ISQua Webinar - Nick Sevdalis - September 2017

Implementation Science
Professor Nick Sevdalis PhD
Professor of Implementation Science & Patient Safety

Director, Centre for Implementation Science
Academic Director (joint), Acute Care – Mental Health Clinical Academic Group, King’s Health Partners
Chief Editor, BMJ Simulation & Technology Enhanced Learning; Associate Editor, Implementation Science
nick.sevdalis@kcl.ac.uk
@NickSevdalis
The interface of 2 fields
Improvement Implementation
Today!
Science Science
Scientific approach to achieving

Scientific study of methods to
better patient experience &
promote the uptake of research
outcomes through changing
findings into routine healthcare –
provider behaviour & organisation,
practice or policy
using systematic change methods
& strategies
Lecture aims
• To introduce the field of implementation research
• To familiarise you with key concepts of implementation

science, in the context of quality improvement
• To allow you to think of strategies to measure

implementation quality or success
• To trigger reflection on the interface between improvement

and implementation sciences
Getting started
• Quality: the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with
current professional knowledge
• High quality care is

– Safe
– Timely
– Effective
– Efficient
– Patient-centred
– Equitable
• Quality improvement: better patient experience and outcomes achieved

through changing provider behaviour and organisation through using a
systematic change method and strategies
Health Foundation. Quality Improvement Made Simple. 2013
Evidence is king – we just
need to develop & apply
interventions to improve
care & outcomes
The story of the WHO Surgical Checklist
The first study (2009)
• Major complication rate

decreased 36%
• Mortality decreased 47%
• Post-op infection decreased

48%
Further evidence
Within weeks of the publication in the UK…
• National policy
• All hospitals were asked to

implement the checklist
within 12 months
• Hospitals+specialities urged
to adapt it to their needs
Largest study to date (2014)
Pre-checklist (N=109,341) Post-checklist (N=106,370)
30-day mortality = 0.71% 30-day mortality = 0.65%

Complications risk = 3.86% Complications risk = 3.82%
Largest study to date (2014)
“The likely reason for the failure
…is that it was not actually used”
Pre-checklist (N=109,341) Post-checklist (N=106,370)
30-day mortality = 0.71% 30-day mortality = 0.65%

Complications risk = 3.86% Complications risk = 3.82%
Large variation in checklist application…
Some poor local implementation
“Our chief exec
“It just appeared…” had a bee in their
bonnet and it was
‘no you will do
this’…”
“It was sth they were
just doing one day”
“There was no discussion

or introduction or
anything. Typical.”
Poor implementation = Loss of effectiveness?
Event type N
Wrong site surgery 179
Retained foreign object post-procedure 107
Wrong implant / prosthesis 59
Misplaced naso- or oro-gastric tubes 40
Wrong route administration of medication 25
Overdose of insulin due to abbreviations or incorrect device 11
Other never events 21
TOTAL 442
Annual data summary, 2015-16

Guidelines are useful – but implementation?
+ Positive to have an integrated approach to
patient safety
+ Policy-level support & endorsement
- Local implementation?
- How do we know an implementation is
actually working?
September 2015
Another intervention: Skills training
Evidence
18% decrease in observed mortality (vs 7%

in controls)
(2006-08; 74 vs 34 VA hospitals;
N=182,409)
Substantial training programme
✓ 2 months preparation
✓ 1 day on-site team training session –
incl skills and checklists, telephone
coaching/F-UP for 1 year
Implementation of training modules?
Phase I:
Basic skills &
tasks
Phase II:
Advanced
procedures
Phase III:
Team-based
skills
Problematic…
Adoption rates:
Phase I:
Basic skills &
tasks P.I--36%
P.II--19%
Phase II: P.III--16%
Advanced
procedures
Phase III:
Team-based
skills
Barriers to achieving improvement: evidence
Health Foundation. What’s Getting in the Way? Evidence Scan. 2015

Leading improvement in health services
Health Foundation. The Habits of Improvers. 2015

From ‘knowing’ to ‘doing better’
Haynes B, Haines A, BMJ 1998;317:273-6

Gap between research and services
Gap between research and services
17 YEARS
Slote Morris et al, J R Soc Med 2011;104:510-20

What is implementation science?
Implementation science supports innovative approaches to
identifying, understanding, and overcoming barriers to the
adoption, adaptation, integration, scale-up and sustainability
of evidence-based interventions
NIH 2015
Implementation success
I = fE + IO’s
• I = Implementation success
• E = Effectiveness of the intervention being

implemented
• IO’s = Implementation factors Proctor et al 2010

Implementation
Definition
outcome
Perception amongst stakeholders new intervention is
Acceptability
agreeable
Adoption Intention to apply or application of new intervention
Perceived relevance of intervention to a setting,

Appropriateness
audience, or problem
Feasibility Extent to which an intervention can be applied
Extent to which an intervention gets applied as

Fidelity
originally designed / intended
Implementation Costs of the delivery strategy, including the costs of

costs the intervention itself
Extend to which eligible patients/population actually

Coverage
receive intervention
Extent to which a new intervention becomes routinely

Sustainability
available / is maintained post-introduction
A tale of two worlds…
Research world Health services
• Intention to maximise • Intention to achieve
intervention efficacy sustainable delivery
• Careful selection of patients • Widespread adoption/scale-up
• Specialised+trained • Generalist practitioners, often

researchers implementing & no further training, no ad hoc
measuring measurement
• Research funds • Service delivery funds

(limited)
Fidelity: a point of tension?
With high fidelity Adapted to need

Intervention
As intended As applicable
implementation
To ensure effect & To ensure
causal attribution sustainability
Developers Implementors
Castro et al, Ann Rev Clin Psychol 2010;6:213-39

Many aspects of fidelity
• What we mean by fidelity:
– Adherence: intervention delivered as designed/written

– Exposure (dose): how much of the intervention was received (i.e.
frequency, duration, coverage rate)
– Quality of delivery: manner in which intervention is delivered
– Participant responsiveness: reactions of participants or recipients
– Programme differentiation: identifying which elements of the
intervention are actually essential (‘active ingredients’)
Carroll et al 2007
Implementation strategies
Methods or techniques used to enhance the adoption,
implementation, and sustainability of a clinical programme, practice
or intervention
Examples include:
- Adaptation & tailoring of interventions to local setting
- Clinical/service stakeholder engagement (e.g. champions, train-the-trainers)
- Training & education
- Patient/service user engagement
- Audit and feedback
Choose and tailor strategies depending on the
context of the service to be imrpoved
Contextual factors
Factors or attributes that can facilitate or act as a barrier to
implementation efforts
Why do we care?
- Success of introducing an integrated service, especially across sites,
depends on contextual factors
- Examples: culture, organisational readiness for change
How do we assess?
- Qualitative interviews (cover senior leaders, middle managers and frontline)
- Validated scales (numerous available)
- Ethnography
A note on enthusiasm…
An individual clinical champion’s enthusiasm for integrated services
is a good strategy for early adoption – but a rather poor strategy for
longer term sustainability
Ergina et al, BMJ 2013;346:f3011

Implementation theories & frameworks
How and why does an intervention work – or not?
- Process models
- Stages and phases of translating evidence into practice
- Determinant frameworks
- Barriers and enablers of implementation outcomes
- Classic theories
- Psychology: Social cognition, theories including cognitive processes, behavioural
decision theory, and more
- Implementation theories
- Adapted specifically for implementation
- Evaluation frameworks
Bridging improvement & implementation research
- Two statements, for reflection and debate:
- We cannot achieve sustainable and scalable improvement without
good understanding of implementation factors
- We cannot deliver high quality improvement research without good
measurement of implementation factors
If you are interested in all this:
clahrcshortcourses@kcl.ac.uk

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Implementation Science

Professor Nick Sevdalis PhD

Professor of Implementation Science & Patient Safety

Scientific approach to achieving

• To introduce the field of implementation research

• To familiarise you with key concepts of implementation

• To allow you to think of strategies to measure

• To trigger reflection on the interface between improvement

• High quality care is

• Quality improvement: better patient experience and outcomes achieved

• Major complication rate

• Mortality decreased 47%

• Post-op infection decreased

• All hospitals were asked to

Pre-checklist (N=109,341) Post-checklist (N=106,370)

30-day mortality = 0.71% 30-day mortality = 0.65%

Pre-checklist (N=109,341) Post-checklist (N=106,370)

30-day mortality = 0.71% 30-day mortality = 0.65%

“There was no discussion

Annual data summary, 2015-16

18% decrease in observed mortality (vs 7%

Health Foundation. What’s Getting in the Way? Evidence Scan. 2015

Health Foundation. The Habits of Improvers. 2015

Haynes B, Haines A, BMJ 1998;317:273-6

Slote Morris et al, J R Soc Med 2011;104:510-20

• E = Effectiveness of the intervention being

• IO’s = Implementation factors Proctor et al 2010

Adoption Intention to apply or application of new intervention

Perceived relevance of intervention to a setting,

Feasibility Extent to which an intervention can be applied

Extent to which an intervention gets applied as

Implementation Costs of the delivery strategy, including the costs of

Extend to which eligible patients/population actually

Extent to which a new intervention becomes routinely

• Careful selection of patients • Widespread adoption/scale-up

• Specialised+trained • Generalist practitioners, often

• Research funds • Service delivery funds

With high fidelity Adapted to need

Castro et al, Ann Rev Clin Psychol 2010;6:213-39

– Adherence: intervention delivered as designed/written

Ergina et al, BMJ 2013;346:f3011

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