Author: Debra Bingham, DrPH, RN, FAAN
Have you ever been a part of a quality improvement (QI) effort that felt like a waste of time?
Have you gone to meeting after meeting or collected a lot of data but no changes were ever made?
Or have you made changes that did not improve outcomes?
Have you wondered what you could do to make QI efforts more effective?
While thinking about how to reduce QI-related frustration, I was reminded of when I first became a labor and delivery nurse. Initially I did not understand the physiology behind the patterns I was seeing. I knew how to recognize some fetal heart monitoring patterns, but I was like the proverbial blind man trying to describe an elephant by the small part of the elephant I could feel. The more I knew about maternal and fetal physiology, the more effective I was at adjusting the clinical plan of care when my patients’ conditions would deteriorate or did not respond as expected to the treatments I provided. A knowledge of maternal and fetal physiology helps clinicians tailor care decisions to individual patients. Similarly, an understanding of the “physiology” or science behind QI makes it possible for RNs, MDs, midwives, and other health professionals to more thoughtfully select the QI strategies and tactics they employ to ensure QI success.
QI, like taking care of patients, is dynamic and context specific. Implementation and improvement science theories, frameworks, and models help “explain how and why implementation succeeds or fails” and helps us identify “strategies to achieve more successful implementation” (Nilsen, P., 2015, pg.1).
The distinction among theories, frameworks, and models can be confusing because these definitions are not always used consistently. At the Institute for Perinatal Quality Improvement (PQI) we use the following definitions:
Implementation Theories (used for predicting and explaining) outline a fact or a set of facts and ideas that either explain or predict implementation effectiveness. Research, as outlined in theories is the solid foundation for all QI efforts.
- Classic theories (theories that originate outside of implementation science research and implementation theories)
o E.M. Roger's Theory of Diffusion
o B.J. Weiner"s Theory of Organization Readiness for Change
o Klein and Sorra’s Determinants and Consequences of Implementation Effectiveness
Implementation Frameworks (used for planning and adjusting the QI implementation strategies and tactics) help describe and identify potential QI implementation barriers and facilitators. Implementation frameworks are useful for identifying the implementation and improvement science research study results that are most relevant to the QI effort.
Examples of Implementation Frameworks are:
- G. Harvey and A. Kitson’s Integrated Promoting Action on Research Implementation in Health Sciences (i-PARIHS)
- L. Damschroder, et al.’s Consolidated Framework for Implementation Research (CFIR; www.CFIRguide.org).
- Graham, I. et al.'s Knowledge to Action Framework
Implementation Process Models (used as checklists and as a guide for writing up the QI Plan) are used to guide the planning and evaluation process that will be used to improve outcomes and translate research into practice. Process models do not predict implementation effectiveness or describe the causal mechanisms of various implementation activities.
Examples of process models are:
- · Mobilize-Assess-Plan-Implement-Track (MAP-IT)
- · Plan-Do-Study-Act (PDSA)
- · Stetler Model
- · Knowledge-to-Action Framework
- · Iowa Model
Implementation frameworks and process models are usually described as occurring in a linear fashion, or step 1 follows step 2. However, the various components of the frameworks and models are messier and much more interactive.
We can take the mystery out of the implementation process by expanding our understanding of relevant theories, frameworks, and models. Knowing more about implementation science will help us more quickly and effectively apply evidence-based practices. Simply acknowledging that change is hard and messy does not go far enough to ensure that a QI leader is effective. Teaching QI leaders about QI tips and tools also does not adequately prepare them to decide which tools to use, and when. It is essential for QI leaders to know the physiology of QI by learning about theories and frameworks. A foundation in implementation science will help them know how to select and use the QI implementation tools effectively and what to do when barriers to successful implementation are identified.
Clinicians’ implementation of evidence-based practices is a high stakes endeavor. Patients want and need clinicians taking care of them who are following the latest evidence-based guidelines. Clinicians also do not have time to waste. We at the Institute for Perinatal Quality Improvement (PQI) are working to expand the use of improvement science to speed up the time it takes to translate research into practice and enhance implementation effectiveness. QI leaders who learn the physiology of change are better prepared to make more thoughtful and tailored decisions. Learning implementation science is critical because QI saves lives!
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Thank you to Zola D. Golub, MEd, RN, IBCLC and Mary Ellen Boisvert, MSN, RN, CLC, CCE, members for their review and contributions to this blog.
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Graham I, Logan J, Harrison M, Straus S, Tetroe J, Caswell W, Robinson N (2006). Lost in knowledge translation: time for a map?. Journal of Continuing Education Health Professionals. 26: 13-24. 10.1002/chp.47.
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Harvey, G. & Kitson, A. (2016). PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice. Implementation Science. 11(33).
Harvey, G. & Kitson, A. (2015). Implementing evidence-based practice in healthcare: a facilitation guide. Routledge Taylor & Francis Group: New York.
Langley, G.J., Moen, R.D., Nolan, K.M., Nolan, T.W., Norman, C.L., Provost, L.P. (2009). The improvement guide: a practical approach to enhancing organization performance. Jossey-Bass: San Franscico, CA.
Nilsen, P. (2015). Making sense of implementation theories, models, and frameworks. Implementation Science. 10(53).
Rogers, E.M. (2003). Diffusion of innovations. 5th Edition. Simon and Schuster. ISBN. 978-0-7432-5823-4.
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Titler, M.G., Kleiber, C., Steelman, V.J., Rakel, B.A., Budreau, G., Everett, L.Q., Tripp-Reimer, T., & Goode, C.J. (2001). The Iowa Model of evidence-based parctice to promote quality care source. Critical Care Nursing, Clinics of North America. 13(4), 497-509.
White, K.M., Dudley-Brown, S., Terhaar, M.F. (2016). Translation of evidence into nursing and healthcare, 2nd Edition. Springer Publishing Company: New York.
Wiener, B.J. (2009). A theory of organizational readiness for change. Implementation Science. 4(67).
*There are links to open access articles or website.