Implementation in the Multilevel Context of Routine Practice and Policy

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1 Implementation in the Multilevel Context of Routine Practice and Policy Michael K. Gould, MD, MS Director for Health Services Research and Implementation Science Department of Research and Evaluation Kaiser Permanente Southern California

2 Disclosures Financial conflicts: None Intellectual conflicts: PCCM clinician Health services researcher Employed by SCPMG

3 Objectives Understand the importance of context and what is meant by multi-level context Describe role of context in common implementation science frameworks Learn from examples of multi-level implementation

4 The Importance of Context Taken out of context, I must seem so strange. Ani DiFranco

5 The Ebbinghaus Illusion Context is everything and perception is relative. Derek Powazek

6 Diffusion Theory: Four Key Elements The innovation Communication channels Time Social system Rogers EM. Diffusion of Innovations, 5 th Edition, 2003.

7 Social System Diffusion takes place within the social system, which includes the following elements: Social structure: patterned arrangement of units (often hierarchical) Communication structure: patterned flows of information Norms: established behavior patterns Opinion leaders Change agents

8 Consolidated Framework for Implementation Research Available at: cfirguide.org Damschroder et al. Implementation Science 2009;4:50.

9 Characteristics of the Inner Setting (CFIR) Structure/Social architecture: age, maturity and size Networks and communication Importance of relationships, informal networks Culture and implementation climate Tension for change Compatibility with organizational norms, values and practices Relative priority Organizational incentives and rewards Learning climate Readiness for implementation Leadership engagement, resources, access to information

10 Characteristics of the Outer Setting (CFIR) Patient needs and resources (patient-centeredness) Cosmopolitanism, social capital, informal networks Peer pressure and competition External polices and incentives Guidelines Regulations, mandates and incentives/penalties P4P, public reporting

11 Four Levels of Influence

12 Four Levels of Change Ferlie and Shortell. Milbank Q 2001; 79:

13 Essential Elements for Change Leadership at all levels Pervasive culture that supports learning throughout the care process Patient-centered, group-centered, non-hierarchical Emphasis on development of effective teams Use of HIT for continuous improvement and external accountability Ferlie and Shortell. Milbank Q 2001;79:

14 Lessons for success VA QUERI Need for alignment across level Coordination across activities Leadership at all levels Attention to stakeholders and their needs Organizational support Contextual influences at all levels Challenges Evolving evidence base and context Yano et al. J Natl Cancer Inst Mongr 2012;44:86-99.

15 EXAMPLES OF EFFECTIVE MULTI-LEVEL IMPLEMENTATION

16 Best Practices for Tobacco Control Success of statewide tobacco control programs Targeted both outer and inner context Most important component: large increases in taxes Greatest success in states with comprehensive programs that targeted multiple levels: Schools Workplaces Restaurants Overarching framework: social normative theory

17 AHA Get with the Guidelines Sponsored by the American Heart Association: heart failure, stroke, atrial fibrillation Local implementation efforts leverage national guidelines and imprimatur of the AHA Guideline recommendations translated into achievement and quality measures Hospitals complete case report forms: Patient management tool National registry Decision support Real-time benchmarking Improved outcomes: reduced 30-day mortality and readmissions

18 Learning from Big Pharma Tremendous reach, effectiveness and impact by targeting decision-makers at multiple levels

19 Learning from Big Pharma Highly coordinated implementation strategy External Context National advertising campaigns Direct to consumers Targeted to specific groups of providers Extensive marketing research Advisory boards, courtship of key opinion leaders Internal Context Sponsorship of educational activities Targeting of hospital P&T committees Individual physician detailing

20 Small Group Exercise Health system leaders discuss how to implement recommendations from the Choosing Wisely campaign of ABIM Foundation Common practices that should be questioned Avoid use of imaging or serum biomarkers for posttreatment surveillance in low-risk breast cancer American Society for Clinical Oncology Top 5 list Also supported by guidelines from ASCO and other oncology professional societies Using EHR data to measure adherence, you find substantial use of this low-value testing

21 Biomarkers for Surveillance: Stage 0-IIB Breast Cancer Region System 1 (N=3,796) System 2 (N=321) System 3 (N=435) p-value At least one biomarker test Percent clinically indicated 1,453 (38%) 144 (45%) 21 (5%) < Medicare/SEER: 30% biomarker Academic center: 77% biomarker Keating et al. J Clin Oncol 2010;25: Hahn et al. Cancer 2013;119

22 Patient Count Biomarkers, Medical Center Level Data No Biomarkers Biomarkers % 46% 63% 59% 67% % 25% 35% 12% 18% 22% 78% 4% Anaheim Fontana Riverside Harbor W. Hills San Diego LAMC Baldwin Pk Bellflower Pan City WLA Ant. Valley Bfield

23 Patient Count Serum Biomarkers, Physician Level Data No Biomarkers Biomarkers Individual oncologists Number of patients per individual oncologist who had biomarker tests out of total patients seen by that oncologist (N=96)

24 Small Group Exercise How would you think about de-implementation of this practice in a multi-level context? What are the important elements of the inner and outer context that would either hasten or hinder local implementation efforts? How would you leverage one or more of the facilitators and overcome one or more of the barriers to implementation?

25 Conclusions Health care in the United States is notoriously expensive while often failing to deliver the care recommended in published guidelines. In this monograph, we emphasize that health-care delivery occurs in a multilevel system that includes organizations, teams, and individuals. The notion that multiple levels of contextual influence affect behaviors through interdependent interactions is a well-established ecological view. Taplin S. J Natl Cancer Inst Monograph 2012:2-10.

26 NCI Funding Opportunity PAR , posted January 1, 2015 Multilevel interventions in cancer care delivery: building from the problem of follow-up to abnormal screening tests (U01) Seeks to advance the science of multi-level interventions by establishing a common conceptualization of levels and level-specific factors that affect practice, and by standardizing metrics and methods for analysis

27 Thank You! Questions:

28 Unifying Conceptual Model Greenhalgh et al. Milbank Q 2004;82:

29 Inner Context (User System) System antecedents for innovation System readiness for innovation Greenhalgh et al. Milbank Q 2004:82:

30 Inner Context (User System) System antecedents for innovation Structural determinants: size, maturity, differentiation Absorptive capacity for new knowledge Receptive context, e.g. strong leadership, clear vision System readiness for innovation Tension for change Assessment of implications Support and advocacy Dedicated time and resources Capacity to evaluate

31 Outer Context Informal networks and norms Cosmopolitanism Formal networks Professional societies Learning collaboratives External mandates and incentives

32 Social-Ecological Model

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