Improving Practice Through Implementation Science and Knowledge Translation
Erin E. Redle, PhD, CCC-SLP
Speech-Language Pathologist & Assistant Professor
Cincinnati Children's Hospital Medical Center
During the 1960s, Everett Rogers (2003) studied the patterns of individual farmers as they faced a series of novel decisions related to pesticides and hybrid seeds. While farming seems far removed from the practices of speech-language pathology and audiology, the principles regarding the dissemination and adoption of innovative ideas and practices-that provided the foundation for the field of implementation science-can be applied to the communication sciences and disorders (CSD) professions. A growing field, implementation science has the potential to improve clinical practice.
Implementation is the adoption of new processes or practices within a particular setting; the terms implementation science and implementation research describe the scientific investigation of the best methods to promote changes in clinical practice (Implementation Science, 2013). As a field, CSD has traditionally produced evidence demonstrating the effectiveness of assessment and intervention methods within the context of research settings. This type of effectiveness research is a prerequisite to understanding what changes should be made in practice, but often requires a great deal of interpretation by the practitioner to identify the specific processes that need to be implemented (e.g., establishing feasible treatment fidelity criteria). Knowledge translation is the process through which new evidence is synthesized and adopted into clinical practice; it complements implementation research, but differs by requiring the provider to identify what practice changes are necessary and why. Understanding the best mechanisms for moving research findings into clinical practice is crucial to improving service delivery and patient outcomes in both medical and educational settings.
Why implementation research is important
If the process of knowing what to do and actually doing it were perfect, there would be no need for knowledge translation or implementation research. Yet, anyone who has ever tried to make a change knows this is not the case. Understanding the best strategies for implementing change not only informs how to most efficiently make changes, it also facilitates the efficient use of resources, such as time and money. A very practical, very well-studied, example is the practice of hand washing. Consistent best evidence, as well as common sense, indicates that proper hand hygiene reduces the number of hospital-acquired infections. Understanding the process for hand washing is not complex; in theory, if providers know that hand washing is necessary or have been taught the procedure, that knowledge should directly translate to consistent hand washing across medical providers. Yet, multiple studies show that hand hygiene is lacking in medical settings. Implementation studies have investigated the relative benefits of multiple strategies for improving adherence to hand-hygiene protocols, including education, reminders, feedback, and counters. However, the relative benefits of different implementation strategies are context dependent and vary across participants, implementation settings, and the combinations of strategies themselves.
Application of implementation research and knowledge translation to CSD
For speech-language pathologists (SLPs) and audiologists, implementation research typically involves changes in clinical care, but can also include changes in administrative activities (e.g., new diagnostic codes) or workflow (e.g., scheduling). There are three kinds of implementation strategies: (1) paper implementation, (2) process implementation, and (3) performance implementation (Fixen, Naoon, Blase, Friedman, & Wallace, 2005). Paper implementation describes methods in which new processes or procedures are detailed or explained, such as developing a protocol for accreditation. Process implementation expands on paper implementation; procedures are operationalized and actively taught, and execution of the procedures is monitored. Examples of different types of process interventions include:
- education (workshops, demonstrations),
- real-time feedback via counters,
- follow-up feedback regarding performance or compliance.
Performance implementation goes one step further; it focuses on measuring the actual impact of the changed procedures on the achievement of desired outcomes. For example, a child who has been enrolled in therapy for several months at a speech-language pathology clinic is discovered to have a previously unidentified hearing loss. To prevent recurrence of such a situation, the clinic develops a protocol that requires an audiologic screening/evaluation prior to initiation of therapy (paper implementation), holds an in-service program to demonstrate the new work flow for scheduling and evaluation (process implementation), and actively measures the incidence of hearing loss among children enrolled in therapy (performance implementation). Another example is the accreditation process of the Council on Academic Accreditation, as the procedures are operationalized, actively taught at sessions throughout the year, and their execution monitored via annual reports and site visits.
In this example, the solution (audiologic evaluation) was both well-established and simple; it did not require understanding a new procedure or adopting complex changes. Knowledge translation is typically much more complex and challenging. Consider the potential complexity of a new therapeutic approach for increasing spontaneous expressive language in children with autism disorder. This hypothetical approach, published in a peer reviewed journal, was found to be effective for children with mild co-occurring cognitive deficits, in an outpatient setting, across 20 sessions over 5 weeks. The article includes multiple appendices detailing the specific intervention procedures. In this example, the SLP must not only determine for which clients this approach is appropriate, but how to implement these procedures in 20-minute-per-week school-based sessions. This example clearly shows that knowledge translation focuses on methods to facilitate the adoption of well-developed evidence, rather than on just implementing new clinical practices (Grimshaw, Eccles, Lavis, Hill, & Squires, 2012).
Where to go from here
Despite the importance of understanding how we deliver care to our patients, few studies have investigated implementation and knowledge translation. A systematic review of knowledge translation in allied health professions shows only two studies that investigated the effectiveness of different knowledge translation strategies in speech-language pathology and only one that does so in audiology (Moodie et al., 2011; Scott et al., 2012).
As practitioners in the field of CSD continue to discover the most effective ways to evaluate and treat individuals with communication disorders, we need to consider the best mechanisms for implementing these findings in everyday clinical practice. If our field follows previously studied adoption patterns, it will take up to 17 years for a new discovery to be adopted by the majority of clinicians-a frightening prospect. To immediately improve our clinical practice, we need to appreciate what is already known about implementing change and simultaneously continue to study the best mechanisms for changing practice patterns. The combination of discovery and implementation will not only most efficiently change our professional practice patterns, but will also improve outcomes for patients in the most efficient ways possible.
Fixen, D. L., Naoon, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231).
Grimshaw, J. M., Eccles, M. P., Lavis, J. N., Hill, S. J., & Squires, J. E. (2012). Knowledge translation of research findings. Implementation Science, 7, 50. Implementation Science. (2013). About Implementation Science. Retrieved June 1, 2013, from www.implementationscience.com/about.
Moodie, S. T., Bagatto, M. P., Miller, L. T., Kothari, A., Seewald, R., & Scollie, S. D. (2011). An integrated knowledge translation experience: Use of the Network of Pediatric Audiologists of Canada to facilitate the development of the University of Western Ontario Pediatric Audiological Monitoring Protocol (UWO PedAMP v1.0). Trends in Amplification, 15(1), 34–56.
Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press.
Scott, S. D., Albrecht, L., O'Leary, K., Ball, G. D., Hartling, L., Hofmeyer, A., ... Dryden, D. M. (2012). Systematic review of knowledge translation strategies in the allied health professions. Implementation Science, 7, 70.
Additional Readings on Implementation Science
Allen, D., & Rixson, L. (2008). How has the impact of "care pathway technologies on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect? International Journal of Evidence-Based Healthcare, 6(1), 78–110.
Balas, E. A., & Boren, S. A. (2000). Managing clinical knowledge for health care improvement. In J. Bemmel & A. T. McCray (Eds.), Yearbook of medical informatics 2000: Patient-centered systems (pp. 65–70). Stuttgart, Germany: Schattauer Verlagsgesellschaft.
Cook, B. G., & Odon, S. L. (2013). Evidence-based practices and implementation science in special education. Exceptional Children, 79, 135–144.
Dougherty, D., & Conway, P. H. (2008). The "3T's" road map to transform U.S. health care: The "how" of high-quality care. The Journal of the American Medical Association, 299(19), 2319–2321.
Duggan, J. M., Hensley, S., Khuder, S., Papadimos, T. J., & Jacobs, L. (2008). Inverse correlation between level of professional education and rate of handwashing compliance in a teaching hospital. Infection Control and Hospital Epidemiology, 29(6), 534–538.
Fuller, C., Michie, S., Savage, J., McAteer, J., Besser, S., Charlett, A., … Stone, S. (2012). The Feedback Intervention Trial (FIT)-Improving hand-hygiene compliance in UK healthcare workers: A stepped wedge cluster randomised controlled trial. PLoS One, 7(10), e41617.
Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in knowledge translation: Time for a map? The Journal of Continuing Education in the Health Professions, 26(1), 132–4.
Huis, A., Holleman, G., van Achterberg, T., Grol, R., Schoonhoven, L., & Hulscher, M. (2013). Explaining the effects of two different strategies for promoting hand hygiene in hospital nurses: A process evaluation alongside a cluster randomised controlled trial. Implement Science, 8, 41.
Kaderavek, J. N., & Justice, L. M. (2010). Fidelity: an essential component of evidence-based practice in speech-language pathology. American Journal of Speech-Language Pathology, 19(4), 369–379.
Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn't. British Medical Journal, 312(7023), 71–72.
U.S. Department of Health and Human Services. (2013). Dissemination and implementation research in health (R01). Retrieved May 24, 2013, from http://grants.nih.gov/grants/guide/pa-files/PAR-10-038.html.