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

Navigating the facilitation journey: a qualitative, longitudinal evaluation of 'Eat Walk Engage' novice and experienced facilitators

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) and integrated-PARIHS (i-PARIHS) frameworks position facilitation as an overarching strategy to enable implementation. In the revised i-PARIHS framework, facilitation is operationalised through a multi-level model with novice, experienced and expert facilitators working together in a network structure to build facilitation knowledge and skills along a continuum. To date, there has been limited evaluation of this facilitation model in practice, which is the aim of the study reported here.

METHODS

A descriptive, qualitative longitudinal study was undertaken to track a team of four novice and two experienced facilitators involved in facilitating the implementation of an intervention known as 'Eat Walk Engage' to improve multidisciplinary team delivery of age-friendly care principles in hospital. Over an 18-month period, repeat interviews were conducted to explore the learning, development, and evolving roles of novice facilitators and the roles of the experienced facilitators in providing support and mentoring. Interview data were analysed using a descriptive qualitative approach and findings were interpreted in collaboration with the participating facilitators.

RESULTS

The findings demonstrated experiential learning in both the novice and experienced facilitator groups as they enacted their roles in practice. The novice facilitators progressively transitioned to becoming more experienced facilitators and the experienced facilitators became increasingly expert, in line with the i-PARIHS concept of a facilitation journey from novice to expert. Strategies to support this development included a staggered approach to learning, regular meetings between the experienced and novice facilitators, reflective writing and informal peer support and networking. However, the roles were not without challenge and these challenges changed over time, from a more specific focus on the demands of the facilitator role to concerns about embedding and sustaining improvements in practice.

CONCLUSIONS

Within a network of peers and a mentored relationship with more experienced facilitators, individuals who are new to an implementation facilitator role can transition along a continuum to become experienced facilitators. Building implementation facilitation capability in this way takes time and requires tailored support and mentorship using a mix of structured and flexible approaches incorporating opportunities for reflection to support individual and group learning.

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.

Intensification of Implementation Strategies: Developing a Model of Foundational and Enhanced Implementation Approaches to Support National Adoption and Scale-up

Implementation strategies are activities to support integration of evidence-based programs (EBPs) into routine care. Comprised of 170+ facilities, the Veterans Affairs Healthcare System is conducive to evaluating feasibility and scalability of implementation strategies on a national level. In previous work evaluating implementation of three EBPs for older Veterans (hospital-based walking, caregiver skills training, group physical therapy), we found facilities varied in their need for implementation support, with some needing minimal guidance and others requiring intensive support. Committed to national scalability, our team developed an implementation intensification model consisting of foundational (low-touch) and enhanced (high-touch) implementation support. This Forum article describes our multilevel and multistep process to develop and evaluate implementation intensification. Steps included (a) review completed trial data; (b) conduct listening sessions; (c) review literature; (d) draft foundational and enhanced implementation support packages; (e) iteratively refine packages; and (7) devise an evaluation plan. Our model of implementation intensification may be relevant to other health care systems seeking strategies that can adapt to diverse delivery settings, optimize resources, help build capacity, and ultimately enhance implementation outcomes. As more health care systems focus on spread of EBPs into routine care, identifying scalable and effective implementation strategies will be critical.

Testing the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to reduce diagnostic error in trauma triage: a study protocol for a randomized pilot trial

BACKGROUND

Non-compliance with clinical practice guidelines in trauma remains common, in part because physicians make diagnostic errors when triaging injured patients. Deliberate practice, purposeful participation in a training task under the oversight of a coach, effectively changes behavior in procedural domains of medicine but has rarely been used to improve diagnostic skill. We plan a pilot parallel randomized trial to test the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to reduce physician diagnostic errors in trauma triage.

METHODS

We will randomize a national convenience sample of physicians who work at non-trauma centers (n = 60) in a 1:1 ratio to a deliberate practice intervention or to a passive control. We will use a customized, theory-based serious video game as the basis of our training task, selected based on its behavior change techniques and game mechanics, along with a coaching manual to standardize the fidelity of the intervention delivery. The intervention consists of three 30-min sessions with content experts (coaches), conducted remotely, during which physicians (trainees) play the game and receive feedback on their diagnostic processes. We will assess (a) the fidelity with which the intervention is delivered by reviewing video recordings of the coaching sessions; (b) the acceptability of the intervention through surveys and semi-structured interviews, and (c) the effect of the intervention by comparing the performance of trainees and a control group of physicians on a validated virtual simulation. We hypothesize that trainees will make ≥ 25% fewer diagnostic errors on the simulation than control physicians, a large effect size. We additionally hypothesize that ≥ 90% of trainees will receive their intervention as planned.

CONCLUSIONS

The results of the trial will inform the decision to proceed with a future hybrid effectiveness-implementation trial of the intervention. It will also provide a deeper understanding of the challenges of using deliberate practice to modify the diagnostic skill of physicians.

TRIAL REGISTRATION

Clinical trials.gov ( NCT05168579 ); 23 December 2021.

Conceptual and relational advances of the PARIHS and i-PARIHS frameworks over the last decade: a critical interpretive synthesis

BACKGROUND

The number of research publications reporting the use of the Promoting Action on Research Implementation in Health Services (PARIHS) framework and the integrated PARIHS (i-PARIHS) framework has grown steadily. We asked how the last decade of implementation research, predicated on the (i-)PARIHS framework (referring to the PARIHS or i-PARIHS framework), has contributed to our understanding of the conceptualizations of, relationships between, and dynamics among the core framework elements/sub-elements. Building on the Helfrich et al. (2010) review of research on the PARIHS framework, we undertook a critical interpretive synthesis to: (1) identify conceptual and relational advances in the (i-)PARIHS framework and (2) identify conceptual and relational aspects of the (i-)PARIHS framework that warrant further work.

METHODS

We performed a systematic search in PubMed/PubMed Central, Ovid MEDLINE, CINAHL, JSTOR, SCOPUS, Web of Science, and PsycInfo. Articles were eligible for synthesis if they (a) were peer-reviewed articles, written in English, and published between January 2009 and December 2021, (b) applied the (i-)PARIHS framework explicitly to guide implementation research, and (c) made conceptual (expanding the conceptualization of core elements) and/or relational contributions (elaborating relationships among elements/sub-elements, or theorizing the relationships using empirical data). We used a critical interpretive synthesis approach to synthesize conceptual-relational advances of the (i-)PARIHS framework.

RESULTS

Thirty-seven articles were eligible for synthesis. Twenty-four offered conceptual contributions, and 18 offered relational contributions (5 articles contributed in both ways). We found conceptual expansion of all core (i-)PARIHS elements, with most emphasis on context (particularly outer context and leadership), facilitation, and implementation success. Articles also gave insights into the complex relationships and relational dynamism among these elements, characterized as contingent, interactive, multilevel, and temporal effects.

CONCLUSIONS

We observed developmental advances of the (i-)PARIHS framework and proposed several directions to further advance the framework. Conceptualization of (i-)PARIHS elements (particularly evidence/innovation and recipients) need to be further developed by specifying conceptual and operational definitions of underlying sub-elements. Relationships among (i-)PARIHS elements/sub-elements need to be further elaborated through empirical studies that consider situational contingencies and causal complexities. This will require examining necessity and sufficiency of (i-)PARIHS elements/sub-elements in relation to implementation outcomes, interactions among elements, and mechanism-based explanations.

FAST: A Framework to Assess Speed of Translation of Health Innovations to Practice and Policy

The 17-year time span between discovery and application of evidence in practice has become a unifying challenge for implementation science and translational science more broadly. Further, global pandemics and social crises demand timely implementation of rapidly accruing evidence to reduce morbidity and mortality. Yet speed remains an understudied metric in implementation science. Prevailing evaluations of implementation lack a temporal aspect, and current approaches have not yielded rapid implementation. In this paper, we address speed as an important conceptual and methodological gap in implementation science. We aim to untangle the complexities of studying implementation speed, offer a framework to assess speed of translation (FAST), and provide guidance to measure speed in evaluating implementation. To facilitate specification and reporting on metrics of speed, we encourage consideration of stakeholder perspectives (e.g., comparison of varying priorities), referents (e.g., speed in attaining outcomes, transitioning between implementation phases), and observation windows (e.g., time from intervention development to first patient treated) in its measurement. The FAST framework identifies factors that may influence speed of implementation and potential effects of implementation speed. We propose a research agenda to advance understanding of the pace of implementation, including identifying accelerators and inhibitors to speed.

A peek behind the curtain: exploring coaching styles within the implementation and sustainment facilitation (ISF) strategy in the substance abuse treatment to HIV care study

BACKGROUND

The Grasha-Riechmann teaching styles, which includes three didactic and two prescriptive styles, have been shown to help enhance learning within educational settings. Although an adaption of the Grasha-Riechmann style classification has enabled coaching styles to be identified for use as part of quality improvement (QI) initiatives, research has not examined the styles actually utilized by coaches within a QI initiative or how the styles change overtime when the coach is guiding an organization through change implementation. Interactions between coaches and HIV service organization (HSO) staff participating in a large implementation research experiment called the Substance Abuse Treatment to HIV care (SAT2HIV) Project were evaluated to begin building an evidence base to address this gap in implementation research.

METHODS

Implementation & Sustainment Facilitation (ISF) Strategy meetings (n = 137) between coaches and HSO staff were recorded and professionally transcribed. Thematic coding classifications were developed from the Grasha-Riechmann framework and applied to a purposively selected sample of transcripts (n = 66). Four coders independently coded transcripts using NVivo to facilitate text identification, organization, and retrieval for analysis. Coaching style use and changes across the three ISF phases were explored.

RESULTS

Facilitator and formal authority were the two coaching styles predominately used. Facilitator sub-themes shifted from asking questions and providing support to supporting independent action over time. Coaches' use of formal authority sub-styles shifted notably across time from setting expectations or ensuring preparation to offering affirmation or feedback about changes that the HSO's were implementing. The use of the delegator or personal model coaching styles occurred infrequently.

CONCLUSIONS

The current research extends implementation research's understanding of coaching. More specifically, findings indicate it is feasible to use the Grasha-Riechmann framework to qualitatively identify coaching styles utilized in a facilitation-based implementation strategy. More importantly, results provide insights into how different coaching styles were utilized to implement an evidence-based practice. Further research is needed to examine how coaching styles differ by organization, impact implementation fidelity, and influence both implementation outcomes and client outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02495402 . Registered on July 6, 2015.