Understanding Implementation of Complex Interventions in Primary Care Teams

Luig, Thea; Asselin, Jodie; Sharma, Arya M.; Campbell‐Scherer, Denise

doi:10.3122/jabfm.2018.03.170273

Cited by 28 publications

(34 citation statements)

References 48 publications

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“…1 Tackling one element in isolation, however, may produce undesirable consequences in another. 2,3 Meanwhile, physician and medical staff burnout represents an existential threat to the primary care workforce. One-half of all primary care physicians report symptoms of burnout, and 1 in 3 would not choose their specialty again.…”

Section: Introductionmentioning

confidence: 99%

Practice Transformation Under the University of Colorado’s Primary Care Redesign Model

et al. 2019

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PURPOSE We compared the transformation experience of 2 family medicine practices that implemented the Primary Care Redesign (PCR) team-based model to improve access, quality, and experience without increasing cost. The University of Colorado's A.F. Williams Family Medicine clinic (pilot practice) implemented the model in February 2015, and a smaller, community-based practice (wave 2 practice) did so 2 years later, in February 2017. METHODS The PCR model increased the ratio of medical assistants to clinicians from about 1:2 to 2.5:1 while expanding the role of the medical assistants, through enhanced rooming procedures, in-room support (eg, scribing), postclinician wrap-up, and in-basket assistance. We assessed access, clinical quality metrics, staffing costs, and clinician and staff experience and burnout for at least 7 months before and 42 months after the intervention. RESULTS In the pilot practice, compared with preimplementation, there were improvements in total appointments and rates of hypertension control, colorectal cancer screening, and most diabetic quality metrics. In the wave 2 practice, total appointments increased slightly when clinicians were added pre-PCR and then increased substantially after implementation; initially variable hypertension control improved rapidly after implementation. The wave 2 practice's colorectal cancer screening improved gradually, then accelerated postimplementation, while diabetic metrics initially remained stable or declined, then improved postimplementation. New patient appointments began to increase for both practices in late 2015, but grew faster in the pilot practice under PCR. Over time, all experiential domains improved for clinicians; most remained stable for staff. Clinician burnout was reduced by at least one-half in both practices except during low staffing periods, which also adversely affected staff. After a ramp-up period, the number of staff hours per visit remained stable. CONCLUSIONS The PCR model is associated with simultaneous improvements in quality, access, and clinician experience, as well as reductions in burnout, while maintaining staffing costs.

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Section: Introductionmentioning

confidence: 99%

Practice Transformation Under the University of Colorado’s Primary Care Redesign Model

et al. 2019

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“…Aligning with our expert participants, the literature supports that implementation is a dynamic process which does not unfold in a linear fashion [17]. As a result of the Delphi, our process model acknowledges that moving evidence into practice is complex and often unpredictable and is in uenced by many factors [18].…”

Section: Summary Of Key Ndingsmentioning

confidence: 54%

“…The authors advocated for more research to develop a theoretical base for intervention selection or development and for tailoring interventions, based on identi ed barriers and facilitators, to increase their effectiveness [20][21]. In addition, the importance of aligning theories or frameworks with the intervention is noted in the literature [17]. Research has identi ed that clinical outcomes are improved when theories or frameworks guide the implementation process, with speci c attention paid to the t with context [22].…”

Section: Summary Of Key Ndingsmentioning

confidence: 99%

Development of an Implementation Process Model: A Delphi Study

Parker

Kastner

Born

et al. 2020

Preprint

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Background: There is general scarcity of research on key elements of implementation processes and the factors which impact implementation success. Implementation of healthcare interventions is a complex process. Tools to support implementation can facilitate this process and improve effectiveness of the interventions and clinical outcomes. Understanding the impact of implementation support tools is a critical aspect of this process. The objective of this study was to solicit knowledge and consensus from relevant implementation science and knowledge translation healthcare experts in order to refine and validate a process model of key elements in the implementation process.Methods: A two round consensus-based modiﬁed Delphi study involving international experts in knowledge translation and implementation (researchers, scientists, professors, decision-makers) was conducted. Participants rated and commented on all aspects of the process model, including the organization, content, scope, and structure. Delphi questions rated at 75% agreement or lower were reviewed and revised. Qualitative comments supported the restructuring and refinement. A second-round survey followed the same process as Round 1. Results: Fifty-four experts participated in Round 1, and 32 experts participated in Round 2. Twelve percent (n=6) of the Round 1 questions did not reach consensus. Key themes for revision and refinement were: stakeholder engagement throughout the process, iterative nature of the implementation process; importance of context; and importance of using guiding theories or frameworks. The process model was revised and refined based on the quantitative and qualitative data and reassessed by the experts in Round 2. Consensus was achieved on all items in Round 2 and the Delphi concluded. Additional feedback was obtained regarding terminology, target users and definition of the implementation process.Conclusions: High levels of agreement were attained for all sub-domains, elements, and sub-elements of the Implementation Process Model. This validated model will be used to develop an Implementation Support Tool to be used by healthcare providers to facilitate effective implementation and improved clinical outcomes.

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“…Baskerville et al concluded in their systematic review that primary care practices are nearly 3 times more likely to adopt evidence-based guidelines through practice facilitation when there is tailoring of the intervention [7]. Qualitative studies of primary care practice facilitation of complex interventions echo the importance of facilitating team communication, iterative evaluation of the implementation process with real-time feedback, facilitator integration into the practices, and flexibility [43,44].…”

Section: Discussionmentioning

confidence: 99%

Research nurses as practice facilitators to disseminate an asthma shared decision making intervention

et al. 2020

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Background: Practice facilitation is a method of introducing and sustaining organizational change. It involves the use of skilled healthcare professionals called practice facilitators (PFs) to help address the challenges associated with implementing evidence-based guidelines and complex interventions into practice. PFs provide a framework for translating research into practice by building relationships, improving communication, fostering change, and sharing resources. Nurses are well positioned to serve as PFs for the implementation of complex interventions, however, there is little evidence currently available to describe nurses in this role. Additionally, the best strategies to implement complex interventions into practices are still not fully understood. Combining practice facilitation with the train-the-trainer model has the potential to spread knowledge and skills. Shared decision making (SDM), which involves patients and providers jointly engaging in decisions around treatment options, has been shown to improve outcomes for patients with asthma. The goal of this manuscript is to describe and evaluate the practice facilitation process from the ADAPT-NC Study which successfully utilized research nurses to implement a complex asthma SDM toolkit intervention into primary care practices. Methods: As part of a larger study, 10 primary care practices were recruited for a facilitator-led dissemination intervention involving a 12-week rollout of an asthma SDM toolkit (trial registration: 1.28.2014, #NCT02047929). An experienced lead PF trained research nurses as PFs from each of the 4 participating practice-based research networks (PBRNs) in a train-the-trainer model utilizing a one-day training event and subsequent remote meetings. Evaluation of PF engagement was measured through process improvement surveys. Results: Overall, the asthma SDM intervention was successfully implemented within the 4 PBRNs. All 10 facilitatorled practices remained engaged with their PFs, with 8 out of the 10 practices able to incorporate and sustain SDM visits or clinics. Responses from the surveys for process improvement yielded improved PF communication and team dynamics over time.

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Understanding Implementation of Complex Interventions in Primary Care Teams

Cited by 28 publications

References 48 publications

Practice Transformation Under the University of Colorado’s Primary Care Redesign Model

Practice Transformation Under the University of Colorado’s Primary Care Redesign Model

Development of an Implementation Process Model: A Delphi Study

Research nurses as practice facilitators to disseminate an asthma shared decision making intervention

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