Implementation Strategies and Toolkits

So step 2.3 week 5, is about -  Implementation strategies, and toolkits. Essentially it’s translating  knowledge into practice. The learning outcomes for this week are - by  the end of this brief presentation - you should   be able to describe a range of approaches for  translating knowledge into practice, I’ve just   given a few examples, describe how to create a  toolkit using those methodologies or approaches,   and explain why it’s important to actually  think about your dissemination strategy   when you start your research project,  and not just wait until the end. I have to say, that I found  this book incredibly useful   in thinking about dissemination of research.

So Trisha Greenhalgh professor in medicine has   looked at all the literature, and pooled it  together to help you understand how best to   implement your research idea into reality  - so strongly recommend this publication. So there was three methods that I really liked  in there, but that’s just my personal preference,   and you need to read the book to  really decide which ones you like,   but the first one was - Simple care bundles,  and this has been adopted internationally   by different health systems, and the idea for  each intervention you break into three to five   steps, or evidence-based practices, which  someone then can follow so it’s simple, concise.

So if we look at medication review, it  starts from checking the medicine choice   that’s given to a patient is evidence-based,   checking the patient’s renal and liver function,  checking appropriateness in the medicine then,   with regards to dose, frequency, duration,  discussing the medicine’s effectiveness with   the patient, addressing any concerns, and agreeing  an action plan, and that could be your five steps. Then under each of those steps maybe detailed  guidance as to what exactly that means,   but by presenting that way, it’s a manageable,  digestible structure for that intervention. RE-AIM was a framework that was actually  designed for developing interventions for   public health in the public health arena.

But you look at it, you can see that actually  it has all the different elements within it,   that we want within our implementation strategy. Makes us think about how do we get people  to adopt it? Makes you think about how to   ensure the information we want delivering,  is delivered to the expected standard?   How do we maintain it? How do we get  that information to all the people we   want to get to? And how do we check that  it’s actually working as we want it to? So it kind of gives you a structure,  then you need to think about - what   your approach is, it doesn’t tell you what  the approach is, that’s for you to decide.

But actually, by using all this this RE-AIM  framework, you can really think more carefully   about your dissemination approach, and  how you get your knowledge out there. The framework that’s most commonly used at the  moment, is the Knowledge to Action Framework,   and this is based on theory, and it has a centre  point where you develop the new knowledge,   and you synthesise it into something useful for  people to take on board, and you put the tools   associated with it, and all these things you will  have done in developing your complex intervention,   you’ll have standard operating procedures,  you might have checklists, you might have   questionnaires, but equally you have structured  guidance as to how to deliver your intervention.

And then what you do, you put it into an action  cycle, it’s a bit like the plan do act cycle,   but basically, the idea is the people who get  your knowledge, once they’ve decided to adopt it,   then work out how it fits into their system. What problems they’re trying to resolve,   as a result, of which parts of the  knowledge do they want to implement. Then hopefully you will give them  the guidance on how to adapt it. So these adaptations from your  process evaluation can be used   here to say these are things  you should, and shouldn’t do.

And then they look at what the barriers are, you  might want to give them the toolkit to do that   so they can think about - what is it  I really do need to take from this,   and what barriers have I got to overcome  in my local context to make this work? Show them how to monitor it, using the tools that  you use as part of your process evaluation, and   possibly give them tools for evaluating outcomes,  patient satisfaction, and staff satisfaction. And then think about how you get that sustained   so that people use it a while before you then  check it again, and monitor its effectiveness. And it’s a cycle.

So you continually go round,   and get people to, to sort of make the  knowledge their own so they own it. So they’re not being told by an outside  body - this is what you should do,   but they’re saying this is kind of the  framework, then you should now take it,   and operationalise it within your context.

The toolkit then, that you create or whatever you  want to call it, is based around those frameworks   so your core has all those elements  within it so it says - look this is   the knowledge, this is how the intervention  should be delivered, these are the adaptations,   these are the things that, you know you can  use to sustain it, or to monitor it so that’s   what your talk it is, all those elements in it  associated with the framework that you’ve used. Care bundles I think are a really nice way of  describing the intervention, and so placing those   somewhere at the centre of the KTA in that  triangle bit, would be absolutely ideal.

The other thing you need to think about with your  talking though is - how you’re going to get it   out there? Are you going to make it as an app? So  that people are going to use it in the workplace,   is that the most appropriate, make it available by  the internet via a web page, or actually give them   paper versions, and some places still prefer  having paper versions within their settings.

But the important thing is, it’s useless,  this toolkit if no one knows it’s there   so it is really important you get your  adoption strategy right so that people   decide to buy into it, and when you’re doing the  adoption strategy you have the toolkit in place   so they can access it, and see how  then how they can implement it. So just to summarise what I’ve said. There is a wide range strategies, I’ve only given  you three, they were the three that I liked,   the book i introduced earlier  on gives far more detail.

Framework you use then, it’s used to inform the  design of your toolkit so it shows you how to   implement the complex integration to meet the  local needs, how to adapt it, how to measure   effectiveness, and how to help them maintain,  and own the knowledge that you’ve given to them. But hopefully you’ll see now that  actually the process evaluation,   it’s the standard operating procedures,  the training you might give,   all the things that happen throughout the trial  as you deliver it, build it up, are all integral   to your final toolkit so your dissemination  strategy is not something that’s just at the end,   but actually you start working with it from  day one from where you start your project.