demystifying knowledge transfer- an introduction to implementation science master class (newcastle...

Collaborating for Better Care

PartnershipMaster Class: ‘Demystifying Knowledge Transfer’:

Implementing Evidence Based Guidance

An introduction to Implementation Science

28th May 2014

International Centre for Life

@AHSN_NENC@JPresseau

Welcome and Introduction

Professor Paula Whitty

Director of NEQOS & Acting NENC AHSN

Knowledge & Information Programme lead

Programme10.10 Session 1: Implementing evidence based guidance11.00 Session 2: Case studies (working in pairs-followed by group feedback)11.30 Coffee & biscuits11.45 Session 3a: Behavioural approaches to implementing evidence based guidance

Identifying barriers and modifiable determinants12.15 Sessions 3b: Identifying barriers and modifiable determinants of implementation

Neighbour discussion (15 mins) plus some feedback time (15 mins). Jeremy/Justin barrier assessment in case studies

13.15 Lunch14.00 Session 4: Behavioural approaches to implementing evidence based guidance

Designing implementation programmes (Justin and Jeremy)Case studiesNeighbour discussion (15 mins) plus some feedback time (15 mins)

15.15 Coffee15.30 Session 5: Implementation design in case studies (Justin and Jeremy)16.00 Summary, conclusions and group discussion - Jeremy16.20 Concluding remarks - Paula/Jackie16.30 Close

Greetings from Ottawa

Greetings from Newcastle

Session 1: Implementing

Evidence Based Guidance

Prof Jeremy Grimshaw

Dr Justin Presseau

Session 1

Core concepts

Knowledge creation funnel

Background

‘All breakthrough, no follow through’Woolf (2006) Washington Post op ed

Much of the US $100 billion/year worldwide investment in biomedical and health research is wasted because of dissemination and implementation failures

Background

Institute of Medicine; Clinical Research Roundtable, Sung et al. JAMA 289:1278,2003

Background

Why do we need to think about implementation?• Consistent evidence of failure to translate

research findings into clinical practice– 30-40% patients do not get treatments of proven

effectiveness– 20–25% patients get care that is not needed or

potentially harmfulSchuster, McGlynn, Brook (1998). Milbank Memorial Quarterly

Grol R (2001). Med Care

• Suggests that implementation of evidence based care is fundamental challenge for healthcare systems to optimisecare, outcomes and costs

How do healthcare organisations currently address

quality challenges?

Issue guidance

Internal solutions

ISLAGIATT principle

Martin P Eccles

‘It Seemed Like A Good Idea At The Time’

Designing interventions

If you have a hammer, everything looks like nail

External

solutions

External solutions

Throw everything at the problem!

16 28 46 63 56 N =

Absolute effect size

Number of interventions in treatment group

>4 4 3 2 1

Grimshaw et al (2004) Health Technology Assessment

To date, many organisational responses to poor implementation have failed to achieve optimal

care despite considerable investments

Most approaches to changing clinical practice are more often based on beliefs than on scientific

evidence

‘Evidence based medicine should be complemented by evidence based implementation’

Grol (1997). British Medical Journal

Could we do better?

Undoubtedly

Implementing evidence based

practices

• Implementation is about ensuring that stakeholders are aware of and use research evidence to inform their decision making and actions to improve processes and outcomes of care

practices

• Successful implementation depends upon:

– Internal knowledge (eg performance data, tacit knowledge of how organisation (and individuals) work)

– External knowledge (eg clinical and implementation science)

– Behaviour and organisational change expertise

practices

Quality by any means necessary suggests need to use all tools and levers at your disposal

Implementation Science

• Implementation is a human enterprise that can be studied to understand and improve implementation approaches

• Implementation science is the scientific study of the determinants, processes and outcomes of implementation.

• Goal is to develop a generalisable empirical and theoretical basis to optimise implementation activities

applied health researchcapacity buildingco-optation - cooperation - competingdiffusion*dissemination* getting knowledge into practiceimpactImplementation*knowledge communicationknowledge cycleknowledge exchange knowledge managementknowledge translation

knowledge mobilization knowledge transfer linkage and exchangepopularization of research, research into practiceresearch mediationresearch transferresearch translation science communication teaching“third mission” translational research transmission utilization

*cited most frequently

Implementation science

• Implementation science is a research relatively new field in health research

• Inherently interdisciplinary

• Wide range of disciplines need to be engaged

– Clinical

– Health services research

– Social sciences

– Design and engineering

– Informatics

– Methodologists

• Broad range of forms of enquiry needed

Implementation science• Knowledge synthesis (what care should we be providing, what do we

know about the effectiveness of different implementation approaches); • Research into the evolution of and critical discourse around research

evidence; • Research into knowledge retrieval, evaluation and knowledge

management infrastructure• Identification of implementation failures;• Development of methods to assess barriers and facilitators to

implementation;• Development of the methods for optimising implementation programs;• Evaluations of the effectiveness and efficiency of implementation

programs;• Sustainability and scalability of implementation programs;• Development of implementation science theory; and• Development of implementation science research methods.

Knowledge to action cycle

Knowledge to

action cycle

Graham et al (2006).

Lost in Knowledge

Translation. Time for

a Map? Journal of

Continuing Education

for Health

Professionals

Potential barriers to evidence based practice –knowledge management

• Over 20,000 health journals published per year– Average time professionals have available to read = <1 hour/week

• Published research of variable quality and relevance– Research users (consumers, health care professionals, policy makers,

researchers) often poorly trained in critical appraisal skills

• Individual studies rarely by themselves provide sufficient evidence for policy or practice changes– Individual studies are often misleading

Don’t believe the hype: early highly

positive results often contradicted

• Analyzed 115 articles published in 1990-2003 in the 3 major general medical journals (NEJM, JAMA, Lancet) and specialty journals that had received over 1000 citations each by August 2004

• 49 reported evaluations of health care interventions; 45 claimed that the interventions were effective.

• By 2004 5/6 non randomised studies and 9/39 randomised trials were already contradicted or found to be exaggerated

Don’t believe the hype: early highly

positive results often contradicted

Ioannidis JP. JAMA 2005

Don’t generate the hype

• AHSC release average of 49 press releases annually

• 44% promoted animal or laboratory research

– 74% of these explicitly claimed relevance to human health.

• 47.5% were about primary human research

– 23% omitted study size

– 34% failed to quantify results

– 17% promoted studies with the strongest designs (randomized trials or meta-analyses)

– 40% reported results of weak designs (uncontrolled studies, small samples (30 participants), surrogate primary outcomes, or unpublished data) but 58% lacked relevant caution

Don’t generate the hype

Systematic reviews are a generic methodology used to synthesise evidence from a broad range of research methods addressing different questions

Knowledge creation funnelThe steps involved in undertaking a systematic review include

– stating the objectives of the research

– defining eligibility criteria for studies to be included

– identifying (all) potentially eligible studies

– applying eligibility criteria

– assembling the most complete dataset feasible

– analysing this dataset, using statistical synthesis and sensitivity analyses, if appropriate and possible

– preparing a structured report of the research.

Systematic reviews are a generic methodology used to synthesise evidence from a broad range of research methods addressing different questions

– Effectiveness of health care interventions– Diagnostic and screening tests– Determinants of health– Aetiological epidemiological studies– Genetic epidemiological studies– Health system issues (eg quality of discharge coding)– Qualitative methods – consumers’ experiences of

health care

Clarke MJ, Hopewell S, Juszczak E, Eisinga A, Kjeldstrøm M. Compression stockings for preventing deep vein thrombosis in airline passengers. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004002.

Cochrane Effective Practice and

Organisation of Care (EPOC) Group

• Cochrane Effective Practice and Organisation of Care (EPOC) group undertakes systematic reviews of interventions to improve health care systems and health care delivery including:

– Professional interventions (e.g. continuing medical education, audit and feedback)

– Financial interventions (e.g. professional incentives)

– Organisational interventions (e.g. the expanded role of pharmacists)

– Regulatory interventions

Organisation of Care (EPOC) GroupEPOC Progress to date

• 96 reviews, 1 overview, 36 protocols

• Professional interventions – Audit and feedback: effects on professional practice and health care

outcomes

– The effects of on-screen, point of care computer reminders on processes and outcomes of care

• Organisational interventions– The effectiveness of strategies to change organisational culture to

improve healthcare performance

– Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases

Organisation of Care (EPOC) GroupEPOC Progress to date

• Financial interventions– The impact of user fees on access to health services in low- and

middle-income countries

– Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians

• Regulatory interventions – Effects of changes in the pre-licensure education of health workers on

health-worker supply

– Pharmaceutical policies: effects of cap and co-payment on rational drug use

Organisation of Care (EPOC) Group

Intervention # of trials Median absolute

effect

Interquartile

Audit and feedback

(Ivers 2011)

140 +4.3% +0.5% - +16%

Educational meetings

(Forsetlund 2009)

81 +6% +3 – +15%

Financial incentives

(Scott 2011)

3 NA NA

Hand hygiene

(Gould 2010)

1 NA NA

Factors influencing effectiveness of

audit and feedbackIvers N et al. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Library 2012

– Larger effects were seen if:

• baseline compliance was low.

• the source was a supervisor or colleague

• it was provided more than once

• it was delivered in both verbal and written formats

• it included both explicit targets and an action plan

Summary

• The results of individual studies need to be interpreted alongside the totality of evidence (ie systematic reviews)

• Emphasis on KT of individual studies may distract the stakeholder group (increasing the noise to signal)

– ‘Don’t believe the hype’

– ‘Don’t generate the hype’

• Substantial evidence of effectiveness of implementation interventions

• Average effects modest but considerable variation of observed effectssuggesting that intervention design features and contextual factors likely effect modifiers

• Key (research and service) challenge is how to optimise interventions and tailor intervention to context

Knowledge infrastructure

• Knowledge management is fundamental challenge for health care organisations wishing to use evidence

• There is a need to develop knowledge infrastructure (services and processes)– Knowledge intelligence services– Rapid synthesis services– Requirements for statement about evidence

considered in high level policy documents (eg senior management team submissions)

– ….

Is research working for you?

http://www.cfhi-fcass.ca/PublicationsAndResources/ResourcesAndTools/SelfAssessmentTool.aspx

1. Acquire1.1 Are we able to acquire research?1.2 Are we looking for research in the right places?

2. Assess2.1 Can we tell if the research is valid and of high quality?2.2 Can we tell if the research is relevant and applicable?

3. Adapt3.1 Can we summarize results in a user-friendly way

4. Apply4.1 Do we lead by example and show that we value research use?4.2 Do our decision making processes have a place for research?

Knowledge to Action loopFrom: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006

Adapting knowledge to local context

• May require additional data collection to assess applicability of knowledge to local context

• May require modification of recommended actions based upon applicability, resources and contextual issues

Summary

• Implementation is about ensuring that stakeholders are aware of and use research evidence to inform their decision making and actions to improve processes and outcomes of care

• Implementation science is the scientific study of the determinants, processes and outcomes of implementation.

Summary

• Successful implementation depends upon:– Internal knowledge (eg performance data, tacit knowledge

of how organisation (and individuals) work)

– External knowledge (eg clinical and implementation science)

– Behaviour and organisational change expertise

• Adopting a systematic (theoretically informed) approach will likely enhance likelihood of successful implementation

• The knowledge to action cycle is a useful planning framework.

Session 2: Case Studies

How would you tackle this?

• Two scenarios: choose one scenario, then work in pairs at your tables– Hand hygiene

– Diabetes care

• Spend 15 minutes in pairs

• Feedback to your table for 5 minutes

• General thoughts from tables 10 minutes

Scenario 1Hand hygiene in hospital

staff• Healthcare-associated infections are

among top 10 causes of hospital deaths worldwide

• Hand hygiene (washing or disinfecting hands) is most effective and cost-effective prevention method

• Adherence to hand hygiene recommendations consistently below 50%

Scenario 2Diabetes care in primary care

2011-2012 National diabetes audit showed:- 66% of patients meet guideline-recommended

treatment targets HbA1c (<=58mmol/mol) - 47% had blood pressure < 140/80mmHg- 41% reaching cholesterol target of <4mmol/L- 22% meeting all three targets - Care process completion has plateaued

2011 National study of 99 practices showed:• 73% of patients received general education• 51% with BMI>30 received weight advice• 68% received self-management advice• 59% prescribed for HbA1c when above target• 40% prescribed when BP above target

How would you improve the implementation of hand hygiene

practices in hospital?

How would you improve the quality of diabetes care in primary care?

Spend 15 minutes in pairsFeedback to your table for 5 minutesGeneral thoughts from tables 10 minutes

Feedback

How would you improve the implementation of hand hygiene

practices in hospital?

How would you improve the quality of diabetes care in primary care?

Session 3a: Behavioural

approaches to implementing

evidence based guidance

Dr Justin Presseau

Barriers to implementation• Structural (e.g. financial disincentives)

• Organisational (e.g. inappropriate skill mix, lack of facilities or equipment)

• Peer group (e.g. local standards of care not in line with desired practice)

• Individual (e.g. knowledge, attitudes, skills)

• Professional - patient interaction (e.g. problems with information processing)

A behaviour change approach to

implementation science

• Behaviour change approaches apply to any level: from individuals to groups to organisations– Diagnosis:

• Who needs to do what, differently?

• What is preventing them from doing so

– Intervention: • Help them change what they do to promote

implementation

Identifying behaviours of interest

• What is the behavior (or series of linked behaviors) that you are trying to change?

• Who performs the behavior(s)? (potential adopter)

• When and where does the potential adopter perform the behavior?

• Are there obvious practical barriers to performing the behavior?

• Is the behavior usually performed in stressful circumstances? (potential for acts of omission)

Identifying whose behaviour(s)

need to change

• Often useful to specify target behaviours in terms of:– Actor performing the behaviour– Action being performed– Target at which the action is directed– Context in which action is performed– Time during which the action is performed.

• Provides clarity regarding what to change

Why use theory?• An organized, heuristic, coherent, and systematic

articulation of a set of statements related to significant questions that are communicated in a meaningful whole for the purpose of providing a generalisable form of understanding.

Meleis AI: Theoretical nursing. Development and progress

• It describes observations, summarizes current evidence, proposes explanations, and yields testable hypotheses.

• It represents aspects of reality that are discovered or invented for describing, explaining, predicting and controlling a phenomenon

The Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG). (2006) Imp Sci

Assessing barriers to

implementation

Why use theory?

• Interventions are likely to be more effective if they target determinants of behaviour

• Theoretical frameworks facilitate accumulation and integration of evidence– across context, population and behaviour

– of effects and of causal mechanisms

• Allows refinement and development of theory and, hence, more effective interventions

implementation

What levels of theory?• Ferlie and Shortell suggest four levels of interventions to

improve the quality of health care: – the individual health professional; – health care groups or teams; – organisations providing health care (e.g., NHS trusts); – the larger health care system or environment in which

individual organisations are embedded. • Different types of theory will be relevant to interventions

at different levelsFerlie, Shortell (2001). Milbank Quarterly

implementation

Making sense of theory

• Multiple theories and frameworks of individual and organizational behaviourchange, often with conceptually overlapping constructs

• Two recent attempts to make theory more accessible

– Theoretical domains framework

– Behaviour change wheel

Theoretical domains framework

• Conceptual mapping of 128 explanatory constructs drawing on 33 psychological theories

• Identified 14 domains covering main known factors influencing behaviour and behaviourchange

Theoretical domains framework• Knowledge

– Aware of guidelines and evidence?

• Skills– Sufficient training in techniques required?

• Social/professional role and identity – Is the action part of what the actor sees as

‘typical’ of their profession?

• Beliefs about capabilities– Confident in capacity to do the behaviour?

What makes it easier or difficult?

• Optimism– Is the actor generally optimistic that doing

the behaviour will make a difference in the grand scheme of things?

• Beliefs about consequences– What the the benefits and negative aspects

of doing the behaviour?

• Reinforcement– Does the behaviour lead to any personal or

external reward when it is performed?

• Intentions – How motivated is the actor to do this?

• Goals– How much of a priority is this action

compared to other competing demands?

• Memory, attention and decision processes

– Does the actor ever forget? Are there reminders in place?

• Environmental context and resources – Are there sufficient resources to do the

behaviour? If not, what is missing?

• Social influences– Who influences the decision to perform the

behaviour?

• Emotion– Is performing the behaviour stressful?

• Behavioural regulation– What does the actor personally do to ensure

that they perform the behaviour?

Cane et al 2012 (Impl.Sci.)

Behaviour Change Wheel

From the TDF to COM-B

Michie, van Stralen, West (2011) Impl.Sci.

Ability• Physical • Psychological

Environmental factors • Physical• Social

Conscious and automatic decision processes

Physical: physical skillsPsychological: Knowledge, cognitive and interpersonal skills, memory/ attention/ decisions processes, behavioural regulation

Reflective: intention, goals, social/professional role and identity, beliefs about capabilities, beliefs about consequences, optimismAutomatic: reinforcement, emotions

Physical: Environmental context and resourcesSocial: Social influences

Linking the TDF to the COM-B Model

Michie, Atkins, West (2014)

Should we use the TDF or COM-B?

• COM-B highlights higher-level factors

• TDF provides a fine-grained analysis that can be aggregated to the COM-B level

Summary so far

Whatever the level of granularity of the assessment, theory provides a way to assess barriers to implementation that provides…

– Common language for building cumulative knowledge-base to learn from past successes (and failures)

– Move beyond trial and error and ISLAGIATT

– Provides a basis for designing targeted interventions optimised to address identified barriers to improve care

Sessions 3b: Identifying barriers

and modifiable determinants of

implementation

Professor Jeremy Grimshaw

Dr Justin Presseau

• Neighbour discussion (15 min) Feedback time (15 min)

• Barrier assessment in case studies

Small group exercise

• Diagnosing the implementation problem

1. Whose behaviour needs to change?

2. Which behaviour(s)/actions do they need to change?

3. What are the barriers stopping them?

• Using COM-B or TDF as your framework for assessing barriers

Scenario 1Hand hygiene in

hospital staff

Scenario 2Diabetes care in

primary care

In pairs, discuss the following

1. What is the specific behaviour in terms of:ACTION: the specific behaviour(s)ACTOR(s): the person(s) whose behaviour needs to changeTARGET: details of the recipient of the action CONTEXT: where is the action performed?TIME: When is the action performed

2. Using the TDF or COM-B, identify which barriers may stopping them

With your neighbour: Choose a scenario:

Small group exercise

• Feedback

• What are advantages and disadvantages of using the theoretical domains framework

Case study – physician hand hygiene

Theoretical domains framework –

physician hand hygiene example

Determinants of behaviour• Knowledge• Skills• Social/professional role and identity • Beliefs about capabilities• Optimism• Beliefs about consequences• Reinforcement• Intentions • Goals• Memory, attention and decision processes• Environmental context and resources • Social influences• Emotion• Behavioural regulation

Cane et al (2012)

Knowledge

• I am (not) aware of hand hygiene guidelines and have (not) heard of the 4 moments of hand hygiene

• I am (not) aware of evidence linking hand hygiene to health care associated infections

• Education about hand hygiene ensures that I practice it consistently

Beliefs about consequences

• Practicing hand hygiene reduces the transmission of infection

• While improper hand hygiene can contribute to infection, it is not the only factor that can do so

• Practicing hand hygiene gives patients confidence in their physician

Beliefs about Capabilities

• Hand hygiene is easy to practice

• I am not confident that I am following hand hygiene guidelines when practicing hand hygiene

Social influence

• Patients expectations do (not) influence me to perform hand hygiene

• If I see someone practicing hand hygiene, it influences me to do the same

• Team culture influences others hand hygiene practice

• Hand hygiene is always a necessity

• Hand hygiene is not my highest priority in patient emergency situations

• Hand hygiene is one of many priorities that I have to balance every day

Skills

• I do (not) consider hand hygiene a skill

• I have (not) had training in hand hygiene practice

• With repetition, hand hygiene practice becomes automatic

Memory, attention, decision processes

• Hand hygiene is (not) an automatic process for me

• When not touching the patient or patient environment, hand hygiene is unnecessary

• Reminders are useful for my hand hygiene practice

• Easily visible hand hygiene stations make it easier to remember hand hygiene

Social professional role and identity

• Hand hygiene is a standard part of my patient consultations

• My hand hygiene is in line with my peers

• Physician hand hygiene compliance is suboptimal

• It is my job to be a hand hygiene role model to the members of my team

Environment

• Easy access to hand hygiene stations makes it easier to practice hand hygiene

• The location of hand hygiene stations is important in facilitating hand hygiene practice

• Practicing hand hygiene takes time

• When I am busy, I am less likely to comply with hand hygiene guidelines

Environment - Nonparticipant Observation

• Observations made while on a Surgery and Medicine Unit confirmed what was said in the physician interviews:

– Alcohol dispensers are sometimes empty

– Alcohol dispensers blend in with the wall

– Beside alcohol bottle baskets are empty

Case study:

the iQuaD example• Three dominant theories and approaches in implementation

science:– “If you build it they will come”: the structural approach to

behaviour change

– “There is no ‘I’ in team”: change involves exchanges and shared processes between individuals working in teams within organisations

– “Between the ears” : individuals’ perceptions, cognitions beliefs, schemas, cognitive associations about their behaviour

• Rarely ever considered alongside each other. Need for empirical comparison of theory for utility in implementation science

The improving Quality in Diabetes care (iQuaD) study1,2

Aim: investigate how effectively and consistently factors from predominant organisational and behaviour theories predict- multiple evidence-based clinical behaviors promoted in guidelines- same sample of clinicians, primary care diabetes management in the UK

Design: Predictive. Questionnaires sent at baseline and 12 months later to GPs and nurses in 99 practices across the UK

National study of primary care in the UK

1 Eccles et al (2011, Impl Sci); 2 Presseau et al (in press, Journal of Behavioral Medicine)

National study

• Outcomes: – Clinician-level: clinicians’ self-reported behaviour at 12 months follow-up

– Practice level: patient report of care received and patient medical records

• Recruitment and response rates1

– 12 months follow-up

• 427 (289 GPs, 138 nurses) returned questionnaire (51% response rate).

• Mean of 41 patients/practice responded to questionnaire

• Main Findings

• Gaps in quality of care across the behaviours1

• Theory-based factors that predicted high quality care2

1 Eccles et al (2011, Impl Sci); 2 Presseau et al (in press, Journal of Behavioral Medicine)

Prescribing ...

1. ...additional antihypertensive drugs for people with type 2 diabetes whose blood pressure (BP) is above a target of 140 mm Hg for Systolic BP or 80 mm Hg for Diastolic

2. ...additional therapy for the management of glycaemic control (HbA1c) for the management of HbA1c in people whose HbA1c is higher than 8.0%, despite maximum dosage of 2 oral hypoglycaemic drugs.

Providing advice about...

1. ... weight management to people with type 2 diabetes whose BMI is above a target of 30kg/m2, even following previous management.

2. ... self-management to people with type 2 diabetes.

3. ...general education about diabetes for people with type 2 diabetes.

Examining...

1. ...foot circulation & sensation in the feet of people with

type 2 diabetes.

Health professionals: 63%Patient Records: 40%

Health professionals: 78%People with diabetes: 51%

Eccles et al (2011, Impl Sci)

National study: gaps in quality of care

Staffing ratios

Meetings

Appointment length

Admin support

Recall system

Insulin initiation

Dedicated diabetes clinic

Structured education

Access to specialist care

List size

National study: testing structural correlates

Procedural Justice

Relational Justice

Implementation Behaviour

Participative Safety

Support for Innovation Implementation Behaviour

Vision

Task Orientation

Altruism, Courtesy, Sportsmanship,

Conscientiousness, Civic Virtue

Organizational Citizenship Behaviours (Moorman, 1991)

Team Climate (Anderson & West, 1994)

Organizational Justice (Greenberg 1990)

Elovainio, Steen, Presseau, Francis et al. (2012) Family Practice.

R2adj = 0.01 (0.00, 0.03)

R2adj = 0.00 (0.00, 0.03)

Predicting 12m self-report (median, range):

R2adj = 0.00 (0.00, 0.00)

National study: testing team theories

Presseau, Johnston, Francis, Hrisos, Stamp, Steen, Hawthorne, Grimshaw, Elovainio, Hunter, Eccles (in press) Journal of Behavioral Medicine

Outcome Expectations

Self-efficacy

Proximal Goals

Attitude

Subjective Norm

Intention Implementation Behaviour

Anticipated Consequences

Evidence of habit

Action Planning

Coping Planning

Social Cognitive Theory

Learning Theory

Planning

R2adj = 0.15 (0.09, 0.50)

R2adj = 0.14 (0.09, 0.48)

Predicting 12m self-report (median, range):

R2adj = 0.15 (0.09, 0.50)

R2adj = 0.15 (0.07, 0.43)

National study: testing behaviour theories

• Constructs from Organizational Theories did not predict implementation-related behaviours

• Constructs from Behaviour Theories consistently predicted multiple behaviours and scores showed room for improvement:

– Social cognitive theory in particular, along with habit and post-intentional factors

• Testing different theories in the same sample across multiple behaviours provides empirical theory selection through internal replication– Can be used to design intervention to improve care by targeting

modifiable factors shown to consistently predict clinicians behaviour

National study: testing multiple theories

Analytical Effortful Resource intensive Slow, Low capacity Conscious, deliberate2

Perceptual and cued Minimal effort, resources Fast, High capacity Unconscious Automatic Default process Operates in parallel2

Clinician Behaviour

Reflective process1

Impulsive process1

1Strack & Deutch, 2004; 2Evans 2008

• Dual process approach provides an opportunity to jointly • Skilled decision-making involving behaviours with highly salient consequences

(reflective process)• Automatic responses to environmental cues in stable contexts (impulsive process)

• Dual process models suggest that behaviour is determined by two interacting process1

Towards a dual process model of clinician behaviour

Motivational Phase Volitional Phase

Clinician Behaviour

IntentionAction Planning

Coping Planning

Towards a dual process model of clinician behaviour

Automaticity

1Presseau, Johnston, Heponiemi, Elovainio, Francis, Eccles, et al (in press) Annals of Behavioral Medicine

Tested a dual process model predicting

• …six clinical behaviours in same sample

• Hypothesising differences relative importance of reflective and impulsive system depending on the behaviour

• Motivational process remain a key direct and indirectpredictor of clinician behaviour

• Volitional process help to explain how intentions are translated into behaviour for advising behaviours but not examining behaviours (unclear for prescribing)

• Automatic processes are involved in prescribing, examiningand advising behaviours, though not without the input of the reflective process

both reflective and automatic processes involved in predicting clinician behaviours

both could be targeted to promote the implementation of healthcare interventions

Summary so far

Michie, van Stralen, West (2011) Impl.Sci.

• Physical • Psychological

• Physical• Social

• Conscious • Automatic

Interpreting iQuaD findings

according to COM-B

Predictive

Session 4: Behavioural approaches to

implementing evidence based guidance

Designing implementation programmes

Dr Justin Presseau

• Choice of implementation intervention should be based upon:– ‘Diagnostic’ assessment of barriers

– Understanding of mechanism of action of interventions

– Empirical evidence about effects of interventions

– Available resources

– Practicalities, logistics etc

Who needs to do what differently?

Using a theoretical framework, which barriers and enablers need

to be addressed?

Which intervention components could overcome the modifiable

barriers and enhance the enablers?

How will we measurebehaviour change?

Using a theoretical framework, which barriers and enablers need to be addressed?

Which intervention components could overcome the modifiable barriers and enhance the enablers?

• What is the behavior (or series of linked behaviors) that you are trying to change?

• Who performs the behavior(s)? (potential adopter)

• When and where does the potential adopter perform the behavior?

• Are there obvious practical barriers to performing the behavior?

• Is the behavior usually performed in stressful circumstances? (potential for acts of omission)

Designing interventionsWho needs to do what differently?

to be addressed?

Which intervention components could overcome the modifiable barriers and enhance the enablers?

• COM-B• TDF• Behaviour change

theory

Using a theoretical framework, which barriers and enablers need to be addressed?

Designing interventionsWe have found it useful to distinguish…

– What we are trying to change – Why are we trying to change it? (constructs: barriers

and enablers)– How are we going to change it, including

• Intervention functions and Behaviour change techniques

• Context: the mode of delivery (eg group meeting, DVD)

• Content: how the technique will be operationalised

Behaviour change wheel

Michie, van Stralen, West (2012)

Central: COM-B model of behaviour

• Intervention functions surround the COM-B

• Policy categories to support change

Behaviour change wheel: intervention

functionsIncrease knowledge and understanding

Use communication tools to provoke positive or negative emotions or behaviour

Develop an expectation that a reward will be provided for performance

Develop an expectation that performance will result in cost or punishment

Developing physical, cognitive or social skills

Reduce performance opportunities through rule-setting

Make a change to the external social or physical

context

Exposure to someone that one identifies with

to imitate

Facilitation beyond education, training and environmental

restructuring

COM-B TDF Intervention functions

Physical capability Physical skills Training

Psychological capability Knowledge Education

Cognitive and interpersonal skills

Training

Memory, attention and decision processes

Training; Environmental restructuring; Enablement

Behavioural regulation Education; Training; Modelling; Enablement

Capability

Michie, Atkins, West (2014), p113-114

From TDF, to COM-B to Intervention Functions

Physical opportunity Environmental context and resources

Training; Restriction; Environmental restructuring; Enablement

Social opportunity Social influences Restriction; Environmentalrestructuring; Modelling; Enablement

Opportunity

From TDF, to COM-B to Intervention Functions

Reflective motivation

Professional/social role and identity

Education; Persuasion; Modelling

Beliefs about capabilities Education; Persuasion; Modelling; Enablement

Optimism Education; Persuasion; Modelling; Enablement

Beliefs aboutconsequences

Education; Persuasion; Modelling

Intentions Education; Persuasion; Incentivisation; Coercion; Modelling

Goals Education; Persuasion; Incentivisation; Coercion; Modelling; Enablement

Automatic motivation

Reinforcement Training; Incentivisation; Coercion; Environmental restructuring

Emotion Persuasion; Incentivisation; Coercion; Modelling; Enablement

Motivation

Links between COM-B and intervention functions

in the Behaviour Change Wheel

Intervention functions

Physical capability

Psychological capability

Physical opportunity

Social opportunity

Automatic motivation

Reflective motivationMichie, Atkins, West (2014, p116)

Designing interventions – from functions to

behaviour change techniques

Need greater clarity re: specific content of interventions to change behaviour- What does an ‘educational session’ involve? What does providing a new piece of guidance

involve? What does ‘we sent our GPs on a training day’ actually involve? What are the active ingredients of change?

- If we want to replicate and generalise efforts in implementation science, we need a shared understanding of the content of our interventions

Goals and PlanningGoal setting (behavior) OR Goal setting (outcome)Problem solvingAction planningReview behavior goal(s) OR Review outcome goal(s)Discrepancy between current behavior and goalBehavioral contractCommitment

Feedback and monitoringMonitoring of behaviour by others without feedbackFeedback on behaviour/outcomes of behaviourFeedback on outcomes of behaviourSelf-monitoring of behaviourSelf-monitoring of outcomes of behaviourMonitoring of outcome(s) of behaviour without feedbackBiofeedback

Social SupportSocial support (unspecified)Social support (practical)Social support (emotional)

Shaping KnowledgeInstruction on how to perform the behaviourInformation about AntecedentsRe-attributionBehavioural experiments

Natural ConsequencesInfo about health consequencesInfo about emotional consequences Info re social and environment consequencesSalience of consequencesMonitoring of emotional consequencesAnticipated regret

Comparison of behaviourDemonstration of the behaviourSocial comparisonInformation about others’ approval

AssociationsPrompts/cuesCue signalling rewardReduce prompts/cuesRemove access to the rewardRemove aversive stimulusSatiationExposureAssociative learning

Repetition and substitutionBehavioural practice/rehearsalBehaviour substitutionHabit formationHabit reversalOvercorrectionGeneralisation of target behaviourGraded tasksComparison of outcomesCredible sourcePros and consComparative imagining of future outcomes

Reward and threatIncentive (outcomeMaterial incentive (behaviour)Social incentiveNon-specific incentiveSelf-incentiveSelf-rewardReward (outcome)Material reward (behaviour)Non-specific rewardSocial rewardFuture punishment

RegulationConserving mental resourcesPharmacological supportReduce negative emotionsParadoxical instructions

AntecedentsAdding objects to the environmentRestructuring the physical environmentRestructuring the social environmentAvoidance/reducing exposure to cues for behaviourDistractionBody changes

IdentityIdentification of self as role modelFraming/reframingIncompatible beliefsValued self-identifyIdentity associated with changed behaviour

Scheduled consequencesBehaviour costPunishmentRemove rewardReward approximationRewarding completionSituation-specific rewardReward incompatible behaviourReward alternative behaviourReduce reward frequencyRemove punishment

Self-beliefVerbal persuasion about capabilityMental rehearsal of successful performFocus on past successSelf-talk

Covert learningImaginary punishmentImaginary rewardVicarious consequences

V1 Behaviour change techniques taxonomy (Michie et al 2013)

Examples of techniques w/ definitions

• Graded tasks: “Set easy-to-perform tasks, making them increasingly difficult, but achievable, until behaviour is performed”– Capability (Psychological) in COM-B – Beliefs about Capabilities in TDF

• Habit formation: “Prompt rehearsal and repetition of the behaviour in the same context repeatedly so that the context elicits the behaviour”– Motivation (automatic) in COM-B– Behavioural Regulation and Reinforcement in TDF

• Feedback on behaviour: “Monitor and provide informative or evaluatvefeedback on performance of the behaviour (e.g. form, frequency, duration, intensity)”– Motivation (reflective) in COM-B– Behaviour regulation in TDF

Not all techniques are useful, and many techniques are designed to address specific types of barriers

From behaviour change techniques to

theory-informed barriers

• Behaviour change techniques can be mapped onto the theory-based barriers and facilitators from the models covered

– Behaviour change theories

– TDF

– COM-B

• Behaviour change wheel (intervention functions)

Supporting change through policy

Michie, van Stralen, West (2012)

Policy initiatives can facilitate intervention functions impact on COM-B components

Policy categories

Intervention functions

Communication/marketing

Guidelines

Fiscal measures

Regulation

Legislation

Environmental and social planning

Service provision

Links between policy categories and intervention

functions in the Behaviour Change Wheel

Michie, Atkins, West (2014, p138)

Optimising interventions

Usability studies

• Develop prototype intervention

• Test prototype in 5 to 8 subjects to review content and format using ‘think aloud’ methodology. These sessions will be audio recorded and the results transcribed and analysed.

• In general a modest number of subjects are required for usability testing (e.g. 8-9 subjects), and often 4 to 5 are necessary to identify 80% of the usability problems.

• Cycles of design, development and testing will be completed until no further major revisions are needed.

Case studies

• Neighbour discussion(15 min) Feedback time (10 min)

• Implementation design in case studies

Scenario 1Hand hygiene in

hospital staff

Scenario 2Diabetes care in

primary care

In pairs, discuss the following

Based on the barriers you identified using the TDF or COM-B, select…1. Potential intervention functions to target those barriers2. Potential policy categories that would support that intervention

function

With your neighbour: Choose the same scenario

Session 5: Behavioural approaches to

implementing evidence based guidance

Implementation design in case studies

Dr Justin Presseau

Case study of physician hand hygiene

physician hand hygienePhysician need to practice hand hygiene routinely

Beliefs about consequences –failure to practice hand hygiene not necessarily associated with adverse event

Persuasion/social influence –information on hospital associated infections and negative associated consequences, emphasis on hand hygiene as a team level responsibility delivered to team session by social influential

to be addressed?

physician hand hygiene

Choice of implementation intervention should be based upon:

– ‘Diagnostic’ assessment of barriers

– Understanding of mechanism of action of interventions

– Empirical evidence about effects of interventions

– Available resources

– Practicalities, logistics etc

1. Initial sensitisation (residents)Intervention content: Refresher about: – the 4 moments of hand hygiene (knowledge) – what is the patient environment (knowledge)– TOH hand hygiene compliance and infection rates (beliefs about

consequences, social influences (priority for chief resident and hospital))

Proposed delivery for Medicine:– When: During Resident Orientation -1st day of block– What: 1-2 slides on hand hygiene to be developed by team and given to

Chief Resident– Who will deliver: Chief Resident at the beginning of the block

2. Reinforcement (residents, attending physicians)Intervention Content: Knowledge about:

– Infection rates, the 4 moments, the patient environment (exact content to be developed and will be clinically relevant) (knowledge)

– Add Glo Germ demonstration in one of these sessions to illustrate technique (booth after session for all to try if interested) (skills)

Proposed delivery for Medicine:– When: During Antibiotic Stewardship Rounds – a weekly pause of rounds

that lasts a few minutes (already in practice) (social influence)– What: A hand hygiene curriculum delivered weekly (~2min/session) X 4 (for

one block)– Who will deliver: Local experts/opinion leaders

3. Address environmental barriers (unit staff)

Intervention Content: – Ensure that hand hygiene resources are easily accessible and noticeable

(including systems to ensure hand hygiene resources are routinely replaced)

Proposed delivery for Medicine:– How: Will walk through the chosen unit(s)

– Who will deliver: Members of the study team

– Accountability – unit

MedicineM1

MedicineM4

SurgeryM1

SurgeryM4

Resident Audit Scores % Change Between Pre and Post

Control Group

Intervention Group

Aim: Conduct a cluster-RCT to evaluate the effectiveness and costs of a

theory-based multiple behaviour change intervention targeting general practitioners (GPs) and nurses, to support improvement in the provision of high quality care for people with type 2 diabetes in the North East of England

AdvisingPrescribing Examining

Local example:

Prescribing ...

1. ...additional antihypertensive drugs for people with type 2 diabetes whose blood pressure (BP) is above a target of 140 mm Hg for Systolic BP or 80 mm Hg for Diastolic

2. ...additional therapy for the management of glycaemic control (HbA1c) for the management of HbA1c in people whose HbA1c is higher than 8.0%, despite maximum dosage of 2 oral hypoglycaemic drugs.

Providing advice about...

1. ... weight management to people with type 2 diabetes whose BMI is above a target of 30kg/m2, even following previous management.

2. ... self-management to people with type 2 diabetes.

3. ...general education about diabetes for people with type 2 diabetes.

Examining...

1. ...foot circulation & sensation in the feet of people with

type 2 diabetes.

Eccles et al (2011, Impl Sci)

Evidence from our previous national study: gaps in quality of care

Design: Cluster randomised controlled trial (stratified by practice size)

- Theory-based process evaluation - Interview based process evaluation- Fidelity of delivery- Cost analysis

Recipients: GPs, nurses, healthcare assistants delivering care to people with type 2

diabetes

Timeline:

– Intervention development from Sept 2012 to start of Sept 2013– Pilot May/June 2013– Recruitment began in March 2013– Intervention delivery started mid September 2013– Follow-up 12 months later

The IDEA trial

RecruitGPs,nurses,healthcareassistants

in44Practices

BaselineQuestionnaire

Randomisation(stratifiedbypracticesize)

InterventionPractices(22) ControlPractices(22)

DeliverIntervention

Interviews(4)

Follow-upquestionnaire

Outcomes(12monthslater)-Random100patientsperpractice(anonymouspostalquestionnaire)

-Patientcomputerrecords

The IDEA trial: flow chart

Outcome expectations

Self-efficacy

Proximal Goals

Automaticity

Goal conflict Goal Facilitation

Goal Priority

Action Planning

Coping Planning

- Based on findings from iQuaD1,2,3

- Social Cognitive Theory4 + volitional constructs5 + dual process model3,6

- Reciprocal determinism1 operationalised to involve environment factors:- Automaticity (automatic response to cues)3

- Competing behaviours (conflict, facilitation and priority)4,5

Behaviour

Eccles et al (2011); 2,3 Presseau et al (in pressa; in pressb) 4 Bandura (1998); 5 Sniehotta (2009), 6 Strack & Deutsch (2004); 7,8 Presseau et al (2009, 2011);

Logic model

Intervention content

1 BCTs from Michie et al (2013). ABM

Target Construct Behaviour Change Techniques1

Self-efficacy - Demonstration of the behaviour

(beliefs about

capabilities)- Social comparison

- Verbal persuasion of capability

- Behavioural practice/rehearsal

- Graded tasks

Outcome expectations - Information about health consequences

(beliefs about

consequences)- Credible source

Proximal goals

(Reflective motivation)

- Goal setting (behaviour)

- Discrepancy between current behaviour and goal

- Commitment

Action planning - Action planning

Coping planning - Problem solving

- Adding objects to the environment

Habit/Automaticity - Behavioural practice/rehearsal

(Automatic motivation) - Habit formation

- Action planning and problem solving

• Self-administered pre-intervention questionnaire

• Pre-reading, website and PDF-based

• Group-based workshop to each practice– PowerPoint slides– Participant Workbooks– Small group tasks– Video case studies

• DVD of materials during evaluation

• Self-administered post-intervention questionnaire

• DVD of materials after evaluation

Intervention Control

✓ ✓

Format

clinical expert

behaviour change expert

Intervention providers

44 GP practices in the North-east of England

Setting

Audio recorded sessions- Transcribed/coded for delivery of BCTs, by whom

Facilitator debrief questionnaires- Independently completed; reported delivery of BCTs;

coverage across 6 behaviours; intensity Participant feedback

- Write plans on feedback forms

Training sessions based on BCTs1) Facilitator handbook2) Within facilitator team: observe, coping planning 3) Within research team: practice/rehearsal 4) Feedback on to facilitator team after delivery

1 Bellg et al 2002

Fidelity of delivery

– Intervention may or may not be effective

– Process evaluation to understand mechanism of change

– Theory-based process evaluation1,2:• Pre/post theory-based questionnaires

• Test for change in targeted constructs between intervention and control

1,2 Grimshaw et al (2007; submitted) Implementation Science;

Outcome expectations

Self-efficacy

Proximal Goals

Automaticity

Goal conflict Goal Facilitation

Goal Priority

Action Planning

Coping Planning

Behaviour

Process evaluation (quantitative)

• Four practices randomly selected for follow-up interviews

– TDF based barriers and facilitators to engaging in the intervention sessions

– Participants: clinicians participating in the intervention, practice manager

Process evaluation (qualitative)

• Cost of delivering the intervention• Staff training (facilitators)

• Primary care costs

• Increases in standard materials used (e.g., leaflets)

• Time use in consultation

• Average cost per patient to the NHS for medication prescribed

• Costs of service usage by people with Type 2 diabetes

Cost analysis

Summary

• Designing interventions involves assessing barriers to change and identifying interventions that potentially address these

• Behavioural theories may be helpful to inform barrier assessment and intervention choice

• Intervention mapping is a technique for systematically considering barriers and potential interventions

Developing the field of

• Implementation science is a relatively new field - few health researchers have been engaged in the field for more than 10 years

• Substantive level of research activity– Cochrane Effective Practice and Organisation of Care

(EPOC) group register includes over 6,000 RCTs and quasi experiments of interventions to improve health care delivery and health care services

• Increasing funding and reporting opportunities for knowledge translation research

• Move towards research programs and laboratories

Implementation Research Laboratories• Research teams integrated into healthcare systems

undertaking program(s) of research directly relevant to healthcare systems’ priorities

• Reduces problems relating to convening de novo research teams, seeking project by project funding, negotiating access with healthcare systems, conducting study, writing up (usually out of funding period)

• Opportunities for formal and informal linkages of mutual advantage to research team and healthcare system

• More explicitly recognise relatives roles and responsibilities of research team and healthcare system

Developing the field of implementation

science

Developing the field of implementation

science

www.implementationscience.com

Summary• Implementation science is a relatively new field

of health services research

• Rapid progress has been made but substantial challenges remain

• Opportunities to foster linkages between implementation service departments and implementation researchers to form implementation science laboratories and address I2 challenge

Discussion

• Based on the workshop today, what are your current views on:

– Value of behavioural approaches to implementing evidence based guidance?

– What would be needed to adopt these approaches in practice?

– Are there any additional approaches that might complement behavioural approaches?

Closing remarks

Professor Paula Whitty

Director of NEQOS & Acting NENC AHSN Knowledge & Information Programme lead

Dr. Jackie Gray

Medical Epidemiologist, NEQOS

Get involved in the Work

Programme

• Sign up at the registration desk (in main foyer)

• Email Dr Jackie Gray jackie.gray5@nhs.net

Keep up to date with developments:• Sign up for the e- bulletin at the registration desk (if you haven’t

already)

Resources will be available on:

You Tube - video will be uploaded (link included in next e- bulletin)

Slide Share - slide deck will be uploaded (link included in next e-bulletin)

AHSN web site www.ahsn-nenc.org.uk

NEQOS web site www.neqos.nhs.uk/

Twitter - @AHSN_NENC

Thank you

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