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Welcome to EBBP.org's course on the implementation of evidence-based practices.
Upon completion of this learning module you will have:
Evidence-based behavioral practice: making decisions about how to promote healthful behaviors by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected.
How exactly do practitioners and their institutions or organizations go about implementing evidence-based practices?
What can be done to ensure they have access to information about evidence-based interventions?
What can be done to assure they possess the knowledge, skills, and means to implement the interventions successfully?
The answers to these questions can be found in implementation science.
Questions and barriers to implementation may arise at multiple levels of healthcare delivery: the patient level, the provider team or group level, the organizational level, or the market/policy level.
Upon completion of this learning module, you will have:
Take a moment to review what an evidence-based practice is and what considerations go into effectively implementing an intervention.
For more information, or to review more about the steps of the EBBP process, try the EBBP Process Module at http://www.ebbp.org/training.html
While an expert panel outside your organization might rate an intervention as having a ―gold standard level of evidence supporting its use, stakeholders within your organization may have an entirely different perception of that same evidence.
The implementation process is very similar to the EBBP process, with activities that can be revisited, expanded, refined, and re-evaluated throughout the course of the process. These essential activities(1) are:
The first step of implementation, Plan, is conceptually very similar to the first three steps of EBBP: Ask, Acquire, and Appraise.
Evidence-based interventions begin with three key steps:
Critically appraise the evidence for validity and applicability to the problem at hand.
Similar to the first three steps of EBBP, the implementation process involves planning a course of action to promote effective implementation. During the Plan activity, you should:
Appraise those implementation strategies to determine what aspects will work in your setting and what elements may need to be adapted.
When conducting a critical appraisal of an implementation strategy, there are certain elements you should be sure to review:
How rigorous were the monitoring and evaluation methods used to track progress toward goals and milestones?
During the Apply step of EBBP, evidence is applied by engaging in collaborative health decision-making.
With implementation, you are engaging the communities, institutions, organizations, etc., that will be impacted by the process of implementing the intervention.
Just as certain factors need to be taken into account during the Apply step for EBBP, there are factors that can affect the execution of an intervention‘s implementation. These factors include:
The final step of evidence-based behavioral practice is Analyze and Adjust, in which intervention outcomes are assessed and certain aspects are adjusted. Evaluating the implementation process has the same objective.
Results are measured against objectives developed in the planning stages that are specific, measurable, attainable, relevant, and timely (SMART).
The four essential activities of implementation were developed by Laura J. Damschroder and colleagues as the fifth domain in The Consolidated Framework for Implementation Research (CFIR). The CFIR is a comprehensive framework that includes common constructs from a broad array of published implementation theories.
Constructs are organized into five major domains: intervention characteristics, outer setting, inner setting, characteristics of individuals involved, and the process of implementation. While this course will focus mainly on the fifth domain, the process of implementation, it is important that you are familiar with all five.
Things to consider when examining the characteristics of an intervention:
How much will the intervention cost to implement?
Node 1: Patient needs and resources
Node 2: Networking and peer pressure
Node 3: External policies and incentives
Public or benchmark reporting
An organization‘s readiness to implement an intervention can be determined by several factors, such as its structural characteristics and internal networks.
Node 1: Structural characteristics
Node 2: Networks and communications
Node 3: Culture and implementation climate
―People are not passive recipients of innovations. Rather they seek innovations, experiment with them, evaluate them, find—or fail to find—meaning in them, develop positive or negative feelings about them, challenge them, complain about them, ‗work around‘ them, gain experience with them, modify them to fit particular tasks, and try to improve or redesign them – often through dialogue with other users.
Greenhalgh, T., et al. (2004). Diffusion of innovations in service organizations: systemic review and recommendations. The Milbank Quarterly, 82(4), 581–629.
Node 1: Knowledge and beliefs about the intervention
Node 2: Self-efficacy and stage of change
Node 3: Individual identification with organization
How individuals perceive the organization and their commitment to the organization may affect their willingness to fully engage in implementation efforts or use an intervention.
This course will focus mainly on the fifth domain of the CFIR, the process of implementation:
The four essential activities of the implementation process are:
Evaluate: gathering and analyzing quantitative and qualitative feedback about the progress and quality of implementation
Take a few moments to look at the genesis of the Project Educare program:
Node 1: The Idea
Node 2: The Funding
Node 3: The Current Team
As you begin planning the implementation of Project Educare, you meet with your team to discuss possible options for developing a training course that can reach clinical mental health counselors throughout the state and educate them on how to implement evidence-based practices for the treatment of children and adolescents.
Surveys from the in-person trainings along with follow-up communications with some participants indicated that clinicians had more favorable attitudes toward EBP and were implementing EBP practices with more confidence after attending the trainings. However, conducting similar in-person trainings statewide is simply not feasible, given the size of your team and budget.
Each of your team members has an opinion about how the in-person trainings can be adapted for Project Educare.
Your team has come up with a few options for how to present the curriculum from the in-person training to a statewide audience.
Help your team choose the option that best meets your initial intervention goals by reviewing each one and considering the pros and cons.
Implementation leaders can help generate support and encourage uptake of an intervention, as well as provide valuable input. These individuals can positively influence the opinions of their colleagues and peers, serve as role models, and actively champion the intervention.
You and your team have given some thought to what characteristics will distinguish the implementation leaders for this initiative, and you have chosen the following criteria:
Node 1:Subject matter expertise
Experts on the content can help your team adapt the materials you have for the online format and ensure that the information remains clear and correct.
You and your team decide it would be beneficial to contact someone from the state's DMH Child and Adolescent task force on evidence-informed practices who can put you in contact with participating program directors, providers and parents.
Gathering input from the people who will be most impacted will help you generate a final course that will be meaningful to all members of your target audience.
Node 2:E-learning development expertise
Converting instructor led activities into an online format can be challenging. You will want someone with experience in this, as well as someone who can provide ideas for how to create a final product that is as interactive and engaging as the in-person training
If it's decided that discussion boards or video excerpts of expert trainers should be included, you will want someone who knows how best to integrate these types of elements into the overall online experience.
Node 3: Stakeholder experience/influence
Stakeholders with experience and influence will be able to exert that influence through authority, status, and credibility, encouraging other clinicians to participate by setting the right example.
You will want to look for people who are enthusiastic about the goals of the training and who ideally have formal or informal influence on the attitudes and beliefs of their colleagues. Those who have the ability to exert influence through either their authority and status or representativeness and credibility can be recruited as implementation leaders.
Another important factor to consider is the individual's leadership style. A leader with a more proactive approach will likely spend more time encouraging the implementation.
Node 4: Available time of the stakeholder
This project will require a varying amount of time and effort from your stakeholders. Those who you will look to as implementation leaders must have the availability to commit their time.
Node 5: Available time of the stakeholder
Some implementation leaders may be able to volunteer, while others may require reimbursement for their time. This factor should be taken into careful consideration, as your team is on a tight budget.
Node 1: Concept
Node 2: Funding
Node 3: Current Team
An important part of planning an intervention is reviewing the available evidence. Your team has discovered several studies, reviews, and articles that seem pertinent to your project to develop a high impact, in-person training program.
Based on the research you've found, your team has developed some basic options for the Evidence-Based Training Initiative. Take a moment to review the chosen options shown on the screen.
Basic options for the Evidence-Based Training Initiative (EBTI):
Once initial training is complete, each mental health agency will assign a supervisor to meet with other agency providers every two weeks about implementing evidence-based practices with their patients.
Your team has also decided to use the Fixsen implementation model as a basis for EBTI. You meet with your team to discuss Fixsen and the evidence-based practices you want to teach.
Node 1: Carlos, a university professor
―There are core implementation components we will want to focus on as we plan and carry out our implementation efforts. The first few I found in the Fixsen implementation model are staff selection and pre-service and in-service training. As we select the agencies we are going to work with, we‘ll need to develop a process to determine how many personnel they will commit and what sort of experience those participants should have.
Node 2: Gary, a community mental health provider
―Fixsen also recommends that we provide ongoing consultation and coaching. We will need to determine what the consultation will look like, who will be responsible for it, and how it should happen. How are we going to select the experts who will conduct this training and provide continuing support
Node 3: Alexis, a parent representative
―We need to consider how we will evaluate our progress and the quality of our implementation efforts as well. How do we want to assess the use and outcomes of the evidence-based practices we'll be teaching during the training and reinforcing during the consultation and coaching process?
You and your team have chosen the following criteria for selecting participating agencies:
Agencies with influence will be in a better position to lead other organizations by example, and may be able to disseminate the training further than agencies with little influence.
Participants with more experience treating children and adolescents will be in a better position to understand, apply, and teach others than clinicians with comparatively little experience in the field. Because evidence-based practices will be further disseminated throughout the agencies by those trained, it is important that the participants be dedicated and have the necessary background to conduct the training appropriately. Node 3 Availability of participating clinicians This project will require a considerable time commitment, and both the trainers and participating clinicians must have the availability to attend the trainings. Participating clinicians who will act as supervisors will need to be available to meet with their colleagues every two weeks about implementing evidence-based practices with their patients and to lay the groundwork for training new staffers in the future. Node 4 Budget impact Consider whether the agency qualifies for a fellowship to cover expenses and whether they have the budget to support any additional expenses, like compensating clinicians for their time or upgrading videoconferencing equipment to ensure they can participate in all segments of the training. Node 5 Commitment to further dissemination Agencies that currently partner or plan to partner with a training university will be able to disseminate the training to students, broadening the intervention‘s reach. Participating agencies should also plan to disseminate the training to additional staff once the participating clinician or clinicians are sufficiently trained, to ensure that the message of EBTI reaches as many clinicians as possible. Plan Engage Execute Evaluate
Participants with more experience treating children and adolescents will be in a better position to understand, apply, and teach others than clinicians with comparatively little experience in the field.
Because evidence-based practices will be further disseminated throughout the agencies by those trained, it is important that the participants be dedicated and have the necessary background to conduct the training appropriately.
Availability of participating clinicians
This project will require a considerable time commitment, and both the trainers and participating clinicians must have the availability to attend the trainings.
Participating clinicians who will act as supervisors will need to be available to meet with their colleagues every two weeks about implementing evidence-based practices with their patients and to lay the groundwork for training new staffers in the future.
Consider whether the agency qualifies for a fellowship to cover expenses and whether they have the budget to support any additional expenses, like compensating clinicians for their time or upgrading videoconferencing equipment to ensure they can participate in all segments of the training.
Commitment to further dissemination
Agencies that currently partner or plan to partner with a training university will be able to disseminate the training to students, broadening the intervention‘s reach.
Participating agencies should also plan to disseminate the training to additional staff once the participating clinician or clinicians are sufficiently trained, to ensure that the message of EBTI reaches as many clinicians as possible.