Facilitation as a role and process in achieving evidence-based practice in nursing: a focused review of concept and meaning

'We listened and supported and depended on each other': a qualitative study of how leadership influences implementation of QI interventions

BACKGROUND

There is growing recognition in the literature of the 'Herculean' efforts required to bring about change in healthcare processes and systems. Leadership is recognised as a critical lever for implementation of quality improvement (QI) and other complex team-level interventions; however, the processes by which leaders facilitate change are not well understood. The aim of this study is to examine 'how' leadership influences implementation of QI interventions.

METHODS

We drew on the leadership literature and used secondary data collected as part of a process evaluation of the Safer Care for Older Persons in residential Environments (SCOPE) QI intervention to gain insights regarding the processes by which leadership influences QI implementation. Specifically, using detailed process evaluation data from 31 unit-based nursing home teams we conducted a thematic analysis with a codebook developed a priori based on the existing literature to identify leadership processes.

RESULTS

Effective leaders (ie, those who care teams felt supported by and who facilitated SCOPE implementation) successfully developed and reaffirmed teams' commitment to the SCOPE QI intervention (theme 1), facilitated learning capacity by fostering follower participation in SCOPE and empowering care aides to step into team leadership roles (theme 2) and actively supported team-oriented processes where they developed and nurtured relationships with their followers and supported them as they navigated relationships with other staff (theme 3). Together, these were the mechanisms by which care aides were brought on board with the intervention, stayed on board and, ultimately, transplanted the intervention into the facility. Building learning capacity and creating a culture of improvement are thought to be the overarching processes by which leadership facilitates implementation of complex interventions like SCOPE.

CONCLUSIONS

Results highlight important, often overlooked, relational and sociocultural aspects of successful QI leadership in nursing homes that can guide the design, implementation and scaling of complex interventions and can guide future research.

Integrating causal pathway diagrams into practice facilitation to address colorectal cancer screening disparities in primary care

BACKGROUND

Colorectal cancer (CRC) is the second leading cause of cancer death and the second most common cancer diagnosis among the Hispanic population in the United States. However, CRC screening prevalence remains lower among Hispanic adults than among non-Hispanic white adults. To reduce CRC screening disparities, efforts to implement CRC screening evidence-based interventions in primary care organizations (PCOs) must consider their potential effect on existing screening disparities. More research is needed to understand how to leverage existing implementation science methodologies to improve health disparities. The Coaching to Improve Colorectal Cancer Screening Equity (CoachIQ) pilot study explores whether integrating two implementation science tools, Causal Pathway Diagrams and practice facilitation, is a feasible and effective way to address CRC screening disparities among Hispanic patients.

METHODS

We used a quasi-experimental, mixed methods design to evaluate feasibility and assess initial signals of effectiveness of the CoachIQ approach. Three PCOs received coaching from CoachIQ practice facilitators over a 12-month period. Three non-equivalent comparison group PCOs received coaching during the same period as participants in a state quality improvement program. We conducted descriptive analyses of screening rates and coaching activities.

RESULTS

The CoachIQ practice facilitators discussed equity, facilitated prioritization of QI activities, and reviewed CRC screening disparities during a higher proportion of coaching encounters than the comparison group practice facilitator. While the mean overall CRC screening rate in the comparison PCOs increased from 34 to 41%, the mean CRC screening rate for Hispanic patients did not increase from 30%. In contrast, the mean overall CRC screening rate at the CoachIQ PCOs increased from 41 to 44%, and the mean CRC screening rate for Hispanic patients increased from 35 to 39%.

CONCLUSIONS

The CoachIQ program merges two implementation science methodologies, practice facilitation and causal pathway diagrams, to help PCOs focus quality improvement efforts on improving CRC screening while also reducing screening disparities. Results from this pilot study demonstrate key differences between CoachIQ facilitation and standard facilitation, and point to the potential of the CoachIQ approach to decrease disparities in CRC screening.

What is known about the role of external facilitators during the implementation of complex interventions in healthcare settings? A scoping review

OBJECTIVE

To synthesise current knowledge about the role of external facilitators as an individual role during the implementation of complex interventions in healthcare settings.

DESIGN

A scoping review was conducted. We reviewed original studies (between 2000 and 2023) about implementing an evidence-based complex intervention in a healthcare setting using external facilitators to support the implementation process. An information specialist used the following databases for the search strategy: MEDLINE, CINAHL, APA PsycINFO, Academic Search Complete, EMBASE (Scopus), Business Source Complete and SocINDEX.

RESULTS

36 reports were included for analysis, including 34 different complex interventions. We performed a mixed thematic analysis to synthesise the data. We identified two primary external facilitator roles: lead facilitator and process expert facilitator. Process expert external facilitators have specific responsibilities according to their role and expertise in supporting three main processes: clinical, change management and knowledge/research management.

CONCLUSIONS

Future research should study processes supported by external facilitators and their relationship with facilitation strategies and implementation outcomes. Future systematic or realist reviews may also focus on outcomes and the effectiveness of external facilitation.

Building a sharable literature collection to advance the science and practice of implementation facilitation

Background

Implementation science seeks to produce generalizable knowledge on strategies that promote the adoption and sustained use of evidence-based innovations. Literature reviews on specific implementation strategies can help us understand how they are conceptualized and applied, synthesize findings, and identify knowledge gaps. Although rigorous literature reviews can advance scientific knowledge and facilitate theory development, they are time-consuming and costly to produce. Improving the efficiency of literature review processes and reducing redundancy of effort is especially important for this rapidly developing field. We sought to amass relevant literature on one increasingly used evidence-based strategy, implementation facilitation (IF), as a publicly available resource.

Methods

We conducted a rigorous systematic search of PubMed, CINAHL, and Web of Science citation databases for peer-reviewed, English-language articles with "facilitation" and a combination of other terms published from January 1996 to December 2021. We searched bibliographies of articles published from 1996 to 2015 and identified articles during the full text review that reported on the same study. Two authors screened 3,168 abstracts. After establishing inter-rater reliability, they individually conducted full-text review of 786 relevant articles. A multidisciplinary team of investigators provided recommendations for preparing and disseminating the literature collection.

Findings

The literature collection is comprised of 510 articles. It includes 277 empirical studies of IF and 77 other articles, including conceptual/theoretical articles, literature reviews, debate papers and descriptions of large-scale clinical initiatives. Over half of the articles were published between 2017 and 2021. The collection is publicly available as an Excel file and as an xml file that can be imported into reference management software.

Conclusion

We created a publicly accessible collection of literature about the application of IF to implement evidence-based innovations in healthcare. The comprehensiveness of this collection has the potential to maximize efficiency and minimize redundancy in scientific inquiry about this strategy. Scientists and practitioners can use the collection to more rapidly identify developments in the application of IF and to investigate a wide range of compelling questions on its use within and across different healthcare disciplines/settings, countries, and payer systems. We offer several examples of how this collection has already been used.

Getting to Fidelity: Consensus Development Process to Identify Core Activities of Implementation Facilitation

Transferring successful implementation strategies from research to practice requires approaches for assessing fidelity to the strategy's core components. Implementation facilitation (IF) is a strategy involving an interactive process of problem-solving, enabling, and supporting individuals in efforts to implement clinical innovations that occurs in the context of a recognized need for improvement and supportive interpersonal relationships. Because IF is a dynamic strategy involving numerous activities, our objective was to conduct a rigorous consensus development process to identify core activities for monitoring fidelity to IF when applied in clinical settings. We first conducted a scoping literature review to identify the range of activities used when IF has been applied in clinical settings, searching multiple citation databases for English-language articles including "facilitation" or other commonly-used terms for the strategy published from 1996-2015. Through multi-stage screening, 135 articles (from 94 studies) were identified for data extraction on IF activities, frequency with which IF activities were identified as 'core' by study authors, and study outcomes. From the literature review, we identified 32 distinct IF activities and developed definitions/examples for each. Next, we conducted a 3-stage, modified-Delphi expert panel consensus development process to identify core IF activities across three implementation phases (i.e., Pre-Implementation, Implementation, Sustainment). The expert panel identified 8 core activities for the Pre-Implementation Phase, 8 core activities for the Implementation Phase, and 4 core activities for the Sustainment Phase. This work provides an important foundation for developing measures/tools to assess use of core IF activities to ensure the strategy is delivered with fidelity.

An external facilitation intervention to increase uptake of an adverse drug event reporting intervention

Background

Adverse drug events (ADEs) are a leading cause of emergency department visits and hospital admissions in Canada. ActionADE prevents repeat ADEs by enabling clinicians to document and communicate standardized ADE information across care settings. We used an external facilitation intervention to promote the uptake of ActionADE in four hospitals in British Columbia, Canada. This study examined whether, how and in what context external facilitation influenced the uptake of ActionADE.

Methods

In this convergent-parallel mixed-methods study, an external facilitator used a four-step iterative process to support site champions using context-specific implementation strategies to increase the ADE reporting rate at their sites. We extracted archival data to assess implementation determinants before and after the implementation of the external facilitation and implementation strategies. We also retrieved data on the mean monthly counts of reported ADEs for each user from the ActionADE server. Zero-inflated Poisson models were used to examine changes in mean monthly counts of reported ADEs per user between pre-intervention (June 2021 to October 2021) and intervention (November 2021 to March 2022) periods.

Results

The external facilitator and site champions co-created three functions: (1) educate pharmacists about what and how to report in ActionADE, (2) educate pharmacists about the impact of ActionADE on patient outcomes, and (3) provide social support for pharmacists to integrate ADE reporting into clinical workflows. Site champions used eight forms to address the three functions. Peer support and reporting competition were the two common strategies used by all sites. Sites' responses to external facilitation varied. The rate of mean monthly counts of reported ADEs per user significantly increased during the intervention period compared to the pre-intervention period at LGH (RR: 3.74, 95% CI 2.78 to 5.01) and RH (RR: 1.43, 95% CI 1.23 to 1.94), but did not change at SPH (RR: 0.68, 95% CI: 0.43 to 1.09) and VGH (RR: 1.17, 95% CI 0.92 to 1.49). Leave of absence of the clinical pharmacist champion and failure to address all identified functions were implementation determinants that influenced the effectiveness of external facilitation.

Conclusion

External facilitation effectively supported researchers and stakeholders to co-create context-specific implementation strategies. It increased ADE reporting at sites where clinical pharmacist champions were available, and where all functions were addressed.

Facilitating implementation of primary care mental health over time and across organizational contexts: a qualitative study of role and process

BACKGROUND

Healthcare organizations have increasingly utilized facilitation to improve implementation of evidence-based practices and programs (e.g., primary care mental health integration). Facilitation is both a role, related to the purpose of facilitation, and a process, i.e., how a facilitator operationalizes the role. Scholars continue to call for a better understanding of this implementation strategy. Although facilitation is described as dynamic, activities are often framed within the context of a staged process. We explored two understudied characteristics of implementation facilitation: 1) how facilitation activities change over time and in response to context, and 2) how facilitators operationalize their role when the purpose of facilitation is both task-focused (i.e., to support implementation) and holistic (i.e., to build capacity for future implementation efforts).

METHODS

We conducted individual monthly debriefings over thirty months with facilitators who were supporting PCMHI implementation in two VA networks. We developed a list of facilitation activities based on a literature review and debriefing notes and conducted a content analysis of debriefing notes by coding what activities occurred and their intensity by quarter. We also coded whether facilitators were "doing" these activities for sites or "enabling" sites to perform them.

RESULTS

Implementation facilitation activities did not occur according to a defined series of ordered steps but in response to specific organizational contexts through a non-linear and incremental process. Amount and types of activities varied between the networks. Concordant with facilitators' planned role, the focus of some facilitation activities was primarily on doing them for the sites and others on enabling sites to do for themselves; a number of activities did not fit into one category and varied across networks.

CONCLUSIONS

Findings indicate that facilitation is a dynamic and fluid process, with facilitation activities, as well as their timing and intensity, occurring in response to specific organizational contexts. Understanding this process can help those planning and applying implementation facilitation to make conscious choices about the facilitation role and the activities that facilitators can use to operationalize this role. Additionally, this work provides the foundation from which future studies can identify potential mechanisms of action through which facilitation activities enhance implementation uptake.

Improving colorectal cancer screening in rural primary care: Preliminary effectiveness and implementation of a collaborative mailed fecal immunochemical test pilot

BACKGROUND

Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer (CRC) screening rates. We piloted a collaborative mailed FIT program with health plans and rural clinics to evaluate preliminary effectiveness and refine implementation strategies.

METHODS

We conducted a single-arm study using a convergent, parallel mixed-methods design to evaluate the implementation of a collaborative mailed FIT program. Enrollees were identified using health plan claims and confirmed via clinic scrub. The intervention included a vendor-delivered automated phone call (auto-call) prompt, FIT mailing, and reminder auto-call; clinics were encouraged to make live reminder calls. Practice facilitation was the primary implementation strategy. At 12 months post mailing, we assessed the rates of: (1) mailed FIT return and (2) completion of any CRC screening. We took fieldnotes and conducted postintervention key informant interviews to assess implementation outcomes (eg, feasibility, acceptability, and adaptations).

RESULTS

One hundred and sixty-nine Medicaid or Medicare enrollees were mailed a FIT. Over the 12-month intervention, 62 participants (37%) completed screening of which 21% completed the mailed FIT (most were returned within 3 months), and 15% screened by other methods (FITs distributed in-clinic, colonoscopy). Enrollee demographics and the reminder call may encourage mailed FIT completion. Program feasibility and acceptability was high and supported by perceived positive benefit, alignment with existing workflows, adequate staffing, and practice facilitation.

CONCLUSION

Collaborative health plan-clinic mailed FIT programs are feasible and acceptable for implementation in rural clinics and support CRC screening completion. Studies that pragmatically test collaborative approaches to mailed FIT and patient navigation follow-up after abnormal FIT and support broad scale-up in rural settings are needed.

Facilitating facilitators to facilitate-Some general comments on a strategy for knowledge implementation in health services

Numerous endeavours to ensure that day-to-day healthcare is both evidence-based and person-centred have generated extensive, although partial, comprehension of what guarantees quality improvement. To address quality issues, researchers and clinicians have developed several strategies as well as implementation theories, models, and frameworks. However, more progress is needed regarding how to facilitate guideline and policy implementation that guarantees effective changes take place in a timely and safe manner. This paper considers experiences of engaging and supporting local facilitators in knowledge implementation. Drawing on several interventions, considering both training and support, this general commentary discusses whom to engage and the length, content, quantity, and type of support along with expected outcomes of facilitators' activities. In addition, this paper suggests that patient facilitators could help produce evidence-based and person-centred care. We conclude that research about the roles and functions of facilitators needs to include more structured follow-ups and also improvement projects. This can increase the speed of learning with respect to what works, for whom, in what context, why (or why not), and with what outcomes when it comes to facilitator support and tasks.

Connecting for Care: a protocol for a mixed-method social network analysis to advance knowledge translation in the field of child development and rehabilitation

BACKGROUND

Connections between individuals and organizations can impact knowledge translation (KT). This finding has led to growing interest in the study of social networks as drivers of KT. Social networks are formed by the patterns of relationships or connections generated through interactions. These connections can be studied using social network analysis (SNA) methodologies. The relatively small yet diverse community in the field of child development and rehabilitation (CD&R) in Canada offers an ideal case study for applying SNA. The purposes of this work are to (1) quantify and map the structure of Canadian CD&R KT networks among four groups: families, health care providers, KT support personnel, and researchers; (2) explore participant perspectives of the network structure and of KT barriers and facilitators within it; and (3) generate recommendations to improve KT capacity within and between groups. Aligning with the principles of integrated KT, we have assembled a national team whose members contribute throughout the research and KT process, with representation from the four participant groups.

METHODS

A sequential, explanatory mixed-method study, within the bounds of a national case study in the field of CD&R. Objective 1: A national SNA survey of family members with advocacy/partnership experience, health care providers, KT support personnel, and researchers, paired with an anonymous survey for family member without partnership experience, will gather data to describe the KT networks within and between groups and identify barriers and facilitators of network connections. Objective 2: Purposive sampling from Phase 1 will identify semi-structured interview participants with whom to examine conventional and network-driven KT barriers, facilitators, and mitigating strategies. Objective 3: Intervention mapping and a Delphi process will generate recommendations for network and conventional interventions to strengthen the network and facilitate KT.

DISCUSSION

This study will integrate network and KT theory in mapping the structure of the CD&R KT network, enhance our understanding of conventional and network-focused KT barriers and facilitators, and provide recommendations to strengthen KT networks. Recommendations can be applied and tested within the field of CD&R to improve KT, with the aim of ensuring children achieve the best health outcomes possible through timely access to effective healthcare.

A co-created nurse-driven catheterisation protocol can reduce bladder distension in acute hip fracture patients - results from a longitudinal observational study

Background

Urinary retention is common in elderly patients undergoing acute hip fracture surgery. Avoiding overfilling the urinary bladder is important to avoid detrusor muscle damage and associated motility problems. The aim of this study was to analyse associations between the co-creation of a nurse-driven urinary catheterisation protocol and the incidence of bladder distension in patients undergoing hip fracture surgery.

Methods

This is a single-centre implementation intervention with a retrospective longitudinal observation design, using five measures points, spanning from June 2015 to March 2020. The intervention was theory driven and the participants, together with the facilitators and researcher, co-created a nurse-driven urinary catheterisation protocol. Data were retrieved from the hip fracture register. Uni- and multivariable logistic regressions were used for analyses of changes in bladder distension and urinary volume of ≥500 ml over the years.

Results

A total of 3078 patients were included over a five-year period. The implementation intervention was associated with a reduction in the proportion of patients with bladder distension of 31.5% (95% confidence interval 26.0–37.0), from year 1 to year 5. The multivariable analysis indicated a 39% yearly reduction in bladder distension, OR 0.61 (95% confidence interval 0.57–0.64, p <  0001). There was a reduction in the proportion of patients with a bladder volume of ≥500 ml of 42.8% (95% confidence interval 36.2–49.4), from year 1 to year 5. The multivariable analysis found a 41% yearly reduction in patients with a bladder volume of ≥500 ml, OR 0.59 (95% confidence interval 0.55–0.64, p <  0.0001). The intervention was associated with improved documentation of both catheter indications and removal plans.

Conclusion

The use of predefined catheter indications and a tighter bladder scanning schedule were associated with a reduction in the incidence of both bladder distension and urine volume ≥ 500 ml in hip fracture patients. Registered nurses can play an active role in the facilitation of timely and appropriate catheter treatment in patients with hip fractures.

Trial registration

Clinical Trial Registry ISRCTN 17022695 registered retrospectively on 23 December 2021, in the end of the study, after data collection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-01057-z.

The Influence of Context on Implementation and Improvement: Protocol for a Mixed Methods, Secondary Analyses Study

BACKGROUND

Caring for the well-being of older adults is one of the greatest challenges in modern societies. Improving the quality of care and life for older adults and the work lives of their care providers calls for effective knowledge translation of evidence-based best practices.

OBJECTIVE

This study's purpose is to contribute to knowledge translation by better understanding the roles of organizational context (workplace environment) and facilitation (process or role) in implementation and improvement success. Our study has 2 goals: (1) to advance knowledge translation science by further developing and testing the Promoting Action on Research Implementation in Health Services framework (which outlines how implementation relies on the interplay of context, facilitation, and evidence) and (2) to advance research by optimizing implementation success via tailoring of modifiable elements of organizational context and facilitation.

METHODS

This is secondary analyses of 15 years of longitudinal data from the Translating Research in Elder Care (TREC) program's multiple data sources. This research is ongoing in long-term care (LTC) homes in western Canada. TREC data include the following: 5 waves of survey collection, 2 clinical trials, and regular ongoing outcome data for LTC residents. We will use a sequential exploratory and confirmatory mixed methods design. We will analyze qualitative and quantitative data holdings in an iterative process: (1) comprehensive reanalysis of qualitative data to derive hypotheses, (2) quantitative modeling to test hypotheses, and (3) action cycles to further refine and integrate qualitative and quantitative analyses. The research team includes 4 stakeholder panels: (1) system decision- and policy makers, (2) care home managers, (3) direct care staff, and (4) a citizen engagement group of people living with dementia and family members of LTC residents. A fifth group is our panel of external scientific advisors. Each panel will engage periodically, providing their perspectives on project direction and findings.

RESULTS

This study is funded by the Canadian Institutes of Health Research. Ethics approval was obtained from the University of Alberta (Pro00096541). The results of the secondary analyses are expected by the end of 2023.

CONCLUSIONS

The project will advance knowledge translation science by deepening our understanding of the roles of context, the interactions between context and facilitation, and their influence on resident and staff quality outcomes. Importantly, findings will inform understanding of the mechanisms by which context and facilitation affect the success of implementation and offer insights into factors that influence the implementation success of interventions in nursing homes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40611.

Effective Facilitator Strategies for Supporting Primary Care Practice Change: A Mixed Methods Study

PURPOSE

Practice facilitation is an evidence-informed implementation strategy to support quality improvement (QI) and aid practices in aligning with best evidence. Few studies, particularly of this size and scope, identify strategies that contribute to facilitator effectiveness.

METHODS

We conducted a sequential mixed methods study, analyzing data from EvidenceNOW, a large-scale QI initiative. Seven regional cooperatives employed 162 facilitators to work with 1,630 small or medium-sized primary care practices. Main analyses were based on facilitators who worked with at least 4 practices. Facilitators were defined as more effective if at least 75% of their practices improved on at least 1 outcome measure-aspirin use, blood pressure control, smoking cessation counseling (ABS), or practice change capacity, measured using Change Process Capability Questionnaire-from baseline to follow-up. Facilitators were defined as less effective if less than 50% of their practices improved on these outcomes. Using an immersion crystallization and comparative approach, we analyzed observational and interview data to identify strategies associated with more effective facilitators.

RESULTS

Practices working with more effective facilitators had a 3.6% greater change in the mean percentage of patients meeting the composite ABS measure compared with practices working with less effective facilitators (P <.001). More effective facilitators cultivated motivation by tailoring QI work and addressing resistance, guided practices to think critically, and provided accountability to support change, using these strategies in combination. They were able to describe their work in detail. In contrast, less effective facilitators seldom used these strategies and described their work in general terms. Facilitator background, experience, and work on documentation did not differentiate between more and less effective facilitators.

CONCLUSIONS

Facilitation strategies that differentiate more and less effective facilitators have implications for enhancing facilitator development and training, and can assist all facilitators to more effectively support practice changes.

Stakeholder Perspectives of Attributes and Features of Context Relevant to Knowledge Translation in Health Settings: A Multi-Country Analysis

BACKGROUND

Context is recognized as important to successful knowledge translation (KT) in health settings. What is meant by context, however, is poorly understood. The purpose of the current study was to elicit tacit knowledge about what is perceived to constitute context by conducting interviews with a variety of health system stakeholders internationally so as to compile a comprehensive list of contextual attributes and their features relevant to KT in healthcare.

METHODS

A descriptive qualitative study design was used. Semi-structured interviews were conducted with health system stakeholders (change agents/KT specialists and KT researchers) in four countries: Australia, Canada, the United Kingdom, and the United States. Interview transcripts were analyzed using inductive thematic content analysis in four steps: (1) selection of utterances describing context, (2) coding of features of context, (3) categorizing of features into attributes of context, (4) comparison of attributes and features by: country, KT experience, and role.

RESULTS

A total of 39 interviews were conducted. We identified 66 unique features of context, categorized into 16 attributes. One attribute, Facility Characteristics, was not represented in previously published KT frameworks. We found instances of all 16 attributes in the interviews irrespective of country, level of experience with KT, and primary role (change agent/KT specialist vs. KT researcher), revealing robustness and transferability of the attributes identified. We also identified 30 new context features (across 13 of the 16 attributes).

CONCLUSION

The findings from this study represent an important advancement in the KT field; we provide much needed conceptual clarity in context, which is essential to the development of common assessment tools to measure context to determine which context attributes and features are more or less important in different contexts for improving KT success.

Primary aim results of a clustered SMART for developing a school-level, adaptive implementation strategy to support CBT delivery at high schools in Michigan

BACKGROUND

Schools increasingly provide mental health services to students, but often lack access to implementation strategies to support school-based (and school professional [SP]) delivery of evidence-based practices. Given substantial heterogeneity in implementation barriers across schools, development of adaptive implementation strategies that guide which implementation strategies to provide to which schools and when may be necessary to support scale-up.

METHODS

A clustered, sequential, multiple-assignment randomized trial (SMART) of high schools across Michigan was used to inform the development of a school-level adaptive implementation strategy for supporting SP-delivered cognitive behavioral therapy (CBT). All schools were first provided with implementation support informed by Replicating Effective Programs (REP) and then were randomized to add in-person Coaching or not (phase 1). After 8 weeks, schools were assessed for response based on SP-reported frequency of CBT delivered to students and/or barriers reported. Responder schools continued with phase 1 implementation strategies. Slower-responder schools (not providing ≥ 3 CBT components to ≥10 students or >2 organizational barriers identified) were re-randomized to add Facilitation to current support or not (phase 2). The primary aim hypothesis was that SPs at schools receiving the REP + Coaching + Facilitation adaptive implementation strategy would deliver more CBT sessions than SPs at schools receiving REP alone. Secondary aims compared four implementation strategies (Coaching vs no Coaching × Facilitation vs no Facilitation) on CBT sessions delivered, including by type (group, brief and full individual). Analyses used a marginal, weighted least squares approach developed for clustered SMARTs.

RESULTS

SPs (n = 169) at 94 high schools entered the study. N = 83 schools (88%) were slower-responders after phase 1. Contrary to the primary aim hypothesis, there was no evidence of a significant difference in CBT sessions delivered between REP + Coaching + Facilitation and REP alone (111.4 vs. 121.1 average total CBT sessions; p = 0.63). In secondary analyses, the adaptive strategy that offered REP + Facilitation resulted in the highest average CBT delivery (154.1 sessions) and the non-adaptive strategy offering REP + Coaching the lowest (94.5 sessions).

CONCLUSIONS

The most effective strategy in terms of average SP-reported CBT delivery is the adaptive implementation strategy that (i) begins with REP, (ii) augments with Facilitation for slower-responder schools (schools where SPs identified organizational barriers or struggled to deliver CBT), and (iii) stays the course with REP for responder schools.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03541317 , May 30, 2018.

Understanding how and why quality circles improve standards of practice, enhance professional development and increase psychological well-being of general practitioners: a realist synthesis

OBJECTIVES

To understand how and why participation in quality circles (QCs) improves general practitioners' (GPs) psychological well-being and the quality of their clinical practice. To provide evidence-informed and practical guidance to maintain QCs at local and policy levels.

DESIGN

A theory-driven mixed method.

SETTING

Primary healthcare.

METHOD

We collected data in four stages to develop and refine the programme theory of QCs: (1) coinquiry with Swiss and European expert stakeholders to develop a preliminary programme theory; (2) realist review with systematic searches in MEDLINE, Embase, PsycINFO and CINHAL (1980-2020) to inform the preliminary programme theory; (3) programme refinement through interviews with participants, facilitators, tutors and managers of QCs and (4) consolidation of theory through interviews with QC experts across Europe and examining existing theories.

SOURCES OF DATA

The coinquiry comprised 4 interviews and 3 focus groups with 50 European experts. From the literature search, we included 108 papers to develop the literature-based programme theory. In stage 3, we used data from 40 participants gathered in 6 interviews and 2 focus groups to refine the programme theory. In stage 4, five interviewees from different healthcare systems consolidated our programme theory.

RESULT

Requirements for successful QCs are governmental trust in GPs' abilities to deliver quality improvement, training, access to educational material and performance data, protected time and financial resources. Group dynamics strongly influence success; facilitators should ensure participants exchange knowledge and generate new concepts in a safe environment. Peer interaction promotes professional development and psychological well-being. With repetition, participants gain confidence to put their new concepts into practice.

CONCLUSION

With expert facilitation, clinical review and practice opportunities, QCs can improve the quality of standard practice, enhance professional development and increase psychological well-being in the context of adequate professional and administrative support.

PROSPERO REGISTRATION NUMBER

CRD42013004826.

Profiling knowledge brokers in the rehabilitation sector across Canada: A descriptive study

RATIONALE

Knowledge brokers (KBs) can help promote the uptake of the latest research evidence into clinical practice. Little is known about who they are, the types of roles they perform, and the training they receive. Establishing a portrait of Canadian KBs working in the rehabilitation sector may inform health care organizations and knowledge translation specialists on how best to advance KBs practices. The overall goal was to describe the profile of KBs working to promote the uptake of evidence within rehabilitation settings in Canada. Specifically, this study aimed to describe the sociodemographic and professional characteristics, work activities, and training of KBs.

METHODS

A cross-sectional online survey was administered to KBs working in rehabilitation settings across Canada. The survey included 20 questions covering sociodemographic and professional characteristics, work activities, and training opportunities. Response frequency and percentage were calculated for all categorical variables, and the weighted average (WA) for each role was calculated across participants. Descriptive analysis was conducted for all open-ended questions.

RESULTS

Of 475 participants accessing the website, 198 completed the survey questionnaire, including 99 clinicians, 35 researchers, and 26 managers. While over two-thirds of respondents had completed a graduate degree, only 38% reported receiving KBs-related training. The respondents' primary roles corresponded to a linking agent (WA = 1.84), followed by capacity builder (WA = 1.76), information manager (WA = 1.71), facilitator (WA = 1.41), and evaluator (WA = 1.32).

CONCLUSIONS

KBs are mostly expert clinicians who tend to perform brokering activities part-time targeting their peers. Participants mostly perform the linking agent, capacity builder, and information roles. Moreover, only a few participants received formal training to perform brokering activities.

How Type of Practice Ownership Affects Participation with Quality Improvement External Facilitation: Findings from EvidenceNOW

BACKGROUND

Facilitation is an implementation strategy that can help primary care practices improve healthcare quality and build quality improvement (QI) capacity when delivered in a flexible manner by trained professionals. Practice ownership is associated with use of QI. However, little is known about how practices of different ownership participate in external facilitation, and this could inform future initiatives.

OBJECTIVE

Using data from EvidenceNOW, we examined how practice ownership influences participation in external facilitation.

STUDY DESIGN

We used an iterative mixed-methods design.

PARTICIPANTS, APPROACH, AND MEASURES

We collected data from practices on practice characteristics (e.g., location, size, payer mix) and ownership type via surveys and from facilitators on the number of hours, encounters, and months each practice had with a facilitator via facilitation logs. Using multivariable linear regression, we examined the association between facilitation and ownership (n = 1117 practices). We conducted semi-structured interviews with EvidenceNOW leadership (n = 12) and facilitators (n = 51) and observed facilitators in a subset of practices (n = 64); we analyzed this qualitative data for patterns of facilitation.

KEY RESULTS

In the fully adjusted model, differences by ownership were non-significant; FQHCs, however, had significantly less participation in facilitation than clinician-owned practices across two measures (unadjusted difference: - 2.83, p < 0.01 for number of encounters, and - 2.04, p < 0.01 for number of months with encounters). Qualitative data showed that Health System and FQHC ownership influenced types of practices enrolled in EvidenceNOW, and suggested that in these practices lower autonomy and greater complexity compared to clinician-owned ownership influenced facilitation participation patterns.

CONCLUSIONS

Practice ownership shaped how but not how much practices participated in external facilitation. This finding highlights the importance of tailoring facilitation approaches based on ownership-related characteristics in future QI initiatives.

Supporting care home residents in the last year of life through 'Needs Rounds': Development of a pre-implementation programme theory through a rapid collaborative online approach

Background

Realist evaluation aims to address the knowledge to practice gap by explaining how an intervention is expected to work, as well as what is likely to impact upon the success of its implementation, by developing programme theories that link contexts, mechanisms and outcomes. Co-production approaches to the development of programme theories offer substantial benefits in addressing power relations, including and valuing different types of knowledge, and promoting buy-in from stakeholders while navigating the complex social systems in which innovations are embedded. This paper describes the co-production of an initial programme theory of how an evidence based intervention developed in Australia - called 'Palliative Care Needs Rounds' - might work in England and Scotland to support care home residents approaching their end of life.

Methods

Using realist evaluation and iPARIHS (integrated Promoting Action on Research Implementation in Health Services) we sought to determine how contexts and mechanisms of change might shape implementation outcomes. Pre-intervention online interviews (n = 28) were conducted (February-April 2021), followed by four co-design online workshops with 43 participants (April-June 2021). The online interviews and workshops included a range of stakeholders, including care home staff, specialist palliative care staff, paramedics, general practitioners, and relatives of people living in care homes.

Results

This methodology paper reports developments in realist evaluation and co-production methodologies, and how they were used to develop context, mechanisms, outcomes (CMOs) configurations, and chains of inference. The initial (pre-intervention) programme theory is used to illustrate this process. Two developments to iPARIHS are described. First, involving stakeholders in the collaborative co-design workshops created opportunities to commence facilitation. Second, we describe developing iPARIHS' innovation component, to include novel stakeholder interpretations, perceptions and anticipated use of the intervention as they participated in workshop discussions.

Conclusions

This rapid and robust co-production methodology draws on interactive collaborative research practices (interviews, workshop discussions of data, illustrative vignettes and visual methods). These innovative and engaging methods can be packaged for online processes to develop, describe and interrogate the CMOs in order to co-produce a programme theory. These approaches also commence facilitation and innovation, and can be adopted in other implementation science and realist studies.

Integration of a task strengthening strategy for hypertension management into HIV care in Nigeria: a cluster randomized controlled trial study protocol

BACKGROUND

In regions with weak healthcare systems, critical shortages of the healthcare workforce, and increasing prevalence of dual disease burdens, there is an urgent need for the implementation of proven effective interventions and strategies to address these challenges. Our mixed-methods hybrid type II effectiveness-implementation study is designed to fill this evidence-to-practice gap. This study protocol describes a cluster randomized controlled trial which evaluates the effectiveness of an implementation strategy, practice facilitation (PF), on the integration, adoption, and sustainability of a task-strengthening strategy for hypertension control (TASSH) intervention within primary healthcare centers (PHCs) in Lagos State, Nigeria.

DESIGN

Guided by the Consolidated Framework for Implementation Research (CFIR) and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM), this study tests the impact of a proven effective implementation strategy to integrate hypertension management into the HIV care cascade, across 30 PHCs. The study will be conducted in three phases: (1) a pre-implementation phase that will use CFIR to develop a tailored PF intervention for integrating TASSH into HIV clinics; (2) an implementation phase that will use RE-AIM to compare the clinical effectiveness of PF vs. a self-directed condition (receipt of information on TASSH without PF) on BP reduction; and (3) a post-implementation phase that will use RE-AIM to evaluate the effect of PF vs. self-directed condition on adoption and sustainability of TASSH. The PF intervention components comprise (a) an advisory board to provide leadership support for implementing TASSH in PHCs; (b) training of the HIV nurses on TASSH protocol; and (c) training of practice facilitators, who will serve as coaches, provide support, and performance feedback to the HIV nurses.

DISCUSSION

This study is one of few, if any trials, to evaluate the impact of an implementation strategy for integrating hypertension management into HIV care, on clinical and implementation outcomes. Findings from this study will advance implementation science research on the effectiveness of tailoring an implementation strategy for the integration of an evidence-based, system-level hypertension control intervention into HIV care and treatment.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT04704336 ). Registered on 11 January 2021.

Data-driven approach for tailoring facilitation strategies to overcome implementation barriers in community pharmacy

Background

Implementation research has delved into barriers to implementing change and interventions for the implementation of innovation in practice. There remains a gap, however, that fails to connect implementation barriers to the most effective implementation strategies and provide a more tailored approach during implementation. This study aimed to explore barriers for the implementation of professional services in community pharmacies and to predict the effectiveness of facilitation strategies to overcome implementation barriers using machine learning techniques.

Methods

Six change facilitators facilitated a 2-year change programme aimed at implementing professional services across community pharmacies in Australia. A mixed methods approach was used where barriers were identified by change facilitators during the implementation study. Change facilitators trialled and recorded tailored facilitation strategies delivered to overcome identified barriers. Barriers were coded according to implementation factors derived from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Tailored facilitation strategies were coded into 16 facilitation categories. To predict the effectiveness of these strategies, data mining with random forest was used to provide the highest level of accuracy. A predictive resolution percentage was established for each implementation strategy in relation to the barriers that were resolved by that particular strategy.

Results

During the 2-year programme, 1131 barriers and facilitation strategies were recorded by change facilitators. The most frequently identified barriers were a ‘lack of ability to plan for change’, ‘lack of internal supporters for the change’, ‘lack of knowledge and experience’, ‘lack of monitoring and feedback’, ‘lack of individual alignment with the change’, ‘undefined change objectives’, ‘lack of objective feedback’ and ‘lack of time’. The random forest algorithm used was able to provide 96.9% prediction accuracy. The strategy category with the highest predicted resolution rate across the most number of implementation barriers was ‘to empower stakeholders to develop objectives and solve problems’.

Conclusions

Results from this study have provided a better understanding of implementation barriers in community pharmacy and how data-driven approaches can be used to predict the effectiveness of facilitation strategies to overcome implementation barriers. Tailored facilitation strategies such as these can increase the rate of real-time implementation of innovations in healthcare, leading to an industry that can confidently and efficiently adapt to continuous change.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01138-8.

Sustaining implementation facilitation: a model for facilitator resilience

BACKGROUND

Implementation facilitators enable healthcare staff to effectively implement change, yet little is known about their affective (e.g., emotional, mental, physical) experiences of facilitation. We propose an expansion to the Integrated Promoting Action on Research in Health Services (i-PARIHS) framework that introduces facilitation intensity and facilitator resilience to better assess facilitators' affective experiences.

METHODS

We used an instrumental case study and facilitator data (logged reflections and debrief session notes) from the Coordination Toolkit and Coaching initiative to conceptualize facilitation intensity and facilitator resilience and to better understand the psychological impact of the facilitation process on facilitator effectiveness and implementation success.

RESULTS

We define facilitation intensity as both the quantitative and/or qualitative measure of the volume of tasks and activities needed to engage and motivate recipients in implementation, and the psychological impact on the facilitator of conducting facilitation tasks and activities. We define facilitator resilience as the ability to cope with and adapt to the complexities of facilitation in order to effectively engage and motivate staff, while nurturing and sustaining hope, self-efficacy, and adaptive coping behaviors in oneself.

CONCLUSIONS

Facilitators' affective experience may help to identify potential relationships between the facilitation factors we propose (facilitation intensity and facilitator resilience). Future studies should test ways of reliably measuring facilitation intensity and facilitator resilience and specify their relationships in greater detail. By supporting facilitator resilience, healthcare delivery systems may help sustain the skilled facilitator workforce necessary for continued practice improvement.

TRIAL REGISTRATION

The project was registered with ClinicalTrials.gov ( NCT03063294 ) on February 24, 2017.

From novice to expert: methods for transferring implementation facilitation skills to improve healthcare delivery

BACKGROUND

There is substantial evidence that facilitation can address the challenges of implementing evidence-based innovations. However, facilitators need a wide variety of complex skills; lack of these can have a negative effect on implementation outcomes. Literature suggests that novice and less experienced facilitators need ongoing support from experts to develop these skills. Yet, no studies have investigated the transfer process. During a test of a facilitation strategy applied at 8 VA primary care clinics, we explored the techniques and processes an expert external facilitator utilized to transfer her skills to two initially novice internal facilitators who became experts.

METHODS

In this qualitative descriptive study, we conducted monthly debriefings with three facilitators over a 30-month period and documented these in detailed notes. Debriefings with the expert facilitator focused on how she trained and mentored facilitation trainees. We also conducted, recorded, and transcribed two semi-structured qualitative interviews with each facilitator and queried them about training content and process. We used a mix of inductive and deductive approaches to analyze data; our analysis was informed by a review of mentoring, coaching, and cognitive apprenticeship literature. We also used a case comparison approach to explore how the expert tailored her efforts.

RESULTS

The expert utilized 21 techniques to transfer implementation facilitation skills. Techniques included both active (providing information, modeling, and coaching) and participatory ones. She also used techniques to support learning, i.e., cognitive supports (making thinking visible, using heuristics, sharing experiences), psychosocial supports, strategies to promote self-learning, and structural supports. Additionally, she transferred responsibility for facilitation through a dynamic process of interaction with trainees and site stakeholders. Finally, the expert varied the level of focus on particular skills to tailor her efforts to trainee and local context.

CONCLUSIONS

This study viewed the journey from novice to expert facilitator through the lens of the expert who transferred facilitation skills to support implementation of an evidence-based program. It identified techniques and processes that may foster transfer of these skills and build organizational capacity for future implementation efforts. As the first study to document the implementation facilitation skills transfer process, findings have research and practical implications.

Co-design and feasibility of a pharmacist-led minor ailment service

BACKGROUND

Community pharmacies provide an appropriate setting to deliver minor ailment services (MASs). Many community pharmacy services have been developed previously without stakeholder involvement. As a result, implementation of services may fail to produce the expected impact. The aim of this research was to co-design and test the feasibility of an Australian MAS for minor ailment presentations.

METHODS

This study used co-design methodology which included two phases: (1) a focus group with stakeholders to allow the conceptualization of the service and agreement on service elements; (2) a literature review of clinical guidelines and three working meetings with a team of editors and general practitioners for the development of treatment pathways. Following this, a study evaluating the feasibility of the co-designed service was undertaken. The qualitative part of the methodology associated with the feasibility study comprised semi-structured interviews with MAS pharmacists, observation and completion of a tool by change facilitators identifying barriers and facilitators to service delivery. Qualitative data obtained for all phases were analysed using thematic analysis.

RESULTS

The developed service included the following components: (i) an in-pharmacy consultation between the patient and pharmacist, (ii) treatment pathways accessible to pharmacists on the internet to guide consultations, (iii) existing digital communication systems used by general practice to exchange patient information, (iv) training, and (v) change facilitation. As a result of feasibility testing, twenty-six implementation factors were identified for practice change, with the main change being the simplification of the pharmacist-patient consultation and data collection processes.

CONCLUSIONS

An Australian MAS was generated as a result of co-design, while testing revealed that the co-designed service was feasible. As a result of integrating the views of multiple stakeholders, the designed MAS has been adapted to suit healthcare practices, which may increase the acceptance and impact of MAS when implemented into practice.

Comparative effectiveness of external vs blended facilitation on collaborative care model implementation in slow-implementer community practices

OBJECTIVE

To evaluate the comparative effectiveness of external facilitation (EF) vs external + internal facilitation (EF/IF), on uptake of a collaborative chronic care model (CCM) in community practices that were slower to implement under low-level implementation support.

STUDY SETTING

Primary data were collected from 43 community practices in Michigan and Colorado at baseline and for 12 months following randomization.

STUDY DESIGN

Sites that failed to meet a pre-established implementation benchmark after six months of low-level implementation support were randomized to add either EF or EF/IF support for up to 12 months. Key outcomes were change in number of patients receiving the CCM and number of patients receiving a clinically significant dose of the CCM. Moderators' analyses further examined whether comparative effectiveness was dependent on prerandomization adoption, number of providers trained or practice size. Facilitation log data were used for exploratory follow-up analyses.

DATA COLLECTION

Sites reported monthly on number of patients that had received the CCM. Facilitation logs were completed by study EF and site IFs and shared with the study team.

PRINCIPAL FINDINGS

N = 21 sites were randomized to EF and 22 to EF/IF. Overall, EF/IF practices saw more uptake than EF sites after 12 months (Δ_EF/IF-EF  = 4.4 patients, 95% CI = 1.87-6.87). Moderators' analyses, however, revealed that it was only sites with no prerandomization uptake of the CCM (nonadopter sites) that saw significantly more benefit from EF/IF (Δ_EF/IF-EF  = 9.2 patients, 95% CI: 5.72, 12.63). For sites with prerandomization uptake (adopter sites), EF/IF offered no additional benefit (Δ_EF/IF-EF  = -0.9; 95% CI: -4.40, 2.60). Number of providers trained and practice size were not significant moderators.

CONCLUSIONS

Although stepping up to the more intensive EF/IF did outperform EF overall, its benefit was limited to sites that failed to deliver any CCM under the low-level strategy. Once one or more providers were delivering the CCM, additional on-site personnel did not appear to add value to the implementation effort.

Planning and implementing quality improvement projects in clinical practice: Third-year nursing students' learning experiences

AIMS AND OBJECTIVES

To evaluate the impact of an educational design to develop nursing students' competence to work systematically with quality improvement in clinical practice.

BACKGROUND

Competence in how to improve the quality and safety of healthcare services based on new knowledge is crucial for healthcare quality. Nursing education should give students opportunities to engage in quality improvement projects to gain this competence.

DESIGN

This project qualitatively evaluated the impact of the course on students' ability to plan and implement a quality improvement project in their clinical placement.

METHODS

Data from retrospective focus group interviews and written project reports were analysed by means of qualitative content analysis. Fifty-five students participated in the study. COREQ reporting guidelines were used.

RESULTS

Three themes were derived from the analysis: (a) the importance of anchoring the quality improvement project in the clinic; (b) experiencing the steps of a quality improvement project; and (c) challenging student role.

CONCLUSIONS

Course design that facilitates student-run small-scale quality improvement projects under supervision can enhance nurse students' competence in quality improvement work, as well as raise the students' awareness of the responsibility they will undertake as future nurses.

RELEVANCE TO CLINICAL PRACTICE

Nursing students work on quality improvement project in clinical placement may enhance their awareness and competence in developing quality and safety of healthcare services as future nurses.

The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework.

METHODS

This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail.

RESULTS

The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated.

CONCLUSIONS

In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

Development of a knowledge translation taxonomy in the field of health prevention: a participative study between researchers, decision-makers and field professionals

Objectives

The current literature lacks a detailed and standardised description of public health knowledge translation (KT) activities designed to be applied at local levels of health systems. As part of an ongoing research project called the Transfert de connaissances en regions (TC-REG project), we aim to develop a local KT taxonomy in the field of health prevention by means of a participative study between researchers, decision-makers and field professionals. This KT taxonomy provides a comparative description of existing local health prevention KT strategies.

Methods

Two methods were used to design a participative process conducted in France to develop the taxonomy, combining professional meetings (two seminars) and qualitative interviews. The first step involved organising a seminar in Paris, attended by health prevention professionals from health agencies in four regions of France and regional non-profit organisations for health education and promotion. This led to the drafting of regional KT plans to be implemented in the four regions. In a second step, we conducted interviews to obtain a clear understanding of the KT activities implemented in the regions. Based on data from interviews, a KT taxonomy was drawn up and discussed during a second seminar.

Results

Our work resulted in a KT taxonomy composed of 35 standardised KT activities, grouped into 11 categories of KT activities, e.g. dissemination of evidence, support for use of evidence through processes and structures, KT advocacy, and so on.

Conclusions

The taxonomy appears to be a promising tool for developing and evaluating KT plans for health prevention in local contexts by providing some concrete examples of potential KT activities (advocacy) and a comparison of the same activities and their outcomes (evaluation).

Evaluating the feasibility of implementing a Telesleep pilot program using two-tiered external facilitation

BACKGROUND

Obstructive sleep apnea (OSA) can negatively impact patients' health status and outcomes. Positive airway pressure (PAP) reverses airway obstruction and may reduce the risk of adverse outcomes. Remote monitoring of PAP (as opposed to in-person visits) may improve access to sleep medicine services. This study aimed to evaluate the feasibility of implementing a clinical program that delivers treatment for OSA through PAP remote monitoring using external facilitation as an implementation strategy.

METHODS

Participants included patients with OSA at a Veteran Affairs Medical Center (VAMC). PAP adherence and clinical disease severity on treatment (measured by the apnea hypopnea index [AHI]) were the preliminary effectiveness outcomes across two delivery models: usual care (in-person) and Telehealth nurse-delivered remote monitoring. We also assessed visit duration and travel distance. A prospective, mixed-methods evaluation examined the two-tiered external facilitation implementation strategy.

RESULTS

The pilot project included N = 52 usual care patients and N = 38 Telehealth nurse-delivered remote monitoring patients. PAP adherence and disease severity were similar across the delivery modalities. However, remote monitoring visits were 50% shorter than in-person visits and saved a mean of 72 miles of travel (median = 45.6, SD = 59.0, mode = 17.8, range 5.4-220). A total of 62 interviews were conducted during implementation with a purposive sample of 12 clinical staff involved in program implementation. Weekly external facilitation delivered to both front-line staff and supervisory physicians was necessary to ensure patient enrollment and treatment. Synchronized, "two-tiered" facilitation at the executive and coordinator levels proved crucial to developing the clinical and administrative infrastructure to support a PAP remote monitoring program and to overcome implementation barriers.

CONCLUSIONS

Remote PAP monitoring had similar efficacy to in-person PAP services in this Veteran population. Although external facilitation is a widely-recognized implementation strategy in quality improvement projects, less is known about how multiple facilitators work together to help implement complex programs. Two-tiered facilitation offers a model well-suited to programs where innovations span disciplines, disrupt professional hierarchies (such as those between service chiefs, clinicians, and technicians) and bring together providers who do not know each other, yet must collaborate to improve access to care.

Context as a Facilitator of the Implementation of Evidence-based Nursing: A Meta-synthesis

Nurses have numerous difficulties in implementing science due to obstacles related to the work context. The aim is to explore the work-context-related facilitators of the application of evidence in clinical practice by nursing professionals. Qualitative meta-synthesis of primary studies on nurses' experiences of work-context-related facilitators, as defined by the Promoting Action on Research Implementation in Health Services model. Using the Qualitative Appraisal and Review Instrument of the Joanna Briggs Institute. Of the total 57 primary research articles included, an explanatory model of the facilitating factors related to the work context was generated on the basis of four general categories: institutional support (leadership), multidisciplinary support (teamwork and communication), culture of improving quality of care (nursing professionals' attitudes towards change) and use of research (valuing research). Action can be taken on the facilitating factors of the evidence-based practice application in nursing clinical environments, providing resources and motivation from the organization.

Time and Organizational Cost for Facilitating Implementation of Primary Care Mental Health Integration

BACKGROUND

Integrating mental health services into primary care settings is complex and challenging. Although facilitation strategies have successfully supported implementation of primary care mental health integration and other complex innovations, we know little about the time required or its cost.

OBJECTIVE

To examine the time and organizational cost of facilitating implementation of primary care mental health integration.

DESIGN

Descriptive analysis.

PARTICIPANTS

One expert external facilitator and two internal regional facilitators who helped healthcare system stakeholders, e.g., leaders, managers, clinicians, and non-clinical staff, implement primary care mental health integration at eight clinics.

INTERVENTION

Implementation facilitation tailored to the needs and resources of the setting and its stakeholders.

MAIN MEASURES

We documented facilitators' and stakeholders' time and types of activities using a structured spreadsheet collected from facilitators on a weekly basis. We obtained travel costs and salary information. We conducted descriptive analysis of time data and estimated organizational cost.

KEY RESULTS

The external facilitator devoted 263 h (0.09 FTE), including travel, across all 8 clinics over 28 months. Internal facilitator time varied across networks (1792 h versus 1169 h), as well as clinics. Stakeholder participation time was similar across networks (1280.6 versus 1363.4 person hours) but the number of stakeholders varied (133 versus 199 stakeholders). The organizational cost of providing implementation facilitation also varied across networks ($263,490 versus $258,127). Stakeholder participation accounted for 35% of the cost of facilitation activities in one network and 47% of the cost in the other.

CONCLUSIONS

Although facilitation can improve implementation of primary care mental health integration, it requires substantial organizational investments that may vary by site and implementation effort. Furthermore, the cost of using an external expert to transfer facilitation skills and build capacity for implementation efforts appears to be minimal.

External facilitators' perceptions of internal facilitation skills during implementation of collaborative care for mental health teams: a qualitative analysis informed by the i-PARIHS framework

Background

Facilitation is a key strategy that may contribute to successful implementation of healthcare innovations. In blended facilitation, external facilitators (EFs) guide and support internal facilitators (IFs) in directing implementation processes. Developers of the i-PARIHS framework propose that successful facilitation requires project management, team/process, and influencing/negotiating skills. It is unclear what IF skills are most important in real-world settings, which could inform recruitment and training efforts. As prior qualitative studies of IF skills have only interviewed IFs, the perspectives of their EF partners are needed. Furthermore, little is known regarding the distribution of implementation tasks between IFs and EFs, which could impact sustainability once external support is removed. In the context of an implementation trial, we therefore: 1) evaluated IFs’ use of i-PARIHS facilitation skills, from EFs’ perspectives; 2) identified attributes of IFs not encompassed within the i-PARIHS skills; and 3) investigated the relative contributions of IFs and EFs during facilitation.

Methods

Analyses were conducted within a hybrid type II trial utilizing blended facilitation to implement the collaborative chronic care model within mental health teams of nine VA medical centers. Each site committed one team and an IF to weekly process design meetings and additional implementation activities over 12 months. Three EFs worked with three sites each. Following study completion, the EFs completed semi-structured qualitative interviews reflecting on the facilitation process, informed by the i-PARIHS facilitation skill areas. Interviews were analyzed via directed content analysis.

Results

EFs emphasized the importance of IFs having strong project management, team/process, and influencing/negotiating skills. Prior experience in these areas and a mental health background were also benefits. Personal characteristics (e.g., flexible, assertive) were described as critical, particularly when faced with conflict. EFs discussed the importance of clear delineation of EF/IF roles, and the need to shift facilitation responsibilities to IFs.

Conclusions

Key IF skills, according to EFs, are aligned with i-PARIHS recommendations, but IFs’ personal characteristics were also emphasized as important factors. Findings highlight traits to consider when selecting IFs and potential training areas (e.g., conflict management). EFs and IFs must determine an appropriate distribution of facilitation tasks to ensure long-term sustainability of practices.

Trial registration

Clinicaltrials.gov, September 7, 2015, #NCT02543840.

From novice to expert: a qualitative study of implementation facilitation skills

BACKGROUND

It is widely reported that facilitation can aid implementation of evidence-based practices. Although scholars agree that facilitators need a diverse range of skills, only a few retrospective studies have identified some of these. During the test of a facilitation strategy within the context of a VA initiative to implement evidence-based care delivery models, we documented the skills an expert external facilitator transferred to two initially novice internal regional facilitators. Ours is the first study to explore facilitation skills as they are being applied and transferred.

METHODS

Facilitators applied the strategy at eight primary care clinics that lacked implementation capacity in two VA networks. We conducted monthly debriefing interviews over a 30-month period and documented these in detailed notes. External facilitator interviews focused specifically on training and mentoring internal facilitators and the skills that she transferred. We also conducted, recorded, and transcribed two qualitative interviews with each facilitator and queried them about training content and process. We conducted a content analysis of the data, using deductive and inductive methods, to identify skills the external facilitator helped internal facilitators learn. We also explored the complexity of facilitation skills and grouped them into overarching skillsets.

RESULTS

The external facilitator helped internal facilitators learn 22 complex skills; with few exceptions, these skills were not unique but overlapped with one another. We clustered 21 of these into 5 groups of overarching skillsets: (1) building relationships and creating a supportive environment, (2) changing the system of care and the structure and processes that support it, (3) transferring knowledge and skills and creating infrastructure support for ongoing learning, (4) planning and leading change efforts, and (5) assessing people, processes, and outcomes and creating infrastructure for program monitoring.

CONCLUSIONS

This study documented a broad range of implementation facilitation skills that are complex and overlapping. Findings suggest that studies and initiatives planning or applying facilitation as an implementation strategy should ensure that facilitators have or have the opportunity to learn the skills they need. Because facilitation skills are complex, the use of didactic methods alone may not be sufficient for transferring skills; future work should explore other methods and techniques.

Implementation of a behavioral medicine approach in physiotherapy: a process evaluation of facilitation methods

Background

In a quasi-experimental study, facilitation was used to support implementation of the behavioral medicine approach in physiotherapy. The facilitation consisted of an individually tailored multifaceted intervention including outreach visits, peer coaching, educational materials, individual goal-setting, video feedback, self-monitoring in a diary, manager support, and information leaflets to patients. A behavioral medicine approach implies a focus on health related behavior change. Clinical behavioral change was initiated but not maintained among the participating physiotherapists. To explain these findings, a deeper understanding of the implementation process is necessary. The aim was therefore to explore the impact mechanisms in the implementation of a behavioral medicine approach in physiotherapy by examining dose, reach, and participant experiences.

Methods

An explorative mixed-methods design was used as a part of a quasi-experimental trial. Twenty four physiotherapists working in primary health care were included in the quasi-experimental trial, and all physiotherapists in the experimental group (n = 15) were included in the current study. A facilitation intervention based mainly on social cognitive theory was tested during a 6-month period. Data were collected during and after the implementation period by self-reports of time allocation regarding participation in different implementation methods, documentation of individual goals, ranking of the most important implementation methods, and semi-structured interviews. Descriptive statistical methods and inductive content analysis were used.

Results

The physiotherapists participated most frequently in the following implementation methods: outreach visits, peer coaching, educational materials, and individual goal-setting. They also considered these methods to be the most important for implementation, contributing to support for learning, practice, memory, emotions, self-management, and time management. However, time management support from the manager was lacking.

Conclusions

The findings indicate that different mechanisms govern the initiation and maintenance of clinical behavior change. The impact mechanisms for initiation of clinical behavior change refers to the use of externally initiated multiple methods, such as feedback on practice, time management, and extrinsic motivation. The lack of self-regulation capability, intrinsic motivation, and continued support after the implementation intervention period were interpreted as possible mechanisms for the failure of maintaining the behavioral change over time.

What is needed by staff to implement PROMs into routine oncology care? A qualitative study with the multi-disciplinary team

INTRODUCTION

The aim of this study was to identify strategies to implement patient-reported outcome measures (PROMs) into routine oncology outpatients' clinical care.

METHODS

Qualitative focus groups were conducted with staff from multiple disciplines using a semistructured interview guide, with supporting data collected in field notes. Data were analysed using a Directed Content Analysis guided by an implementation science framework. The synthesis of the extracted data aimed to identify key requirements which correspond to intrinsic enablers and barriers for implementation.

RESULTS

52 staff members from the multi-disciplinary team participated. Data extracted showed five key themes and three key requirements regarding implementation of PROMs. Staff would consider using PROMs if there was strong research evidence that demonstrates benefits for patient outcomes, if PROM data was relevant to current clinical practice, and if applied appropriately in the specific setting. These findings add pragmatic detail and new knowledge to the current evidence on pathways to PROM implementation. This data can be used to inform implementation of PROMs into health services.

CONCLUSION

Staff have valuable tacit knowledge of what works in practice that offers a unique opportunity to increase successful implementation of a PROM intervention for patient symptom reporting.

The feasibility of implementing education on older person care to practice on medical units: Nurses' perceptions and the influence of practice context

AIM

As part of a larger primary study on evidence-informed practice with hospitalised older people, we aimed to (a) examine nursing staffs' perceptions of the interactive geriatric educational intervention and to explore how perceptions of their work context may influence their ability to enact the evidence-informed assessment and care approaches discussed during the educational sessions and (b) compare differences in perceptions of context between RNs, LPNs and HCAs.

METHOD

A survey-based evaluation that used both closed and open-ended questions was conducted as part of an interactive educational intervention on cognitive impairment and managing responsive behaviours. Data were gathered on participants' perceptions of the education intervention and organisational context.

RESULTS

Findings from this study suggest when education is tailored to nurses' articulated educational needs, it is well received; however, barriers to implementation exist. Assessment of the context by using a standardised survey tool to get the nursing staffs' perceptions of organisational context revealed strengths in leadership support and day-to-day interactions with other nurses and healthcare professionals, but potential barriers related to lack of facilitation to transfer new knowledge into practice existed.

CONCLUSION

Providing evidence-based education related to care of older patients and evaluating nursing staffs' perceptions of the education and their context has laid the groundwork for a long-term relationship with the managers and nursing staff on the participating medical units. Further investigation about how best to incorporate the facilitator role into the medical units to support evidence-based practices with older patients is warranted.  IMPLICATIONS FOR PRACTICE: While nurses are receptive to new knowledge, the unpredictable workload of acute care creates challenges to implementing this new knowledge. Assessment of contextual factors that influence evidence-informed practice facilitates planning for implementation of new knowledge and support practice change.

Implementing clinical guidelines to promote integration of mental health services in primary health care: a qualitative study of a systems policy intervention in Uganda

Background

Clinical practice guidelines (CPG) are developed based on a synthesis of evidence regarding the best options for the assessment, diagnosis and treatment of diseases and are recognized as essential quality improvement tools. However, despite growing availability of CPG, research evaluating their use for mental disorders in Uganda is lacking. For a successful implementation of CPG to be achieved, a number of considerations need to be put in place.

Objective

This study aimed to assess the feasibility and acceptability of the educational intervention that we developed towards improvement of the primary health care providers (PHCPs) uptake of the Uganda Clinical Guidelines (UCG) in integrating mental health services into PHC in Mbarara district, southwestern Uganda.

Methods

This was a descriptive cross-sectional qualitative study with a semi-structured in-depth interview guide. The educational intervention we were assessing had four components: (i) summarized UCG on common mental disorders; (ii) modified Health Management Information System (HMIS) registers to include mental health; (iii) clinician's checklist outlining the steps to be followed; and iv) support supervision/training.

Results

Six themes emerged from the study while the components of the intervention formed the apriori subthemes. Key results based on the subthemes show: (i) summarized UCG: the participants liked the packaging stating that it eased their work, was time saving and user friendly; (ii) modified register: participants appreciated the modifications made to the register updating the existing record in the Health Management Information System (HMIS) registers to include mental health disorders; (iii) TRAINING and support supervision: the PHCPs attributed the success in using the summarized UCG to the training they received, and they further expressed the need to regularize the training in assessment for mental health and support by the mental health specialists.

Conclusion

Our study demonstrates that the use of summarized UCG, modified HMIS registers to include mental health, training and support supervision by mental health specialists in implementing the UCG in integrating mental health at PHC settings is feasible and acceptable by the PHCPs in Mbarara district, southwestern Uganda. Given the need for improved mental health care in Uganda, this intervention could be rigorously evaluated for effectiveness, scalability and generalizability.

What Influences Sustainment and Nonsustainment of Facilitation Activities in Implementation? Analysis of Organizational Factors in Hospitals Implementing TeamSTEPPS

Implementation processes are often long and complex, requiring sustained facilitation efforts. Drawing on organizational and implementation literature, we examined the influence of senior management support (SMS), middle management support (MMS), facilitator team time availability (TIME) and team continuity (CONTINUITY) on sustainment of internal facilitation activities. For 2 years, we followed 10 small rural hospitals implementing TeamSTEPPS, a patient safety program, and conducted quarterly interviews with key informants. We coded, calibrated, and analyzed the data using the fuzzy-set qualitative comparative analysis. We found that five hospitals sustained facilitation activities and the combination of SMS, MMS, and CONTINUITY (i.e., presence of all three factors) was a sufficient condition for sustainment. Five other hospitals did not sustain facilitation activities and they either lacked MMS or lacked both TIME and CONTINUITY. In follow-up analyses, we found that team leadership continuity also influenced sustainment patterns. We discussed the implications for research and practice.

Types of internal facilitation activities in hospitals implementing evidence-based interventions

BACKGROUND

Implementation models, frameworks, and theories recognize the importance of activities that facilitate implementation success. However, little is known about internal facilitation activities that hospital personnel engage in during implementation efforts.

PURPOSE

The aim of the study was to examine internal facilitation activities at 10 critical access hospitals in rural Iowa during their implementation of TeamSTEPPS, a patient safety intervention, and to identify characteristics that distinguish different types of facilitation activities.

METHODS

We followed 10 critical access hospitals for 2 years after the onset of implementation, conducting quarterly interviews with key informants. On the basis of the transcripts from the first two quarters, a coding template was developed using inductive analyses. The template was then applied deductively to code all interview transcripts. Using comparative analysis, we examined the characteristics that distinguish between the facilitation types.

RESULTS

We identified four types of facilitation activities-Leadership, Buy-in, Customization, and Accountability. Individuals and teams engaged in different types of facilitation activities, both in a planned and an ad hoc manner. These activities targeted at both people and practices and exhibited varying temporal patterns (start and peak time).

CONCLUSION

There are four types of facilitation activities that hospitals engage in while implementing evidence-based practices, offering a parsimonious way to characterize facilitation activities. New theoretical and empirical research opportunities are discussed.

PRACTICE IMPLICATIONS

Understanding the types of facilitation activities and their distinguishing characteristics can assist managers in planning and executing implementations of evidence-based interventions.

Specifying and comparing implementation strategies across seven large implementation interventions: a practical application of theory

BACKGROUND

The use of implementation strategies is an active and purposive approach to translate research findings into routine clinical care. The Expert Recommendations for Implementing Change (ERIC) identified and defined discrete implementation strategies, and Proctor and colleagues have made recommendations for specifying operationalization of each strategy. We use empirical data to test how the ERIC taxonomy applies to a large dissemination and implementation initiative aimed at taking cardiac prevention to scale in primary care practice.

METHODS

EvidenceNOW is an Agency for Healthcare Research and Quality initiative that funded seven cooperatives across seven regions in the USA. Cooperatives implemented multi-component interventions to improve heart health and build quality improvement capacity, and used a range of implementation strategies to foster practice change. We used ERIC to identify cooperatives' implementation strategies and specified the actor, action, target, dose, temporality, justification, and expected outcome for each. We mapped and compiled a matrix of the specified ERIC strategies across the cooperatives, and used consensus to resolve mapping differences. We then grouped implementation strategies by outcomes and justifications, which led to insights regarding the use of and linkages between ERIC strategies in real-world scale-up efforts.

RESULTS

Thirty-three ERIC strategies were used by cooperatives. We identified a range of revisions to the ERIC taxonomy to improve the practical application of these strategies. These proposed changes include revisions to four strategy names and 12 definitions. We suggest adding three new strategies because they encapsulate distinct actions that were not described in the existing ERIC taxonomy. In addition, we organized ERIC implementation strategies into four functional groupings based on the way we observed them being applied in practice. These groupings show how ERIC strategies are, out of necessity, interconnected, to achieve the work involved in rapidly taking evidence to scale.

CONCLUSIONS

Findings of our work suggest revisions to the ERIC implementation strategies to reflect their utilization in real-work dissemination and implementation efforts. The functional groupings of the ERIC implementation strategies that emerged from on-the-ground implementers will help guide others in choosing among and linking multiple implementation strategies when planning small- and large-scale implementation efforts.

TRIAL REGISTRATION

Registered as Observational Study at www.clinicaltrials.gov ( NCT02560428 ).

Specifying and comparing implementation strategies across seven large implementation interventions: a practical application of theory

BACKGROUND

The use of implementation strategies is an active and purposive approach to translate research findings into routine clinical care. The Expert Recommendations for Implementing Change (ERIC) identified and defined discrete implementation strategies, and Proctor and colleagues have made recommendations for specifying operationalization of each strategy. We use empirical data to test how the ERIC taxonomy applies to a large dissemination and implementation initiative aimed at taking cardiac prevention to scale in primary care practice.

METHODS

EvidenceNOW is an Agency for Healthcare Research and Quality initiative that funded seven cooperatives across seven regions in the USA. Cooperatives implemented multi-component interventions to improve heart health and build quality improvement capacity, and used a range of implementation strategies to foster practice change. We used ERIC to identify cooperatives' implementation strategies and specified the actor, action, target, dose, temporality, justification, and expected outcome for each. We mapped and compiled a matrix of the specified ERIC strategies across the cooperatives, and used consensus to resolve mapping differences. We then grouped implementation strategies by outcomes and justifications, which led to insights regarding the use of and linkages between ERIC strategies in real-world scale-up efforts.

RESULTS

Thirty-three ERIC strategies were used by cooperatives. We identified a range of revisions to the ERIC taxonomy to improve the practical application of these strategies. These proposed changes include revisions to four strategy names and 12 definitions. We suggest adding three new strategies because they encapsulate distinct actions that were not described in the existing ERIC taxonomy. In addition, we organized ERIC implementation strategies into four functional groupings based on the way we observed them being applied in practice. These groupings show how ERIC strategies are, out of necessity, interconnected, to achieve the work involved in rapidly taking evidence to scale.

CONCLUSIONS

Findings of our work suggest revisions to the ERIC implementation strategies to reflect their utilization in real-work dissemination and implementation efforts. The functional groupings of the ERIC implementation strategies that emerged from on-the-ground implementers will help guide others in choosing among and linking multiple implementation strategies when planning small- and large-scale implementation efforts.

TRIAL REGISTRATION

Registered as Observational Study at www.clinicaltrials.gov ( NCT02560428 ).

Facilitating successful implementation of a person-centred intervention to support family carers within palliative care: a qualitative study of the Carer Support Needs Assessment Tool (CSNAT) intervention

BACKGROUND

An understanding of how to implement person-centred interventions in palliative and end of life care is lacking, particularly for supporting family carers. To address this gap, we investigated components related to successful implementation of the Carer Support Needs Assessment Tool (CSNAT) intervention, a person-centred process of carer assessment and support, using Promoting Action on Research Implementation in Health Services (PARIHS) as a theoretical framework. This study identifies how the PARIHS component of 'facilitation' and its interplay with the components of 'context' and 'evidence' affect implementation success.

METHODS

MRC Framework Phase IV study to evaluate implementation of the CSNAT intervention at scale, over six months, in 36 UK palliative care services. 38 practitioners acting as internal facilitators in 35/36 services were interviewed. Field notes were collected during teleconference support sessions between the external and internal facilitators.

RESULTS

Successful implementation was associated with internal facilitators' 'leverage' including their positioning within services, authority to change practice, and having a team of supportive co-facilitators. Effective facilitation processes included a collaborative approach, ongoing communication, and proactive problem solving to address implementation barriers. Facilitators needed to communicate the evidence and provide legitimacy for changing practice. Contextual constraints on facilitation included having to adjust recording systems to support implementation, organisational changes, a patient-focused culture and lack of managerial support.

CONCLUSIONS

The CSNAT intervention requires attention to both facilitation processes and conducive organisational structures for successful implementation. These findings are likely to be applicable to any person-centred process of assessment and support within palliative care.

Quality circles for quality improvement in primary health care: Their origins, spread, effectiveness and lacunae- A scoping review

Quality circles or peer review groups, and similar structured small groups of 6–12 health care professionals meet regularly across Europe to reflect on and improve their standard practice. There is debate over their effectiveness in primary health care, especially over their potential to change practitioners’ behaviour. Despite their popularity, we could not identify broad surveys of the literature on quality circles in a primary care context. Our scoping review was intended to identify possible definitions of quality circles, their origins, and reported effectiveness in primary health care, and to identify gaps in our knowledge. We searched appropriate databases and included any relevant paper on quality circles published until December 2017. We then compared information we found in the articles to that we found in books and on websites. Our search returned 7824 citations, from which we identified 82 background papers and 58 papers about quality circles. We found that they originated in manufacturing industry and that many countries adopted them for primary health care to continuously improve medical education, professional development, and quality of care. Quality circles are not standardized and their techniques are complex. We identified 19 papers that described individual studies, one paper that summarized 3 studies, and 1 systematic review that suggested that quality circles can effectively change behaviour, though effect sizes varied, depending on topic and context. Studies also suggested participation may affirm self-esteem and increase professional confidence. Because reports of the effect of quality circles on behaviour are variable, we recommend theory-driven research approaches to analyse and improve the effectiveness of this complex intervention.

Facilitating Implementation of Research Evidence (FIRE): an international cluster randomised controlled trial to evaluate two models of facilitation informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework

BACKGROUND

Health care practice needs to be underpinned by high quality research evidence, so that the best possible care can be delivered. However, evidence from research is not always utilised in practice. This study used the Promoting Action on Research Implementation in Health Services (PARIHS) framework as its theoretical underpinning to test whether two different approaches to facilitating implementation could affect the use of research evidence in practice.

METHODS

A pragmatic clustered randomised controlled trial with embedded process and economic evaluation was used. The study took place in four European countries across 24 long-term nursing care sites, for people aged 60 years or more with documented urinary incontinence. In each country, sites were randomly allocated to standard dissemination, or one of two different types of facilitation. The primary outcome was the documented percentage compliance with the continence recommendations, assessed at baseline, then at 6, 12, 18, and 24 months after the intervention. Data were analysed using STATA15, multi-level mixed-effects linear regression models were fitted to scores for compliance with the continence recommendations, adjusting for clustering.

RESULTS

Quantitative data were obtained from reviews of 2313 records. There were no significant differences in the primary outcome (documented compliance with continence recommendations) between study arms and all study arms improved over time.

CONCLUSIONS

This was the first cross European randomised controlled trial with embedded process evaluation that sought to test different methods of facilitation. There were no statistically significant differences in compliance with continence recommendations between the groups. It was not possible to identify whether different types and "doses" of facilitation were influential within very diverse contextual conditions. The process evaluation (Rycroft-Malone et al., Implementation Science. doi: 10.1186/s13012-018-0811-0) revealed the models of facilitation used were limited in their ability to overcome the influence of contextual factors.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN11598502 . Date 4/2/10. The research leading to these results has received funding from the European Union's Seventh Framework Programme (FP7/2007-2013) under grant agreement no. 223646.

Impact of Practice Facilitation in Primary Care on Chronic Disease Care Processes and Outcomes: a Systematic Review

BACKGROUND

More than 100 million individuals in the USA have been diagnosed with a chronic disease, yet chronic disease care has remained fragmented and of inconsistent quality. Improving chronic disease management has been challenging for primary care and internal medicine practitioners. Practice facilitation provides a comprehensive approach to chronic disease care. The objective is to evaluate the impact of practice facilitation on chronic disease outcomes in the primary care setting.

METHODS

This systematic review examined North American studies from PubMed, EMBASE, and Web of Science (database inception to August 2017). Investigators independently extracted and assessed the quality of the data on chronic disease process and clinical outcome measures. Studies implemented practice facilitation and reported quantifiable care processes and patient outcomes for chronic disease. Each study and their evidence were assessed for risk of bias and quality according to the Cochrane Collaboration and the Grade Collaboration tool.

RESULTS

This systematic review included 25 studies: 12 randomized control trials and 13 prospective cohort studies. Across all studies, practices and their clinicians were aware of the implementation of practice facilitation. Improvements were observed in most studies for chronic diseases including asthma, cancer (breast, cervical, and colorectal), cardiovascular disease (cerebrovascular disease, coronary artery disease, dyslipidemia, hypertension, myocardial infarction, and peripheral vascular disease), and type 2 diabetes. Mixed results were observed for chronic kidney disease and chronic illness care.

DISCUSSION

Overall, the results suggest that practice facilitation may improve chronic disease care measures. Across all studies, practices were aware of practice facilitation. These findings lend support for the potential expansion of practice facilitation in primary care. Future work will need to investigate potential opportunities for practice facilitation to improve chronic disease outcomes in other health care settings (e.g., specialty and multi-specialty practices) with standardized measures.

Enhancing implementation of measurement-based mental health care in primary care: a mixed-methods randomized effectiveness evaluation of implementation facilitation

BACKGROUND

Mental health care lags behind other forms of medical care in its reliance on subjective clinician assessment. Although routine use of standardized patient-reported outcome measures, measurement-based care (MBC), can improve patient outcomes and engagement, clinician efficiency, and, collaboration across care team members, full implementation of this complex practice change can be challenging. This study seeks to understand whether and how an intensive facilitation strategy can be effective in supporting the implementation of MBC. Implementation researchers partnering with US Department of Veterans Affairs (VA) leaders are conducting the study within the context of a national initiative to support MBC implementation throughout VA mental health services. This study will focus specifically on VA Primary Care-Mental Health Integration (PCMHI) programs.

METHODS

A mixed-methods, multiple case study design will include 12 PCMHI sites recruited from the 23 PCMHI programs that volunteered to participate in the VA national initiative. Guided by a study partnership panel, sites are clustered into similar groups using administrative metrics. Site pairs are recruited from within these groups. Within pairs, sites are randomized to the implementation facilitation strategy (external facilitation plus QI team) or standard VA national support. The implementation strategy provides an external facilitator and MBC experts who work with intervention sites to form a QI team, develop an implementation plan, and, identify and overcome barriers to implementation. The RE-AIM framework guides the evaluation of the implementation facilitation strategy which will utilize data from administrative, medical record, and primary qualitative and quantitative sources. Guided by the iPARIHS framework and using a mixed methods approach, we will also examine factors associated with implementation success. Finally, we will explore whether implementation of MBC increases primary care team communication and function related to the care of mental health conditions.

DISCUSSION

MBC has significant potential to improve mental health care but it represents a major change in practice. Understanding factors that can support MBC implementation is essential to attaining its potential benefits and spreading these benefits across the health care system.