Theories in implementation science Michel Wensing

Transcription

1 Theories in implementation science Michel Wensing Professor at Radboud University Medical Centre Primary care research coordinator Editor in chief of Implementation Science

2 Outline Introduction Theories in implementation science Behaviour change psychology Diffusion of innovations Economic market theory Normalisation process theory Organizational readiness Concluding remarks

3 From bench to bed or bookshelf??

4 IMPLEMENTATION A planned process and systematic introduction of innovations and/or changes of proven value; the aim being that these are given a structural place in professional practice, in the functioning of organisations or in the health care system ZonMw 1997

5 Key questions in implementation science 1. How is the knowledge made available to physicians and other decision makers? knowledge 2. Which decisions and actions in healthcare practice and health policy are evidence-based? current practice 3. Which interventions and policies contribute to better implementation of recommended practices? strategies 4. How can improvement be organized, regulated, and funded? sustainable improvement

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7 Theory: A system of ideas or statements held as an explanation or account of a group of facts or phenomena ICEBerg. Designing theoretically informed implementation interventions. Implem Sci 2006;1:4.

8 Why bother about theory? 1. To guide the choice of hypotheses, measures, interventions and data-analysis in research 2. To develop knowledge in a systematic way, which is more efficient than non-systematic methods 3. To make research evidence accessible for practical use in an accessible way ( nothing is so practical as a valid theory ) 4. There is always theory, even if not explicitly stated or explicitly rejected thus it is better to be transparant about it

9 Theories in implementation science

10 Some popular theories in implementation science Guideline implementability framework: how guideline characteristics influence uptake (Gagliardi) Theoretical Domains Framework: how individuals change their behaviour (Michie) Diffusion of innovations theory: how innovation spread in social networks through contagion (Rogers) Normalisation Process Theory: how innovations become accepted and integrated in routine procesess (May) Standard economic market theory: how price and transparancy influences volume (Smith) Organizational readiness theory: how organisation is prepared for implementation (Weiner)

11 Some popular theories Guideline implementability framework: how guideline characteristics influence uptake (Gagliardi) EVIDENCE Theoretical Domains Framework: how individuals change their behaviour (Michie) COGNITIONS Diffusion of innovations theory: how innovation spread in social networks through contagion (Rogers) NETWORKS Normalisation Process Theory: how innovations become accepted and integrated in routine procesess (May) CULTURE Standard economic market theory: how price and transparancy influences volume (Smith) INCENTIVES Organizational readiness: how organisation is prepared for implementation (Weiner) SYSTEMS

12 TICD checklist of determinants of practice Based on comprehensive analysis of 12 comprehensive frameworks, theory syntheses, planning models Focused on barriers and enablers of change of professional practice or organisation of care Includes 57 concepts in 9 domains Flottorp SA, Oxman AD, Krause J, Musila NR, Wensing M, Godycki Cwirko M, Baker R, and Eccles MP. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implem Sci 2013

13 Theoretical Domains Framework Summarizes behavior change psychology in 14 concepts: Knowledge, skills, social/professional role and identity, Beliefs about capabilities, optimism, beliefs about consequences, intentions, goals Memory, attention, decision processes, Environmental context and resources, social influences, reinforcement Emotions, behavioural regulation Cane et al. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implem Sci 2012;7:37.

14 Behavior change wheel (Michie 2011) Michie et al. The behavior change wheel: a new method for characterising and designing behaviour change interventions. Implem Sci 2011;6:42.

15 Example: blood transfusion behaviors Qualitative interviews with intensive care physicians at 10 hospitals in Canada: Seven TDF domains populated by 31 specific beliefs, such as: Confident not to transfuse if patient stable (belief about capabilities) It requires more evidence to support restrictive transfusion (knowledge ) Conflicting beliefs about not adhering to guidelines (Social/professional role and identity) Islam et al. A cross country comparison of intensive care physicians beliefs about their transfusion behavior: a qualitative study using the theoretical domains framework. Implem Sci 2012;7:93.

16 Strengths and weaknesses Strengths Makes relevant psychology theory accessible for wider audience Overcomes terminology problems Growing body of empirical studies related to TDF Weaknessess Involves psychology of decision making superficially (Brehaut 2012) Ignores behavoural routines (Nilsen 2012) Lumps contribution from sociology, economics and related sciences into one domain environmental influences

17 Diffusion of innovations theory (Rogers) Broad sociological theory: Key concepts: segments in target population (innovators, early adapters, early majority, late majority, laggards) attributes of innovations that contribute to diffusion (complexity, adaptability, triability, compatibility, ) Key individuals: change agents and opinon leaders S-shaped diffusion curve (note: tipping point) Rogers EM. Diffusion of innovations. Firstsecond-third edition. New York: The Free Press, 1995.

18 Strenghts and weaknesses Strengths: Makes sense intuitively Long history of related research in different fields Link to social network analysis Weaknesses: Modern information technology has changed the world Few interventions based on this theory

19 Standard economic theory Economic theory of the firm: Volume of any activity is determined by the price of its outputs and costs of its production In a perfect market, price and costs are the same in the long run (prices can be higher than costs in non-perfect or new markets) Under specific conditions, the perfect markets provides the best outcomes for society

20 Example: pay for performance in general practice Analysis of patient record data from 148 practices in the UK, focusing on 23 incentived actions and 19 non-incentivised actions Improvements on most indicators before incentives started Accelerated improvements for most incentivised actions in first years, plateau after 3 years No improvements on non-incentivised actions Doran et al. Effect of financial incentives on incentivised and non incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework. BMJ 2011;342.

21 Strenghts and weaknesses Strengths: Long history and broad range of applications Specific, quantifiable hypotheses Strong support in empirical research Weaknesses: Assumption of rational decision making is contested Perfect markets hardly exist, particularly in healthcare Quality and equity may conflict with market mechanisms

22 Normalisation Process Theory Theory based on constructivistic social science: Focus on action, behaviors, what people do, work (rather than culture, attitude, knowledge, organizations, societies, etc.) Key concepts: coherence of intervention, cognitive participation of target group, collective action to implement innovation, reflexive monitoring regarding use of innovation Focus on uptake on relapse prevention (normalization, sustainable improvement) May CR et al. Development of a theory of implementation and integration: Normalization Process Theory. Implem Sci 2009;4:29.

23 Example: implementing stepped care for depression in primary care Semi-structured group interviews with GPs and others (n=80) Wide range of potential determinants of implementation identified NPT concepts coherence and cognitive participation seemed most relevant Some NPT sub-concepts could not clearly be separated in the analyses of these interviews Franx et al. Implementing a stepped care approach in primary care. Implem Sci 2012; 7:8.

24 Strenghts and weaknesses Strengths: Makes constructivistic social science accessible for wider audience Derived from empirical research (on telemedicine) Different from other theoretical perspectives Weaknesses: Sensiziting qualities of NPT concepts is the eye of the beholder Focused on finding specification rather than falsification No clear perspective on interventions

25 Organizational readiness for change From organizational science: Readiness for change is a characteristic of organizations and concerns the shared views of organisations members It covers change committment and change efficacy ( willing and able ) It influences likelihood to initiate change, level of effort, persistence, and cooperativeness of behaviors Weiner B. A theory of organizational readiness for change. Implem Sci 2009;4:67.

26 Strengths and weaknesses Strengths Makes system theory specific and testable Relates to managers experience Has raised high interest Weaknesses Are organizations indeed organic units? Research evidence? Clinical relevance?

27 Types of theories Impact theories: describe hypotheses and assumptions about how a specific intervention will facilitate a desired change, as well as the causes, effects, and factors determining success (or lack of it) in improving health care Process theories: describe how implementation activities should be planned, organized, and scheduled in order to be effective (the organizational plan) and how the target group will utilize and be influenced by the activities (the utilization plan) Grol R, Bosch M, Hulscher M, Eccles M, Wensing M. Planning and studying improvement in patient care: the use of theoretical perspectives. Milbank Quaterly 2007;85:

28 Concluding remarks Consider a broad range of theories to avoid narrow vision Consider research evidence Realize that no theory has been able to predict much of human or organizational performance Realize also that non-theoretical approaches are not better, and probably less good

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