Managing conditions for change when initiating interventions to change work practices in healthcare Anna Westerlund PhD student Umeå University Dep. of Public Health and Clinical medicine
Starting points Implementation issues are like gravity they are always present whether they are addressed or not Unfortunately, attempts to use evidence-based interventions or other innovations are often made without a lot of attention to implementation issues Consequently, 5-15% success rates are typical for interventions that rely on people interacting with other people (changing behaviour of practitioners who interact with intended recipients) Vernez G, Karam R, Mariano LT, DeMartini C. Evaluating comprehensive school reform models at scale: Focus on implementation. Santa Monica, CA: RAND Corporation, 2007.
The gap what we know and what we do The problems of transfer and realization of knowledge Interventions to improve quality of care From intervention to practice a challenge!
From intervention to practice a challenge! ~ potential answers?
(Model adapted from Greenhalgh T, Glenn R, MacFarlane F, et al. Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Q. 2004; 82: 581-629.) Motivation Prior knowledge Learning style Tension for change Readiness for change - Team mental models Implementation in health care what matters? Adopter related factors Professional teams and individual clinicians Managerial support Org. climate Resources and time Readiness for change Decision making structures Implementation process related factors Factors influencing implementation of innovations System related factors Health care organization Communication/information Hands-on support Plan of action External and internal collaboration Characteristics of the innovation itself Relative advantage Compatible values & practices Complexity of knowledge Possibility to adapt
Four studies - Three empirical cases Case 2 Study 2 and Study 3 The (county-wide) implementation of a parental support program (ICDP) in Västerbotten Study 2: Investigates involved actors perspectives on the contributions of implementation factors during an early phase of ICDP implementation and also to identify strategies used to address and manage these factors. Study 3: Investigates if, to what extent and why (why not) the initiative leads to changed work practices, these changes fidelity to the original program and to what degree new practices are sustained over time.
International Child Health Development Program = Vägledande samspel Universellt Hälsofrämjande basprogram Empatibaserat Sensitivisering och närvaro istället för instruktion Ej evidensbaserat! www.icdp.info Sherr L, Skar A-M, Clucas C et al. Evaluation of the Parental guidance program based on the International Child Development Program. Report to the Ministry of Children, Equality and Social Inclusion, Norway, 2011. 7
ICDP i Västerbotten Varför ICDP? Ökad psykisk ohälsa bland barn och unga. Behov av att utveckla det psykosociala stödet till föräldrar uttrycks från flera håll i länet Efterforskningar inom Salut och BHV vad är lämpligt? Landat i ett beslut om införande av ICDP Uppstart 2010 vid tio hälsocentraler Utbildning 2 nivåer = personal vid hc blir certifierade vägledare Mål att införliva ICDP i det ordinarie/befintliga föräldrastöd som erbjuds på hälsocentralerna
Implementing parental support (ICDP) in child health care Strategies used in relation to implementation factors perceived to be important to manage
Methods: Questionnaires Semistructured interviews - revolving round implementation factors Example from questionnaire:
Typical answer Study 1 Results
Implementing parental support (ICDP) in child health care Evaluation of the ICDP intervention s impact on child health care practitioners and their work practices Study 2
Study 2: Preliminary results Similarities between the core of ICDP and the traditional approach and work practices Large variation in how (well) the knowledge gained during ICDP education is transferred to the practical settings investigated - From rustrom teaching to open questions and vivid discussions. - Focus shifted from traditional content in parental support groups (such as safety and breastfeeding) to parent-child attatchment and interaction. - From silent and passive to active groups. - A developed consciousness among practitioners, regarding the significance of choice of verbal approach when interacting with parents.
Att reflektera kring: Komplex intervention - åstadkomma beteendeförändringar hos personalen (utveckla praxis) räcker utbildningsinsatsen? Hur VET man att kunskap omsätts i praktik? (Erbjuds föräldrar i Västerbotten ICDP nu?) Utvärdering kräver specifikation kring vilka beteendeförändringar som förväntas (när interventionen inte är glasklar)! Flexibilitet/anpassning versus trogen tillämpning by the book? Vad är bäst? Vid evidensbaserad intervention vad händer med evidensen om flexibilitet/anpassning tillåts? Möjlighet att stärka evidensen för t.ex. universella föräldrastödsprogram kan man då studera en anpassad version av interventionen?