I have found particularly helpful. If you are able to sit in on existing meetings, particularly if they are talking about the proposed practice change, you can learn so much about potential barriers and facilitators. When I have that kind of opportunity, I listen intently to what people are saying, to what is not said, and to reactions people have. I go into the meeting with a framework (like the theoretical domains framework or the consolidated framework for implementation research – if these are new terms for you, definitely check out the link to a previous bulletin where these are introduced), and I make a note about different barriers and facilitators that arise over the course of the discussion. During conversations with key team members afterwards, I ask probing questions to understand more about what was said.
If you are working on a resource-constrained project, there are inexpensive and relatively fast ways to understand the barriers and facilitators to change. It is important that you get this information, even if from less-than-rigorous methods – without it, you may select implementation strategies or develop an implementation plan that will be less effective. .
In this Project Spotlight by Ashleigh Townley, Joanne Wincentak, and Shauna Kingsnorth from Holland Bloorview Kids Rehabilitation Hospital describe how they used the theoretical domains framework to assess the barriers and facilitators to implementing heart and stroke guidelines for children’s rehab.
Using the theoretical domains framework to select implementation strategies
By Ashleigh Townley, Joanne Wincentak, and Shauna Kingsnorth
Knowledge Broker, Holland Bloorview Kids Rehabilitation Hospital
Evidence to Care (EtC) is the knowledge translation unit at Holland Bloorview Kids Rehabilitation Hospital, Canada’s largest children’s rehabilitation hospital. Our team promotes knowledge translation by identifying the best available research evidence in childhood disability and developing strategies to influence care.
Over the past three years, EtC and the Brain Injury Rehabilitation Team (BIRT) have worked to implement Heart and Stroke Best Practice Guidelines recommendations. Working with clinicians, mangers, clients and families, EtC led a prioritization activity where managing depression was identified as the first recommendation for implementation. Clinicians selected an 8-item screening questionnaire called the Patient Reported Outcome Measures System (PROMIS) Pediatric Depression Screen to identify clients who could benefit from further depression investigation.
The Theoretical Domains Framework (TDF) was used to plan and evaluate the implementation of the PROMIS tool (1). The TDF is a meta-framework that combines 84 constructs and 14 domains from 33 psychological theories relevant to behaviour change. EtC created an interview guide using the TDF domains and constructs, and met with the BIRT team to discuss the current state of depression care (e.g. screening, assessment and treatment processes; clinical disciplines involved; how information is shared); and PROMIS implementation needs such as perceived barriers and facilitators; competing priorities; clinical scope of practice; resources (processes, personnel, time) were explored.
EtC then mapped clinician’s answers to implementation strategies in the Behaviour Change Wheel’s COM-B system as recommended by TDF developers (1).
Here is a snapshot of implementation supports selected:
EtC is using the Determinants of Implementation Behavior Questionnaire (DIBQ), a validated TDF questionnaire, as both a (i) process evaluation tool, to assess and adjust implementation strategies as needed; and (ii) an outcome evaluation tool to determine the impact of the PROMIS, implementation supports, and inform modifications going forward (2).
(1) Cane, J., O’Connor, D., and Michie, S. ( 2012). Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science, 7 (37). Retrieved from: http://www.implementationscience.com/content/7/1/37
(2) Huijg, M. J., Gebhardt, A. W., Dusseldorp, E., Verheijden, W. M., van der Zouwe, N., Middelkoop, JC. B., and Crone, R. M. (2014). Measuring determinants of implementation behavior: psychometric properties of a questionnaire based on the theoretical domains framework. Implementation Science, 9 (33). Retrieved from: http://www.implementationscience.com/content/9/1/33
Implementation Resources - July Picks
While it might be a bit of a stretch to label this 2017 article as “classic”, this is an article keeps coming up as a foundational article that really helps people tease apart different purposes and components of implementation strategies. Even if you have read it before, it’s full of great information, so worth reading again.
A brand new article presenting the most comprehensive published adaptation framework. If you are thinking about adaptations, this is definitely an article worth checking out.