How to Identify the Problem and Propose an Intervention. Dana A. Telem MD MPH Associate Professor of Surgery University of Michigan

Transcription

1 How to Identify the Problem and Propose an Intervention Dana A. Telem MD MPH Associate Professor of Surgery University of Michigan

2 Disclosures Medtronic, Consulting Division Healthcare economics and policy Gore, Consulting Hernia

3 Creating Change What is the problem? What behavior are we trying to change? Why are we trying to change the behavior? Who is performing the behavior? How are we going to implement change? How will we measure change?

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5 What Problem Are you Trying to Solve Practice gap Differences between observed processes and outcomes compared to those achievable based on a current body of knowledge surrounding a problem. Identifying and addressing practice gaps is deceptively simple Extends beyond an extensive literature review to establish best practices. Requires a deep understanding of why the current practice patterns exist, their associated outcomes, and the best ways to support provider behaviors necessary to close the gap.

6 What is the Problem Data! Data! Data!

7 Defining the Problem

8 Identifying the Cause We have to identify the CAUSE to solve the problem Most models do not include mechanisms to assess motivation and behavior

9 Traditional Models Fishbone (Ishikawa): Cause and Effect

10 Procedure Agree on a problem statement (effect). Brainstorm the major categories of causes of the problem. Use generic (or specific!) headings: Methods Machines (equipment) People (manpower) Materials Measurement Environment Write the categories of causes as branches from the main arrow. Brainstorm all the possible causes of the problem. Ask: Why does this happen? Each idea is a branch from the appropriate category. Causes can be written in several places if they relate to several categories. Repeat question for each cause sub causes branching off the causes. When the group runs out of ideas, focus attention to places on the chart where ideas are few.

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12 What s the Downside?

13 ISLAGIATT ISLAGIATT syndrome (it seemed like a good idea at the time) Beliefs rather than evidence Evidence based medicine complimented by evidence based implementation.

14 Implementation Science Dissemination research How and when research evidence spreads Implementation research How to MOVE evidence-based interventions into healthcare practice and policy

15 Conceptual Model for Implementation Research

16 Designing an Intervention 109 different models to use! Theoretical Domains Framework (TDF) Integrative framework of 14 domains based on 35 theoretical models of human behavior Barriers and facilitators to behavioral change Behavior is assessed using mixed-methods including stakeholder surveys or interviews

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18 TDF allows linkage of domains to evidencebased behavior change interventions

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20 Examples: Telem et al. Ann Surg. Under Review.

21 Measuring Results Determine outcome metrics a priori Meaningful/Measurable Timely Dynamic process!

22 Take Homes Use available data to identify the problem Engage those with diverse mindsets and different exposures to the problem Without attention to drivers of behavior, change won t be sustainable Outcome measurement is a continuous and dynamic process

23 References Fisher ES, Shortell SM, Savitz LA. Implementation Science: A Potential Catalyst for Delivery System Reform. JAMA. 2016;315(4): Lauer MS. Comparative effectiveness research: the view from the NHLBI. J Am Coll Cardiol. 2009;53(12): Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Am J Infect Control. 2002;30:S1-S46 Aboumatar H, Ristaino P, Davis RO, et al. Infection prevention promotion program based on the PRECEDE model: improving hand hygiene behaviors among healthcare personnel. Infect Control Hosp Epidemiol. 2012;33: Gonzales R, Handley M, Ackerman S, O Sullivan P. Increasing the translation of evidence into practice, policy and public health improvements: A framework for training health professionals in implementation and dissemination science. Acad Med. 2012;87(3): Titler M. The evidence for evidence-based practice implementation. In: Hughes RG. Patient safety and quality: An Evidence-based handbook for nurses. US: Agency for Healthcare Research and Quality;2008:1-49. French SD1, Green SE, O'Connor DA, McKenzie JE, Francis JJ, Michie S, Buchbinder R, Schattner P, Spike N, Grimshaw JM. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. 2012;7:38. Lawton R, Heyhoe J, Louch G, Ingleson E, Glidewell L, Willis TA, McEachan RR, Foy R; ASPIRE programme. Using the Theoretical Domains Framework (TDF) to understand adherence to multiple evidence-based indicators in primary care: a qualitative study. Implement Sci. 2016;11:113. Bussières AE, Patey AM, Francis JJ, Sales AE, Grimshaw JM; Canada PRIme Plus Team., Brouwers M, Godin G, Hux J, Johnston M, Lemyre L, Pomey MP, Sales A, Zwarenstein M. Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework. Implement Sci. 2012;7:82. Francis JJ, O'Connor D, Curran J. Theories of behavior change synthesized into a set of theoretical groupings: introducing a thematic series on the theoretical domains framework. Implement Sci. 2012;7:35.

24 Thank