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1.  Factors influencing the implementation of fall-prevention programmes: a systematic review and synthesis of qualitative studies 
Background
More than a third of people over the age of 65 years fall each year. Falling can lead to a reduction in quality of life, mortality, and a risk of prolonged hospitalisation. Reducing and preventing falls has become an international health priority. To help understand why research evidence has often not been translated into changes in clinical practice, we undertook a systematic review and synthesis of qualitative research in order to identify what factors serve as barriers and facilitators to the successful implementation of fall-prevention programmes.
Methods
We conducted a review of literature published between 1980 and January 2012 for qualitative research studies that examined barriers and facilitators to the effective implementation of fall-prevention interventions among community-dwelling older people and healthcare professionals. Two reviewers independently screened studies for inclusion, extracted data, and assessed methodological quality according to predefined criteria. Findings were synthesised using meta-ethnography.
Results
Of the 5010 articles identified through database searching, 19 were included in the review. Analysis of the 19 studies revealed limited information about the mechanisms by which barriers to implementation of fall-prevention interventions had been overcome. Data synthesis produced three overarching concepts: (1) practical considerations, (2) adapting for community, and (3) psychosocial. A line of argument synthesis describes the barriers and facilitators to the successful implementation of fall-prevention programmes. These concepts show that the implementation of fall-prevention programmes is complex and multifactorial. This is the first systematic review and synthesis of qualitative studies to examine factors influencing the implementation of fall-prevention programmes from the perspectives of both the healthcare professional and the community-dwelling older person.
Conclusions
The current literature on barriers and facilitators to the implementation of fall-prevention programmes examines a variety of interventions. However, the ways in which the interventions are reported suggests there are substantial methodological challenges that often inhibit implementation into practice. We recommend that successful implementation requires individuals, professionals, and organisations to modify established behaviours, thoughts, and practice. The issues identified through this synthesis need to be fully considered and addressed if fall-prevention programmes are to be successfully implemented into clinical practice.
doi:10.1186/1748-5908-7-91
PMCID: PMC3576261  PMID: 22978693
Fall prevention; Systematic review; Meta-ethnography; Implementation
2.  A pragmatic cluster randomised trial evaluating three implementation interventions 
Background
Implementation research is concerned with bridging the gap between evidence and practice through the study of methods to promote the uptake of research into routine practice. Good quality evidence has been summarised into guideline recommendations to show that peri-operative fasting times could be considerably shorter than patients currently experience. The objective of this trial was to evaluate the effectiveness of three strategies for the implementation of recommendations about peri-operative fasting.
Methods
A pragmatic cluster randomised trial underpinned by the PARIHS framework was conducted during 2006 to 2009 with a national sample of UK hospitals using time series with mixed methods process evaluation and cost analysis. Hospitals were randomised to one of three interventions: standard dissemination (SD) of a guideline package, SD plus a web-based resource championed by an opinion leader, and SD plus plan-do-study-act (PDSA). The primary outcome was duration of fluid fast prior to induction of anaesthesia. Secondary outcomes included duration of food fast, patients’ experiences, and stakeholders’ experiences of implementation, including influences. ANOVA was used to test differences over time and interventions.
Results
Nineteen acute NHS hospitals participated. Across timepoints, 3,505 duration of fasting observations were recorded. No significant effect of the interventions was observed for either fluid or food fasting times. The effect size was 0.33 for the web-based intervention compared to SD alone for the change in fluid fasting and was 0.12 for PDSA compared to SD alone. The process evaluation showed different types of impact, including changes to practices, policies, and attitudes. A rich picture of the implementation challenges emerged, including inter-professional tensions and a lack of clarity for decision-making authority and responsibility.
Conclusions
This was a large, complex study and one of the first national randomised controlled trials conducted within acute care in implementation research. The evidence base for fasting practice was accepted by those participating in this study and the messages from it simple; however, implementation and practical challenges influenced the interventions’ impact. A set of conditions for implementation emerges from the findings of this study, which are presented as theoretically transferable propositions that have international relevance.
Trial registration
ISRCTN18046709 - Peri-operative Implementation Study Evaluation (POISE).
doi:10.1186/1748-5908-7-80
PMCID: PMC3457838  PMID: 22935241
3.  Welcome to Implementation Science 
Implementation research is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services and care. This relatively new field includes the study of influences on healthcare professional and organisational behaviour.
Implementation Science will encompass all aspects of research in this field, in clinical, community and policy contexts. This online journal will provide a unique platform for this type of research and will publish a broad range of articles – study protocols, debate, theoretical and conceptual articles, rigorous evaluations of the process of change, and articles on methodology and rigorously developed tools – that will enhance the development and refinement of implementation research. No one discipline, research design, or paradigm will be favoured.
Implementation Science looks forward to receiving manuscripts that facilitate the continued development of the field, and contribute to healthcare policy and practice.
doi:10.1186/1748-5908-1-1
PMCID: PMC1436009
4.  Improving continence services for older people from the service-providers’ perspective: a qualitative interview study 
BMJ Open  2013;3(7):e002926.
Objective
To examine in depth the views and experiences of continence service leads in England on key service and continence management characteristics in order to identify and to improve our understanding of barriers to a good-quality service and potential facilitators to develop and to improve services for older people with urinary incontinence (UI).
Design
Qualitative semistructured interviews using a purposive sample recruited across 16 continence services.
Setting
3 acute and 13 primary care National Health Service Trusts in England.
Participants
16 continence service leads in England actively treating and managing older people with UI.
Results
In terms of barriers to a good-quality service, participants highlighted a failure on the part of commissioners, managers and other health professionals in recognising the problem of UI and in acknowledging the importance of continence for older people and prevalent negative attitudes towards continence and older people. Patient assessment and continence promotion regardless of age, rather than pad provision, were identified as important steps for a good-quality service for older people with UI. More rapid and appropriate patient referral pathways, investment in service capacity, for example, more trained staff and strengthened interservice collaborations and a higher profile within medical and nurse training were specified as being important facilitators for delivering an equitable and high-quality continence service. There is a need, however, to consider the accounts given by our participants as perhaps serving the interests of their professional group within the context of interprofessional work.
Conclusions
Our data point to important barriers and facilitators of a good-quality service for older people with UI, from the perspective of continence service leads. Further research should address the views of other stakeholders, and explore options for the empirical evaluation of the effectiveness of identified service facilitators.
doi:10.1136/bmjopen-2013-002926
PMCID: PMC3731733  PMID: 23901026
Geriatric Medicine
5.  Interventions in Organizational and Community Context: A Framework for Building Evidence on Dissemination and Implementation in Health Services Research 
The effective dissemination and implementation of evidence-based health interventions within community settings is an important cornerstone to expanding the availability of quality health and mental health services. Yet it has proven a challenging task for both research and community stakeholders. This paper presents the current framework developed by the UCLA/RAND NIMH Center to address this research-to-practice gap by: 1) providing a theoretically-grounded understanding of the multi-layered nature of community and healthcare contexts and the mechanisms by which new practices and programs diffuse within these settings; 2) distinguishing among key components of the diffusion process—including contextual factors, adoption, implementation, and sustainment of interventions—showing how evaluation of each is necessary to explain the course of dissemination and outcomes for individual and organizational stakeholders; 3) facilitating the identification of new strategies for adapting, disseminating, and implementing relatively complex, evidence-based healthcare and improvement interventions, particularly using a community-based, participatory approach; and 4) enhancing the ability to meaningfully generalize findings across varied interventions and settings to build an evidence base on successful dissemination and implementation strategies.
doi:10.1007/s10488-007-0144-9
PMCID: PMC3582701  PMID: 17990095
dissemination; diffusion; implementation; organizational context; community-based research; evidence-based interventions
6.  Development of a Theory-Based Intervention to Increase Prescription of Inspiratory Muscle Training by Health Professionals in the Management of People with Chronic Obstructive Pulmonary Disease 
Physiotherapy Canada  2011;63(3):315-323.
ABSTRACT
Purpose: The purpose of this paper is twofold: (1) to provide an overview of the literature on barriers to evidence-based practice (EBP) and the effectiveness of implementation interventions in health care; and (2) to outline the development of an implementation intervention for improving the prescription of inspiratory muscle training (IMT) by physical therapists and other health professionals for people with chronic obstructive pulmonary disease (COPD).
Summary of Key Points: Individuals, organizations, and the research itself present barriers to EBP in physical therapy. Despite the evidence supporting the use of IMT, this treatment continues to be under-used in managing COPD. Current health services research shows that traditional information-based approaches to implementation, such as didactic lectures, do not adequately address the challenges health professionals face when trying to make changes in practice. We propose the development of a theory-based intervention to improve health professionals' use of IMT in the management of COPD. It is postulated that a behavioural intervention, based on the theory of planned behaviour (TPB), may be more effective than an information-based strategy in increasing the prescription of IMT by health professionals.
Conclusion: TPB may be used to understand the antecedents of health professionals' behaviour and to guide the development of implementation interventions. Further research is needed to evaluate the effectiveness of this proposed intervention in the management of people with COPD.
doi:10.3138/ptc.2010-15
PMCID: PMC3157991  PMID: 22654237
evidence-based practice; inspiratory muscle training; knowledge translation; physical therapist; theory of planned behaviour; entraînement des muscles inspiratoires; physiothérapeute; pratique fondée sur les preuves scientifiques; théorie du comportement planifié; transmission des connaissances
7.  Organizational readiness to change assessment (ORCA): Development of an instrument based on the Promoting Action on Research in Health Services (PARIHS) framework 
Background
The Promoting Action on Research Implementation in Health Services, or PARIHS, framework is a theoretical framework widely promoted as a guide to implement evidence-based clinical practices. However, it has as yet no pool of validated measurement instruments that operationalize the constructs defined in the framework. The present article introduces an Organizational Readiness to Change Assessment instrument (ORCA), organized according to the core elements and sub-elements of the PARIHS framework, and reports on initial validation.
Methods
We conducted scale reliability and factor analyses on cross-sectional, secondary data from three quality improvement projects (n = 80) conducted in the Veterans Health Administration. In each project, identical 77-item ORCA instruments were administered to one or more staff from each facility involved in quality improvement projects. Items were organized into 19 subscales and three primary scales corresponding to the core elements of the PARIHS framework: (1) Strength and extent of evidence for the clinical practice changes represented by the QI program, assessed with four subscales, (2) Quality of the organizational context for the QI program, assessed with six subscales, and (3) Capacity for internal facilitation of the QI program, assessed with nine subscales.
Results
Cronbach's alpha for scale reliability were 0.74, 0.85 and 0.95 for the evidence, context and facilitation scales, respectively. The evidence scale and its three constituent subscales failed to meet the conventional threshold of 0.80 for reliability, and three individual items were eliminated from evidence subscales following reliability testing. In exploratory factor analysis, three factors were retained. Seven of the nine facilitation subscales loaded onto the first factor; five of the six context subscales loaded onto the second factor; and the three evidence subscales loaded on the third factor. Two subscales failed to load significantly on any factor. One measured resources in general (from the context scale), and one clinical champion role (from the facilitation scale).
Conclusion
We find general support for the reliability and factor structure of the ORCA. However, there was poor reliability among measures of evidence, and factor analysis results for measures of general resources and clinical champion role did not conform to the PARIHS framework. Additional validation is needed, including criterion validation.
doi:10.1186/1748-5908-4-38
PMCID: PMC2716295  PMID: 19594942
8.  Evaluating the State of Quality-Improvement Science through Evidence Synthesis: Insights from the Closing the Quality Gap Series 
The Permanente Journal  2013;17(4):52-61.
Context:
The Closing the Quality Gap series from the Agency for Healthcare Research and Quality summarizes evidence for eight high-priority health care topics: outcomes used in disability research, bundled payment programs, public reporting initiatives, health care disparities, palliative care, the patient-centered medical home, prevention of health care-associated infections, and medication adherence.
Objective:
To distill evidence from this series and provide insight into the “state of the science” of quality improvement (QI).
Methods:
We provided common guidance for topic development and qualitatively synthesized evidence from the series topic reports to identify cross-topic themes, challenges, and evidence gaps as related to QI practice and science.
Results:
Among topics that examined effectiveness of QI interventions, we found improvement in some outcomes but not others. Implementation context and potential harms from QI activities were not widely evaluated or reported, although market factors appeared important for incentive-based QI strategies. Patient-focused and systems-focused strategies were generally more effective than clinician-focused strategies, although the latter approach improved clinician adherence to infection prevention strategies. Audit and feedback appeared better for targeting professionals and organizations, but not patients. Topic reviewers observed heterogeneity in outcomes used for QI evaluations, weaknesses in study design, and incomplete reporting.
Conclusions:
Synthesizing evidence across topics provided insight into the state of the QI field for practitioners and researchers. To facilitate future evidence synthesis, consensus is needed around a smaller set of outcomes for use in QI evaluations and a framework and lexicon to describe QI interventions more broadly, in alignment with needs of decision makers responsible for improving quality.
doi:10.7812/TPP/13-010
PMCID: PMC3854810  PMID: 24079357
9.  The effectiveness and cost-effectiveness of a participative community singing programme as a health promotion initiative for older people: protocol for a randomised controlled trial 
BMC Public Health  2011;11:142.
Background
The growth in numbers of older people represents a considerable cost to health and social care services in the United Kingdom. There is an acknowledged need to address issues of social exclusion and both the physical and mental health of this age group. In recent years there has been much interest in the potential contribution of the arts to the health of communities and individuals. There is some evidence that participative singing may be of benefit to older people, however studies to date are limited in number and have lacked rigour. There is therefore a need to build on this knowledge base to provide more quantifiable evidence of both effectiveness and cost effectiveness of singing as a health intervention for this population group.
Methods
The proposed study is a pragmatic randomised controlled trial with two parallel arms. The primary hypothesis is that singing groups for older people improve both physical and mental aspects of quality of life when compared to usual activities. Potential participants will be volunteers over 60 years living in the community and recruited through publicity. Eligible and consenting participants will be randomized to either a singing group or a control group. Singing groups will take part in a twelve week planned programme of singing and control groups will continue with usual activities. The primary outcome measure will be the York SF-12, a health related quality of life measure which will be administered at baseline, three and six months after baseline. The study will evaluate both effectiveness and cost-effectiveness.
Discussion
This study proposes to add to the existing body of evidence on the value of singing for older people by using a rigorous methodological design, which includes a power calculation, a standardised intervention and assessment of cost-effectiveness. It should be regarded as a stage in a progressive programme of studies in this area. If group singing is found to be effective and cost-effective it may offer an alternative means to maintaining the health of people in later life.
Trial Registration
ISRCTN62404401
doi:10.1186/1471-2458-11-142
PMCID: PMC3053252  PMID: 21356071
10.  Outcomes Research: An Overview and the Implications for Health Informaticians 
Outcomes research is a major topic of discussion relative to professional practice and education. Combining outcomes research and evidence based practice can provide a structure for the improvement of the cost/quality ratio in healthcare and hence should be a major factor in health informatics education and practice. As healthcare organizations begin to adopt electronic medical record systems and information management systems to increase efficiency and improve quality of care, attention must be paid to the elements of an information system that will allow for data collection to examine outcomes, effectiveness, and performance monitoring. This poster provides an overview of outcomes research definitions, methods, and criticisms, and explores the implications for the design and management of information systems to facilitate valid and valuable outcomes research.
PMCID: PMC2243275
11.  Implementing Evidence-Based Patient Self-Management Programs in the Veterans Health Administration: Perspectives on Delivery System Design Considerations 
Journal of General Internal Medicine  2010;25(Suppl 1):68-71.
While many patient self-management (PSM) programs have been developed and evaluated for effectiveness, less effort has been devoted to translating and systematically delivering PSM in primary and specialty care. Therefore, the purpose of this paper is to review delivery system design considerations for implementing self-management programs in practice. As lessons are learned about implementing PSM programs in Veterans Health Administration (VHA), resource allocation by healthcare organization for formatting PSM programs, providing patient access, facilitating PSM, and incorporating support tools to foster PSM among its consumers can be refined and tailored. Redesigning the system to deliver and support PSM will be important as implementation researchers translate evidence based PSM practices into routine care and evaluate its impact on the health-related quality of life of veterans living with chronic disease.
doi:10.1007/s11606-009-1123-5
PMCID: PMC2806957  PMID: 20077155
self-management; implementation; veterans health administration
12.  A Literature Review on Care at the End-of-Life in the Emergency Department 
The hospitalisation and management of patients at the end-of-life by emergency medical services is presenting a challenge to our society as the majority of people approaching death explicitly state that they want to die at home and the transition from acute care to palliation is difficult. In addition, the escalating costs of providing care at the end-of-life in acute hospitals are unsustainable. Hospitals in general and emergency departments in particular cannot always provide the best care for patients approaching end-of-life. The main objectives of this paper are to review the existing literature in order to assess the evidence for managing patients dying in the emergency department, and to identify areas of improvement such as supporting different models of care and evaluating those models with health services research. The paper identified six main areas where there is lack of research and/or suboptimal policy implementation. These include uncertainty of treatment in the emergency department; quality of life issues, costs, ethical and social issues, interaction between ED and other health services, and strategies for out of hospital care. The paper concludes with some areas for policy development and future research.
doi:10.1155/2012/486516
PMCID: PMC3303563  PMID: 22500239
13.  Change What? Identifying Quality Improvement Targets by Investigating Usual Mental Health Care 
Efforts to improve community-based children’s mental health care should be based on valid information about effective practices and current routine practices. Emerging research on routine care practices and outcomes has identified discrepancies between evidence-based practices and “usual care.” These discrepancies highlight potentially potent quality improvement interventions. This article reviews existing research on routine or “usual care” practice, identifies strengths and weaknesses in routine psychotherapeutic care, as well as gaps in knowledge, and proposes quality improvement recommendations based on existing data to improve the effectiveness of children’s mental health care. The two broad recommendations for bridging the research-practice gap are to implement valid, feasible measurement feedback systems and clinician training in common elements of evidence-based practice.
doi:10.1007/s10488-010-0279-y
PMCID: PMC2874058  PMID: 20177769
Usual care; Psychotherapy
14.  The relationship between baseline Organizational Readiness to Change Assessment subscale scores and implementation of hepatitis prevention services in substance use disorders treatment clinics: a case study 
Background
The Organizational Readiness to Change Assessment (ORCA) is a measure of organizational readiness for implementing practice change in healthcare settings that is organized based on the core elements and sub-elements of the Promoting Action on Research Implementation in Health Services (PARIHS) framework. General support for the reliability and factor structure of the ORCA has been reported. However, no published study has examined the utility of the ORCA in a clinical setting. The purpose of the current study was to examine the relationship between baseline ORCA scores and implementation of hepatitis prevention services in substance use disorders (SUD) clinics.
Methods
Nine clinic teams from Veterans Health Administration SUD clinics across the United States participated in a six-month training program to promote evidence-based practices for hepatitis prevention. A representative from each team completed the ORCA evidence and context subscales at baseline.
Results
Eight of nine clinics reported implementation of at least one new hepatitis prevention practice after completing the six-month training program. Clinic teams were categorized by level of implementation-high (n = 4) versus low (n = 5)-based on how many hepatitis prevention practices were integrated into their clinics after completing the training program. High implementation teams had significantly higher scores on the patient experience and leadership culture subscales of the ORCA compared to low implementation teams. While not reaching significance in this small sample, high implementation clinics also had higher scores on the research, clinical experience, staff culture, leadership behavior, and measurement subscales as compared to low implementation clinics.
Conclusions
The results of this study suggest that the ORCA was able to measure differences in organizational factors at baseline between clinics that reported high and low implementation of practice recommendations at follow-up. This supports the use of the ORCA to describe factors related to implementing practice recommendations in clinical settings. Future research utilizing larger sample sizes will be essential to support these preliminary findings.
doi:10.1186/1748-5908-5-46
PMCID: PMC2902416  PMID: 20546584
15.  The Translation Evidence Mechanism. The Compact between Researcher and Clinician 
The Open Dentistry Journal  2010;4:133-139.
Currently, best evidence is a concentrated effort by researchers. Researchers produce information and expect that clinicians will implement their advances in improving patient care. However, difficulties exist in maximizing cooperation and coordination between the producers, facilitators, and users (patients) of best evidence outcomes. The Translational Evidence Mechanism is introduced to overcome these difficulties by forming a compact between researcher, clinician and patient. With this compact, best evidence may become an integral part of private practice when uncertainties arise in patient health status, treatments, and therapies. The mechanism is composed of an organization, central database, and decision algorithm. Communication between the translational evidence organization, clinicians and patients is through the electronic chart. Through the chart, clinical inquiries are made, patient data from provider assessments and practice cost schedules are collected and encrypted (HIPAA standards), then inputted into the central database. Outputs are made within a timeframe suitable to private practice and patient flow. The output consists of a clinical practice guideline that responds to the clinical inquiry with decision, utility and cost data (based on the “average patient”) for shared decision-making within informed consent. This shared decision-making allows for patients to “game” treatment scenarios using personal choice inputs. Accompanying the clinical practice guideline is a decision analysis that explains the optimized clinical decision. The resultant clinical decision is returned to the central database using the clinical practice guideline. The result is subsequently used to update current best evidence, indicate the need for new evidence, and analyze the changes made in best evidence implementation. When updates in knowledge occur, these are transmitted to the provider as alerts or flags through patient charts and other communication modalities.
doi:10.2174/1874210601004020133
PMCID: PMC2944992  PMID: 20871753
16.  Prescribing Data in General Practice Demonstration (PDGPD) project - a cluster randomised controlled trial of a quality improvement intervention to achieve better prescribing for chronic heart failure and hypertension 
Background
Research literature consistently documents that scientifically based therapeutic recommendations are not always followed in the hospital or in the primary care setting. Currently, there is evidence that some general practitioners in Australia are not prescribing appropriately for patients diagnosed with 1) hypertension (HT) and 2) chronic heart failure (CHF). The objectives of this study were to improve general practitioner’s drug treatment management of these patients through feedback on their own prescribing and small group discussions with peers and a trained group facilitator. The impact evaluation includes quantitative assessment of prescribing changes at 6, 9, 12 and 18 months after the intervention.
Methods
A pragmatic multi site cluster RCT began recruiting practices in October 2009 to evaluate the effects of a multi-faceted quality improvement (QI) intervention on prescribing practice among Australian general practitioners (GP) in relation to patients with CHF and HT. General practices were recruited nationally through General Practice Networks across Australia. Participating practices were randomly allocated to one of three groups: two groups received the QI intervention (the prescribing indicator feedback reports and small group discussion) with each group undertaking the clinical topics (CHF and HT) in reverse order to the other. The third group was waitlisted to receive the intervention 6 months later and acted as a “control” for the other two groups.
De-identified data on practice, doctor and patient characteristics and their treatment for CHF and HT are extracted at six-monthly intervals before and after the intervention. Post-test comparisons will be conducted between the intervention and control arms using intention to treat analysis and models that account for clustering of practices in a Network and clustering of patients within practices and GPs.
Discussion
This paper describes the study protocol for a project that will contribute to the development of acceptable and sustainable methods to promote QI activities within routine general practice, enhance prescribing practices and improve patient outcomes in the context of CHF and HT. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR), Trial # 320870.
doi:10.1186/1472-6963-12-273
PMCID: PMC3515472  PMID: 22913571
17.  Impacts of Evidence-Based Quality Improvement on Depression in Primary Care: A Randomized Experiment 
Journal of General Internal Medicine  2006;21(10):1027-1035.
CONTEXT
Previous studies testing continuous quality improvement (CQI) for depression showed no effects. Methods for practices to self-improve depression care performance are needed. We assessed the impacts of evidence-based quality improvement (EBQI), a modification of CQI, as carried out by 2 different health care systems, and collected qualitative data on the design and implementation process.
OBJECTIVE
Evaluate impacts of EBQI on practice-wide depression care and outcomes.
DESIGN
Practice-level randomized experiment comparing EBQI with usual care.
SETTING
Six Kaiser Permanente of Northern California and 3 Veterans Administration primary care practices randomly assigned to EBQI teams (6 practices) or usual care (3 practices). Practices included 245 primary care clinicians and 250,000 patients.
INTERVENTION
Researchers assisted system senior leaders to identify priorities for EBQI teams; initiated the manual-based EBQI process; and provided references and tools.
EVALUATION PARTICIPANTS
Five hundred and sixty-seven representative patients with major depression.
MAIN OUTCOME MEASURES
Appropriate treatment, depression, functional status, and satisfaction.
RESULTS
Depressed patients in EBQI practices showed a trend toward more appropriate treatment compared with those in usual care (46.0% vs 39.9% at 6 months, P = .07), but no significant improvement in 12-month depression symptom outcomes (27.0% vs 36.1% poor depression outcome, P = .18). Social functioning improved significantly (mean score 65.0 vs 56.8 at 12 months, P = .02); physical functioning did not.
CONCLUSION
Evidence-based quality improvement had perceptible, but modest, effects on practice performance for patients with depression. The modest improvements, along with qualitative data, identify potential future directions for improving CQI research and practice.
doi:10.1111/j.1525-1497.2006.00549.x
PMCID: PMC1831644  PMID: 16836631
quality improvement; depression; continuous quality management; social function
18.  Implementing nutrition guidelines for older people in residential care homes: a qualitative study using Normalization Process Theory 
Background
Optimizing the dietary intake of older people can prevent nutritional deficiencies and diet-related diseases, thereby improving quality of life. However, there is evidence that the nutritional intake of older people living in care homes is suboptimal, with high levels of saturated fat, salt, and added sugars. The UK Food Standards Agency therefore developed nutrient- and food-based guidance for residential care homes. The acceptability of these guidelines and their feasibility in practice is unknown. This study used the Normalization Process Theory (NPT) to understand the barriers and facilitators to implementing the guidelines and inform future implementation.
Methods
We conducted a process evaluation in five care homes in the north of England using qualitative methods (observation and interviews) to explore the views of managers, care staff, catering staff, and domestic staff. Data were analyzed thematically and discussed in data workshops; emerging themes were then mapped to the constructs of NPT.
Results
Many staff perceived the guidelines as unnecessarily restrictive and irrelevant to older people. In terms of NPT, the guidelines simply did not make sense (coherence), and as a result, relatively few staff invested in the guidelines (cognitive participation). Even where staff supported the guidelines, implementation was hampered by a lack of nutritional knowledge and institutional support (collective action). Finally, the absence of observable benefits to clients confirmed the negative preconceptions of many staff, with limited evidence of reappraisal following implementation (reflexive monitoring).
Conclusions
The successful implementation of the nutrition guidelines requires that the fundamental issues relating to their perceived value and fit with other priorities and goals be addressed. Specialist support is needed to equip staff with the technical knowledge and skills required for menu analysis and development and to devise ways of evaluating the outcomes of modified menus. NPT proved useful in conceptualizing barriers to implementation; robust links with behavior-change theories would further increase the practical utility of NPT.
doi:10.1186/1748-5908-7-106
PMCID: PMC3514214  PMID: 23110857
Normalization process theory; Nutrition policy; Guideline; Long-term care; Older people; Qualitative research
19.  Implementation Science for the Prevention and Treatment of HIV/AIDS 
Implementation science is the scientific study of methods to promote the integration of research findings and evidence-based interventions into healthcare policy and practice and, hence, to improve the quality and effectiveness of health services and care. Implementation science is distinguished from monitoring and evaluation by its emphasis on the use of the scientific method. The origins of implementation science include operations research, industrial engineering, and management science. Today, implementation science encompasses a broader range of methods and skills including decision science and operations research, health systems research, health outcomes research, health and behavioral economics, epidemiology, statistics, organization and management science, finance, policy analysis, anthropology, sociology, and ethics. Examples of implementation science research are presented for HIV prevention (prevention of mother-to-child transmission of HIV, male circumcision) and HIV and drug use (syringe distribution, treating drug users with antiretroviral therapy (ART) and opioid substitution therapy). For implementation science to become an established field in HIV/AIDS research, there needs to be better coordination between funders of research and funders of program delivery and greater consensus on scientific research approaches and standards of evidence.
doi:10.1097/QAI.0b013e3181f9c1da
PMCID: PMC3058234  PMID: 21045596
20.  Role of "external facilitation" in implementation of research findings: a qualitative evaluation of facilitation experiences in the Veterans Health Administration 
Background
Facilitation has been identified in the literature as a potentially key component of successful implementation. It has not, however, either been well-defined or well-studied. Significant questions remain about the operational definition of facilitation and about the relationship of facilitation to other interventions, especially to other change agent roles when used in multi-faceted implementation projects.
Researchers who are part of the Quality Enhancement Research Initiative (QUERI) are actively exploring various approaches and processes, including facilitation, to enable implementation of best practices in the Veterans Health Administration health care system – the largest integrated healthcare system in the United States. This paper describes a systematic, retrospective evaluation of implementation-related facilitation experiences within QUERI, a quality improvement program developed by the US Department of Veterans Affairs.
Methods
A post-hoc evaluation was conducted through a series of semi-structured interviews to examine the concept of facilitation across several multi-site QUERI implementation studies. The interview process is based on a technique developed in the field of education, which systematically enhances learning through experience by stimulating recall and reflection regarding past complex activities. An iterative content analysis approach relative to a set of conceptually-based interview questions was used for data analysis.
Findings
Findings suggest that facilitation, within an implementation study initiated by a central change agency, is a deliberate and valued process of interactive problem solving and support that occurs in the context of a recognized need for improvement and a supportive interpersonal relationship. Facilitation was described primarily as a distinct role with a number of potentially crucial behaviors and activities. Data further suggest that external facilitators were likely to use or integrate other implementation interventions, while performing this problem-solving and supportive role.
Preliminary Conclusions
This evaluation provides evidence to suggest that facilitation could be considered a distinct implementation intervention, just as audit and feedback, educational outreach, or similar methods are considered to be discrete interventions. As such, facilitation should be well-defined and explicitly evaluated for its perceived usefulness within multi-intervention implementation projects. Additionally, researchers should better define the specific contribution of facilitation to the success of implementation in different types of projects, different types of sites, and with evidence and innovations of varying levels of strength and complexity.
doi:10.1186/1748-5908-1-23
PMCID: PMC1635058  PMID: 17049080
21.  Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study 
The British Journal of General Practice  2012;62(597):e233-e242.
Background
Primary care is recognised to have an important role in the delivery of care for people with chronic kidney disease (CKD). However, there is evidence that CKD management is currently suboptimal, with a range of practitioner concerns about its management.
Aim
To explore processes underpinning the implementation of CKD management in primary care.
Design and setting
Qualitative study in general practices participating in a chronic kidney disease collaborative undertaken as part of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester.
Method
Semi-structured interviews were conducted with GPs and practice nurses (n = 21). Normalisation Process Theory provided a framework for generation and analysis of the data.
Results
A predominant theme was anxiety about the disclosure of early-stage CKD with patients. The tensions experienced related to identifying and discussing CKD in older people and patients with stage 3A, embedding early-stage CKD within vascular care, and the distribution of work within the practice team. Participants provided accounts of work undertaken to resolve the difficulties encountered, with efforts having tended to focus on reassuring patients. Analysis also highlighted how anxiety surrounding disclosure influenced, and was shaped by, the organisation of care for people with CKD and associated long-term conditions.
Conclusion
Offering reassurance alone may be of limited benefit, and current management of early-stage CKD in primary care may miss opportunities to address susceptibility to kidney injury, improve self-management of vascular conditions, and improve the management of multimorbidity.
doi:10.3399/bjgp12X636056
PMCID: PMC3310029  PMID: 22520910
doctor–patient relations; kidney disease; chronic; normalisation process theory; primary care
22.  Clinical Decision Support Systems for the Practice of Evidence-based Medicine 
Background: The use of clinical decision support systems to facilitate the practice of evidence-based medicine promises to substantially improve health care quality.
Objective: To describe, on the basis of the proceedings of the Evidence and Decision Support track at the 2000 AMIA Spring Symposium, the research and policy challenges for capturing research and practice-based evidence in machine-interpretable repositories, and to present recommendations for accelerating the development and adoption of clinical decision support systems for evidence-based medicine.
Results: The recommendations fall into five broad areas—capture literature-based and practice-based evidence in machine-interpretable knowledge bases; develop maintainable technical and methodological foundations for computer-based decision support; evaluate the clinical effects and costs of clinical decision support systems and the ways clinical decision support systems affect and are affected by professional and organizational practices; identify and disseminate best practices for work flow–sensitive implementations of clinical decision support systems; and establish public policies that provide incentives for implementing clinical decision support systems to improve health care quality.
Conclusions: Although the promise of clinical decision support system–facilitated evidence-based medicine is strong, substantial work remains to be done to realize the potential benefits.
PMCID: PMC130063  PMID: 11687560
23.  Economic Evaluation of Active Implementation versus Guideline Dissemination for Evidence-Based Care of Acute Low-Back Pain in a General Practice Setting 
PLoS ONE  2013;8(10):e75647.
Introduction
The development and publication of clinical practice guidelines for acute low-back pain has resulted in evidence-based recommendations that have the potential to improve the quality and safety of care for acute low-back pain. Development and dissemination of guidelines may not, however, be sufficient to produce improvements in clinical practice; further investment in active implementation of guideline recommendations may be required. Further research is required to quantify the trade-off between the additional upfront cost of active implementation of guideline recommendations for low-back pain and any resulting improvements in clinical practice.
Methods
Cost-effectiveness analysis alongside the IMPLEMENT trial from a health sector perspective to compare active implementation of guideline recommendations via the IMPLEMENT intervention (plus standard dissemination) against standard dissemination alone.
Results
The base-case analysis suggests that delivery of the IMPLEMENT intervention dominates standard dissemination (less costly and more effective), yielding savings of $135 per x-ray referral avoided (-$462.93/3.43). However, confidence intervals around point estimates for the primary outcome suggest that – irrespective of willingness to pay (WTP) – we cannot be at least 95% confident that the IMPLEMENT intervention differs in value from standard dissemination.
Conclusions
Our findings demonstrate that moving beyond development and dissemination to active implementation entails a significant additional upfront investment that may not be offset by health gains and/or reductions in health service utilization of sufficient magnitude to render active implementation cost-effective.
doi:10.1371/journal.pone.0075647
PMCID: PMC3795707  PMID: 24146767
24.  Facilitation strategies to improve the use of evidence in integrated stroke care 
Purpose
Research evidence has identified practices across the care continuum which can improve the chronic condition of stroke; however, challenges remain to implementing this evidence. The two research projects presented evaluated whether facilitation can increase evidence-informed stroke care.
Theory
The Promoting Action on Research Implementation in Health Services framework was used to design and evaluate the facilitation strategies.
Methods
Project one evaluated the effect of a knowledge network, centralised around a knowledge broker, on increasing the awareness and application of evidence across the health care system. Project two used an interactive workshop to help family practitioners contextualise best practice recommendations for the secondary prevention of stroke. The research projects were conducted in primarily rural areas of Canada, and used mixed methods for evaluation.
Results and Conclusions
The results indicate that the knowledge broker/network intervention effectively increased the awareness of evidence, and stimulated improvements in stroke care through increased communication networks. The workshop increased practitioner knowledge and support for health system changes necessary for integrated stroke care. The evaluation identified health-system barriers which affect implementation.
Discussion
These findings identify the need and methods for improving communication, which if implemented can reduce health system barriers to improving integrated stroke care.
PMCID: PMC2430310
stroke services; Canada
25.  Integrating addiction treatment into primary care using mobile health technology: protocol for an implementation research study 
Background
Healthcare reform in the United States is encouraging Federally Qualified Health Centers and other primary-care practices to integrate treatment for addiction and other behavioral health conditions into their practices. The potential of mobile health technologies to manage addiction and comorbidities such as HIV in these settings is substantial but largely untested. This paper describes a protocol to evaluate the implementation of an E-Health integrated communication technology delivered via mobile phones, called Seva, into primary-care settings. Seva is an evidence-based system of addiction treatment and recovery support for patients and real-time caseload monitoring for clinicians.
Methods/Design
Our implementation strategy uses three models of organizational change: the Program Planning Model to promote acceptance and sustainability, the NIATx quality improvement model to create a welcoming environment for change, and Rogers’s diffusion of innovations research, which facilitates adaptations of innovations to maximize their adoption potential. We will implement Seva and conduct an intensive, mixed-methods assessment at three diverse Federally Qualified Healthcare Centers in the United States. Our non-concurrent multiple-baseline design includes three periods — pretest (ending in four months of implementation preparation), active Seva implementation, and maintenance — with implementation staggered at six-month intervals across sites. The first site will serve as a pilot clinic. We will track the timing of intervention elements and assess study outcomes within each dimension of the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, including effects on clinicians, patients, and practices. Our mixed-methods approach will include quantitative (e.g., interrupted time-series analysis of treatment attendance, with clinics as the unit of analysis) and qualitative (e.g., staff interviews regarding adaptations to implementation protocol) methods, and assessment of implementation costs.
Discussion
If implementation is successful, the field will have a proven technology that helps Federally Qualified Health Centers and affiliated organizations provide addiction treatment and recovery support, as well as a proven strategy for implementing the technology. Seva also has the potential to improve core elements of addiction treatment, such as referral and treatment processes. A mobile technology for addiction treatment and accompanying implementation model could provide a cost-effective means to improve the lives of patients with drug and alcohol problems.
Trial registration
ClinicalTrials.gov (NCT01963234).
doi:10.1186/1748-5908-9-65
PMCID: PMC4072605  PMID: 24884976
Primary care integration; Systems change; E-Health; RE-AIM framework

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