Advancing Implementation Science for Quality and Safety in Primary Health Care: The Integrated Care for Older Adults with Complex Health Needs Study (iCOACH)

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Abstract

Introduction:

Implementation science is a foundational field within the broader scope of research and practice focused on implementing change that will improve quality and safety in primary health care. A great deal of attention has been paid over the past few decades to developing and refining frameworks and strategies for implementing best practices in this sector, with the overarching goal of achieving the Institute for Healthcare Improvement's Triple Aim.1 However, despite the importance of frameworks and strategies to enhance the meaningful uptake of best practices in service of these inter-related quality improvement goals, large-scale in-depth studies of the implementation process have been rare.

Introduction:

Primary health care is considered one of the most challenging sectors of health systems in which to promote improvement and change.2 However, it is arguably the health system sector with the highest potential to catalyze transformational changes in the health of certain populations, especially for those with the most complex health and social care needs. Meeting the needs of these patients has proven to be a “wicked” problem,3 raising the importance of strategies to achieve community-based integrated primary health care that can provide the wide range of necessary services in an efficient, high quality, and safe manner. We contend that the challenge of implementing such integrated primary health care constitutes the most important contemporary challenge for improving quality and safety in health care.

Introduction:

The purpose of our research program was to (a) synthesize frameworks of the implementation of best practices in primary health care using meta-narrative methods, (b) complete 9 organizational case studies of the implementation of integrated community-based primary health care in 3 jurisdictions (Ontario and Quebec in Canada, and New Zealand), and (c) compare the findings of the meta-narrative review with our organizational case study findings to strengthen and advance the field of implementation science. Our overarching research question was: “What conceptual and practical advancements in implementation science offer the greatest potential to improve quality and safety in primary health care?”

Methods:

In this study a large international research team collaborated to complete 9 interdisciplinary organizational case studies,4 focused on the implementation of community-based integrated primary health care (CBPHC). The research team consists of patients, carers, inter-professional clinician-scientists, policymakers, anthropologists, economists, health services researchers, and health policy researchers. Exemplary cases of organizations that have successfully integrated CBPHC were sampled from Ontario, Quebec and New Zealand, and mixed-methods case studies were completed focusing on 4 analytic levels: Patient/carer, health care providers, organizations, and policies. Methods included qualitative interviews (n >200), surveys (n >50), and document review (n >50) across all 9 cases. Analysis follows the method of framework analysis 5 using NVIVO qualitative data management software, and will continue through to early 2017. We report on early findings in this abstract.

Methods:

In parallel to the organizational case studies, our research team completed a meta-narrative review of frameworks for implementing best practices in primary health care. The meta-narrative review followed the methods outlined by Greenhalgh et al (2005),6 which was most suited to clarifying our topic given its heterogeneous disciplinary nature. Under the guidance of a specialist librarian, we searched Medline, Pubmed, CINAHL, and the Cochrane Library from 2003–2016 to identify existing reviews of literature that addressed frameworks and theories (and related conceptual guides) for implementing best practices pertinent to primary health care. These publications were reviewed for quality, and data was extracted and analyzed following the meta-narrative approach.

Results:

The organizational case studies include extensive data from a wide variety of stakeholders involved in the implementation of high quality integrated, community-based primary health care for older people with complex needs. In this abstract we focus specifically on data that illustrates gaps in the broader literature summarized in our meta-narrative review.

Results:

Our meta-narrative review identified five distinct storylines, representing the transition of the implementation science literature across the following spectrum: (1) the generation of theoretical constructs to describe implementation, (2) identifying the many factors that influence implementation, (3) developing new comprehensive frameworks to guide implementation, (4) applying and testing existing frameworks, and (5) clarifying the effectiveness of interventions within particular frameworks. These different foci of frameworks for implementation science were developed across a variety of disciplinary and theoretical perspectives.

Results:

Despite the drive for comprehensiveness in the articles included in our meta-narrative review, our organizational case studies have identified a number of key themes excluded from existing literature on frameworks guiding implementation of best practices in primary health care:

Discussion:

These findings illustrate important gaps in the broader implementation science literature that require attention if the field's impact on quality and safety in primary health care is to grow. Three implications, mapped onto our three key findings, should be emphasized:

Discussion:

First, the ad hoc presentation of “best practice implementation initiatives” into busy primary health care settings might conflict with longstanding organizational visions, where local histories and ways of working often take precedence over new initiatives seeking to change practices. It is our assessment that previous literature has underestimated the salience of coherence between clinical practice and organizational vision in the implementation of practice change in health care. Future efforts should seek to better align new best practices with existing organizational visions, and/or situate implementation initiatives within longer term efforts to help organizations evolve their visions effectively toward system-wide improvements.

Discussion:

Second, although interpersonal relationships cannot be engineered, ignoring their relevance in implementation initiatives will only continue to result in failed implementation. Relationships create micro-systems of accountability between individuals, and enable coordination in work practices that is simply not possible through formal systems of inter-organizational collaboration. Embracing trusting, interpersonal relationships between managers, providers, patients and carers, and creating opportunities in which these relationships can be established and grow is essential in the implementation of new ways of practicing within and between organizations.

Discussion:

Finally, patients and carers must be involved in the development of best practices at the health system level from the very beginning. Too many health system improvement interventions are developed without due consideration of whether such interventions will have a meaningful impact on patient experience or population health. An iterative process of piloting and encouraging feedback and re-design of health system improvements is essential to the meaningful integration of patient perspectives into the overall improvement of quality and safety in health care.

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