Changing Practice: Implementation strategies
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CHANGING PRACTICE Evidence Based Implementation
José Francisco García GutiérrezEscuela Andaluza de Salud Pública
PAHO HQ HSS/HRH
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The Path Continuous Improvement Design & Evaluation
Need
Redesign
DesignManagement
AuditImplementation
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NO MAGIC BULLETS!
All strategies are effective sometimes,
but none is effective in all circumstances
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Summary points Systematic reviews of rigorous studies provide
the best evidence on the effectiveness of different strategies to promote the implementation of research findings
Passive dissemination of information is generally ineffective
It seems necessary to use specific strategies to encourage implementation of research based recommendations and to ensure changes in practice
Further research on the relative effectiveness and efficiency of different strategies is required
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Interventions to promote behavioural change among health professionals
Bero, Grilli Grimshaw et al (1998). British Medical Journal.Bero, Grilli, Grimshaw and Oxman (1998). Cochrane Library.
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Consistently effective interventions
Reminders (manual or computerised)
Multifaceted interventions (a combination that includes two or more of the following: audit and feedback, reminders, local consensus processes, or marketing)
Interactive educational meetings (participation of healthcare providers in workshops that include discussion or practice)
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Interventions of variable effectiveness
Audit and feedback (or any summary of clinical performance)
The use of local opinion leaders (practitioners identified by their colleagues as influential)
Local consensus processes (inclusion of participating practitioners in discussions to ensure that they agree that the chosen clinical problem is important and the approach to managing the problem is appropriate)
Patient mediated interventions (any intervention aimed at changing the performance of healthcare providers for which specific information was sought from or given to patients)
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Interventions that have little or no effect
Educational materials (distribution of recommendations for clinical care, including clinical practice guidelines, audiovisual materials, and electronic publications)
Didactic educational meetings (such as lectures)
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TRADITIONAL
MODEL OF DISEMINATION
Publication of informationPublication of information
Target audienceTarget audience
Changes in clinical practiceChanges in clinical practice
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DESIGN OF INTERVENTIONS
Problem identification (Presentation)
Evaluation of barriers (Diagnosis)
Intervention design (Prescription)
Behavioural change/Quality improvement (Cure)
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IMPLEMENTATION PLAN
Objectives
Key messages
Target audience
Responsible person
Situation analysis
Core improvement indicators
DAFO: Identification of barriers & “ad hoc” interventions
Proposal for improvement interventions
Priorization
Context adaptation
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FROM THEORY TO ACTIONThree key questions
Setting up GOALSWhat are we trying to achieve
Establishing INDICATORSHow we do know that a change is an improvement
Developing CHANGESWhat interventions might help to achieve improvements
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