Expanding and Enhancing Implementation Learning
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JoAnn Kirchner, MD
Led by JoAnn Kirchner, MD, QUERI’s Behavioral Health Implementation Facilitation (IF) Learning Hub works to transfer knowledge and skills to support uptake of effective practices. In addition to directing the IF Learning Hub, Dr. Kirchner is a staff psychiatrist with the Central Arkansas Veterans Healthcare System. The main focus of her research has been developing strategies that support the implementation of evidence-based practices in the primary care setting. Dr. Kirchner has been able to facilitate the implementation of primary care-based mental health programs by studying their implementation and, ultimately, developing and evaluating an evidence-based IF strategy.
In a recent interview with CIDER’s QUERI Dissemination Coordinator, Diane Hanks, MA, Dr. Kirchner discussed what the IF Learning Hub has to offer those interested in facilitating the implementation of best practices, in addition to an exciting future for the IF Hub.
First, please define implementation facilitation and why it’s important to any healthcare system, but particularly the VA healthcare system.
Implementation facilitation (IF) is a multifaceted strategy involving a process of interactive problem-solving and support that occurs in a context of a recognized need for improvement and supportive inter-personal relationships. An increasing volume of literature supports IF as an evidence-based strategy for implementing clinical innovations across diverse settings. However, as noted in a report of findings from a meeting on dissemination and training needs sponsored by the National Institutes of Health (NIH), few US-based training programs focus on implementation practitioners or policymakers (Proctor and Chambers, Transl Behav Med, 2017).
In 2011, senior mental health leadership in VA recognized the value of using implementation facilitation to support the implementation of the “Uniform Mental Health Services Handbook” and requested that our team develop a training manual and program to support the development of implementation practitioners within VA clinical operations.
Please describe how the Behavioral Health QUERI Implementation Facilitation (IF) Learning Hub works to transfer knowledge and skills to support the uptake of effective practices.
We do this work through several methods. First, we offer a training program that consists of 16 hours of formal training in implementation facilitation. Though we have delivered the training in both in-person and virtual formats, we are currently only providing the training through a virtual platform. For those who have completed the training program, we host a one-hour “office hours” call once a month during which learning hub faculty are available to provide consultation on the use of implementation facilitation. In addition, we host the Implementation Facilitation Learning Collaborative that meets monthly and serves as a platform for participants to share best practices in IF and to work collaboratively to advance the science and practice of implementation facilitation.
Your learning hub offers an Implementation Facilitation Training Manual. What does it provide and who is the Manual’s main audience?
The Implementation Facilitation Training Manual serves as source material for our training workshop and as a reference for those inside and outside VA who are applying implementation facilitation. The Manual was originally developed to support implementation of evidence-based practices and programs and other clinical innovations in the VA healthcare system and has been used, along with an IF Training Program developed by Behavioral Health (BH) Quality Enhancement Research Initiative (QUERI), to support a multitude of national clinical initiatives. Because the training manual was first developed within the context of a clinical need, we were careful to use language in the manual that was non-technical, straightforward, and appropriate for implementation practitioners rather than more technical research terminology.
Behavioral Health QUERI partners with the VA Office of Mental Health and Suicide Prevention, Office of Connected Care, and VISN 16 to advance the quality of mental healthcare for Veterans.
The most recent version of the IF Training Manual reflects the latest IF research and theory, as well as the experiences of IF experts. The third version of the training manual was updated in December 2020 and is hosted on the VA QUERI website. So far in FY21 alone, the manual has been downloaded more than 1,230 times.
You recently led a study on an IF training program that targeted one evidence-based strategy. Can you describe the study briefly and discuss your findings?
While we have conducted an ongoing formative evaluation of the Implementation Facilitation Training program since 2011, in 2017 we partnered with the VA South Central MIRECC (Mental Illness Research, Education, and Clinical Center) to conduct an independent evaluation of this training program. During the evaluation period, we conducted our trainings with a mix of in-person and virtual participants, with a total of 102 (76 in-person, 26 virtual) participants from seven discrete training sessions included in the evaluation. Using Likert scales, the evaluation team assessed perceived knowledge and confidence in applying that knowledge across the following domains (consistent with IF training learning objectives):
- Facilitating adoption of clinical innovations;
- Roles and activities of external and internal facilitators, as well as site champions;
- Activities for facilitators during pre-implementation, implementation, and sustainability phases;
- Applying methods to overcome barriers;
- Facilitating stakeholder engagement;
- Developing local implementation plans;
- Using virtual facilitation; and
- Evaluating the IF strategy.
Surveys were conducted two weeks prior to training, two weeks after training, and six months after training. Participants reported a significant increase in perceived knowledge and confidence across all IF training learning objectives from pre- to post-training (95% response rate) and pre- to six-month (35% response rate) training follow-up. In addition, there was no significant difference between virtual and in-person participants. When we compared post-training to six-months (30% response rate), increases in perceptions of knowledge remained significant across all learning objectives, though half of the domains showed significantly lower perceived confidence in applying IF skills. Based on these findings, we’ve demonstrated that we have developed an implementation facilitation training program that increases facilitation knowledge, though the perceived confidence to apply that knowledge decreases over six months. Thus, future work is focused on improving the retention of implementation facilitation knowledge and skills with the addition of ongoing mentoring that supplements the Training Program.
Explain why it’s important for VA stakeholders, including healthcare leaders and frontline providers, to have a better understanding of implementation science.
Healthcare leaders and frontline providers are the end-users of the knowledge we create as implementation scientists. As we document evidence-based implementation strategies and products that support implementation of clinical initiatives, it is essential that we create training programs through which we can seamlessly transfer this knowledge to those who will apply it within healthcare systems.
What else should we know about the Implementation Facilitation Learning Hub?
We are growing and changing! Katherine Dollar, PhD, ABPP, will be taking over the leadership role of the Learning Hub, and I will be moving to a trainer role. In addition to myself, we will be adding new trainers to our existing team currently comprised of Kathy Dollar, Jeff Smith, and Eva Woodward, PhD. Drs. Jessica Martin and Christina Shook will be joining our faculty in fall 2021. We are excited to bring additional expertise and experience to our training team.
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