Periodic reflections: a method of guided discussions for documenting implementation phenomena

Erin P Finley, Alexis K Huynh, Melissa M Farmer, Bevanne Bean-Mayberry, Tannaz Moin, Sabine M Oishi, Jessica L Moreau, Karen E Dyer, Holly Jordan Lanham, Luci Leykum, Alison B Hamilton, Erin P Finley, Alexis K Huynh, Melissa M Farmer, Bevanne Bean-Mayberry, Tannaz Moin, Sabine M Oishi, Jessica L Moreau, Karen E Dyer, Holly Jordan Lanham, Luci Leykum, Alison B Hamilton

Abstract

Background: Ethnography has been proposed as a valuable method for understanding how implementation occurs within dynamic healthcare contexts, yet this method can be time-intensive and challenging to operationalize in pragmatic implementation. The current study describes an ethnographically-informed method of guided discussions developed for use by a multi-project national implementation program.

Methods: The EMPOWER QUERI is conducting three projects to implement innovative care models in VA women's health for high-priority health concerns - prediabetes, cardiovascular risk, and mental health - utilizing the Replicating Effective Programs (REP) implementation strategy enhanced with stakeholder engagement and complexity science. Drawing on tenets of ethnographic research, we developed a lightly-structured method of guided "periodic reflections" to aid in documenting implementation phenomena over time. Reflections are completed as 30-60 min telephone discussions with implementation team members at monthly or bi-monthly intervals, led by a member of the implementation core. Discussion notes are coded to reflect key domains of interest and emergent themes, and can be analyzed singly or in triangulation with other qualitative and quantitative assessments to inform evaluation and implementation activities.

Results: Thirty structured reflections were completed across the three projects during a 15-month period spanning pre-implementation, implementation, and sustainment activities. Reflections provide detailed, near-real-time information on projects' dynamic implementation context, including characteristics of implementation settings and changes in the local or national environment, adaptations to the intervention and implementation plan, and implementation team sensemaking and learning. Reflections also provide an opportunity for implementation teams to engage in recurring reflection and problem-solving.

Conclusions: To implement new, complex interventions into dynamic organizations, we must better understand the implementation process as it unfolds in real time. Ethnography is well suited to this task, but few approaches exist to aid in integrating ethnographic insights into implementation research. Periodic reflections show potential as a straightforward and low-burden method for documenting events across the life cycle of an implementation effort. They offer an effective means for capturing information on context, unfolding process and sensemaking, unexpected events, and diverse viewpoints, illustrating their value for use as part of an ethnographically-minded implementation approach.

Trial registration: The two implementation research studies described in this article have been registered as required: Facilitating Cardiovascular Risk Screening and Risk Reduction in Women Veterans (NCT02991534); and Implementation of Tailored Collaborative Care for Women Veterans (NCT02950961).

Keywords: Complexity science; Ethnography; Implementation context; Qualitative methods; Replicating effective programs; Women veterans; adaptation.

Conflict of interest statement

Ethics approval and consent to participate

The implementation initiative described was funded through VA’s Quality Enhancement Research Initiative (QUERI), which uses operational funds to support program improvement. QUERI projects are often conducted as quality improvement, and the DPP project described above falls under that category. The CV Toolkit and CCWV projects described above are considered research and are approved by the Central VA Institutional Review Board and local site Research and Development Boards.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Replicating Effective Programs (REP) Implementation Strategy Enhanced with Stakeholder Engagement and Complexity Science (Adapted from [30, 75])

References

    1. Schensul JJ. Community, culture and sustainability in multilevel dynamic systems intervention science. Am J Community Psychol. 2009;43:241–256. doi: 10.1007/s10464-009-9228-x.
    1. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci [Internet]. 2012 [cited 2017 Sep 5];7. Available from: .
    1. Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci [Internet]. 2017 [cited 2017 Sep 5];12. Available from: .
    1. Green AE, Aarons GA. A comparison of policy and direct practice stakeholder perceptions of factors affecting evidence-based practice implementation using concept mapping. Implement Sci [Internet]. 2011 [cited 2017 Sep 15];6. Available from: .
    1. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655. doi: 10.1136/bmj.a1655.
    1. Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci [Internet]. 2015 [cited 2017 Sep 5];10. Available from: .
    1. Proctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendations for specifying and reporting. Implement Sci [Internet]. 2013 [cited 2017 Sep 5];8. Available from: .
    1. Waltz TJ, Powell BJ, Matthieu MM, Damschroder LJ, Chinman MJ, Smith JL, et al. Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study. Implement Sci [Internet]. 2015 [cited 2017 Sep 5];10. Available from: .
    1. Bunger AC, Powell BJ, Robertson HA, MacDowell H, Birken SA, Shea C. Tracking implementation strategies: a description of a practical approach and early findings. Health Res Policy Syst [Internet]. 2017 [cited 2017 Sep 5];15. Available from: .
    1. Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci [Internet]. 2013 [cited 2017 Mar 14];8. Available from: .
    1. Chambers DA, Norton WE. The Adaptome. Am J Prev Med. 2016;51:S124–S131. doi: 10.1016/j.amepre.2016.05.011.
    1. Stirman SW, Miller CJ, Toder K, Calloway A. Development of a framework and coding system for modifications and adaptations of evidence-based interventions. Implement Sci [Internet]. 2013 [cited 2017 Sep 5];8. Available from: .
    1. Pfadenhauer LM, Gerhardus A, Mozygemba K, Lysdahl KB, Booth A, Hofmann B, et al. Making sense of complexity in context and implementation: the Context and Implementation of Complex Interventions (CICI) framework. Implement Sci [Internet]. 2017 [cited 2017 Sep 5];12. Available from: .
    1. Brewer J. Ethnography. Essent Guide Qual Methods Organ Res. SAGE Publications; 2004. p. 312–322.
    1. Bunce AE, Gold R, Davis JV, McMullen CK, Jaworski V, Mercer M, et al. Ethnographic process evaluation in primary care: explaining the complexity of implementation. BMC Health Serv Res [Internet]. 2014 [cited 2017 Sep 15];14. Available from:
    1. Geertz C. The interpretation of cultures: BasicBooks; 1973.
    1. Greenhalgh T, Swinglehurst D. Studying technology use as social practice: the untapped potential of ethnography. BMC Med [Internet]. 2011 [cited 2017 Sep 5];9. Available from: .
    1. Morgan-Trimmer S, Wood F. Ethnographic methods for process evaluations of complex health behaviour interventions. Trials [Internet]. 2016 [cited 2017 Sep 15];17. Available from: .
    1. Thirsk LM, Clark AM. Using qualitative research for complex interventions: the contributions of hermeneutics. Int J Qual Methods. 2017;16:160940691772106. doi: 10.1177/1609406917721068.
    1. McCullough MB, Chou AF, Solomon JL, Petrakis BA, Kim B, Park AM, et al. The interplay of contextual elements in implementation: an ethnographic case study. BMC Health Serv Res. 2015;15:62. doi: 10.1186/s12913-015-0713-7.
    1. Lanham HJ, Leykum LK, Taylor BS, McCannon CJ, Lindberg C, Lester RT. How complexity science can inform scale-up and spread in health care: understanding the role of self-organization in variation across local contexts. Soc Sci Med. 2013;93:194–202. doi: 10.1016/j.socscimed.2012.05.040.
    1. Stroebel CK, McDaniel RR, Crabtree BF, Miller WL, Nutting PA, Stange KC. How complexity science can inform a reflective process for improvement in primary care practices. Jt Comm J Qual Patient Saf. 2005;31:438–446. doi: 10.1016/S1553-7250(05)31057-9.
    1. Lanham HJ, Palmer RF, Leykum LK, McDaniel RR, Nutting PA, Stange KC, et al. Trust and reflection in primary care practice redesign. Health Serv Res. 2016;51:1489–1514. doi: 10.1111/1475-6773.12415.
    1. Stensaker I, Falkenberg J, Grønhaug K. Implementation activities and organizational Sensemaking. J Appl Behav Sci. 2008;44:162–185. doi: 10.1177/0021886307313794.
    1. Weick KE. Sensemaking in organizations. Thou: Sage Publications; 1995.
    1. Lanham HJ, McDaniel RR, Crabtree BF, Miller WL, Stange KC, Tallia AF, et al. How improving practice relationships among clinicians and nonclinicians can improve quality in primary care. J Comm J Qual Patient Saf. 2009;35:457–466. doi: 10.1016/S1553-7250(09)35064-3.
    1. Simpson KM, Porter K, McConnell ES, Colón-Emeric C, Daily KA, Stalzer A, et al. Tool for evaluating research implementation challenges: A sense-making protocol for addressing implementation challenges in complex research settings. Implement Sci [Internet]. 2013 [cited 2017 May 11];8. Available from: .
    1. Leykum LK, Lanham HJ, Provost SM, McDaniel RR, Pugh J. Improving outcomes of hospitalized patients: the Physician Relationships, Improvising, and Sensemaking intervention protocol. Implement Sci [Internet]. 2014 [cited 2017 Sep 15];9. Available from: .
    1. Hamilton A, Farmer M, Moin T, Finley E, Haskell S, Lang A, et al. Enhancing mental and physical health of women through engagement and retention (EMPOWER): a protocol for a program of research. Implement Sci. In press.
    1. Kilbourne AM, Neumann MS, Pincus HA, Bauer MS, Stall R. Implementing evidence-based interventions in health care: application of the replicating effective programs framework. Implement Sci [Internet]. 2007 [cited 2017 May 11];2. Available from: .
    1. Kilbourne AM, Abraham KM, Goodrich DE, Bowersox NW, Almirall D, Lai Z, et al. Cluster randomized adaptive implementation trial comparing a standard versus enhanced implementation intervention to improve uptake of an effective re-engagement program for patients with serious mental illness. Implement Sci [Internet]. 2013 [cited 2017 May 11];8. Available from: .
    1. Sogolow ED, Kay LS, Doll LS, Neumann MS, Mezoff JS, Eke AN, et al. Strengthening HIV prevention: application of a research-to-practice framework. AIDS Educ Prev Off Publ Int Soc AIDS Educ. 2000;12:21–32.
    1. Carman KL, Dardess P, Maurer M, Sofaer S, Adams K, Bechtel C, et al. Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Aff (Millwood) 2013;32:223–231. doi: 10.1377/hlthaff.2012.1133.
    1. McDaniel RR, Lanham HJ, Anderson RA. Implications of complex adaptive systems theory for the design of research on health care organizations. Health Care Manage Rev. 2009;34:191–199. doi: 10.1097/HMR.0b013e31819c8b38.
    1. Gates EF. Making sense of the emerging conversation in evaluation about systems thinking and complexity science. Eval Program Plann. 2016;59:62–73. doi: 10.1016/j.evalprogplan.2016.08.004.
    1. Ali Mohammed K., Echouffo-Tcheugui Justin B., Williamson David F. How Effective Were Lifestyle Interventions In Real-World Settings That Were Modeled On The Diabetes Prevention Program? Health Affairs. 2012;31(1):67–75. doi: 10.1377/hlthaff.2011.1009.
    1. Lawlor MS, Blackwell CS, Isom SP, Katula JA, Vitolins MZ, Morgan TM, et al. Cost of a group translation of the diabetes prevention program. Am J Prev Med. 2013;44:S381–S389. doi: 10.1016/j.amepre.2012.12.016.
    1. Moin T, Ertl K, Schneider J, Vasti E, Makki F, Richardson C, et al. Women veterans’ experience with a web-based diabetes prevention program: a qualitative study to inform future practice. J Med Internet Res. 2015, e127;17.
    1. Goldstein KM, Melnyk SD, Zullig LL, Stechuchak KM, Oddone E, Bastian LA, et al. Heart matters: gender and racial differences cardiovascular disease risk factor control among veterans. Womens Health Issues. 2014;24:477–483. doi: 10.1016/j.whi.2014.05.005.
    1. Vimalananda VG, Biggs ML, Rosenzweig JL, Carnethon MR, Meigs JB, Thacker EL, et al. The influence of sex on cardiovascular outcomes associated with diabetes among older black and white adults. J Diabetes Complicat. 2014;28:316–322. doi: 10.1016/j.jdiacomp.2013.12.004.
    1. Runnals JJ, Garovoy N, McCutcheon SJ, Robbins AT, Mann-Wrobel MC, Elliott A, et al. Systematic review of women veterans’ mental health. Womens Health Issues. 2014;24:485–502. doi: 10.1016/j.whi.2014.06.012.
    1. Washington DL, Bean-Mayberry B, Riopelle D, Yano EM. Access to Care for Women Veterans: delayed healthcare and unmet need. J Gen Intern Med. 2011;26:655–661. doi: 10.1007/s11606-011-1772-z.
    1. Vogt DS, Bergeron A, Salgado D, Daley J, Ouimette P, Wolfe J. Barriers to veterans health administration care in a nationally representative sample of women veterans. J Gen Intern Med. 2006;21.
    1. Report of the Under Secretary for Health Workgroup . US Department of Veterans Affairs, Office of Public Health and Environmental Hazards. Washington DC: Women Veterans Health Strategic Health Care Group; 2008. Provision of Primary Care to Women Veterans.
    1. Hamilton AB, Poza I, Washington DL. “Homelessness and trauma go hand-in-hand”: pathways to homeless among women veterans. Womens Health Issues. 2011;21:s203–s209. doi: 10.1016/j.whi.2011.04.005.
    1. Hamilton AB, Frayne SM, Cordasco KM, Washington DL. Factors related to Attrition from VA healthcare use: findings from the National Survey of women veterans. J Gen Intern Med. 2013;28:510–516. doi: 10.1007/s11606-013-2347-y.
    1. Friedman SA, Frayne SM, Berg E, Hamilton AB, Washington DL, Saechao F, et al. Travel time and attrition from VHA care among women veterans: how far is too far? Med Care. 2015;53:S15–S22. doi: 10.1097/MLR.0000000000000296.
    1. Jordon M, Lanham HJ, Anderson RA, McDaniel RR., Jr Implications of complex adaptive systems theory for interpreting research about health care organizations. J Eval Clin Pract. 2010;16:228–231. doi: 10.1111/j.1365-2753.2009.01359.x.
    1. Murdoch J. Process evaluation for complex interventions in health services research: analysing context, text trajectories and disruptions. BMC Health Serv Res [Internet]. 2016 [cited 2017 Sep 15];16. Available from: .
    1. Balasubramanian BA, Cohen DJ, Davis MM, Gunn R, Dickinson LM, Miller WL, et al. Learning Evaluation: blending quality improvement and implementation research methods to study healthcare innovations. Implement Sci [Internet]. 2015 [cited 2017 Sep 26];10. Available from: .
    1. Bernard HR. Research methods in anthropology, second edition: qualitative and quantitative approaches. Walnut Creek: AltaMira Press; 1995.
    1. Stirman SW, Kimberly J, Cook N, Calloway A, Castro F, Charns M. The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research. Implement Sci. 2012;7:17. doi: 10.1186/1748-5908-7-17.
    1. Hall TL, Holtrop JS, Dickinson LM, Glasgow RE. Understanding adaptations to patient-centered medical home activities: The PCMH adaptations model. Transl Behav Med [Internet]. 2017 [cited 2017 Sep 15]; Available from: .
    1. Manzano A. The craft of interviewing in realist evaluation. Evaluation. 2016;22:342–360. doi: 10.1177/1356389016638615.
    1. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health Ment Health Serv Res. 2011;38:65–76. doi: 10.1007/s10488-010-0319-7.
    1. Sharp A, Nguyen H, Hahn E, et al. The just do it playbook for implementation science. Arizona: Phoenix; 2014.
    1. Fetters MD, Curry LA, Creswell JW. Achieving integration in mixed methods designs-principles and practices. Health Serv Res. 2013;48:2134–2156. doi: 10.1111/1475-6773.12117.
    1. Averill JB. Matrix analysis as a complementary analytic strategy in qualitative inquiry. Qual Health Res. 2002;12:855–866. doi: 10.1177/104973230201200611.
    1. Hamilton. Qualitative methods in rapid turn-around health services research [Internet]. VA HSR&D Cyberseminar Spotlight on Women’s Health; 2013. Available from: . Accessed 5 Sept 2017.
    1. Atlas. ti 7.0 software. Berlin: Scientific Software Development.
    1. Kedward J, Dakin L. A qualitative study of barriers to the use of statins and the implementation of coronary heart disease prevention in primary care. Br J Gen Pract. 2003;53:684–9.
    1. Stewart RE, Stirman SW, Chambliss DL. A qualitative investigation of practicing psychologists’ attitudes toward research-informed practice: implications for dissemination strategies. Prof Psychol Res Pract. 2012;43:100–109. doi: 10.1037/a0025694.
    1. Raphael K. Recall bias: a proposal for assessment and control. Int J Epidemiol. 1987;16:167–170. doi: 10.1093/ije/16.2.167.
    1. Li J, Hinami K, Hansen LO, Maynard G, Budnitz T, Williams MV. The physician mentored implementation model: a promising quality improvement framework for health care change. Acad Med. 2015;90:303–310. doi: 10.1097/ACM.0000000000000547.
    1. Balasubramanian BA, Chase SM, Nutting PA, Cohen DJ, Strickland PAO, Crosson JC, et al. Using learning teams for reflective adaptation (ULTRA): insights from a team-based change management strategy in primary care. Ann Fam Med. 2010;8:425–432. doi: 10.1370/afm.1159.
    1. Berta W, Cranley L, Dearing JW, Dogherty EJ, Squires JE, Estabrooks CA. Why (we think) facilitation works: insights from organizational learning theory. Implement Sci [Internet]. 2015 [cited 2018 Aug 24];10. Available from: .
    1. Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care QHC. 1998;7:149–158. doi: 10.1136/qshc.7.3.149.
    1. Stetler CB, Legro MW, Rycroft-Malone J, Bowman C, Curran G, Guihan M, et al. Role of “external facilitation” in implementation of research findings: a qualitative evaluation of facilitation experiences in the Veterans Health Administration. Implement Sci [Internet]. 2006 [cited 2017 Sep 15];1. Available from: .
    1. Seidel Stefan, Chandra Kruse Leona, Székely Nadine, Gau Michael, Stieger Daniel. Design principles for sensemaking support systems in environmental sustainability transformations. European Journal of Information Systems. 2017;27(2):221–247. doi: 10.1057/s41303-017-0039-0.
    1. Weick K. Managing the unexpected: complexity as distributed sensemaking. Uncertain Surprise Complex Syst Quest Work Unexpected. Springer-Verlag; 2005.
    1. Baum F. Participatory action research. J Epidemiol Community Health. 2006;60:854–857. doi: 10.1136/jech.2004.028662.
    1. Leykum LK, Pugh JA, Lanham HJ, Harmon J, McDaniel RR. Implementation research design: integrating participatory action research into randomized controlled trials. Implement Sci [Internet]. 2009 [cited 2017 May 11];4. Available from: .
    1. Tabak RG, Khoong EC, Chambers DA, Brownson RC. Bridging research and practices: models for dissemination and implementation research. Am J Prev Med. 2012;43:337–350. doi: 10.1016/j.amepre.2012.05.024.
    1. Skolarus TA, Lehmann T, Tabak RG, Harris J, Lecy J, Sales AE. Assessing citation networks for dissemination and implementation research frameworks. Implement Sci [Internet]. 2017 [cited 2017 Sep 15];12. Available from: .
    1. Hamilton AB, Farmer MM, Moin T, Finley EP, Lang AJ, Oishi SM, et al. Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER): a protocol for a program of research. Implement Sci [Internet]. 2017:12. Available from: .
    1. Huynh AK, Hamilton AB, Farmer MM, Bean-Mayberry B, Stirman SW, Moin T, et al. A Pragmatic Approach to Guide Implementation Evaluation Research: Strategy Mapping for Complex Interventions. Front Public Health [Internet]. 2018 [cited 2018 May 30];6. Available from: .

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir