Implementation science offers theories and methods well suited to address the complexity of oncology.— Sandra A. Mitchell, PhD, CRNP
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Implementation science encompasses the study of methods to accelerate integration of evidence into practice and policy to improve health-care outcomes. At the 2017 ASCO Quality Care Symposium, Sandra A. Mitchell, PhD, CRNP, of the Division of Cancer Control and Population Sciences at the National Cancer Institute (NCI), discussed how we can harness the principles of implementation science to improve the quality of oncology care.1 She set the tone for the conference by stressing that evidence alone is not sufficient to change clinical practice, posing this question: “How ready for implementation are our research-tested interventions?”
Designing Improvement Initiatives
According to Dr. Mitchell, although there is a vast amount of implementation science literature showing an urgent need for health systems to adopt these principles, uptake of this science in oncology has lagged. Have quality-improvement efforts in oncology been siloed, she asked, not fully leveraging implementation strategies? She noted that the generation of knowledge often stops once efficacy is confirmed. At the same time, many of our studies of feasibility and acceptability focus on the conduct of randomized controlled trials, not how to implement the findings into routine clinical practice. Moreover, she explained that studies of efficacy typically do not address such issues as barriers to implementation, the extent to which context moderates intervention efficacy, and sustainability.
Dr. Mitchell briefly discussed other challenges that arise when introducing research-tested interventions into clinical practice, most notably ease of implementation, clinic support and resources for implementation, and workflow, human factors, and cost issues. “There are multiple drivers of practice improvement, and multimodality cancer treatment is incredibly complex. However, implementation science offers theories and methods well suited to address the complexity of oncology,” said Dr. Mitchell.
Dr. Mitchell explained that implementation science has established a solid body of knowledge, with nearly 100 different implementation models, frameworks, and theories proposed, plus more than 10 narrative reviews. She emphasized that the use of theoretical approaches from implementation science can have practical benefits for oncology, helping us to better understand why implementation succeeds or fails. Dr. Mitchell then covered the overarching aims of implementation science theory, which include providing a structure for translating research into practice and understanding what factors influence implementation outcomes.
Dr. Mitchell suggested that implementation outcomes may be the missing piece in the traditional model of outcomes research, which traditionally has focused on health services and patient outcomes. She noted that there are more than 100 measures of implementation outcomes, which may create a lot of overlap and overuse of certain measures.
To that end, Dr. Mitchell said that there were several proposed resources to help guide the selection of implementation strategies. One useful guide is the Expert Recommendations for Implementing Change (ERIC), which offers a menu of implementation strategies allowing researchers to compare and prioritize interventions. However, Dr. Mitchell acknowledged that with 73 strategies and more than 100 frameworks to choose from, selecting the components of an implementation strategy in oncology practice can be daunting.
“To help manage this complexity, we propose a strategic implementation framework with three components: setting the stage, active implementation, and monitor-support-sustain. Implementation requires movement in a fluid manner across these three sets of activities,” noted Dr. Mitchell.
Before Dr. Mitchell walked the audience through the framework, she highlighted another resource that was developed around the interactive website Dissemination and Implementation Models in Health and Research and Practice, which helps the researcher or leader of change to select implementation models and measures (for more information, visit http://dissemination-implementation.org/). Then, she summarized the different evidence sources for practice improvement, from research findings to outcome and quality metrics.
Areas Right for Implementation
As Dr. Mitchell drilled down to specifics, she identified three areas from the literature that are ready for implementation. The first area is preoperative frailty assessment in older adult oncology. After reviewing the current frailty guidelines from the National Comprehensive Cancer Network® (NCCN®), the Society of Geriatric Oncology (SIOG), and the American College of Surgeons, Dr. Mitchell noted that in a recent study of surgical oncologists, approximately half of the respondents did not consider preoperative frailty assessment mandatory, less than 10% employed practice guidelines, and less than 5% collaborate with geriatric specialists.2
“This study indicates there are still a number of barriers and facilitators, and we may not yet have a sufficient cadre of champions and early adopters out there for this new knowledge,” said Dr. Mitchell. She then pointed to several strategies that offer opportunities for implementation of frailty assessments, including educational material/training and a learning collaborative.
The other two areas Dr. Mitchell flagged as being ready for implementation science are survivorship care plans and patient-reported outcomes. Both of these areas were discussed under the umbrella of the implementation strategies and models to accelerate change and practice transformation.
Leadership and Implementation Climate
Not surprisingly, studies show that leadership is a key component of achieving practice transformation. Dr. Mitchell noted that teams with humble and trustworthy leaders foster climates that support practice change and encourage formal and informal performance feedback. Dr. Mitchell underscored the value of becoming a “high-reliability organization,” as such organizations offer a strategic climate that facilitates implementation. Examples of high-reliability organizations include airlines, nuclear power plants, and even amusement parks, which have had remarkable success in preventing safety and quality failures.
“One of the important lesson from high-reliability organizations is a collective mindfulness, where everyone is looking to identify, report, and correct problems. This empowers staff to recognize early indicators of a problem and speak up,” revealed Dr. Mitchell. She urged the audience to think like implementation scientists and engage strategies to progress toward a high-reliability organization, “where everyone is in the quality game.” ■
Disclosure: Dr. Mitchell reported no potential conflicts of interest.
1. Neuss MN, Chambers DA, Mitchell SA: Implementation science. 2017 ASCO Quality Care Symposium. General Session 1. Presented March 4, 2017.
2. Ghignone F, van Leeuwen BL, Montroni I, et al: The assessment and management of older cancer patients. Eur J Surg Oncol 42:297-302, 2016.