What's Missing in Most Health Care-Related Implementation Science Projects
Photos: Hoag Levins
Convincing a clinical staff anywhere to cease using an ineffective practice in favor of adopting an evidence-based replacement has been one of American medicine's most intractable challenges. As the new field of implementation science has evolved over the last twenty years, one reality has become obvious. Merely declaring that a department or staff should adopt a new practice or procedure has little chance of success unless that effort is properly planned, coached, exactly measured, and effectively managed toward long-term sustainability.
Lisa Saldana, Senior Research Scientist at the Oregon Social Learning Center (OSLC), is a clinical psychologist who has been working on a comprehensive system for achieving this over the last two decades. Her address as featured speaker at the PISCE@LDI seminar filled LDI's auditorium with an audience of scientists from across Penn's schools keenly interested in understanding more about Saldana's "SIC" implementation system.
Welcoming attendees to the seminar was PISCE@LDI Director Rinad Beidas, PhD (above, left), Associate Professor of Psychiatry at the Perelman School of Medicine and LDI Senior Fellow. She explained that in 2011, Saldana, along with OSLC Science Director Patty Chamberlain, PhD, published the results of their pioneering experiment to determine how best to measure the actual progress of an implementation project.
Measuring the process
Above, right, in the audience were Melanie Pellecchia, PhD, Assistant Professor of Psychiatry at the Perelman School of Medicine; Courtney Benjamin Wolk, PhD, Assistant Professor of Psychiatry at Perelman and LDI Senior Fellow; Nancy Hodgson, RN, PhD, FAAN, Associate Professor and Chair of Gerontology at Penn School of Nursing and LDI Senior Fellow; and Gwendolyn Lawson, PhD, Postdoctoral Fellow at the Penn Center for Mental Health.
Above, left, Saldana explains her "Stages of Implementation Completion" or "SIC" system that monitors an implementation effort through eight stages involving 46 different activities. Included are administrative actions, staff behaviors and infrastructure-related items. "It's about treatment and intervention fidelity," she said. "We think about the mechanisms of action. What is it that makes the intervention work? What is the underlying structure of that fidelity measure? What is it that we're trying to hold true to?"
Above right, in the audience are Meghan Lane-Fall, MD, MSHP, Assistant Professor of Anesthesiology and Critical Care at Perelman and LDI Senior Fellow; Linda Fleisher, PhD, MPH, Center for Injury Research and Prevention Senior Scientist at Children's Hospital of Philadelphia and LDI Senior Fellow; Vivian Byeon, Clinical Research Coordinator at the Penn Center for Mental Health; Mary Phan, BA, Clinical Research Coordinator at the Penn Center for Mental Health; and Rinad Beidas.
Saldana explained that the eight stages of monitoring go from pre-implementation planning, through the full-length implementation process, to proven sustainability. "The SIC," she said, "produces three scores -- duration score, proportion of completion score, and stage score." She noted that one of the most common reasons cited for an implementation failure is "personnel turnover" but said it was more complicated than that. Her studies have found that different results can occur depending on who is turning over as well as the timing of specific turnovers during an implementation effort.
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Hoag Levins is the Editor of Digital Publications at the University of Pennsylvania's Leonard Davis Institute of Health Economics (LDI), and a former staff reporter and editor at newspapers and magazines in Philadelphia, New York and Washington, D.C.