1. health and fitness

BRIDGING RESEARCH AND
PRACTICE
The ISF, Organizational Readiness
and100 Million Healthier Lives
Abraham Wandersman
University of South Carolina
27 May 2015
[email protected]
OVERVIEW
• Bridging Research and Practice
• Interactive Systems Framework for Dissemination
and Implementation
• Readiness and Readiness Heuristic
• Culture of Health
• 100 Million Healthier Lives by 2020
• Institute for Healthcare Improvement ‘s SCALE
project funded by Robert Wood Johnson
Foundation
RESEARCH
PRACTICE
Evidence based substance abuse and crime
prevention programs in schools
• The 2011 study found that,” while schools reported
implementing a large number of prevention programs
during the 2004–05 school year, only a small
proportion reported implementing programs
(approximately 7.8 percent) supported by research
evidence “
• ~44.3% of the estimated 7.8% of research-based
programs met minimal standards for fidelity of
implementation….
• Therefore, 3.5% of the programs were research-based
and well-implemented
U.S. Department of Education, Office of Planning, Evaluation and Policy Development, Policy and Program
Studies Service (2011). Prevalence and Implementation Fidelity of Research-Based Prevention Programs in
Public Schools: Final Report, Washington, D.C.
Do Electronic Medical Records Save Money?
• Experts have long argued that computerized patient records will save the health system money
by helping doctors reduce the number of redundant or inappropriate tests they order. A new
study published in Health Affairs, disputes that, suggesting that office-based physicians who
have access to electronic records of patient care are actually more likely to order additional
imaging tests and laboratory tests than doctors who rely on paper records.
• The study was based on a 2008 federal survey that collected data from 28,000 patient visits to
1,100 doctors.
• It found that doctors who could call up electronic images of a patient’s previous imaging tests
—such as X-rays and CT scans — ordered new imaging tests in 18 percent of the visits;
physicians without such access ordered imaging on only 12.9 percent of the visits. The rate was
70 percent higher for the most advanced and expensive images.
• The study’s authors argue that previous research that showed savings were done at leading
medical centers with sophisticated technology. Many doctors’ offices buy off-the-shelf systems,
primarily for billing purposes, that may not be able to track down redundancies or lack
software to help doctors decide if a test is appropriate.
• We still believe that widespread adoption of electronic medical records will improve
care and reduce costs. It is also clear that many office-based physicians will need
help in making the transition. (emphasis added)
NY TIMES EDITORIAL ON STUDY PUBLISHED IN HEALTH AFFAIRS ( March 6, 2012 )
BRIDGING RESEARCH AND PRACTICE
*WHERE DO
EVIDENCE BASED PRACTICES COME
FROM AND WHERE DO THEY GO
*RESEARCH TO PRACTICE MODELS
*THE INTERACTIVE SYSTEMS FRAMEWORK FOR
DISSEMINATION AND IMPLEMENTATION (ISF)
Feedback Loop
1. Identity
problem or
disorder(s) and
review
information to
determine its
extent
2.With an emphasis
on risk and
protective factors,
review relevant
information—both
from fields outside
prevention and
from existing
preventive
intervention
research programs
RISK AND
PROTECTIVE
FACTORS
EPIDEMIOLOGY
3. Design,
conduct, and
analyze pilot
studies and
confirmatory and
replication trials
of the preventive
intervention
program
EFFICACY TRIALS
4. Design,
conduct, and
analyze largescale trails of
the preventive
intervention
program
EFFECTIVENESS
5. Facilitate
large-scale
implementation
and ongoing
evaluation of
the preventive
intervention
program in the
community
PRACTICE
TRIALS
FIGURE 1.1 The preventive intervention research cycle. Preventive intervention research is represented in boxes
three and four. Note that although information from many different fields in health research, represented in the
first and second boxes, is necessary to the cycle depicted here, it is the review of this information, rather than the
original studies, that is considered to be part of the preventive intervention research cycle. Likewise, for the fifth
box, it is the facilitation by the investigator of the shift from research project to community service program with
ongoing evaluation, rather than the service program itself, that is part of the preventive intervention research cycle.
Although only one feedback loop is represented here, the exchange of knowledge among researchers and between
researchers and community practitioners occurs throughout the cycle.
Funding
Putting It Into Practice— Delivery System
General Capacity
Use
Innovation-Specific
Capacity Use
Supporting the Work—Support System
Macro
Policy
Climate
General Capacity
Building
Innovation-Specific
Capacity Building
Distilling the Information— Synthesis & Translation System
Synthesis
Translation
Existing Research and Theory
Interactive Systems Framework for
Dissemination and Implementation
Delivery System
General
Capacity
General Capacities
Types of General Capacities
(non-exhaustive)
Authors
Culture
Drzensky et al., 2012; Glisson, 2007; Glisson & Schoenwald,
2005; Hemmelgarn et al., 2006
Climate
Aarons et al., 2011; Beidas et al., 2013; Damschroder et al.,
2009; Glisson, 2007; Greenhalgh et al., 2004, Hall & Hord,
2010; Lehman et al., 2002
Organizational
Innovativeness
Damschroder et al., 2009; Fetterman & Wandersman, 2005;
Greenhalgh et al., 2004; Klein & Knight, 2005; Rafferty et al.,
2013; Rogers, 2003
Resource Utilization
Armstrong et al., 2006; Greenhalgh et al., 2004; Klein et al.,
2001; Rogers, 2003; Simpson, 2002
Leadership
Aarons & Sommerfield, 2012; Becan, Knight, & Flynn, 2012;
Beidas et al., 2013; Fixsen et al., 2005; Grant, 2013; Rafferty et
al., 2013; Simpson et al., 2002
Structure
Damschroder et al., 2009; Flaspohler et al., 2008; Greenhalgh
et al., 2004, Lehman et al., 2002; Rafferty et al., 2013; Rogers,
2003
Staff Capacity
Flaspohler et al., 2008; McShane & Van Glinow, 2009; Simpson
et al., 2002
GC Components are “Normal”
Leadership
Low
Medium
High
Interactive Systems Framework for
Dissemination and Implementation
Delivery System
General
Capacity
InnovationSpecific Capacity
An Innovation
•Any policy,
program, or
process that is
new to a
setting
Innovation-Specific Capacities
Types of Innovation-Specific Capacities;
(non-exhaustive)
Authors
Innovation-Specific
knowledge, skills, and
abilities
Program Champion
Wandersman, Chien, & Katz, 2012; Fixsen et al., 2005;
Greenhalgh et al., 2004; Simpson, 2002
Specific Implementation
Supports
Aarons et al., 2011; Beidas et al., 2013; Damshroder et al.,
2009; Fetterman & Wandersman, 2005; Greenhalgh et al.,
2004; Hall & Hord, 2010; Rogers, 2003; Schoenwald &
Hoagwood, 2001; Weiner et al., 2008.
Interorganizational
Relationships
Aarons et al., 2011; Flaspohler et al., 2004; Powell et al.,
2012
Atkins et al., 2008; Damshroder et al., 2009; Greenhalgh et
al., 2004; Gladwell, 2002; Grant, 2013; Rafferty et al., 2013;
Rogers, 2003
Interactive Systems Framework for
Dissemination and Implementation
Delivery System
General
Capacity
Motivation
InnovationSpecific Capacity
Motivation for Innovation
Types of Motivations
(non-exhaustive)
Authors
Relative Advantage
Armenakis et al., 1993; Damschroder et al., 2009; Hall &
Hord, 2010; Rafferty et al., 2013; Rogers, 2003; Weiner, 2009
Compatibility
Chinman et al., 2004; Durlak & Dupre, 2008; Fetterman &
Wandersman, 2005; Greenhalgh et al., 2004; Rogers, 2003;
Simpson, 2002
Complexity
Damschroder & Hagedorn, 2011; Fixsen et al., 2005;
Greenhalgh et al., 2004; Meyers, Durlak & Wandersman,
2012; Wandersman et al., 2008.
Trialability
Armenakis et al., 1993; Greenhalgh et al., 2004; Rapkin et al.,
2012; Rogers, 2003
Observability
Beutler, 2001; Chinman et al., 2004; Damschroder et al.,
2009; Ford et al., 2008; Rossi, Lipsey, & Freeman, 2004
Priority
Armenakis & Harris, 2009; Greenhalgh et al., 2004;
Flaspohler et al., 2008
A Heuristic
Readinessi =
Motivationi x General Capacity x
Innovation-Specific Capacityi
R = MC
2
Interactive Systems Framework for
Dissemination and Implementation
Delivery System
General
Capacity
Motivation
InnovationSpecific Capacity
Readiness Building Strategies
Support System
General
Capacity
Motivation
InnovationSpecific Capacity
Readiness Overview
•To describe importance of building
organizational readiness to help get
innovations into place
•To present preliminary results on the
evidence that readiness can be changed
•To discuss implications for providing
supportive interventions to help make
organizations better at providing services
Readiness: Facilitating Innovation Use
• Organizational readiness is important if we want to
help organizations put an innovation into place
• Flaspohler et al. (2008), Scaccia et al. (2015),
Weiner et al. (2008)
• Assessment of organizational readiness is
important:
• Before an innovation is selected (adoption)
• Before the innovation is put into place
• During implementation
• During sustainability planning
Building Readiness
Broad Strategies
Ways to support an Innovation
Tools
Technical
Assistance
Training
Quality
Assurance/
Quality
Improvement
Evidence-Based System for Innovation Support (EBSIS)
(Wandersman, Chien, & Katz, 2012)
Testing out systems to help assess and develop readiness and capability:
Building Readiness Through an Evidence-Based System for Implementation
Support (EBSIS)
Relationships
Readiness
Outcomes
Improved:
Training
Initial Readiness
To
Achieve
Desired
Outcomes
•
•
•
General
Capacities
InnovationSpecific
Capacities
Motivation
Technical
Assistance
Tools
Quality Assurance
Quality Improvement
• General
Capacity
• Innovation
- Specific
Capacity
• Motivation
Initial Research Questions about Readiness
• What evidence is there that the factors and
subcomponents can be changed by support system
interventions (e.g. tools, training, etc…)?
• Do support system activities that target specific
components of readiness lead to better innovation
outcomes than those that do not?
Research Synthesis (Scaccia, 2014)
• Ways to analyze large amounts of research across multiples
studies
• Looked in Behavioral Health, Medical, and Grey Literature
Synthesis and Translation System
Synthesis
Translation
Article Descriptions
•Content Areas:
• Health care (112; 65%),
• Public health (29; 18%),
• Behavioral health (14; 8%)
• Education (11; 6%).
• Business literature (4; 2%)
• US Federal Government (3; <2%).
•Articles were published between 1972 and
2013, with 94% being published after the
year 2000
Readiness Outcomes
•Readiness can be changed by targeted
support
• Odds Ratio = 3.1; 95% CI [1.23,7.48]
• Log odds: 1.13 (SE = 0.46; p = 0.0137).
• Wald Test: X2 (2, 173) = 58.7, p < 0.001
Innovation Outcomes
•Do Support System Activities that target
readiness have better innovation outcomes?
•Yes; Almost 7 times more likely to report
positive outcomes
• OR = 6.8; 95% CI [1.18,38.83]
• Log odds = 1.917 (SE = 0.84; p = 0.0234)
• X2 (2, 85) = 6.2, p = 0.044
Building a Culture of Health—RWJF
• If most of health and well-being is determined by
• Social/Economic/Environmental factors
• Then we need to stop doing business as usual
• Because we aim at something new
• We need to rethink strategy
• Grantees need to rethink operations
• That means more Empowerment Evaluation
Healthy Community Initiatives
• Our Healthier Communities Initiatives (HCI) are built on the concept
that local communities can work together to provide healthy choices
and support the pursuit of healthy lifestyles. Ys across the country
work in collaboration with community leaders to change policies and
physical surroundings to bring healthy living within reach of all
people.
• CDC
• Lets Move
• And many more
What is 100 Million
Healthier Lives?
An unprecedented collaboration of change agents
pursuing an unprecedented result:
100 Million People Living Healthier Lives by 2020
What?
An unprecedented collaboration of change agents pursuing an unprecedented result: 100 million people living
healthier lives by 2020.
How?
Unite a Guiding Coalition across people and organizations to achieve 100 million people living healthier lives by
2020.
Co-design core strategies and an asset-based implementation plan through workgroups (i.e., December meeting
and ongoing)
Develop infrastructure for learning, improvement, and motivation. (i.e., RWJF SCALE Initiative).
Engage health care, people, and communities to improve health
Create meaningful connections, removal of barriers, and ongoing support
Key Stats
•
•
•
•
162 members working on the ground to improve health have committed to being part of the community
91 partners ready to play a leadership role in 100 Million Healthier Lives
7 sponsors willing to providing some level of financial support
192 action plans submitted, detailing how individuals/organizations/networks will take action in improving
health
Theory of change – 100 Million Healthier Lives
Unprecedented
collaboration
Large-scale
improvement
innovation
System
innovation to
remove barriers
100 Million
People Living
Healthier
Lives by 2020
Overview of Spreading Community Accelerators through
Learning and Evaluation - SCALE
Generously supported by the Robert Wood Johnson Foundation: A 20-month
intensive “learning and doing” program for 20 communities working on
becoming pacesetters who are paired with an improvement coach and 4 mentor
communities.
What are the goals of SCALE?
1. Learn what it takes to create effective inter-community
spread (focus of majority of the formative evaluation, as
this is where there is a great deal to be learned).
2. Develop capability within communities to improve health
and achieve a culture of health.
3. Develop a system for effective teamwork between
communities that supports synthesis and dissemination
(spread system).
4. Explore whether the SCALE approach can be used as the
basis of a learning system in the future, for the RWJF Culture
of Health and/or 100 Million Lives Campaign.
Approach to scale: peer to peer spread
Content bright
spots (eg,
CureViolence,
100,000
Homes)
Pace-setter
communities
Pace-setter
communities
(Wave 3) - 20
Wave 2 (20)
Pace-setter
communities
Adopter/Pacesetter communities
(Wave 3) - 20
Wave 1 (20)
Pace-setter
communities
High functioning
communities (4)
communities
(peer mentors)
Wave 2 (20)
Pace-setter
(Wave 3) - 20
Pace-setter
communities
(Wave 3) - 20
Other communities in
our learning system
(Wellville, Frontier,
CDC, AF4Q, ReThink...)
Scale-up of other
communities;
spread of lessons
learned
Additional pace-setter
communities through
other community
improvement efforts
SCALE: Learning and Doing
 Community Health Improvement and Leadership Academy (CHILA)
 Intensive support from improvement coaches and other community
health leaders
 Peer-to-peer learning activities
 Development of community-specific health goals
 Collaborative and supportive evaluation team
 Peer-learning and knowledge-sharing technology platform
 Support and tools from the broader 100 Million Healthier Lives initiative
Formative Evaluation
• Rossi, Lipsey, and Freeman (2004) emphasize the use of formative
evaluation for program improvement.
o IHI also recommends the use of theory-based formative evaluation (Parry
2013)
• We build on this and suggest that formative evaluation can help
ameliorate limitations or failures in program theory (idea),
implementation, and evaluation (Wandersman, 2009).
• Wandersman and colleagues have developed FORECAST (Formative
Evaluation and Consultation Systems Technique) (1994, 2013).
Pacesetter Community FORECAST Model
Draft: February 9, 2015
Phases of Project
Application Process/Outreach Process
Developm
ent of RFA
Development of
Selection Process
Readiness Criteria
(Inclusion/Exclusion
)
Identification of
Potential
Pacesetters
Create CHIA and
Community of
Practice
Needs and Asset Assessment
Onboarding
Implementation
Outcome
Evaluation
Synthesis and
Translation
EBSIS to evaluate process of support
RFA
Announcem
ent
Review,
Selection and
Sorting of
Applicants
Develo
p
MOUs
Welcoming
Process
Refine
Scope of
Work
Phase 2
Readiness
Assessment
Supports to
Pacesetters to
identify
community need
and innovation
Case Studies
Coordinate
Community of
Practice and CHIA
Implementation
(Note: activity
not specified in
SCALE plan
And other assessments during this
period
Short Term
Outcome
Evaluation
Changes in
Readiness
Formative Evaluation
Anticipated Progress on
the Triple Aim Journey
Triple Aim Level 3
Triple Aim Level 4
Triple Aim Level 5
Synthesize and
Translate Results
Proposed formative evaluation questions
1. How do we synthesize, document, disseminate, translate and
support implementation lessons learned from SCALE to facilitate
spread across additional communities in the future-- to make
progress towards 100M healthier lives and a culture of health?
2. What are the accelerators and inhibitors of progress in pacesetter
communities across the phases of the SCALE project?
a. What are the criteria and associated indicators to assess performance of
pacesetter communities?
b. Can indicators of readiness and capability (capacity and motivation) predict
progress?
3. How are these accelerators and inhibitors influenced by other
aligned initiatives in a community? What can we say about the
contribution of the SCALE approach to progress (e.g., CHILA,
mentors, meso-system coaches)?
4. What are the facilitators and inhibitors of intercommunity spread
(e.g., pace setters to pace setters, bright spots to pacesetters,
mentor to pacesetters ) under the SCALE approach? How can the
SCALE approach be improved to increase effectiveness and
efficiency of spread?
Assessing Initial Readiness
• Development of an application (RFA); we looked at:
1. Sources of Motivation to participate in SCALE
2. Specific skills needed for SCALE tasks (innovation-specific
capacity)
3. General organizational characteristics (General Capacity)
• We expect that mentor communities will be “more ready” than
pacesetters.
Assessing Ongoing Readiness in SCALE
• Readiness is dynamic and will change over time:
• After “onboarding phase”
• After Training Academy (CHILA)
• Regular intervals (e.g. interactions with mentors)
• We will be looking at a smaller subset of communities in a more indepth, case study approach.
How does SCALE relate to the lSF?
Switch strategies
Delivery system: 20 Pacesetter
communities
• Multistakeholder coalitions that
include healthcare, community and
public health systems
• Selected based on readiness to adopt
improvement approach via
application and demonstrated
previous capacity in implementing
multistakeholder change
Support with sustainable
business model development
Improvement advisers
Triple Aim?
• Community Health
Improvement Academy
• Intercommunity
Learning system
• Meso-system coaches
• Advanced
community peer mentors
Harvest bright spots; create toolkits
Facilitated connections to content bright spots
Redesign of learning system and approach as needed
“Content bright spots” – eg CureViolence
Prior knowledge of what works in communitie
ANSWER
The Interactive Systems Framework for
Dissemination and Implementation
What is the name of a framework for bridging research
and practice that integrates research-to-practice
models with community-centered/ practice centered
models?
ABE
BONO
ANSWER
This heuristic, R=MC^2, helps us to think
about components likely essential to
implementation.
WHAT IS THE HUERISTIC FORMULA
FOR READINESS?
ABE
BONO
ANSWER
This unprecedented collaboration of change
agents is pursuing an unprecedented result
Hello! Hello! What’s IHI’s 100 Million
Healthier People by 2020, yeah yeah
yeah!
ABE
BONO
ANSWER
This initiative looks to Spreading Community
Accelerators through Learning and Evaluation
What is the name of the IHI project
funded by RWJ that explores intercommunity spread?
ABE
BONO
References
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Intersection of Research to Practice Models and Community-centered Models. American Journal of Community
Psychology, 41, 182-196.
• Greenhalgh, T., Robert, G., MacFarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of Innovations in Service
Organizations: Systematic Review and Recommendations. The Milbank Quarterly, 82(4), 581-629.
• Kane, H., Lewis, M. A., Williams, P. A., & Kahwati, L. C. (2014). Using qualitative comparative analysis to
understand and quantify translation and implementation. Translational Behavioral Medicine, 4(2), 201-208.
• Miller, W., & Rollnick, S. (2013). Motivational Interviewing; 3rd ed. Guilford Press. New York.
• Øvretveit, J (2003). What are the best strategies for ensuring quality in hospitals? Copenhagen, WHO Regional
Office for Europe (Health Evidence Network report; http://www.euro.who.int/document/e82995.pdf, accessed
7.23.13).
• Ragin, C. C. (2009). Qualitative comparative analysis using fuzzy sets (fsQCA).Configurational Comparative
Methods, 87-121.
• Scaccia, J.P., Cook, B.S., Lamont, A., Wandersman, A., Castellow, J., Katz, J., & Beidas, R. (in press). A practical
implementation science heuristic for organizational readiness: R=MC2. Journal of Community Psychology.
• Wandersman, A., Duffy, J., Flaspohler, P., Noonan, R., Lubell, K., Stillman, L., et al. (2008). Bridging the gap
between prevention research and practice: The Interactive Systems Framework for Dissemination and
Implementation. American Journal of Community Psychology, 41, 171-181.
• Weiner, B., Amick, H., & Lee, S. Y. (2008). Conceptualization and measurement of organizational readiness for
change: a review of the literature in health services research and other fields. Medical Care Research and
Review.