External facilitators’ perceptions of internal facilitation skills during implementation of collaborative care for mental health teams: a qualitative analysis informed by the i-PARIHS framework

Abstract

Background: Facilitation is a key strategy that may contribute to successful implementation of healthcare innovations. In blended facilitation, external facilitators (EFs) guide and support internal facilitators (IFs) in directing implementation processes. Developers of the i-PARIHS framework propose that successful facilitation requires project management, team/ process, and influencing/negotiating skills. It is unclear what IF skills are most important in real-world settings, which could inform recruitment and training efforts. As prior qualitative studies of IF skills have only interviewed IFs, the perspectives of their EF partners are needed. Furthermore, little is known regarding the distribution of implementation tasks between IFs and EFs, which could impact sustainability once external support is removed. In the context of an implementation trial, we therefore: 1) evaluated IFs' use of i-PARIHS facilitation skills, from EFs' perspectives; 2) identified attributes of IFs not encompassed within the i-PARIHS skills; and 3) investigated the relative contributions of IFs and EFs during facilitation. Methods: Analyses were conducted within a hybrid type II trial utilizing blended facilitation to implement the collaborative chronic care model within mental health teams of nine VA medical centers. Each site committed one team and an IF to weekly process design meetings and additional implementation activities over 12 months. Three EFs worked with three sites each. Following study completion, the EFs completed semi-structured qualitative interviews reflecting on the facilitation process, informed by the i-PARIHS facilitation skill areas. Interviews were analyzed via directed content analysis. Results: EFs emphasized the importance of IFs having strong project management, team/process, and influencing/ negotiating skills. Prior experience in these areas and a mental health background were also benefits. Personal characteristics (e.g., flexible, assertive) were described as critical, particularly when faced with conflict. EFs discussed the importance of clear delineation of EF/IF roles, and the need to shift facilitation responsibilities to IFs.

Multi-tiered external facilitation: the role of feedback loops and tailored interventions in supporting change in a stepped-wedge implementation trial

“…Given these wide ranging activities, previous work has illustrated the importance of models of external facilitation that go beyond a lone facilitator [5,11,[16][17][18]. Researchers have described the roles and impacts of facilitator dyads, such as in blended external and internal facilitation designs [19][20][21][22][23][24], and mixed discipline facilitator designs [16][17][18]. These models involve sharing and coordinating different functions of facilitation, though manuscripts rarely detail how they work together.…”

Primary aim results of a clustered SMART for developing a school-level, adaptive implementation strategy to support CBT delivery at high schools in Michigan

“…For organizational barriers, Facilitation-based on the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) [39] frameworkprovides schools with ongoing consultation from an expert in strategic thinking and EBP implementation to garner administrative support, solve logistical challenges, and build community buy-in. In several communitybased cluster-randomized trials, Facilitation has been shown to improve mental health EBP uptake [30,34,[40][41][42][43][44][45] and to be highly cost-effective [46,47].…”

Facilitation as a component of evidence implementation: a multinational perspective

“…This has been recognized by other researchers in the field, with some referring to it as blended facilitation where a teambased approach that leverages the complementary skills and expertise of external and internal facilitators is used. [22][23][24] Although there are commonalities, facilitation activities involved some level of local contextualization where there were unique or additional activities performed to accommodate the local needs and requirements of the health organization involved in each case, as well as methodological guidance or assistance with the development, implementation and analysis of findings and/or disseminating the findings. In this article, where cases of facilitation occurred as part of the JBI EITP, numerous contextual factors influenced the success of the implementation initiative.…”