philip m. ullrich, ph.d. spinal cord injury queri irc philip m. ullrich, ph.d. spinal cord injury...
TRANSCRIPT
Philip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRCPhilip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRC
Philip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRC
PARiHS FrameworkPARiHS Framework
Promoting Action on Research Promoting Action on Research Implementation in Health ServicesImplementation in Health Services
Philip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRCPhilip M. Ullrich, Ph.D. Spinal Cord Injury QUERI IRC
•PARiHS Framework:PARiHS Framework:
History History Features Features Proposed utility Proposed utility Application Example Application Example
PARiHS OriginsPARiHS Origins
Royal College of Nursing Institute, UKRoyal College of Nursing Institute, UK 1990s1990s Contemporary models of the processes of Contemporary models of the processes of
implementing research into practice are inadequate.implementing research into practice are inadequate. UnidimensionalUnidimensional Non-interactiveNon-interactive
PARiHS FrameworkPARiHS Framework developmental aims:developmental aims:
Accurately represent the complexities Accurately represent the complexities of implementation.of implementation.
Useful for guiding clinicians charged Useful for guiding clinicians charged with implementing research into with implementing research into practice.practice.
Useful for explaining variability in theUseful for explaining variability in the
success of implementation projects.success of implementation projects.
PARiHS Framework ElementsPARiHS Framework Elements
Evidence.Evidence.
Context.Context.
Facilitation.Facilitation.
Weak to strong support for implementationWeak to strong support for implementation
Evidence Sub-elements:Evidence Sub-elements: Research evidence.Research evidence.
Weak: Anecdotal evidence, descriptive.Weak: Anecdotal evidence, descriptive. Strong: RCTs, evidence-based guidelines.Strong: RCTs, evidence-based guidelines.
Clinical experience.Clinical experience. Weak: Expert opinion divided.Weak: Expert opinion divided. Strong : Consensus.Strong : Consensus.
Patient preferences and experiences.Patient preferences and experiences. Weak: Patients not involved.Weak: Patients not involved. Strong : Partnership with patients.Strong : Partnership with patients.
Local information.Local information.
Context Sub-elements:Context Sub-elements: Culture.Culture.
Weak: Task driven, low morale.Weak: Task driven, low morale. Strong : Learning organization, patient-centered.Strong : Learning organization, patient-centered.
Leadership.Leadership. Weak: Poor organization, diffuse roles.Weak: Poor organization, diffuse roles. Strong : Clear roles, effective organization.Strong : Clear roles, effective organization.
Evaluation.Evaluation. Weak: Absence of audit and feedbackWeak: Absence of audit and feedback Strong : Routine audit and feedback.Strong : Routine audit and feedback.
Facilitation Sub-elements:Facilitation Sub-elements:
Characteristics (of the facilitator).Characteristics (of the facilitator). Weak: Low respect, credibility, empathy.Weak: Low respect, credibility, empathy. Strong: High respect, credibility, empathy.Strong: High respect, credibility, empathy.
Role.Role. Weak: Lack of role clarity.Weak: Lack of role clarity. Strong: Clear roles.Strong: Clear roles.
Style.Style. Weak: Inflexible, sporadic.Weak: Inflexible, sporadic. Strong: Flexible, consistent.Strong: Flexible, consistent.
PARiHS Framework: PARiHS Framework: Elements and SubelementsElements and Subelements
EvidenceEvidence.. ResearchResearch Clinical experienceClinical experience Patient experiencePatient experience Local knowledgeLocal knowledge
ContextContext.. CultureCulture LeadershipLeadership EvaluationEvaluation
Facilitation.Facilitation. CharacteristicsCharacteristics RoleRole StyleStyle
PARiHS FrameworkPARiHS FrameworkSuccessful implementation is most likely to Successful implementation is most likely to
occur when:occur when:1.1. Scientific evidence is viewed as sound and Scientific evidence is viewed as sound and
fitting with professional and patient beliefs.fitting with professional and patient beliefs.
2.2. The healthcare context is receptive to The healthcare context is receptive to implementation in terms of supportive implementation in terms of supportive leadership, culture, and evaluative leadership, culture, and evaluative systems.systems.
3.3. There are appropriate mechanisms in There are appropriate mechanisms in place to facilitate implementation.place to facilitate implementation.
PARiHS FrameworkPARiHS Framework developmental history:developmental history:
1998 - 2002. Development, conceptual 1998 - 2002. Development, conceptual analysis.analysis.
2003 to present. Diagnostic/evaluative tool 2003 to present. Diagnostic/evaluative tool development.development.
2001-2003. Empirical case studies.2001-2003. Empirical case studies.
PARiHS FrameworkPARiHS Framework current knowledge base:current knowledge base:
Numerous case reports available, in support Numerous case reports available, in support of face validity and practical appeal.of face validity and practical appeal.
Theoretical positions of the framework are Theoretical positions of the framework are still in development.still in development.
One published instrument related to PARiHS.One published instrument related to PARiHS.
PARiHS Diagnostic and PARiHS Diagnostic and Evaluative utility?Evaluative utility?
PARiHS Diagnostic and Evaluative grid:PARiHS Diagnostic and Evaluative grid:
Kitson et al., 2008.
SummarySummary::
PARiHS framework has long been the subject PARiHS framework has long been the subject of theoretical development.of theoretical development.
Empirical foundations for the framework Empirical foundations for the framework have not developed at pace with theory.have not developed at pace with theory.
Exploratory work in applying PARiHS to Exploratory work in applying PARiHS to implementation interventions is encouraging.implementation interventions is encouraging.
SummarySummary::SummarySummary::Summary:
CIPRS: Stetler & Damschroder Theoretical Frameworks
Using Theory for Implementation Using Theory for Implementation PlanningPlanning
Select theory of planned behaviorchange
Assess fit with initial theory
Identify potential strategies for achieving change
Select interventionsthat fit with plannedstrategies (based on theory)
Identify interventiontools that fit bothstrategy and theory
Launch interventionusing identified toolsand strategies
Evaluate effectivenessof intervention,strategies, tools
See references: Sales et al., 2006
CIPRS: Stetler & Damschroder Theoretical Frameworks
Selecting a Theory Selecting a Theory -- 11 Consider Context
Study characteristics Professional discipline/perspective Intervention characteristics Inner and outer setting Individuals involved Implementation process
Consider Level Individuals Teams Organization System
Why PARiHS FrameworkWhy PARiHS Framework for Spinal Cord Injury for Spinal Cord Injury
(SCI) QUERI?:(SCI) QUERI?:SCI system of care and targets for changeSCI system of care and targets for change
a.a. EvidenceEvidence ResearchResearch LocalLocal ClinicalClinical PatientPatient
b.b. ContextContext
Opportunities to work with other QUERI groups.Opportunities to work with other QUERI groups.
Implementation Project Implementation Project Example 1Example 1
SCI Pressure Ulcer Management SCI Pressure Ulcer Management Tool (SCI PUMT)Tool (SCI PUMT) Implement a toolkit designed to Implement a toolkit designed to
standardize monitoring of pressure standardize monitoring of pressure ulcer healing in the ulcer healing in the
VA SCI system of care. VA SCI system of care. PUMT:PUMT:
Training tools (education protocol, CD, Training tools (education protocol, CD, models)models)
Competency assessmentCompetency assessment
SCI PUMT SCI PUMT ImplementationImplementation
12 SCI centers randomized to receive one 12 SCI centers randomized to receive one of two implementation strategies:of two implementation strategies:
1.1. Simple: Local “champion” Simple: Local “champion” receives toolkit materials.receives toolkit materials.
2.2. Enhanced: PARIHS-informed Enhanced: PARIHS-informed external facilitation strategy. external facilitation strategy.
SCI PUMT Enhanced SCI PUMT Enhanced FacilitationFacilitation
Diagnostic AssessmentDiagnostic Assessment. . Measure factors important to implementation at all Measure factors important to implementation at all participating sites. Specifically, the diagnostic participating sites. Specifically, the diagnostic assessment will measure: assessment will measure: EVIDENCE: Appraisals of 4 sources of EVIDENCE: Appraisals of 4 sources of evidence: evidence:
(1) Published scientific evidence. (1) Published scientific evidence. (2) Clinical experience or (2) Clinical experience or
professional knowledge.professional knowledge.(3) Patient experiences and (3) Patient experiences and
beliefs.beliefs.(4) Evidence derived from local (4) Evidence derived from local
experiences.experiences.CONTEXT: Appraisals of 3 aspects of CONTEXT: Appraisals of 3 aspects of context context
(1) Organizational culture. (1) Organizational culture. (2) Leadership. (2) Leadership. (3) Evaluation.(3) Evaluation.
SCI PUMT SCI PUMT Enhanced FacilitationEnhanced Facilitation
Diagnostic AssessmentDiagnostic Assessment. .
Measures: Measures:
Organizational Readiness for Change Assessment (ORCA)Organizational Readiness for Change Assessment (ORCA)1) Questionnaire, 3 scales: 1) Questionnaire, 3 scales:
Evidence, Context, Facilitation. Evidence, Context, Facilitation.
Structured InterviewsStructured Interviews Evidence, Context, Facilitation. Evidence, Context, Facilitation.
Depends upon results of diagnostic.Depends upon results of diagnostic.
SCI PUMT SCI PUMT Enhanced FacilitationEnhanced Facilitation
ANDAND Pre-diagnostic efforts Pre-diagnostic efforts Evidence: Evidence:
Presentations of empirical research by nursing leaders.Presentations of empirical research by nursing leaders.
ContextContext Involving national and local SCI leadership.Involving national and local SCI leadership.
FacilitationFacilitation Selecting and training nurse facilitators.Selecting and training nurse facilitators.