Improvement Science Summit - A Participants Point of View

Article Contributed by Eileen Engh, MSN, RN-BC, CPN

ISRN Research Associate, STAR-2 study PI and participant ISRN 2013 Improvement Science Summit

It’s not often that one conference can achieve so many goals and introduce so many new ideas relevant and critical to our understanding of healthcare systems today.  In this case the 2013 Improvement Science Summit, in San Antonio, Texas achieved and exceeds expectations.  We were encouraged to give rapid consideration to the setting and the care needs under examination.

I would like to capture in reflection a few highlights and concepts introduced and underscored in the course of the summit. 

Dr. Kathleen Stevens opened the summit and offered us a summary of the notable achievements made by the ISRN a just a few short years;   

• A cyber infrastructure was developed and implemented,
• Landmark studies have been conducted,
• Evidence for healthcare systems has been generated,
• And a network or “collaboratory”, has been created to conduct research.   

I had the opportunity as a site Principal Investigator to experience the entire spectrum of the achievements made by the ISRN.  As Dr. Steven’s shared each achievement, I had such appreciation for the pioneering work led by the ISRN.  I had an eye witness account of just how responsive and relevant the network is as they introduced the tools to conduct the STAR 2 protocol, one of the landmark studies designed to address the gaps in our healthcare organizations today.       

Dr. Jack Needleman moderated the summit meeting.  His comments truly resonated.  “The key question to keep in mind is how do we make and sustain change in our healthcare systems.  Systematic Research is essential to making and sustaining change.  We need a conceptual understanding of what works.”   I couldn’t agree more.  When something works, we need to understand– why it worked! 

I’ve practiced clinical nursing, and supported the transition training and professional development of nurses in a pediatric academic medical center for many years.  I’ve carefully observed as changes have been made in our health care system.  It’s been more than a curiosity to appreciate why some changes are sustained, while others are not.   Laura Damschroder, MS, MPH Co implementation Research Coordinator, Diabetes QUERI Research investigator, VA HSR& D Center for Practice Management & Outcomes research presentation really impressed me. Her work and model introduced new ways to look at change and increase our understanding of healthcare environments.   She shared frameworks for the study of Improvement and Implementation, from her “Worldview”.  

She spoke truth about the Traditional Research Framework that ends with a publication compared to a “Natural” dissemination and implementation framework.  Models and tools that can support how interventions can be sustained in our complex organizations are critical to our understanding and application. I took 15 pages notes during her presentation!   She compared the PRECIS tool, Explanatory Trial and Pragmatic Trial.  These are important because the Pragmatic Explanatory Continuum looks at 10 dimensions.  (Thrope, K. E.) The Explanatory Trial – aka efficacy trial looks a high internal validity and the Pragmatic Trial aka Effectiveness Trial – has high external validity (I think there was a typo on the slide).  The big deal with all this underscores the need to understand the objectives of Implementation Research – which wants to answer, What Works Where and Why?  Can we generalize knowledge about how to implement and sustain interventions?  Can we replicate successful implementation, navigate complex implementations and improve prospects for sustainability.   Ms. Damschroder, shared the Consolidated Framework for implementation Research (CFIR).  CFIR is a comprehensive framework to promote consistent use of constructs, terminology and definitions.  The CFIR has 5 major domains.  The reference to learn more about this is http://www.implementationscience.com/content/4/1/50.  There is also a wiki www.cfir.wiki.net. 

Dr. John Ovretveit, , BSC(Hons), Mphil, PhD, CPsychol, Csci, MIHM the director of research and professor of Health Innovation Implementation and Evaluation from the Karolinska Institute, Stockholm, Sweden  is amazing.  You have to see him in action to appreciate how very spot on he is!  He carefully prepared us by setting the stage to understand a big problem with a solution that worked.  The problem addressed the environment in public restrooms, specifically the floor around men’s urinals.  The story of success blended the application of male psychology, urinal design, and the image of a painted fly in the urinal bowl.  It works, and it works most of the time to reduce spillage.  It has now been widely adopted across Europe to keep public restrooms clean.   However, he noted that this approach doesn’t work with Buddhist Monks…. The point with this was to illustrate, “Copy the principle – not the prescription”.  He asked, can you explain this variation?

He also shocked us with a story about an RCT protocol that was a huge financial investment.  The study was conducted over many years beginning in 2005.  The results were published in 2012. To provide context, it was a HIT evaluation in the Swedish Health Informatics Center.  The investigators religiously adhered to the RCT protocol to protect the integrity of the RCT study.  During the same period, and parallel to the protocol timeline, the following technological changes were introduced globally:  IPhone, Amazon E-books, Facebook, web 2.0, web design, Twitter, and consumer driver interactions with the internet.  When the study was published the results were STONEAGE.  The key message is that we need alternative designs that are rapid, responsive, and relevant!!  (Riley, W.T.) Rapid, responsive, relevant (R3) research: a call for a rapid learning health research enterprise. See http://www.clintransmed.com/content/2/1/10)

 More importantly he pointed out, the funders really get it!!  In the next 5 years we can expect massive shifts toward applied research.   The more levels that are involved in an intervention, the more complicated it is to predict the outcomes.