Integrating Implementation Science and Quality Improvement: An Implementation Guide
By Dr. Julia E. Moore, Executive Director
Implementation science is growing at an ever-increasing pace - there has been a rapid surge in publications, academic positions, training programs, funding opportunities, and new journals. The field originated because of a recognized gap between what we know from the evidence and what is happening in practice on the front lines. That is the underlying driver of all implementation work. But there is an increasing recognition that we are not effectively “implementing” our own implementation science evidence with those who need it most – frontline practitioners. This has become a common theme and topic at conferences among experts, and even in journal articles.
Bringing applied implementation science to mainstream improvement efforts
We obviously spend a lot of time thinking about this problem, trying to figure out how to build tools, resources, training, and supports for people and organizations who want to apply implementation science. While there is a rapidly growing demand for this kind of work, it seems as though most of the people interested in implementation science are essentially “early adopters” of implementation science. Yes, that means you, the person reading this are probably an early adopter of applying implementation science. It is wonderful and amazing to see that growing momentum, but if we want to ultimately have large scale impact, we need to think of outside of the box on how to shift from early adopters to gaining mainstream traction.
Over the past two years, I have been working with organizations that have helped me stretch my thinking and consider outside of the box ways to bring implementation science into the mainstream. I began to think deeply about what quality improvement approaches bring to the table. I’m not alone in thinking about this. Rohit Ramaswamy and colleagues have written compelling arguments (Chapter 3 of Continuous Quality Improvement in Healthcare) and Per Nilsen has an upcoming chapter on quality improvement in the Handbook of Implementation Science. These chapters highlight how we can not only leverage quality improvement as a vehicle to bring implementation science into healthcare, but to recognize that we have much to learn from quality improvement.
Similarities and differences between quality improvement and implementation science
I now believe that embedding “core components” of implementation science into existing quality improvement methods may be one of the fastest and most efficient ways to enhance the uptake of implementation science methods at scale in healthcare. Instead of asking people to give up their current approach, what if we distill the core components of our field and embed those into existing processes?
We can step back and look at what quality improvement approaches and quality improvement experts have done well that we can learn from:
1) Developing good aim statements
Each quality improvement methodology has a specific way of helping people develop clear and concrete team statements. While implementation scientists are also good at the equivalent activity (i.e. developing good research questions), we do not have a great method of helping change agents and implementers develop clear aim statements when implementing evidence-based programs and practices.
2) Having a suite of practical and useable tools
One of the first questions I get from quality improvement experts who are interested in implementation science is, “can you send me the core set of tools that we could use?”
But we don’t have a core set of tools (i.e., simple “how to” guides), we have 100+ theories, models, and frameworks, a small subset of which have tools – tools that are not typically user-friendly and not easy to use without background training and context. When quality improvement experts have sent me packages of quality improvement tools, I’ve been able to quickly understand them, at least at a superficial level, and can immediately see how they could be applied to my work or the work of other implementers. We can definitely learn from their success at spreading and scaling the use of quality improvement tools.
3) Embedding a process for rapid cycle testing
Quality improvement approaches involve doing rapid cycle testing, for example plan-do-study-act (PDSA). Because the field of implementation science started with researcher conducting rigorous trials, we do not have a good history or experience with embedding rapid cycle testing into our implementation efforts. This is a major opportunity for growth.
4) Locally driven change that creates a sense of autonomy
Because quality improvement approaches are typically driven from locally identified problems and led by local teams, there’s a much greater likelihood that people feel a sense of autonomy around the project and their work. We know that having a sense of autonomy is a key component of motivation.
5) The spread and scale of the field of quality improvement
The leaders in the field quality improvement have done a phenomenal job of spreading and scaling the use of quality improvement approaches. Almost every hospital in Canada, United States, Australia, and beyond has at least one person trained in a quality improvement methodology, and the majority of hospitals have many people who are trained. In fact, there are even provinces who underwent initiatives to train massive numbers of healthcare professionals in specific quality improvement approaches. How did they achieve such widespread use of quality improvement and what can we learn from that?
This month, we have an example from Gina De Souza and Maryanne D’Arpino from the Canadian Patient Safety Institute, a Canadian organization that has been innovatively thinking about how to integrate quality improvement and implementation science (referred to as knowledge translation because of the Canadian context).
An Implementation Guide That Integrates Quality Improvement and Implementation Science
By Gina De Souza, Senior Program Manager, Canadian Patient Safety Institute, and Maryanne D’Arpino, Senior Director, Canadian Patient Safety Institute
Canadian Patient Safety Institute (CPSI) launched 4 Safety Improvement Project in 2018/2019. Thirty teams from across Canada have been participating in the Safety Improvement Project Learning Collaborative with a lifecycle that extends over 18 months. A brief description of each project is provided below:
Teamwork and Communication leads to improved patient safety culture and positive patient outcomes.
Medication Safety at Care Transitions improves medication safety at discharge for frail, elderly patients with poly-morbidity.
Enhanced Recovery Canada leads to improved outcomes and system efficiencies for colorectal surgery patients.
Measurement and Monitoring of Safety creates a culture of safety and reduces harm.
The learning design for these projects is unique in that it is guided by a Knowledge Translation/Quality Improvement integrated approach. A review of literature demonstrated the use of both Knowledge Translation (KT) and Quality Improvement (QI) being applied to diverse patient clinical situations for improvement of patient outcomes, but although both are supported by their own evidence Koczwara and colleagues describe the connection between these fields as “Although the goals of the two fields seem complementary, they interact only sporadically and superficially, often at odds, and remain isolated from each other not only through their distinct methodology, but also through their effect on and engagement with the healthcare system.” (Koczwara et al., 2018).
As such, CPSI has consulted with the Centre for Implementation and has identified synergies between KT and QI that will leverage the strengths of each field for greater impact on patient safety.
The phases of the projects are guided by process models from the Knowledge to Action Framework, Model for Improvement and is guided by COM-B theory. The learning design and phases of this integration is graphically depicted below.
An applied example of how we used a Fishbone diagram and looked to COM-B (Capability, Opportunity and Motivation) Behaviour Change Wheel constructs (Michie et al., 2014) to brainstorm potential barriers to improving the behaviour of influenza vaccine rates is shown below:
Canadian teams are actively engaged with the CPSI Safety Improvement Project and benefiting by:
Support of expert faculty and coaches through in-person and virtual learning sessions, site visits and coaching calls who are knowledgeable about the best-known evidence as well as practical ideas, tips and tools in order to help implementation teams choose interventions (context-tailored strategies together with evidence-based change ideas) that accelerate improvement in patient safety outcomes. Teams also learn how these strategies can be adapted while evaluating Implementation Quality in order to understand why an intervention worked or did not work.
Use of a collaborative virtual space and learning management system for access to learning resources, networking and sharing of new innovations, developed resources and lessons learned
A secure database for monthly data entry and reporting of measures for improvement as well as a multi-site longitudinal study that is being used to evaluate measurable and sustainable outcomes for their projects based on pan-Canadian priorities
Opportunity to demonstrate, showcase and share the practices that support meeting strategic and operational objectives at a congress event.
Spotlight resources:
Koczwara, B., Stover, A. M., Davies, L., Davis, M. M., Fleisher, L., Ramanadhan, S., Schroeck, F. R., Zullig, L. L., Chambers, D. A., & Proctor, E. (2018). Harnessing the Synergy Between Improvement Science and Implementation Science in Cancer: A Call to Action. Journal of Oncology Practice, 14(6), 335–340. https://doi.org/10.1200/JOP.17.00083
Michie, S., Atkins, L., & West, R. (2014). The Behaviour Change Wheel: A Guide to Designing Interventions. Silverback Publishing.
These articles were featured in our monthly Implementation in Action bulletin! Want to receive our next issue? Subscribe here.
Tools that can help: