Mixed-method analysis of program leader perspectives on the sustainment of multiple child evidence-based practices in a system-driven implementation
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Understanding program leader perspectives on the sustainment of evidence-based practice (EBP) in community mental health settings is essential to improving implementation. To date, however, much of the literature has focused on direct service provider perspectives on EBP implementation. The aim of this mixed-method study was to identify factors associated with the sustainment of multiple EBPs within a system-driven implementation effort in children's mental health services.Data were gathered from 186 leaders at 59 agencies within the Los Angeles County Department of Mental Health who were contracted to deliver one of six EBPs within the Prevention and Early Intervention initiative.Multi-level analyses of quantitative survey data (N = 186) revealed a greater probability of leader-reported EBP sustainment in large agencies and when leaders held more positive perceptions toward the EBP. Themes from semi-structured qualitative interviews conducted with a subset of survey participants (n = 47) expanded quantitative findings by providing detail on facilitating conditions in larger agencies and aspects of EBP fit that were perceived to lead to greater sustainment, including perceived fit with client needs, implementation requirements, aspects of the organizational workforce, availability of trainings, and overall therapist attitudes about EBPs.Findings inform EBP implementation efforts regarding decisions around organizational-level supports and promotion of EBP fit.Keywords:
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Material and methods All presentations made during scientific meetings from June 2011 to December 2013 were reviewed and their domains of study (research) were identified. Scientific meetings at a Military Teaching Hospital were organized, in order to promote research within Benin Armed Forces Health Services, through monthly meetings. Semester and annual planning was done for presentations as each department was asked to propose 2 research conclusions per year. Research conclusions were programmed and presented as well as their perspectives.
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Abstract Background Healthcare-related adverse events occur because of complex healthcare systems. The patient safety reporting system is a core component of patient safety initiatives in hospitals. However, hospital management often encounters a cultural barrier with its implementation and struggles to overcome the same. Implementation science would be useful for analysing implementation strategies. This study determines the effects of the implemented strategy on an increase in the number of patient safety reports and the determinants of successful implementation, using the implementation framework. Methods Mixed method analysis was performed in Fujita Health University Hospital (FHUH), a large volume hospital in Japan. We identified strategies to implement the patient safety reporting system by scrutinising internal documents using the Consolidated Framework for Implementation Research (CFIR). The electronic reporting systems developed in 2004 in the FHUH and the number of reports were analysed using the staff data and hospital volumes. Results Reports ( n = 110,058) issued between April 2004 and March 2020 were analysed. The number of reports increased from 2004 to 2008 and from 2013 to 2019, reaching 14,037 reports per year. Between 2009 and 2012, the FHUH experienced a stagnation period where the number of reports were not increasing. From the qualitative materials, we identified 74 strategies which contributed to the implementation of the patient safety reporting system. Among these, the domain of ‘intervention characteristics’ in the CFIR contained 12 strategies, ‘outer settings’ contained 20, ‘inner settings’ contained 21, ‘characteristics of individuals’ contained 8, and ‘process’ contained 13. There were two concentrated periods of the implemented strategies, the number was 17 in 2007 and 10 in 2016. These concentrated periods preceded a remarkable increase in the number of patient safety reports. Conclusions A safety culture had been fostered in FHUH in the study period. A relationship between number of strategies and development of a reporting culture was observed. The intensity of adequate strategies was needed for implementation of patient safety reporting system. Therefore, the implementation framework is useful for analysing patient safety initiatives for safety culture.
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Abstract Background While significant strides have been made in health research, the incorporation of research evidence into healthcare decision-making has been marginal. The purpose of this paper is to provide an overview of how the utility of health services research can be improved through the use of theory. Integrating theory into health services research can improve research methodology and encourage stronger collaboration with decision-makers. Discussion Recognizing the importance of theory calls for new expectations in the practice of health services research. These include: the formation of interdisciplinary research teams; broadening the training for those who will practice health services research; and supportive organizational conditions that promote collaboration between researchers and decision makers. Further, funding bodies can provide a significant role in guiding and supporting the use of theory in the practice of health services research. Summary Institutions and researchers should incorporate the use of theory if health services research is to fulfill its potential for improving the delivery of health care.
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Presentation The Centers for Medicare and Medicaid Services (CMS) provide healthcare coverage for 100 million people and, particularly through provisions of the Affordable Care Act, the agency strives to improve care and to ensure coverage for all Americans. Government agencies like CMS need processes that encourage improvements in value and outcomes and reduce variation in quality, and yet have been slow to embrace quality improvement (QI) methods. With QI, the agency could be more effective in partnering with providers to achieve “triple aim” outcomes of improving patient experiences with health care, improving population health, and reducing percapita health care costs [1]. Most CMS work proceeds through contracts that specify actions and on-time deliverables (such as supplies or helpdesk services). Similarly, contracts to “Quality Improvement Organizations” (QIOs) typically require that an “evidence-based” intervention be applied in a certain number of clinical settings – not that the intervention be tested further and adapted to the local context, or even that a particular outcome be achieved. Such contracts are eminently auditable, an important fact in the scrutiny of government contracting by CMS, Congress, the press, and others. Translating efficacious interventions into effective health care processes and outcomes at a local level ordinarily requires iterative, exploratory testing and adaptation, which is the core of QI. CMS’s traditional purpose has been to pay the bills and uphold the “standard of care”; it generally does not issue research grants that allow exploration of novel implementation approaches. Although CMS has not historically been at the forefront of QI methods, the agency’s position is simultaneously changing to adopt QI and encountering challenges along the way. Key points: • Implementation of evidence-based interventions with strict fidelity to the research protocol is often an ineffective strategy; testing and adaptation are usually necessary for optimal implementation and for scaling up. • Quality improvement methods such as statistical process control (SPC), frequent and repeated measurement, rapid-cycle testing of interventions and strategies, and qualitative insights about causal chains and effectiveness are powerful implementation tools that could work better to achieve program goals than implementation of rigidly specified interventions. • Writing an auditable contract for these approaches poses challenges. • Strategic partnerships between QI researchers, QI leaders, and government staffers/officials might be effective in promoting familiarity with QI methods and structuring contracts to allow for integration of QI methods while meeting audit and evaluation needs.
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Washington State has been a national leader in efforts to improve the workers' compensation (WC) health care delivery system. In 2002, the WA Department of Labor and Industries (DLI) initiated a major system intervention to improve quality and outcomes in WC health care. Two Centers of Occupational Health and Education (COHE) were developed as pilot sites to test the intervention, which included physician financial incentives to reward the adoption of occupational health best practices, improved care coordination, use of evidence-based protocols to improve clinical care, and development of patient tracking systems. We conducted a rigorous evaluation to determine whether COHE patients, compared with non-COHE comparison group patients, had reduced work disability and decreased disability and medical expenditures (n = 105,607). Throughout the 8 years of evaluation, the research team worked closely with statewide and local COHE advisory groups to maintain critical support for the initiative. The evaluation showed the COHE was associated (p < 0.001) with: (1) a 30% decrease in the likelihood of long-term (one-year) disability, (2) a reduction of 4 disability days per case, and (3) a decrease of $267 in disability costs per claim (and non-significant reduction in medical costs). These evaluation results, coupled with the strong advisory group support, led to the passage of a state law in March 2011 expanding the COHE on a statewide permanent basis, with over 1,800 physicians now participating in the expanded COHE network. Our research demonstrates the importance of: (1) evaluators working closely with key stakeholder groups to engender critical support for a system intervention and to help overcome political opposition that may arise, (2) conducting rigorous evaluation research to determine the effects of the system intervention, and (3) where possible reducing the administrative burden of physicians.
Funding for the COHE system.
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Following publication of the original article [1], the authors reported an error in one of the authors' names. In this Correction the incorrect and correct author name are shown. The original article has been corrected.
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