What Is Implementation Science?
In my incoming president’s address during the 2015 ACCP Global Conference on Clinical Pharmacy in San Francisco last October, I shared my “theme” for this year—“Closing the Gap: Implementing Policies, Programs, and Evidence-Based Practices.” The essence of my theme is “making the good better.” At its epicenter is my strong and genuine desire to promote the adoption of dissemination and implementation (D&I) science (see definitions in Box), also known as “knowledge translation,” within the field of pharmacy. My purpose in this issue of the ACCP PRN Report, taking the baton from my introductory President’s Column in the November 2015 ACCP Report, is to provide PRN members with the key fundamentals of implementation science (IS) so that they can incorporate the principles into their personal clinical practice and research/scholarship.
Box.Definitions from the Health Services Resources Information Central at the National Library of Medicinea
Implementation science—The study of methods to promote the integration of research findings and evidence into health care policy and practice. It seeks to understand the behavior of health care professionals and other stakeholders as a key variable in the sustainable uptake, adoption, and implementation of evidence-based interventions.
Dissemination science—The purposive distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to spread information and the associated evidence-based interventions. Research on dissemination addresses how information about health promotion and care interventions is created, packaged, transmitted, and interpreted among a variety of important stakeholder groups.
aU.S. National Library of Medicine. Dissemination and Implementation Science. Available at https://www.nlm.nih.gov/hsrinfo/implementation_science.html.
Why Does IS Exist?
It has long been recognized that there is a gap, and, in some cases, a crevasse, between knowledge and practice. IS facilitates the closing of this gap efficiently and effectively. Clinical pharmacists are commonly responsible for implementing new clinical programs, drug-related policies, and clinical practice guidelines within the health care delivery system where they work. Although applying IS to the practice of implementation is becoming commonplace in many health-related disciplines, the field of pharmacy has been slow to take advantage of its full potential. Below, I have summarized a stepwise process of systematically applying IS to your own practice. For PRN members who wish to pursue a scholarly approach to their implementation, there is a tremendous opportunity to contribute to the existing biomedical literature.
Step 1—Determine the evidence-based practice that will serve as the targeted intervention to implement. It sounds quite elementary, but this step really is the most important of all the steps. Note that, in most cases, there must be a solid evidence base for the program, policy, or clinical practice guideline. Yes, evidence-based medicine is just the beginning; it’s not the end! Your choice of an intervention should be made collectively by all involved stakeholders so that there is optimal buy-in and support within the health-system system.
Step 2—Specify a contextual framework that is informed by an established model and theory. This is the single most crucial phase that uniquely differentiates a run-of-the-mill implementation from one that intentionally uses true IS. This important step harnesses the powerful potential to optimize the efficiency and effectiveness of the implementation. To gain the best possible understanding of the value of a contextual framework, please take the time to review in detail the Consolidated Framework for Implementation Research (CFIR) at www.cfirguide.org/. CFIR is broadly applicable to many types of implementation in the health care setting. The development of CFIR in 2009 created some much-needed consistency and standardization in the field of IS. CFIR contains 29 constructs in five major domains that cover the intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and process of implementation. Take some time to familiarize yourself with the standardized constructs, and think about them as they pertain to a recent implementation in your own practice setting or research environment. I think you will find that they open up an entirely new and comprehensive way of approaching an implementation. Once you have mastered the general concepts in a framework, you can explore others that have been modified for specific contexts such as patient-centered medical homes or care transitions (http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=1882). For a highly comprehensive and searchable website on D&I models, use www.dissemination-implementation.org/ to find exactly what you need.
Step 3—Conduct implementation research. For PRN members involved in the practice of implementing “stuff,” steps 1 and 2 are necessary and sufficient. For PRN members who aspire to conduct implementation research (IR), however, there are some additional steps. As with any research project, it is important to identify an answerable research question and develop specific research aims. Because IR commonly uses qualitative research techniques, there may be no definable hypotheses. The next step is to select a study design. Although randomized controlled trials are occasionally done, they are certainly not the norm in IR. Observational study designs and other unique adaptive designs, such as the “stepped-wedge,” are more commonly used. Most commonly, however, is a mixed-methods approach. “Hybrid” describes designs that aim to evaluate various combinations of effectiveness and implementation outcome measures. After determining your study design, you should identify your outcome measures. There are many measures to choose from, and https://www.gem-beta.org/Public/Home.aspx is an excellent searchable database. For information technology–related surveys, https://healthit.ahrq.gov/health-it-tools-and-resources/health-it-survey-compendium is a fantastic resource. Until you develop proficiency in IR, I highly recommend collaborating with experienced IR experts, who can provide mentorship and guidance. Although IR has its own vernacular and conventions, it is very attainable and highly innovative in the field of clinical pharmacy!
In summary, I encourage all PRN members to learn the rapidly growing and fascinating fields of IS and IR. In my opinion, these are the next frontiers for clinical pharmacy, and their potential is unlimited. If any PRN would like to explore the possibility of developing programming at an upcoming ACCP Annual Meeting, please let me know if I can assist in any way.