Where is the Implementation in
Implementation Science?
Rohit Ramaswamy
January 21, 2014
From Knowing to Doing: The Gap
“Our thinking about health
care has to change and we
have to begin to look at
health care as a systems and
delivery problem, not a
disease problem”
– Dr. Jim Yong Kim,
President, World Bank
What is Implementation Science?
• NIH
– Implementation science is the study of methods to promote the integration of
research findings and evidence into healthcare policy and practice.
• Implementation Science Journal
– the scientific study of methods to promote the systematic uptake of clinical
research findings and other evidence-based practices into routine practice, and
hence to improve the quality and effectiveness of health care.
• Canadian Institute of Health Research
– the exchange, synthesis and ethically-sound application of knowledge- within
a complex system of interactions among researchers and users - to accelerate
the capture of the benefits of research for [people] through improved health,
more effective services and products, and a strengthened health care system
Implementation Science Steps (Bhattacharya)
1. Identify care gaps and the need for change.
2. Identify barriers to consistent use of guidelines.
3. Review evidence on implementation interventions.
4. Tailor or develop intervention to improve
performance.
5. Implement intervention.
6. Evaluate the process of implementation.
7. Evaluate outcomes of the intervention (Grahamet
al., 2006b).
What is Implementation ?
• NIH Definition:
– “the use of strategies to adopt and integrate
evidence-based health interventions and change
practice patterns within specific settings”
• NIRN Definition:
– “a specified set of activities designed to put into
practice an activity or program of known
dimensions”
The Implementation Research/Applied
Implementation Continuum
IMPLEMENTATION SCIENCE
CONTEXT SPECIFIC
KNOWLEDGE
ABOUT
GOOD
IMPLEMENTATION
PRACTICE
IMPLEMENTATION RESEARCH
WHAT APPROACHES WORK BEST IN
THE TRANSLATION OF RESEARCH TO
APPLICATION ?
GENERALIZABLE
KNOWLEDGE
ABOUT
APPROACHES
APPLIED IMPLEMENTATION
HOW SHOULD THESE APPROACHES
BE ADAPTED AND APPLIED IN
PARTICULAR PRACTICE CONTEXTS
AND SETTINGS TO ACHIEVE
SUSTAINABLE OUTCOMES ?
Applied Implementation – Key
Components
PROCESSES
IMPLEMENTATION
SYSTEM
DESIGN
ORGANIZATIONS
EVALUATION
IMPLEMENTATION
FRAMEWORKS
AND TOOLS
FACILITIES
EQUIPMENT
SUPPLIES
SIX SIGMA
LEAN
MFI
CONTINUOUS
QUALITY
IMPROVEMENT
Designing Implementation Systems:
Design Process (Brown)
Designing Implementation Systems:
Design Approach
Mental Health Delivery System Design –
Sehore District, Madhya Pradesh, India
Applied Implementation – Key
Components
PROCESSES
IMPLEMENTATION
SYSTEM
DESIGN
ORGANIZATIONS
EVALUATION
IMPLEMENTATION
FRAMEWORKS
AND TOOLS
FACILITIES
EQUIPMENT
SUPPLIES
SIX SIGMA
LEAN
MFI
CONTINUOUS
QUALITY
IMPROVEMENT
Getting to Outcomes (Wandersman)
#1
Needs/
Resources/
Readiness
#2
Goals &
Objectives
#3
Best
Practices
#4
Fit
#5
Capacities
RESULTS
#10
Sustain
#6
Plan
#9
Improve /
CQI
#8
Outcome
Evaluation
#7
Process
Evaluation
12
NIRN Framework (Fixsen)
Implementation Example
Tobacco-Cessation Strategy
NIRN Framework
Understanding
Context
Planning for
Change
Understanding
Current
Processes
Evaluating Risk
Evaluating
Capacity
Integrating
Change
Implementing
Process
Monitoring
Performance
Improving
Continually
Fixsen, Blase, Bartley, Duda, Metz, Naoom, Sims, Van Dyke, 2011
Applied Implementation – Key
Components
PROCESSES
IMPLEMENTATION
SYSTEM
DESIGN
ORGANIZATIONS
EVALUATION
IMPLEMENTATION
FRAMEWORKS
AND TOOLS
FACILITIES
EQUIPMENT
SUPPLIES
SIX SIGMA
LEAN
MFI
CONTINUOUS
QUALITY
IMPROVEMENT
What is Quality Improvement ?
• Quality Improvement is a formal approach to
the analysis of system performance and
systematic efforts to improve it.
• Key words:
– Formal approach
– Analysis
– System performance
– Systematic efforts
Improving Healthcare – Quality Goals
QUALITY GOALS
Effective
Safe
Equitable
Patient Centered
Timely
Efficient
QI Methods
• Several methodologies developed and tested
for industrial quality applications are now
being used in healthcare
• Most popular QI methodologies:
– Lean
– Six Sigma
– PDSA/Model for Improvement
QI Tools: A Suite of Options
Example – Jacaranda Health Maternity
Clinic – Nairobi Kenya
Example – Flow Improvement in Ghana
AFTER
Post Surgery Recovery Times
35
30
30
25
25
20
15
20
15
10
10
5
5
0
0
Post Surgery Recovery Times in Minutes
10
80
150
220
290
360
430
500
570
640
710
780
850
920
990
1060
1130
1200
1270
1340
1410
Frequency
35
10
80
150
220
290
360
430
500
570
640
710
780
850
920
990
1060
1130
1200
1270
1340
1410
Frequency
BEFORE
Post Surgery Recovery Time
Post Surgery Recovery Times in Minutes
Monitoring changes after quality
improvement
Example – Flow Improvement in Wake County
Frequency
Baseline
10
8
6
4
2
0
Under 1 hour: 59%
1-1.5 hours: 19%
Over 1.5 hours: 22%
Wait time between registration and chart up (minutes)
Frequency
Post-Intervention
14
12
10
8
6
4
2
0
Under 1 hour: 60%
1-1.5 hours: 40%
Over 1.5 hours: 0%
Wait time between registration and chart up (minutes)
• 74% reduction in
patients turned
away
• Reduction in wait
time variability
ONLINE GLOBAL MPH
New concentration area in Applied Implementation
Science
• Design of Implementation Systems
• Implementing Global Health Programs
• Gillings Global Implementation Laboratory
• Monitoring and Evaluation
Thank You!