This document provides an overview of implementation science and its aims to develop strategies for improving health processes and outcomes. It discusses the translation continuum from pre-intervention to dissemination and implementation studies. Key factors that impact successful implementation include context, innovation characteristics, recipients, and facilitation. This is illustrated through a clinical case example where a study called ASSIST used a multifaceted strategy including a quality improvement team and external facilitator to successfully improve metabolic monitoring rates for patients on antipsychotics from 70% to over 90%.

1. What is Implementation Science
and why should you care?
JoAnn E. Kirchner
Professor, Department of Psychiatry, UAMS
VA Team-Based Behavioral Health
Incorporating Implementation Science to Support Core Clinical Competencies: An
Overview and Clinical Example, (in review) JoAnn Kirchner, Eva Woodward,
Jeffrey Smith, Geoff Curran, Amy Kilbourne, and Mark Bauer.

2. Presentation Overview
 Overview of Implementation Science
 Frame Implementation Science within the translation continuum
 Definitions
 Factors that Impact Implementation
 Clinical Case
 Example of an implementation science
intervention
 Revisit our Clinical Case
 Discussion

3. Health-Related Research Implementation
Brownson, Colditz, Proctor, 2012

4. Health-Related Research Implementation
Brownson, Colditz, Proctor, 2012
Pre-
intervention

5. Health-Related Research Implementation
Brownson, Colditz, Proctor, 2012
Efficacy
Studies
Pre-
intervention

6. Health-Related Research Implementation
Brownson, Colditz, Proctor, 2012
Effectiveness
Studies
Efficacy
Studies
Pre-
intervention

7. Health-Related Research Implementation
Brownson, Colditz, Proctor, 2012
Dissemination and
Implementation
Studies
Effectiveness
Studies
Efficacy
Studies
Pre-
intervention

8. Health-Related Research Implementation
Brownson, Colditz, Proctor, 2012
Dissemination and
Implementation
Studies
Effectiveness
Studies
Efficacy
Studies
Pre-
intervention

9. Health-Related Research Implementation
Brownson, Colditz, Proctor, 2012
Dissemination and
Implementation
Studies
Effectiveness
Studies
Efficacy
Studies
Pre-
intervention
T1
T2
T3
T4

10. Health-Related Research Implementation
Dissemination and Implementation Studies
Sustainment
Implementation
Preparation
Exploration

11. Definitions
Dissemination

12. Definitions
Dissemination
Quality
Improvement

13. Definitions
Dissemination
Quality
Improvement
Implementation

14. Definitions
Implementation SCIENCE: “The scientific study of
methods to promote the systematic uptake of research
findings and other evidence-based practices into
routine care…..”
Eccles and Mittman, Implementation Science, 2006

15. Implementation Science Aims
Implementation Science aims to:
 Develop effective strategies for improving health-
related processes and outcomes
 Produce generalizable knowledge regarding
implementation processes, barriers, facilitators, and
strategies
 Develop, test, and refine implementation theories and
hypotheses, interventions, and measures

16. Factors that Impact Implementation
integrated - Promoting Action on Research
Implementation in Health Services Framework
i-PARIHS Framework

17. Successful
Implementation

18. Context
Successful
Implementation
• Inner context: local and organizational
• leadership support
• culture
• organizational priorities
• Outer context
• policy drivers and priorities
• incentives and mandates
• inter-organizational networks

19. Innovation
• Relative advantage
• Usability
• Trialability
• Evidence
• research-based evidence
• clinical experience
• patient preferences
and experiences
Successful
Implementation

20. Recipient
• Motivation
• Values and beliefs
• Goals
• Skills and knowledge
• Time
• Resources and support
• Local opinion leaders
• Power and authority
Successful
Implementation

21. Context
Innovation
Recipient
Successful
Implementation

22. Context
Innovation
Recipient
Successful
Implementation

23. Facilitation
 Arose from the education and nursing discipline
 Acknowledges that while research evidence is important,
clinical experience and professional knowledge directly impact
adoption
 Multifaceted process
 Bundles an integrated set of implementation strategies
 Which strategy is applied varies based on the needs of the
implementation process
 Dynamic in nature that involves interactive problem solving

24. Context
Innovation
Recipient
Successful
Implementation
Facilitation
i-PARIHS Framework

25. Clinical Case: Mr. A

26. Clinical Case: Mr. A
Dr. C is a psychiatrist practicing within a large integrated
healthcare system that provides primary and specialty care. He
prides himself on being current with recommended standards of
care and evidence-based treatments. Mr. A is a 33 y/o single
male with a ten-year diagnosis of schizophrenia who presents
as a new patient without any prior medical records. He reports
that he has done well in the past when treated with olanzapine
but has not been on medication for six months. He exhibits
mild psychotic symptoms including occasional non-command
auditory hallucinations, confused thinking, and social isolation.
After a thorough evaluation, Dr. C confirms the schizophrenia
diagnosis and no history of diabetes, and restarts Mr. A on
olanzapine 15 mg daily, requesting that he see the receptionist
to be weighed before leaving and then to go to the lab for a
baseline hemoglobin A1C and lipid profile. His return
appointment is made for four weeks.

27. Clinical Case: Mr. A
When Mr. A returns, he displays no confusion, reports almost
complete resolution of auditory hallucinations, but continues to
report social isolation. He states that he left immediately after
his appointment and did not get weighed or go to the laboratory.
Dr. C continues olanzapine at the current dose and provides
directions to the receptionist for a weigh-in and asks the
receptionist to direct Mr. A to the laboratory.

28. A Study of Strategies to Improve
Schizophrenia Treatment
(ASSIST)

29. Dr. C’s clinic
Contextual Factors
 The chief of psychiatry conveyed the importance of metabolic monitoring in several staff
meetings after a new performance standard was introduced at the hospital
Innovation
 Because antipsychotic side effect monitoring was an evidence-based practice, clinic staff
believed it was clinically valuable
 However, staff were not accustomed to prioritizing antipsychotic side effect monitoring, and
competing time demands led to prioritizing other important measures such as suicide risk
assessments
 Additionally, a computerized clinical reminder for metabolic side effect monitoring was not
perceived as helpful by clinicians
Recipient
 Providers were quite open to the evidence that antipsychotic monitoring was clinically
valuable
 However, two clinicians who were well-respected among the staff (“opinion leaders”)
regularly complained about any new performance measures, and believed that because
standards changed so often, none were valid or important

30. ASSIST
 Multifaceted implementation strategy to improve
metabolic side effect monitoring for patients with
schizophrenia who were prescribed
antipsychotics in Dr. C’s out patient clinic
 Utilized a local QI team comprised of opinion
leaders involved in medication management of
patients with schizophrenia and an external
facilitator
 Facilitator identified local barriers to
recommended metabolic side effect monitoring

31. ASSIST
 Initial efforts only produced modest (10-15%)
improvements and by the third month, rates had
returned to almost baseline
 The facilitator re-engaged with the local QI team for
ideas on strategies that could produce sustainable
improvements
 Dr. C suggested the monthly performance reports, while
helpful, were not timely in identifying patients who had
not been monitored in compliance with performance
standards
 The facilitator worked with IT staff to develop a
computerized report emailed to Dr. C on a weekly basis
identifying patients due for metabolic monitoring

32. ASSIST
 Dr. C used the information to contact clinicians to
encourage them to complete metabolic monitoring
 At the end of the 6-month implementation period, the
proportion of patients whose weight was monitored as
recommended increased from 70% to 93%, with
dramatic increases in glucose and lipid monitoring rates
also (53% to 80% and 29% to 67%, respectively)
 For the first time ever, the clinic was compliant with the
performance standards for metabolic side effect
monitoring, and the clinic remained in compliance at
one-year follow up

33. Clinical Case: Mrs. B

34. Clinical Case: Mrs. B
Prior to her return appointment, Dr. C receives a
computerized report noting that Mrs. B had not
received metabolic monitoring following a new
prescription of an antipsychotic. Dr. C contacts Mrs.
B and directs her to the lab. Dr. C receives a lab alert
noting that Mrs. B’s fasting glucose is 180. Dr. C
tapers the olanzapine and initiates aripiprazole Mrs. B
responded well without exacerbation of her psychotic
symptoms and no abnormal glucose, lipid or weight
changes.

35. Resources
 Introduction to Implementation Science,
COPH, Dr. Geoff Curran
 Implementation Science , the Journal
 Dissemination and Implementation Research
in Health: Translating Science to Practice.
Edited by Ross C. Brownson, Graham A. Colditz, Enola
K. Proctor Oxford University Press, NY:NY 2012

36. Discussion