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Implementation science and translational public health. Faculty of Medicine Department of Community Medicine Dr Sudabeh Mohamadi. Introduction. Implementation science:
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Implementation science andtranslational public health Faculty of Medicine Department of Community Medicine DrSudabehMohamadi
Introduction Implementation science: • the study of strategies undertaken to implement evidence-based technologies, services, diagnostics, or therapeutics (referred to henceforth as ‘healthcare interventions’) in ‘real-life’ populations and contexts.
The subject of study, as described by the National Institutes of Health (NIH), is the implementation method itself or the ‘strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings’.
‘Implementation research is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services and care’.
The primary aim of implementation science is an optimistic one—focused on finding the opportunities to improve health and healthcare for all populations where gaps in care currently persist.
The goal of implementation science is not only to inform policymakers that create guidelines and new regulations, but also to examine how and why these guidelines, policies, and regulations too often fail at the front lines of service delivery.
Preventive health technologies, including ARV medications, can now reduce the risk of perinatally acquired HIV from approximately 25 per cent to less than 2 per cent.
The purpose of implementation science is to study the myriad approaches to implementation that are taken with any given healthcare technology or service with the goal of understanding how to close gaps between ‘what we know’ (evidence-based interventions) and ‘what we actually do’ at the front lines of healthcare.
The audiences for this evidence on implementation strategies are policymakers, programmemanagers, health system designers, and global health practitioners. • But, most importantly, the audience is the front-line healthcare workers who seek to more rapidly and reliably deliver the fruits of modern medical science to their patients every day.
While this image locates implementation science in the third translation, we would argue that the study of implementation is also salient to the fourth translation, ‘to population health’.
Implementation science as a science • Parallel investment in the study of implementation in health systems will ensure that all patients can reap the benefits of clinically meaningful new technologies.
Origins of implementation science • Implementation science shares both quantitative and qualitative analytic traditions as part of its history.
W. Edwards Deming’s system of profound knowledge lies at the heart of the implementation intellectual tradition. • This system has four central aspects: • understanding of systems • understanding of variation • theory of knowledge • psychology of change
The NIH notes that implementation science fundamentally, ‘seeks to understand the behaviour of healthcare professionals and support staff, healthcare organizations, healthcare consumers and family members, and policymakers in context as key variables in the sustainable adoption, implementation and uptake of evidence-based interventions’
Theory of knowledge = Epistemology • Study of how we know things
In general, the objectives of monitoring and evaluation programs and implementation are similar: • to understand what is working well, what is not working, and why.
However, most monitoring and evaluation activities necessarily focus on measuring the services provided rather than on the barriers to implementation.
The scientific rigor of implementation research broadens the scope of monitoring and evaluation activities to understand the etiology of gaps between expected results and observed outcomes.
despite similarities in objectives and data sources to routine programmemonitoring, implementation science remains foremost a rigorous hypothesis-driven investigational activity.
The problems of the new discipline The study of implementation is complicated by four important problems. These are the problems of: • Scale • Context • Methods • Overconfidence
The problem of scale • The global public health literature is replete with studies of small-scale implementation where a particular problem is addressed using a well-resourced, robust implementation strategy that produces a successful ‘pilot’ result under study circumstances.
This now ‘evidence-based’ intervention is then appropriately selected by practitioners and policymakers to be replicated elsewhere. Yet, as the intervention is spread and implemented in multiple different contexts, facing different constraints, and without the carefully controlled study circumstances of the pilot study, the intervention’s results are often not replicated.
Rapid response systems (RRS): • clinical interventions designed to provide an earlier bedside response in the hospital setting to a patient’s changing haemodynamics and to nursing, patient, or family concerns about changes in the patient’s condition.
The problem of context • Scaling up requires an accounting of how social, economic, and political contextual details might exert as much influence on uptake of an intervention as the specific details of the healthcare technology itself
As the implementation context varies further from the context of the original efficacy study, the chances of implementation success may diminish further.
Healthcare organizations are themselves constantly changing which may influence the uptake of an intervention. • In order to better inform service delivery, ongoing evaluations of implementation effectiveness will need to provide implementers with real-time continuous feedback on how they are changing to affect outcomes.
The problem of method • Methods for studying the variety of approaches that may be taken to implement a new diagnostic technique or therapeutic across heterogeneous contexts remains scarcely documented.
Only a small fraction of the studies appearing in the journal describe implementation studies from resource-limited contexts.
The problem of overconfidence and unintended variation • The principles of authority, autonomy, and independent responsibility for services to the individual patient are deeply embedded in the psychology of the practitioner and in the psychology of many patients who seek the expert counsel of their doctors.
Physician decisions are influenced by: • their peers • their patients • their professional societies
Implementation science study design The core elements of study design: • understanding the subject of study • identifying the primary research question • planning measures • selecting the format for the study including considerations of control groups and strategies for eliminating bias
These are not unique to implementation science studies, but in the context of studying implementation they do have unique features.
Understanding the subject of implementationscience: the approach to implementation • The units of study may be individual patients, but more often the units of study are health facilities, hospital wards, health districts, or geographic populations.
As a clinical researcher studies new interventions and tries to characterize and control for the variability between individual patients, the implementation scientist studies new approaches to provide an existing technology and tries to characterize and control for variability between units of study (health facilities, hospital wards, health districts).
A non-exhaustive list of examples of implementation approaches might include: 1. Executive mandate—the quintessential top-down approach where a chief executive requires, or mandates, a group of individuals, an organization, or a geopolitical entity to implement a healthcare intervention.
2. Guidelines (‘clinical practice guidelines’)—practice recommendations developed by a discipline’s governing academic society or group of expert practitioners. • Guidelines are often amalgamated from the clinical trials results and are thus referred to as being ‘evidence based’.
3. Clinical protocols or pathways—based on clinical practice guidelines and standards, but locally adapted: step-by-step translation of the guidelines • Protocols or pathways often are represented as flow charts, algorithms, or other similar diagrams.
4. Training—an important implementation approach that focuses primarily in providing knowledge to clinicians, healthcare workers, patients, and families.
5. Task shifting—often the approach to improvement may involve changing the types of personnel or locale where a health technology is provided.
6. Checklists—a tool which provides a simplified visual reminder of aspects of a clinical protocol or pathway. • Checklists are designed to improve consistency and reliability of implementation.
7. Campaigns—public health campaigns have been used to spread evidence-based clinical practices to a large region.
The 3 by 5 Initiative was an initiative of the World Health Organization (WHO) to provide antiretroviral treatment to patients with HIV/AIDS in low- and middle-income countries. The program lasted from December 2003 to December 2005, and the name "3 by 5" refers to the goal of treating 3 million people by 2005.
8. Laws and regulation—National governments can legislate the right to basic primary healthcare services for their citizens as a primary method for implementation.
9. Pay-for-performance and use of incentives and penalties—to improve implementation consistency and reliability. • ‘Payment’ can come in many forms including financial and public recognition.
10. Process improvement—derived from management sciences, views dynamic healthcare systems as complex processes which can be systematically improved using a combination of tools to diagnose system failures (e.g. process maps), an incremental problem-solving approach (e.g. Plan–Do–Study–Act cycles), and time-series measurement and evaluation techniques.
Box 6.9.1 The quality improvement approach • The quality improvement (QI) approach is an implementation method that is grounded in operations research and management science, two well-established fields that have combined the disciplines of statistics, psychology, systems engineering, and iterative learning, to have major impacts on systems performance across countries and industries.
QI seeks to design systems for maximum effectiveness, efficiency, and adaptability and to actively disseminate the best models for health service delivery at a rapid rate.
