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Chandler CE, Louison L, Madenyika N, Robertson N, Hardy B, Allin S, Kimberg D, Fleming WO. Using Quality Improvement as a Mechanism for Fostering Partnerships and Promoting Equity in a Health System Change Model. Matern Child Health J 2024; 28:984-989. [PMID: 38407716 DOI: 10.1007/s10995-024-03916-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 02/27/2024]
Abstract
PURPOSE Quality improvement (QI) processes provide a framework for systematically examining target outcomes and what changes can be made to result in improvement and ensure equity. We present a case study of how QI processes were used as a means of partnership building to enhance equity in designing materials for a Medicaid pilot program, North Carolina Integrated Care for Kids (NC InCK). DESCRIPTION The NC InCK model addresses social determinants of health by providing structured care integration across core child health and social service areas and using an alternative payment model to incentivize high quality child outcomes. During the two-year planning period prior to the NC InCK model launch, we used Plan-Do-Study-Act (PDSA) cycles to conduct usability testing as a QI strategy for a component of the NC InCK model: the Shared Action Plan (SAP). ASSESSMENT We conducted usability testing with four Family Council members, nine care managers, and one physician. Participants reviewed the SAP and provided feedback via a survey. After reviewing feedback with InCK leadership and the Family Council, we implemented recommendations that led to a SAP that uses clear and accessible language, that highlights family strengths and family-identified goals, and that is distinct from other care management plans. CONCLUSION Usability testing forced refinement of materials before NC InCK launched, created opportunities for building and enhancing community partnerships and promoted equity within the NC InCK team and Family Council by considering multiple perspectives when deciding on SAP revisions.
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Affiliation(s)
- Caroline E Chandler
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA.
| | - Laura Louison
- School of Social Work, University of North Carolina at Chapel Hill, 325 Pittsboro St #3550, Chapel Hill, NC, 27599, USA
| | - Nancy Madenyika
- Duke Population Health Management Office, 3100 Tower Blvd Suite 1100, Durham, NC, 27707, USA
| | - Nakenge Robertson
- School of Social Work, University of North Carolina at Chapel Hill, 325 Pittsboro St #3550, Chapel Hill, NC, 27599, USA
| | - Brie Hardy
- Families & Communities Rising, 4220 NC-55, Suite 300, Durham, NC, 27713, USA
| | - Sarah Allin
- Duke Population Health Management Office, 3100 Tower Blvd Suite 1100, Durham, NC, 27707, USA
| | - Dan Kimberg
- UNC Health, 101 Manning Drive, Chapel Hill, NC, 27514, USA
| | - W Oscar Fleming
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
- Public Health Leadership Program, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
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Bartley L, Metz A, Fleming WO. What implementation strategies are relational? Using Relational Theory to explore the ERIC implementation strategies. Front Health Serv 2022; 2:913585. [PMID: 36925772 PMCID: PMC10012668 DOI: 10.3389/frhs.2022.913585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 09/20/2022] [Indexed: 03/18/2023]
Abstract
The identification and use of implementation strategies in implementation research and practice have strengthened our understanding of the implementation process as well as the causal pathways between mechanisms, strategies, and implementation outcomes. Although these contributions have advanced the application of strategies, there is still a need to learn more about how strategies might integrate relational exchanges and interactions. The inclusion of critical perspectives has been limited in implementation science, and theories such as Relational Theory can expand our understanding of the relational nature of implementation and enhance rigor through alternative theoretical applications. This study applied Relational Theory through a qualitative directed content analysis of the 73 Expert Recommendations for Implementation Change (ERIC) implementation strategies and examine relational components in strategy descriptions. Three reviewers used the structured approach to review and categorize the implementation strategies based on the Relational and Transactional Strategy Continuum measure, which operationalizes types of interactions, exchanges and alliances. Relational alliance strategies are those in which there is mutual growth and accountability, frequent interaction, shared power, and potential vulnerability. Operational alliances include forms of working exchanges between parties with balanced transactional and relational features. Operational alliances can be somewhat interactive in nature, with minor exchanges and limited accountability. Transactional alliance strategies are mostly uni-directional, influenced by power differentials, and do not require mutual growth, commitment, or exchange; thus, the power of growth is inherently one-sided. Results from the review suggest more implementation strategies with relational alliance features (highly relational, n = 17, semi-relational, n = 19) compared to transactional (highly transactional, n = 9, semi-transactional, n = 10) and 18 strategies coded as operational alliances. The qualitative review revealed opportunities to further expand how relational exchanges are considered within the implementation strategies descriptions, as well as the role of actors and power dynamics within strategy exchanges. The Relational and Transactional Strategy Continuum measure can help practitioners and researchers consider the sequencing, pairing, and impact on outcomes of different types and combinations of strategies in implementation practice and research. Additionally, the measure can support reflection on strategies that promote positive alliances, frequent connections, bi-directional communication, and power sharing.
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Affiliation(s)
- Leah Bartley
- Kaye Implementation and Evaluation, Tacoma, WA, United States
| | - Allison Metz
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - W. Oscar Fleming
- School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Coffey AM, Powis L, Mullenix A, Rivero V, Evans S, Fatima H, Fleming WO, Lich KH, Orton S, Cilenti D, Margolis L. Enhancing Title V Workforce Capacity to Address Complex Challenges: Impact of the National Maternal and Child Health Workforce Development Center. Matern Child Health J 2022; 26:51-59. [PMID: 35612773 PMCID: PMC9482586 DOI: 10.1007/s10995-022-03430-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 02/17/2022] [Accepted: 03/17/2022] [Indexed: 11/28/2022]
Abstract
Introduction The National Maternal and Child Health Workforce Development Center provides training, coaching, and consultation to Title V programs. The flagship experience is the Cohort program, a 6-8-month leadership development program where Title V programs convene a multisector team to address a pre-selected state/jurisdictional challenge related to health systems transformation. The overall objective of this paper is to demonstrate the impact of skills developed via the Cohort program on state/jurisdictional capacities to address complex challenges. Methods Qualitative, post-Cohort evaluation data were analyzed using inductive and deductive coding and the “Sort and Sift, Think and Shift” method. Themes and supporting text were summarized using episode profiles for each team and subsequently organized using the EvaluLEAD methodology for identifying and documenting impact. Results Teams brought an array of challenges related to health systems transformation and 94% of teams reported achieving progress on their challenge six-months after the Cohort program. Teams described how the Cohort program improved workforce skills in strategic thinking, systems thinking, adaptive leadership, and communication. Teams also reported the Cohort program contributed to stronger partnerships, improved sustainability of their project, produced mindset shifts, and increased confidence. The Cohort program has also led to improved population health outcomes. Discussion Through working with the Center, Title V leaders and their teams achieved episodic, developmental, and transformative results through application of Center tools and skills to complex challenges. Investment in the MCH workforce through skill development is critical for achieving transformative results and solving “wicked” public health problems.
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Affiliation(s)
- Alexandria M Coffey
- Department of Maternal and Child Health, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, North Carolina, 27599, United States.
| | - Laura Powis
- The Association of Maternal and Child Health Programs, 1825 K Street Suite 250, Washington, DC, 20006-1202, United States
| | - Amy Mullenix
- Department of Maternal and Child Health, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, North Carolina, 27599, United States
| | - Vanessa Rivero
- Department of Maternal and Child Health, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, North Carolina, 27599, United States.,Kidzu Children's Museum, 201 South Estes Drive, Chapel Hill, North Carolina, 27514, United States
| | - Shara Evans
- Department of Maternal and Child Health, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, North Carolina, 27599, United States
| | - Hiba Fatima
- Department of Maternal and Child Health, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, North Carolina, 27599, United States
| | - W Oscar Fleming
- Public Health Leadership Program, University of North Carolina - Chapel Hill, Box 7469, Chapel Hill, North Carolina, 27599, United States
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, North Carolina, 27599, United States
| | - Stephen Orton
- North Carolina Institute for Public Health, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, North Carolina, 27599, United States
| | - Dorothy Cilenti
- Department of Maternal and Child Health, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, North Carolina, 27599, United States
| | - Lewis Margolis
- Department of Maternal and Child Health, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, North Carolina, 27599, United States
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Umble KE, Powis L, Coffey AM, Margolis L, Mullenix A, Fatima H, Orton S, Fleming WO, Lich KH, Cilenti D. Developing State Leadership in Maternal and Child Health: Process Evaluation Findings from a Work-Based Learning Model for Leadership Development. Matern Child Health J 2022; 26:156-168. [PMID: 35488949 PMCID: PMC9055367 DOI: 10.1007/s10995-022-03444-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 11/05/2022]
Abstract
Objectives Since 2013 the MCH Bureau has supported the National MCH Workforce Development Center to strengthen the Title V MCH workforce. This article describes the Center’s Cohort Program and lessons learned about work-based learning, instruction, and coaching. Description The Cohort Program is a leadership development program that enrolls state-level teams for skill development and work-based learning to address a self-identified challenge in their state. Teams attend a Learning Institute that teaches concepts, skills, and practical tools in systems integration; change management and adaptive leadership; and evidence-based decision-making and implementation. Teams then work back home on their challenges, aided by coaching. The Program’s goals are for teams to expand and use their skills to address their challenge, and that teams would strengthen programs, organizations, and policies, use their skills to address other challenges, and ultimately improve MCH outcomes. Methods This process evaluation is based on evaluation forms completed by attendees at the three-day Learning Institute; six-month follow-up interviews with team leaders; and a modified focus group with staff. Results Participants and staff believe the Cohort Program effectively merges a practical skill-based curriculum, work-based learning in teams, and coaching. The Learning Institute provides a foundation of skills and tools, strengthens the team’s relationship with their coach, and builds the team. The work-based learning period provides structure, accountability, and a “practice space” for teams to apply the Cohort Program’s skills and tools to address their challenge. In this period, teams deepen collaborations and often add partners. The coach provides accessible and tailored guidance in teamwork and skill application. These dimensions helped teams in develop skills and address state-level MCH challenges. Conclusions for Practice Continuing professional development programs can help leaders learn to address complex state-level MCH challenges through integrated classroom-based skills development, work-based learning on state challenges, and tailored coaching.
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Affiliation(s)
- Karl E. Umble
- Department of Health Policy and Management, University of North Carolina - Chapel Hill, 113 Rosenau Hall CB #7411, Chapel Hill, NC 27599-7411 USA
| | - Laura Powis
- The Association of Maternal and Child Health Programs, 1825 K Street Suite 250, Washington, DC 20006-1202 USA
| | - Alexandria M. Coffey
- Department of Maternal and Child Health, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599 USA
| | - Lewis Margolis
- Department of Maternal and Child Health, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599 USA
| | - Amy Mullenix
- The National MCH Workforce Development Center, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599 USA
| | - Hiba Fatima
- Department of Maternal and Child Health, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599 USA
| | - Stephen Orton
- North Carolina Institute for Public Health, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599 USA
| | - W. Oscar Fleming
- National Implementation Research Network, University of North Carolina - Chapel Hill, Campus, Box 8180, Chapel Hill, NC 27516 USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599 USA
| | - Dorothy Cilenti
- Department of Maternal and Child Health, University of North Carolina - Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599 USA
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Westgard C, Fleming WO. The Use of Implementation Science Tools to Design, Implement, and Monitor a Community-Based mHealth Intervention for Child Health in the Amazon. Front Public Health 2020; 8:411. [PMID: 32974257 PMCID: PMC7466738 DOI: 10.3389/fpubh.2020.00411] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 07/10/2020] [Indexed: 01/04/2023] Open
Abstract
It is essential to analyze the local context and implementation components to effectively deliver evidence-based solutions to public health problems. Tools provided by the field of implementation science can guide practitioners through a comprehensive implementation process, making innovations more adaptable, efficient, and sustainable. It is equally important to report on the design and implementation process so others can analyze, replicate, and improve on the progress made from an intervention. The current study reports on the design and implementation of an mHealth intervention to improve child health in the Amazon of Peru. The study aims to provide insight into how an implementation science tool can be used to improve implementation and reporting of an evidence-based intervention in a global health setting. Methods: Implementation of a community-based mHealth intervention is analyzed and reported through the lens of the Active Implementation Frameworks (AIF). The AIF is used to analyze the design, implementation, adaptation, and monitoring of the intervention. The implementation process is categorized in the four stages of implementation. The results of the analysis and subsequent implementation activities are reported. Results: The exploration stage was used to learn about the local context in the Amazonian communities and identify an evidence-based solution to address poor child health. Several potential solutions were combined to create an innovative mHealth tool. During the installation stage, the stakeholders worked together to improve the intervention and plan for implementation through human-centered design. The providers in the field were trained and data was gathered to monitor implementation. During initial implementation stage, electronic tablets were distributed to community health agents and continuous quality improvement activities allowed for rapid improvements to be implemented. The intervention moved on to full implementation stage as acceptance and fidelity approached 100%. Conclusion: The AIF highlighted several potential barriers to implementation that may have been overlooked without the guidance of a science-based implementation tool. Reporting on the implementation process shows how implementation science tools can be used to foresee and address potential threats to successful implementation. The results of this study provide insight into the components of implementation in Amazonian communities, as well as the process of using implementation science tools in any global health setting.
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Affiliation(s)
- Christopher Westgard
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, United States.,Department of Research, Elementos, Lima, Peru
| | - W Oscar Fleming
- National Implementation Research Network, Frank Porter Graham Developmental Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Fleming WO, Apostolico AA, Mullenix AJ, Starr K, Margolis L. Putting Implementation Science into Practice: Lessons from the Creation of the National Maternal and Child Health Workforce Development Center. Matern Child Health J 2019; 23:722-732. [PMID: 30684106 DOI: 10.1007/s10995-018-02697-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Purpose This article describes how implementation science informed the design of a national training and technical assistance (TA) center, and how implementation best practices have been used to improve the quality of training and technical assistance services offered to states/jurisdictions. Description An existing tool, based on the Implementation Drivers Framework (in: Fixsen et al., Implementation research: a synthesis of the literature, University of South Florida, The National Implementation Research Network, Tampa, 2005), was adapted to assess efforts of the National MCH Workforce Development Center (the Center) against known implementation best practices. Staff identified specific examples of effective practice and gaps for inclusion in this article. Assessment Using implementation science to establish, assess and improve Center practice was both feasible and practical, requiring intentionality, dedicated time, and staff committed to deepening their understanding of implementation science. The Implementation Drivers framework proved useful for creating a shared approach to analysis and identification of opportunities for improvement of Center practice. Conclusion Policymakers and funding agencies should consider how training and technical assistance programs demonstrate knowledge and use of implementation science best practices among other evidence based practices in their work. Increasing attention to the use of implementation science can contribute to a higher quality of service among technical assistance centers, with the long term goal of improving outcomes for training and assistance recipients and the communities they serve. Establishing the link between customer satisfaction and quality of technical assistance, on the one hand, and long term outcomes, on the other, remains a challenge and an area of focus and learning for the Center.
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Affiliation(s)
- W Oscar Fleming
- The National Implementation Research Network, FPG Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,The National Maternal and Child Health Workforce Development Center, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexsandra A Apostolico
- The National Maternal and Child Health Workforce Development Center, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Amy J Mullenix
- The National Maternal and Child Health Workforce Development Center, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Katie Starr
- The National Maternal and Child Health Workforce Development Center, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lewis Margolis
- The National Maternal and Child Health Workforce Development Center, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Aldridge WA, Boothroyd RI, Fleming WO, Lofts Jarboe K, Morrow J, Ritchie GF, Sebian J. Transforming community prevention systems for sustained impact: embedding active implementation and scaling functions. Transl Behav Med 2016; 6:135-44. [PMID: 27012261 PMCID: PMC4807202 DOI: 10.1007/s13142-015-0351-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Traditional efforts to translate evidence-based prevention strategies to communities, at scale, have not often produced socially significant outcomes or the local capacity needed to sustain them. A key gap in many efforts is the transformation of community prevention systems to support and sustain local infrastructure for the active implementation, scaling, and continuous improvement of effective prevention strategies. In this paper, we discuss (1) the emergence of applied implementation science as an important type 3–5 translational extension of traditional type 2 translational prevention science, (2) active implementation and scaling functions to support the full and effective use of evidence-based prevention strategies in practice, (3) the organization and alignment of local infrastructure to embed active implementation and scaling functions within community prevention systems, and (4) policy and practice implications for greater social impact and sustainable use of effective prevention strategies.
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Affiliation(s)
- William A Aldridge
- FPG Child Development Institute, University of North Carolina at Chapel Hill, CB #8185, Chapel Hill, NC, 27599-8185, USA.
| | - Renée I Boothroyd
- FPG Child Development Institute, University of North Carolina at Chapel Hill, CB #8185, Chapel Hill, NC, 27599-8185, USA
| | - W Oscar Fleming
- FPG Child Development Institute, University of North Carolina at Chapel Hill, CB #8185, Chapel Hill, NC, 27599-8185, USA
| | | | - Jane Morrow
- The North Carolina Partnership for Children, Raleigh, NC, USA.,Smart Start of New Hanover County, Wilmington, NC, USA
| | - Gail F Ritchie
- Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, Rockville, MD, USA
| | - Joyce Sebian
- Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, Rockville, MD, USA
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