Facilitation: A Key Strategy in the Field of Implementation Science
The Department of Veterans Affairs (VA) has been a forerunner in the development, promotion, and implementation of evidence-based practices (EBPs) through innovative research initiatives, guidelines, quality improvement efforts, and programs designed to advance implementation science. Effective implementation typically involves a focus on adopting multi-component clinical innovations or programs tailored to individual settings, application of diverse implementation strategies to support adoption, and involvement of multiple stakeholders.
Supporting Clinical Innovation
Implementation facilitation (IF) has been widely used in many health care organizations to support clinical innovation implementation. In its simplest form, IF is a process of interactive problem solving and support that occurs in the context of a recognized need for improvement and a supportive interpersonal relationship. However, IF can also be a complex, multi-faceted strategy that addresses implementation challenges by incorporating many implementation interventions, including identification of and engagement with key stakeholders, i.e., opinion leaders and clinical champions, at all organizational levels; problem identification and resolution; assistance with technical issues; development of information exchange networks; academic detailing; marketing; staff training; patient education; formative evaluation, audit and feedback; and fostering role modeling.
Although facilitation has been used in many disciplines, the tenets of IF in health care arose from the education and nursing disciplines and acknowledge the fact that, while research evidence that supports a given program or practice is important, clinical experience and professional knowledge provide additional evidence that directly affects the adoption of a practice. For example, the experiences of a colleague who has successfully used the program or practice may be more important to a provider than a journal article. In addition, factors within the implementation setting or context influence practice adoption. Thus, the organizational structure, leadership support, prior experience in new practice implementation, and methods of communication directly influence implementation efforts. Finally, characteristics of the EBP or innovation being implemented influence uptake. Implementation facilitation provides a mechanism to address factors that may impede uptake of the innovation, whether they are associated with those receiving the innovation, the context within which the innovation is being implemented, or characteristics of the innovation.
Helping Rather Than Telling
Facilitation involves helping rather than telling. Establishing a partnership based on mutual respect with stakeholders in the implementation setting is critical to successful facilitation activities. It is not a process of providing resources and stepping back or simply telling someone what to do. Rather, facilitation requires the creation of a supportive environment within which knowledge can be exchanged, barriers to implementation identified, and processes to overcome those barriers developed, applied, and refined. Implementation facilitation also involves both doing and enabling. At times, facilitation involves doing something for the organization or its stakeholders. For example, facilitators may provide education or monitor uptake of the innovation through an audit of electronic clinical data and feeding this information back to clinical providers. At other times, they may help and enable clinical providers to provide education or feedback to others. Although facilitation of each implementation effort has its own purpose and goals, ultimately, the overall purpose of facilitation is to provide the help and support needed to improve clinical care and patient outcomes.
Implementation facilitation has been successfully applied in several national initiatives. Kirchner, et al. tested the effectiveness of an IF strategy to implement Primary Care—Mental Health Integration (PC-MHI) at eight VA sites—both rural Community Based Outpatient Clinics and VA Medical Centers—identified by network leadership as being unable to implement the program without assistance. The IF strategy included an external facilitator and a network-level internal facilitator. This strategy was effective compared to support provided in the national rollout of PC-MHI and was later adopted by the VA Office of Mental Health Operations to support the implementation of PC-MHI as well as evidence-based psychotherapies.1,2 Kilbourne, et al, applied a much less intensive model of virtual external facilitation to re-engage Veterans with severe mental illness that had been lost to VA care, which also showed increased effectiveness compared to standard national rollout support.3 Thus, IF intensity and "dose" may vary based on the clinical innovation, innovation users, and the local context.
As noted by others, the rollout of clinical initiatives applying IF must include sufficient resources to support this strategy. Thus, it is critical that researchers document resources used in IF trials so that VA leadership can make informed decisions when designing clinical innovation implementation.