umu.sePublications
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
The role of implementation science in healthcare improvement efforts: investigating three complex interventions
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2018 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Implementeringsvetenskapens roll i hälso- och sjukvårdens förbättringsarbeten : undersökning av tre komplexa interventioner (Swedish)
Abstract [en]

For decades, scholars have found significant gaps between the knowledge available and the knowledge applied in healthcare. Many potential benefits of adequate knowledge based interventions are therefore never achieved. A considerable body of knowledge has evolved on how to promote a better uptake of evidence-based knowledge into routine use. Even so, the actual impact and usefulness of implementation research findings among healthcare practitioners have not been extensively studied.

Accordingly, the overall aim of this thesis is to contribute to the understanding of how the implementation of complex interventions into healthcare can be improved. This is done by investigating whether some of these efforts do correspond with available scientific knowledge on implementation.

The thesis is based on three cases contributing to four studies. The cases studied are: the National Perinatal Patient Safety program (NPPS), the Dynamic and Viable Organisation initiative (DVO), and the International Child Development Program (ICDP). All studies focuses on the early stages of implementation.

A mixed methods approach was adopted, involving both qualitative and quantitative methods. Data collection consisted of interviews, questionnaires, observations, and process diaries. Qualitative content analysis (conventional and directed), descriptive and non-parametric statistics were used. The focus was on implementation strategies used by healthcare actors in relation to factors influencing implementation processes and outcomes. More specifically, healthcare actors perspectives on such factors and whether they were addressed by the strategies used, was investigated. A process evaluation of implementation outcomes was also part of the thesis.

The healthcare actors in focus were the adopters, i.e. practitioners expected to change their work practices, and implementation facilitators. The latter refer to actors with a more or less explicit responsibility to implement new practices or interventions aimed at improving the quality and effectiveness of the provided health services.

Variation was found regarding how the implementation strategies used in the three cases corresponded with available scientific knowledge on implementation. In Case NPPS, the implementation facilitators planned, designed, and ensured that the core interventions of the implementation strategy were executed in a rational manner. Several important implementation factors were addressed by the strategy. The process evaluation of effects on readiness for change by the development of a team mental model among adopters showed positive results.

In Case DVO a strategy was used that evolved over time, partly based on raised questions and feedback from staff and managers involved. The strategy can be described as an intuitive ‘socially accomplished activity’. This strategy involved addressing ‘Implementation Process-related factors’ in order to affect motivation and increase the tension for change among adopters.

In Case ICDP, the results reflected a shortage of strategies during the early stage of implementation. The main intervention was the stepwise ICDP-education. A more comprehensive implementation strategy covering implementation factors highlighted as important among adopters was not developed. The process evaluation revealed vague directives on what was expected regarding the use and adaptation of ICDP to current practice versus preservation of fidelity to the original ICDP. This situation resulted in a rather large variation in how the changes in work practices were perceived among the health centres involved. No health centre practiced ICDP in its original form.

A new knowledge-practice gap is discussed based on the findings in this thesis: a gap between the scientific knowledge on implementation and the actual implementation strategies used in practice during improvement efforts initiated by healthcare actors. The findings show that correspondence between scientific knowledge on implementation and what is actually done in order to accomplish change in practice might be more random (or implicit) than systematic. The question of how to transfer scientific knowledge on implementation into user-friendly resources for practitioners is discussed. A tentative model is suggested, which contributes to existing determinant frameworks by focusing on relations among factors. The model may be used in healthcare practice, to guide the design of an implementation strategy (or as a pathway for tailored implementation interventions) and aid the assignment of responsibilities in relation to factors that are known to affect implementation processes and outcomes.

The question of how to transfer models and frameworks into user-friendly resources needs further attention. It is suggested that action oriented research aiming at further developing and establishing the concept of ‘practical implementation science’ should be conducted. This could be a way of bridging the knowledge-practice gap in healthcare.

Place, publisher, year, edition, pages
Umeå: Umeå University , 2018. , p. 87
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1959
Keywords [en]
healthcare improvement, knowledge-practice gap, implementation science, complex interventions, implementation strategy, change facilitation, case studies
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health; hälso- och sjukvårdsforskning
Identifiers
URN: urn:nbn:se:umu:diva-146509ISBN: 978-91-7601-872-9 (print)OAI: oai:DiVA.org:umu-146509DiVA, id: diva2:1198344
Public defence
2018-05-09, Hörsal D, Unod T9, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2018-04-20 Created: 2018-04-17 Last updated: 2018-06-09Bibliographically approved
List of papers
1. Healthcare system intervention for prevention of birth injuries: process evaluation of self-assessment, peer review, feedback and agreement for change
Open this publication in new window or tab >>Healthcare system intervention for prevention of birth injuries: process evaluation of self-assessment, peer review, feedback and agreement for change
Show others...
2012 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 12, article id 274Article in journal (Refereed) Published
Abstract [en]

Background: Patient safety is fundamental in high quality healthcare systems but despite an excellent record of perinatal care in Sweden some children still suffer from substandard care and unnecessary birth injuries. Sustainable patient safety improvements assume changes in key actors' mental models, norms and culture as well as in the tools, design and organisation of work. Interventions positively affecting team mental models on safety issues are a first step to enhancing change. Our purpose was to study a national intervention programme for the prevention of birth injuries with the aim to elucidate how the main interventions of self-assessment, peer review, feedback and written agreement for change affected the teams and their mental model of patient safety, and thereby their readiness for change. Knowledge of relevant considerations before implementing this type of patient safety intervention series could thereby be increased.

Methods: Eighty participants in twenty-seven maternity units were interviewed after the first intervention sequence of the programme. A content analysis using a priori coding was performed in order to relate results to the anticipated outcomes of three basic interventions: self-assessment, peer review and written feedback, and agreement for change.

Results: The self-assessment procedure was valuable and served as a useful tool for elucidating strengths and weaknesses and identifying areas for improvement for a safer delivery in maternity units. The peer-review intervention was appreciated, despite it being of less value when considering the contribution to explicit outcome effects (i.e. new input to team mental models and new suggestions for actions). The feedback report and the mutual agreement on measures for improvements reached when signing the contract seemed exert positive pressures for change.

Conclusions: Our findings are in line with several studies stressing the importance of self-evaluation by encouraging a thorough review of objectives, practices and outcomes for the continuous improvement of an organisation. Even though effects of the peer review were limited, feedback from peers, or other change agents involved, and the support that a clear and well-structured action plan can provide are considered to be two important complements to future self-assessment procedures related to patient safety improvement.

National Category
Health Sciences
Identifiers
urn:nbn:se:umu:diva-61987 (URN)10.1186/1472-6963-12-274 (DOI)000310146300001 ()2920327 (PubMedID)
Available from: 2012-12-12 Created: 2012-12-04 Last updated: 2018-06-08Bibliographically approved
2. Facilitating system-wide organizational change in health care
Open this publication in new window or tab >>Facilitating system-wide organizational change in health care
2015 (English)In: International Journal of Quality and Service Sciences, ISSN 1756-669X, E-ISSN 1756-6703, Vol. 7, no 1, p. 72-89Article in journal (Refereed) Published
Abstract [en]

Purpose: The purpose of this paper was to investigate the role of an intra-organizational change facilitating function (CFF) in relation to a multi-level development initiative in a health care organization. Involved actors’ views on factors in need of attention and how the CFF related to these factors were studied.

Design/methodology/approach: A longitudinal case study design was used, combining data from questionnaires, process diaries and interviews with employees at the CFF, managers and clinic staff.

Findings: Factors on micro, meso and macro levels, crucial to attend to, were highlighted by respondents at staff and managerial levels. The CFF related to some of these factors by acting upon them, or by developing plans to handle them, while other factors were unattended to. The CFF activities also had indirect influence on other factors. The CFF role and responsibilities were not clearly defined beforehand, and a need to clarify a division of roles and responsibilities is highlighted.

Research limitations/implications: Our study contributes to current knowledge on facilitation of change by relating it to an organizational dimension of implementation.

Practical implications: The description of important factors to handle during a large organizational change process and issues a CFF can encounter may aid others involved in designing and managing large organizational development initiatives.

Originality/value:The study elaborates on less studied functions and roles of an intra-organizational CFF in relation to factors of vital importance for organizational change and development in health-care organizations.

Place, publisher, year, edition, pages
Emerald Group Publishing Limited, 2015
Keywords
change management, health care, organizational development, quality improvement, change facilitation
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-112796 (URN)10.1108/IJQSS-01-2015-0004 (DOI)
Available from: 2015-12-14 Created: 2015-12-14 Last updated: 2018-06-07Bibliographically approved
3. Managing the initiation and early implementation of health promotion interventions: a study of a parental support programme in primary care
Open this publication in new window or tab >>Managing the initiation and early implementation of health promotion interventions: a study of a parental support programme in primary care
Show others...
2017 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 31, no 1, p. 128-138Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Mental health problems are increasing among children and adolescents worldwide, and parental support programmes have been suggested as one preventive intervention. However, the actual impact and low rates of adoption and sustainability of prevention programmes have proven to be a concern, and thus, further studies on their implementation are needed.

AIM: This study focused on the initial implementation of the International Child Development Programme (ICDP) in primary care. The aim was to investigate the involved actors' views on factors likely to affect implementation and the strategies used to manage them.

DESIGN: A case study design with a mixed-methods approach combining quantitative and qualitative data from questionnaires and interviews was used.

METHODS: Eighty-two professionals at different positions in the involved organisations participated. Directed content analysis was used for analyses, focusing on perceived levels of importance and the manifestation of implementation factors.

FINDINGS: Interviews and questionnaires provided descriptions of factors influencing the initial ICDP implementation. Uncertainty on how to manage important factors and vague change strategies was reported. Discrepancies in the perceived levels of importance versus manifestation were found regarding several factors, including hands-on support, time and resources, communication and information, a comprehensive plan of action, follow-ups, and external and internal collaborations. Manifested factors were a need for change, motivation and the ICDP's compatibility with existing norms, values and practices.

CONCLUSIONS: Implementing a parental support programme in a complex setting will benefit from being preceded by a thorough examination of the intervention and the target context and the development of clear implementation strategies based on the results of that examination. This study provides insights into how and by whom knowledge on implementation is applied during the launch of a health promotion programme, and these insights might help increase the rate of adoption and the use of such programmes and thereby increase their effectiveness.

Keywords
child health, health promotion, implementation, parental support programme, parent–child relationship, primary care
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-122412 (URN)10.1111/scs.12329 (DOI)000394988700014 ()27246248 (PubMedID)
Available from: 2016-06-17 Created: 2016-06-17 Last updated: 2018-06-07Bibliographically approved
4. Incorporating the International Child Development Program into child healthcare practices: evaluating how (well) knowledge turns to practice
Open this publication in new window or tab >>Incorporating the International Child Development Program into child healthcare practices: evaluating how (well) knowledge turns to practice
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-146511 (URN)
Available from: 2018-04-11 Created: 2018-04-11 Last updated: 2018-06-09

Open Access in DiVA

fulltext(2184 kB)198 downloads
File information
File name FULLTEXT02.pdfFile size 2184 kBChecksum SHA-512
ca65565d3639ee49954607c3e937ba3a8f8eace340390bf28181952dd30ec2695760d48d10605bc945ebf2d9051f9993cd21c50dbe95afe18a68b6d2e77db879
Type fulltextMimetype application/pdf
spikblad(583 kB)23 downloads
File information
File name FULLTEXT03.pdfFile size 583 kBChecksum SHA-512
9434cdca85850df7677b669fadbec7d283663c8d690d0076ee58f3f7d804ab0ff2061bad4117777cc9d52ccdd08ad0b6000efcb57a32b3df966fbefa40b4036b
Type spikbladMimetype application/pdf
omslag(90 kB)16 downloads
File information
File name COVER01.pdfFile size 90 kBChecksum SHA-512
cb1fb01b35ffa477cf1fa25baf964253bee109233dc42a141152e1fde64ce7f42ade0c8472db826524fd192e0f2dae09aad1e48e4f39cd5a11fa2ff148b6120e
Type coverMimetype application/pdf

Authority records BETA

Westerlund, Anna

Search in DiVA

By author/editor
Westerlund, Anna
By organisation
Epidemiology and Global Health
Public Health, Global Health, Social Medicine and Epidemiology

Search outside of DiVA

GoogleGoogle Scholar
Total: 222 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 2605 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf