Using Implementation Process Models to Spread and Scale an Evidence-Based Intervention

By Dr. Barbara Liu, Executive Director, Regional Geriatric Program of Toronto, and Alekhya Johnson, Knowledge-to-Practice Manager, Regional Geriatric Program of Toronto

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The Mobilization of Vulnerable Elders (MOVE) program is an evidence-based intervention designed to help older adults stay physically active during their stay in hospital. MOVE started as a pilot in in Toronto, Ontario in 2011 and was scaled to 14 hospitals in 2012 with the help of research funding. After that it organically spread to at least 35 hospitals across Ontario from 2015 - 2017. The single biggest driver of provincial spread was hospital participation in the Senior Friendly Hospital Strategy lead by the Regional Geriatric Program of Toronto and its province-wide network. MOVE was aligned with senior-friendly policies and many influential leaders and institutions in the system had implemented or were promoting MOVE. Since then MOVE has spread to other provinces in Canada and even internationally. This spread has all been through networks of opinion leaders and champions. We recently revised our implementation package to facilitate further spread and accessibility.

How implementation science guided the process of spread and scale

The initial development and implementation of the MOVE program was guided by the Knowledge-to-Action process model and the Capability-Opportunity-Motivation-Behaviour Theory. We did not start with a formal spread strategy for MOVE; however, our efforts closely mimic the 5 steps from the Replicating Effective Programs (REP) framework.

1. Re-produce the implementation package

2. Convert program protocols into non-academic language

3. Create a user-friendly manual that can be readily disseminated

4. Seek feedback from end-user organizations

5. Articulate how intervention delivery can be adapted across different sites/organizations

We developed an online implementation playbook that contains a step by step process map for how to implement MOVE in an acute care setting. The majority of our prospective implementers are health providers and hospital administration who have little to no exposure to implementation theories, models, and frameworks, and limited training on the process of implementation. The playbook is laid out in the following categories that are plain language adaptations of the steps in the KTA model: Getting Ready, Selecting Change Strategies, Implementing Change, Planning for Sustainability, and Evaluating Change. Under each category, prospective implementers will find a suggested list of steps and resources that will help them proceed with the process of implementation. Many of our end users are attempting practice change in addition to a full-time clinical role and their time is limited. We noticed that the requests for implementation coaching mainly included questions on how to find specific resources. With this in mind we removed all references to research methods, opened up access to tools that were once locked behind a portal, and re-produced resources as 1-2 page sheets instead of multiple-page manuals. We also added in some new content on sustainability based on recent updates in the literature and some quotes from implementers who have had success with implementing MOVE.

Feel free to peruse the playbook and use our free resources! If any of this inspires you please feel free to get in touch. We would be more than happy to connect.

References and resources:

• https://www.movescanada.ca

• Kilbourne AM, Neumann MS, Pincus HA, Bauer MS, Stall R. Implementing evidence-based interventions in health care: application of the replicating effective programs framework. Implement Sci [Internet]. (2007);2. Available from: http://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-2-42

• Moore, J.E., Mascarenhas, A., Marquez, C. et al. Mapping barriers and intervention activities to behaviour change theory for Mobilization of Vulnerable Elders in Ontario (MOVE ON), a multi-site implementation intervention in acute care hospitals. Implementation Sci 9, 160 (2014). Available from: https://implementationscience.biomedcentral.com/articles/10.1186/s13012-014-0160-6

• Barbara Liu, Julia E Moore, Ummukulthum Almaawiy, Wai-Hin Chan, Sobia Khan, Joycelyne Ewusie, Jemila S Hamid, Sharon E Straus, on behalf of the MOVE ON Collaboration, Outcomes of Mobilisation of Vulnerable Elders in Ontario (MOVE ON): a multisite interrupted time series evaluation of an implementation intervention to increase patient mobilisation, Age and Ageing, Volume 47, Issue 1, January 2018, Pages 112–119. Available from: https://academic.oup.com/ageing/article/47/1/112/3970847

• Lennox L, Doyle C, Reed JE, et al. What makes a sustainability tool valuable, practical and useful in realworld healthcare practice? A mixed-methods study on the development of the Long Term Success Tool in Northwest London. BMJ Open 2017;7:e014417. doi:10.1136/ bmjopen-2016-014417 Available from: https://bmjopen.bmj.com/content/7/9/e014417

• Sobia Khan, Julia Moore, Charmalee Harris, Camellia Dinyarian, Barbara Liu, and Sharon Straus. Unfacilitated diffusion of the mobilization of vulnerable elders (MOVE) program: Mechanisms of spread and adoption in Ontario hospitals. 2017 Annual Dissemination & Implementation Conference. Available from: https://academyhealth.confex.com/academyhealth/2017di/meetingapp.cgi/Paper/21235

Fig. 1: 12 factors used in the LTST

Using a questionnaire, team members rated each factor individually and anonymously, providing comments to suggest actions or share concerns about progress. Team scores were brought together to produce aggregated visual charts demonstrating how the initiative is performing against the given factor (Fig 2) and comment lists for each factor were used to prompt team discussions. To ensure the study captured system and staff changes, the tool was used every 3-6 months throughout the study to assess progress, identify emerging risks and record actions and strategies taken by teams to sustain over time.

Fig. 2

Impact of using a sustainability tool

Sustainability research is often criticised for being too retrospective with decisions of when and how to study sustainability largely driven by practical and financial constraints (1,3,4). Lack of rigorous measurement within sustainability research is identified as a key limitation within implementation science with few studies employing rigorous prospective methods to study the phenonmena (1,5,6). The use of the LTST provided a single lens to focus and provide scope to our study, directing and standardising data capture of this complex topic. It also provided a structured way to capture perceptions of sustainability risks and plans across diverse improvement teams from multiple settings and programmes. The application of the LTST across programmes also supported several benefits for the improvement teams including: supporting teams to build relationships and enhance collaborative working, share diverse opinions, voice and identify actions in response to feedback (7).

Sustainability is a challenging concept to delve into but the use of the LTST may provide a useful approach to assess teams’ perceptions of sustainability to prompt planning and actions to increase chances of long-term success.  For more information on the development and how to apply the LTST please visit: https: //bmjopen.bmj.com/content/7/9/e014417  

Download a PDF version of the tool.

Download the framework and probing questions.

Download the data entry spreadsheet.

References:

1. Shelton R, Cooper BR, Stirman SW. The Sustainability of Evidence-Based Interventions and Practices in Public Health and Health Care. Ssrn. 2018;

2. Lennox L, Doyle C, Reed J, Bell D. What makes a sustainability tool valuable, practical, and useful in real world healthcare practice? A qualitative study on the development of the Long Term Success Tool in Northwest London. BMJ Open. 2017;7(e014417):1–13.

3. Bowman CC, Sobo EJ, Asch SM, Gifford AL. Measuring persistence of implementation: QUERI Series. Implement Sci [Internet]. 2008 Jan [cited 2014 Aug 27];3(21). Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2390585&tool=pmcentrez&rendertype=abstract

4. Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: Lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Qual Saf. 2012;21(10):876–84.

5. Stirman SW, Kimberly J, Cook N, Calloway A, Castro F, Charns M. The sustainability of new programs and innovations : a review of the empirical literature and recommendations for future research. Implement Sci [Internet]. 2012;7(1):17. Available from: http://www.implementationscience.com/content/7/1/17

6. Lennox L, Maher L, Reed J. Navigating the sustainability landscape: A systematic review of sustainability approaches in healthcare. Implement Sci. 2018;13(1):1–17.

7. Lennox L, French C, Reed J. A qualitative exploration of sustainability processes for improvement: the role of structured sustainability tools. In: Nugus P, editor. Transitions and Boundaries in the Coordination and Reform of Health Services. Palgrave Macmillan; 2020. p. In Press.

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