Measuring persistence of implementation: QUERI Series

Bowman, Craig T.; Sobo, Elisa J.; Asch, Steven M.; Gifford, Allen L.

doi:10.1186/1748-5908-3-21

Cited by 82 publications

(74 citation statements)

References 47 publications

(47 reference statements)

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“…Modifying or adapting interventions from their original form to suit the context of provider organizations during the process of implementation has been linked with increased likelihood of sustainability in previous studies [17, 19–22]. These studies considered adaptation as one, among a set of strategies, adopted by implementing organizations to foster program sustainability.…”

Section: Introductionmentioning

confidence: 99%

Modifications to ART service delivery models by health facilities in Uganda in promotion of intervention sustainability: a mixed methods study

2017

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BackgroundIn November 2015, WHO released new treatment guidelines recommending that all diagnosed as HIV positive be enrolled on antiretroviral therapy (ART). Sustaining and expanding ART scale-up programs in resource-limited settings will require adaptations and modifications to traditional ART delivery models to meet the rapid increase in demand. We identify modifications to ART service delivery models by health facilities in Uganda to sustain ART interventions over a 10-year period (2004–2014).MethodsA mixed methods approach involving two study phases was adopted. In the first phase, a survey of a nationally representative sample of health facilities (n = 195) in Uganda which were accredited to provide ART between 2004 and 2009 was conducted. The second phase involved semi-structured interviews (n = 18) with ART clinic managers of 6 of the 195 health facilities purposively selected from the first study phase. We adopted a thematic framework consisting of four categories of modifications (format, setting, personnel, and population).ResultsThe majority of health facilities 185 (95%) reported making modifications to ART interventions between 2004 and 2014. Of the 195 health facilities, 157 (81%) rated the modifications made to ART as “major.” Modifications to ART were reported under all the four themes. The quantitative and qualitative findings are integrated and presented under four themes. Format: Reducing the frequency of clinic appointments and pharmacy-only refill programs was identified as important strategies for decongesting ART clinics. Setting: Home-based care programs were introduced to reduce provider ART delivery costs. Personnel: Task shifting to non-physician cadre was reported in 181 (93%) of the health facilities. Population: Visits to the ART clinic were rationalized in favor of the sub-population deemed to have more clinical need. Two health facilities focused on patients living nearer the health facilities to align with targets set by external donors.ConclusionsOver the study period, health facilities made several modifications ART interventions to improve fit with their resource-constrained settings thereby promoting long-term sustainability. Further research evaluating the effect of these modifications on patient outcomes and ART delivery costs is recommended. Our findings have implications for the sustainability of ART scale-up programs in Uganda and other resource-limited settings.

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Section: Introductionmentioning

confidence: 99%

Modifications to ART service delivery models by health facilities in Uganda in promotion of intervention sustainability: a mixed methods study

2017

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“…8 Sustaining change appears to be an active process that requires continual attention as innovations are adapted to fi t continually evolving environments. 9,10 Additionally, small, independent primary care practices often lack the resources or motivation needed to develop quality improvement strategies that can address multiple clinical issues. 11 The substantial, broad improvements required for optimal primary care cannot be achieved by focusing improvement efforts on specifi c diseases or on individual professional behavior.…”

Section: Introductionmentioning

confidence: 99%

Using Learning Teams for Reflective Adaptation (ULTRA): Insights From a Team-Based Change Management Strategy in Primary Care

Balasubramanian

Chase

Nutting

et al. 2010

The Annals of Family Medicine

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PURPOSEThe Using Learning Teams for Refl ective Adaptation (ULTRA) study used facilitated refl ective adaptive process (RAP) teams to enhance communication and decision making in hopes of improving adherence to multiple clinical guidelines; however, the study failed to show signifi cant clinical improvements. The purpose of this study was to examine qualitative data from 25 intervention practices to understand how they engaged in a team-based collaborative change management strategy and the types of issues they addressed. METHODSWe analyzed fi eld notes and interviews from a multimethod practice assessment, as well as fi eld notes and audio-taped recordings from RAP meetings, using an iterative group process and an immersion-crystallization approach.RESULTS Despite a history of not meeting regularly, 18 of 25 practices successfully convened improvement teams. There was evidence of improved practicewide communication in 12 of these practices. At follow-up, 8 practices continued RAP meetings and found the process valuable in problem solving and decision making. Seven practices failed to engage in RAP primarily because of key leaders dominating the meeting agenda or staff members hesitating to speak up in meetings. Although the number of improvement targets varied considerably, most RAP teams targeted patient care-related issues or practice-level organizational improvement issues. Not a single practice focused on adherence to clinical care guidelines.CONCLUSION Primary care practices can successfully engage in facilitated team meetings; however, leaders must be engaged in the process. Additional strategies are needed to engage practice leaders, particularly physicians, and to target issues related to guideline adherence. Ann Fam Med 2010;8:425-432. doi:10.1370/afm.1159. INTRODUCTIONThe quality of care in the United States is substandard, 1 and the early promise of improving care by translating research into practice has been disappointing. 2,3 Initial efforts to improve quality often target improving knowledge, attitudes, and behaviors of individual health professionals by using such strategies as audit and feedback, reminder systems, continuing medical education, and educational outreach. 4 These strategies have been found to produce modest change. 2,3,[5][6][7][8] Even when improvement changes are adopted, they are often not sustained over time 7 and may deteriorate after practice members' attention shifts elsewhere.8 Sustaining change appears to be an active process that requires continual attention as innovations are adapted to fi t continually evolving environments.9,10 Additionally, small, independent primary care practices often lack the resources 426T E A M -BA SED CHANGE M A NAGEMENT or motivation needed to develop quality improvement strategies that can address multiple clinical issues. 11The substantial, broad improvements required for optimal primary care cannot be achieved by focusing improvement efforts on specifi c diseases or on individual professional behavior. In fact, primary care pract...

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“…Although the turnover of ART-proficient health workers was cited independently as a barrier to the institutionalization of ART programs in the latter health facilities, it is plausible that this could be related to the lack of formal terms of service for health workers in the two lowest-ranked health facilities which could be a disincentive to long-term commitment. In this respect, this study adds to the growing evidence suggesting that there are dynamic interactions in the factors influencing intervention sustainability [19,43–46]. This approach challenges linear and reductionist approaches employed in investigating bottlenecks to the scale-up of public health interventions [44].…”

Section: Discussionmentioning

confidence: 95%

“…It is plausible that having significantly higher patient volumes and the referral character of the latter category of health facilities could have advantaged them in the scale of donor support received. In this regard, Bowman et al [43], earlier proposed that ‘’the longevity of an adopted intervention may be a direct function of original implementation intensity’’ and that variations in the implementation ‘dose received’ should be factored in post-hoc analyses of long-term program sustainability. The findings of this study offer some empirical credence to this notion.…”

Section: Discussionmentioning

confidence: 99%

Assessing the level of institutionalization of donor-funded anti-retroviral therapy (ART) programs in health facilities in Uganda: implications for program sustainability

Zakumumpa

Kwiringira

Rujumba

et al. 2018

Global Health Action

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Background: In the context of declining international assistance for ART scale-up in Sub-Saharan Africa, the institutionalization of ART programs through integrating them in the organizational routines of health facilities is gaining importance as a program sustainability strategy. Objective: The aims of this study were; (i) to compare the level of institutionalization of ART programs in health facilities in Uganda and (ii) to explore reasons for variations in the degree of program institutionalization. Methods: In Phase One, we utilized Level of Institutionalization Scales developed by Goodman (1993) to measure the degree of institutionalization of ART interventions in 195 health facilities across Uganda. The 45-item questionnaire measured institutionalization based on four sub-systems (production, maintenance, supportive, managerial) theorized to make up an organization assessed against two levels of institutionalization; routines (lowest) niche saturation (highest). In Phase Two, four health facilities were purposively selected (2 with the highest and 2 with the lowest institutionalization scores) for a multiple case-study involving semi-structured interviews with ART clinic managers(n = 32), on-site observations and document review. Results: The two highest scoring health facilities had a longer HIV intervention implementation history of between 8 and 11 years. The highest scoring cases associated intervention institutionalization with sustained workforce trainings in ART management, the retention of ART-trained personnel and generating in-house ART manuals. The turnover of ART-proficient staff was identified as a barrier to intervention institutionalization in the lowest-ranked cases. Significant differences in organizational contexts were identified. The two highest-ranked health facilities were well-established, higher-tier hospitals while the lowest scoring health facilities were lower-level health facilities. Conclusions: The level of institutionalization of ART interventions appeared to be differentiated by level of care in the Ugandan health system. Interventions aimed at strengthening program institutionalization in lower-level health centers at the level of human resources for health could enhance ART scale-up sustainability.

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Measuring persistence of implementation: QUERI Series

Cited by 82 publications

References 47 publications

Modifications to ART service delivery models by health facilities in Uganda in promotion of intervention sustainability: a mixed methods study

Modifications to ART service delivery models by health facilities in Uganda in promotion of intervention sustainability: a mixed methods study

Using Learning Teams for Reflective Adaptation (ULTRA): Insights From a Team-Based Change Management Strategy in Primary Care

Assessing the level of institutionalization of donor-funded anti-retroviral therapy (ART) programs in health facilities in Uganda: implications for program sustainability

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