Implementation and improvement science (I&IS) in a time of crisis

UK-IS member Andrew Walker (Implementation Science Lead, Health Innovation Network) discusses two articles (both open access) that provide useful, practical lessons on combining quality improvement and rapid assessment within an implementation science approach, and Kirsty Doull (Acting Permanence Lead and Permanence Consultant, CELCIS, University of Strathclyde) contributes a practice example from Scotland showing how new practices developed in response to restrictions on ‘business as usual’ during the crisis have proved unexpectedly effective and sustainable.

As implementation and improvement researchers and practitioners, many of us are involved in the COVID-19 response. We are supporting service transformation and/or its (rapid) evaluation, and are presented with the challenge of putting the ‘theory’ into practice.

The COVID-19 crisis has seen a rapid mobilisation of knowledge to support the transformation of the health and social care system as it responded to an unprecedented volume of people needing care and the wider knock on effects across social care. As difficult as the crisis has been for individuals, society and health and social care, it presents a real opportunity to use approaches and evidence from implementation and improvement to inform the rapid transformation of services and the implementation of innovation in a way that is more efficient, effective, and sustainable. I&IS has the potential to facilitate and accelerate service innovation and sustainable evidence-based transformation more widely and in the long-term. In particular, the crisis has presented a unique opportunity to allow us to capture insights, in real time, into the impact of specific implementation and improvement interventions.

We have observed in the last few months that I&IS can support the immediate response to and recovery from COVID-19 via rapid cycles of improvement. These approaches can help negotiate the challenges that arise at multiple levels: stopping crisis- specific innovations, amplifying new approaches that improve care, letting go of practices that were (already) not fit for purpose, and restarting aspects of ‘usual care’. In addition, the response to COVID-19 can provide key insights into perennial questions in implementation and improvement science. For example, we can observe and learn what happens when key barriers are removed. We can learn to negotiate the delicate balance between transformation at pace and scale and maintaining quality and safety.

Work by Bijal Balasubramanian and colleagues (2015) describes a learning evaluation model that combines approaches from quality improvement and implementation science. Using it as part of the implementation of the Advancing Care Together (ACT) initiative across multiple sites, they collected qualitative and quantitative data to conduct real-time assessment of implementation and service transformation whilst also assessing changes in local context. The principles underpinning this approach are (1) to collect data and describe changes made by healthcare organisations and how changes are implemented that are relevant to healthcare organisations involved; and (2) to support healthcare organisations use data for continuous service improvement and transformation. The authors provide a helpful figure that clearly visualises their approach of building infrastructure for data collection, collected and syntheses qualitative and quantitative data in rapid cycles, to provide feedback to stimulate learning and improved implementation of the ACT programme.

A more recent (a very timely) paper by Laura Holdsworth and colleagues (2020) outlines that use of rapid assessment procedures for implementation research within the context of patient quality and safety in intensive care (ICU). With its origins in humanitarian crisis, the rapid assessment procedure (RAP) is particularly relevant to the situation with COVID-19. The approach aims to contextually rich data on short timelines to explore the ‘how’ and ‘why’ behind organisational practices and implementation. The authors outline five core features of the approach:

  • Use of mixed methods - typically using qualitative data (interviews, focus groups, document review, and observations) and quantitative data collected via secondary analysis and/or surveys

  • Rapid timeline - start to finish is weeks to months

  • Participation by the population of interest in planning and implementing the research

  • Team approach to the research process – to accelerate the data collection and analysis process

  • Iterative cycles of data collection and analysis

To balance the speed of analysis with rigour, templates are used in the analysis to chart the data against themes derived from existing implementation frameworks (e.g. RE-AIM and CFIR) that are well defined and have an underpinning evidence-base. This also allows more rapid and direct linkages to relevant, wider literature.

Practice perspective – Using a rapid cycle approach to deliver children’s services during COVID-19: The Permanence and Care Excellence (PACE) programme

Many of the local authorities and agencies involved in the Permanence and Care Excellence (PACE) programme - a quality improvement programme aimed at reducing drift and delay in permanence planning and decision-making for looked after children - recognised that quality improvement could be used to capture data and evidence from new innovations to practice and service delivery as a result of COVID-19.

There was a recognition that care planning, permanence planning and decision-making in respect of looked after infants, children and young people could not stop due COVID-19. Rather, technology was utilised to varying degrees to ensure participation and engagement of children, families, carers, and agencies.

Some local authorities did this with ease, with one noting that no formal review of a child's care plan or approval panel had required to be cancelled as a result of COVID-19. All meetings are now being conducted by telephone or video conferencing. One local authority for example noted that the use of video conferencing for one decision-making forum had resulted in 100% attendance from carers - as opposed to only approximately 33% attendance when they took place face to face. The collection of this data, together with positive feedback from participants, has led to this local authority already deciding that these meetings will be conducted via video conferencing even after the COVID-19 restrictions are lifted.

Another local authority was concerned that telephone conferencing which had to be introduced during the pandemic for the panel for the approval of prospective adopters was unnecessarily daunting for prospective adopters, who might not know all the other participants. Consequently, through testing cycles, the authority is now developing a process of sending prospective adopters an introductory video, biography, and a photo of each panel member before the panel. This was informed by qualitative data collected from all participants (which was collected at pre-meetings and de-brief meetings so as to ensure that data collection did not become onerous).

Crucially, feedback from children and young people was gathered on these changes. One young person said that they felt able to join their Review meeting for the very first time as they felt more comfortable doing it by telephone, with the support of a trusted professional, rather than in person. As a result, this local authority, like many others, is now strongly considering offering telephone and video conferencing rather than an invitation to attend in person. They hope this will enable children and young people to participate more fully in such crucial meetings about their care plans.

Using rapid cycles of testing and data collection in this way, leaders can be clear that they have the evidence required to elevate new innovations that were born out of necessity as a response to COVID-19 to the status of ‘core components’ of positive practice that will be enshrined as "business as usual" post-COVID-19. There has also been recognition that quality improvement approaches can be used to provide a framework for evidence-gathering and evaluation even on unplanned change ideas - and that the necessity of being forced to be creative in service delivery has led to changes that were never before thought possible now becoming integrated into daily practice.

For more information about PACE and the work of CELCIS contact:

© UK Implementation Society, 2020

All views expressed are the author's own and not those of the UK Implementation Society.

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