The Implementation Process: Perspectives from Frontline Providers and Managers JoAnn E. Kirchner, MD...
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Transcript of The Implementation Process: Perspectives from Frontline Providers and Managers JoAnn E. Kirchner, MD...
The Implementation Process: Perspectives from Frontline
Providers and ManagersJoAnn E. Kirchner, MD Louise E. Parker, PhD
Laura Bonner, PhDElizabeth M. Yano, PhD, MSPH
Mona Ritchie, MSW
Formative Evaluation
Types of formative evaluation– Developmental evaluation– Implementation-focused evaluation– Progress-focused evaluation– Interpretive evaluation
The “process” as a product
Formative Evaluation: TIDES Developmental evaluation
– Pre-implementation stakeholder interviews with MH and PC leadership
Implementation-focused evaluation – Mid-implementation qualitative interviews – Early feedback of initial findings to implementation team
Progress-focused evaluation– Program penetration and utilization
Interpretive evaluation– Site case studies– Cost analysis– Qualitative interviews
Methods
Conducted 106 qualitative semi-structured interviews during field visits with– Managers across four participating medical centers and three participating regional networks– Providers, administrators, and consumers
across five participating facilities
Analysis– Data management package– Coded by two-investigator teams– Independent coding with resolution of conflicts
Methods
Here we report findings from– 19 medical center and regional network managers– 49 Frontline providers and administrators
Concerning their perspectives on the QI program implementation process
Local Site Resources
Implementation process
Local Frontline Staff:Attitudes Behaviors
Penetration and Sustainability
Local Outcomes
Spread
Importance of site characteristics
Attitudes/beliefs/experiences– Perceived need for the intervention– Competing needs– Staff open to innovation– MH/PC relationship
• Expected would affect implementation success but did not
Importance of site characteristics
Resources– Perceived time to
• Utilize the program Marketing opportunity
• Participate in implementation activities– Organizational structure
– Staffing– Prior QI experience– Tools (e.g., access to informatics support)
Who to Involve
All Informants – Medical Center Managers– Frontline Clinical Managers– Frontline Primary Care Providers (MD, PA, APN)
Frontline Providers
– RNs, LPNs– Mental Health Providers
Key Roles in Implementation
Leadershipleadership support is obviously also critical. Unless the leaders are able to
translate the importance of the initiative, it's probably not going to take place for a variety of reasons. One of which is that there are a thousand things that need to be done, priorities need to be set and it’s leaderships responsibility to make sure that those priorities are delineated and made clear to everybody, what is it that we’re going to do and what is it we're not going to do - Chief of Staff
– Importance of leaders• valuing the program
I think it’s [leadership support] important because if the leadership shows that it’s important enough for them to spend their time, then it implies that it’s important enough for us to spend our time - MH Provider, Physician
Key Roles in Implementation• initiating the program
• “cheerleading”Managers just have to go back out and continue doing cheerleading
sessions. A little more cheerleading. You go back, and you ... when you see that that’s where you are, you have to just go back and reemphasize. Okay. We’ve gotten to here, we’ve got to be over here or...you guys are doing a great job here, but we could do a little more here, and it’s that cheerleading. You know, 90 percent I think of what managers do are cheerleading people on - Network Manager
• resourcesI feel that anything that you have in place, if the head of anything...is not
going to support you, give you what you need, be there for you in every sense of the word, it’s not worth having. I think it is doomed to fail if you don’t have that in place - Network Manager
• importance of management at multiple levels
Key Roles in Implementation
But in absence of clinic perceived need for the program, leadership will have an uphill battle
Key Roles in Implementation Champion
– Who should be a champion?Does that person have credibility with the other staff, you know, and
that’s not measured in what letters you have behind your name. That’s do people listen to you when you speak. I don’t know how you put a degree on that, but that’s what you need - Primary Care, RN
Colleague who has experienced the program High status peers Someone interested in quality improvement and in
improving mental health care in primary care setting Credible Able to communicate well to groups Self-driven Good rapport
Key Roles in Implementation Role/activities of the champion
He’s [the local champion] been the person who’s at our meetings reminding us about the program…And I think the more you do that, the more you get people using it - Primary Care, RN
– Serve as the local expert and resource person– Encourage people to attend related meetings– Remind people about the program– Provide ongoing marketing
Needs of the champion– Time
Key Roles in Implementation Leadership as a champion
– Roles of champion, leadership, and opinion leaders are not distinct in the views of clinical staff and managers
– Thus, implementation researchers may be creating artificial distinctions
Informing Readiness
Message will depend on how ready sites are for a particular intervention (i.e., perceived need)
Regardless of readiness, different audiences (i.e., managers versus frontline) have different needs to promote readiness
Importance of ongoing marketing for allSometimes in the VA, you’ve got to tell me three times to do it because if
you tell me three times, it was really important. If you tell me once and I never hear from you again, then it probably wasn’t important and was a passing fad and I’ll kind of wait – Chief of Staff
PLAN
DO
STUDY
ACT
1st Generation Sites
2nd Generation Sites
1st Generation Sites• sustainability• penetration
Ongoing Formative Evaluation
Developmental evaluation– Site level needs assessment tool
Implementation-focused evaluation– Site level fidelity monitoring tool
Progress-focused evaluation– Program penetration and utilization through National
Depression Monitor
Interpretive evaluation– Formative evaluation of regional dissemination of TIDES– Assessment of the sustainability effort