Evaluation of the Encouraging Better Practice in Aged Care (ebpac) Initiative Final Report

9.3The science of implementation

There is emerging evidence about the aspects of a model of change which are likely to work within different contexts, in particular the need to recognise the various factors or levels (the individual professional, the patient, the team, the organisation, the broader social context, the economic and political context as well as the innovation itself) that influence care outcomes.⁶⁴ This in turn requires a multi-level approach that is organised and planned, and engages relevant stakeholders in the change process.⁶⁵ The tools and frameworks developed to measure and predict the capacity of an innovation to succeed or fail increasingly recognise these inter-relationships and the consequent need to address the ‘many moving parts’ that impact on implementation.⁶⁶ (See Figure )

Figure A multi-level framework predicting implementation outcomes

Innovation

Patient

Provider

Organisation

Structural

Adoption

Fidelity

Implementation Cost

Penetration

Sustainability

Causal Factors Implementation Outcomes

Taken from: Chaudoir, S. et al, Measuring factors affecting implementation of health innovations; a systematic review of structural, organizational, provider, patient and innovation level measures, Implementation Science (2013) 8:22

The majority of evidence regarding implementation has been derived from the health system, which we applied to the residential aged care context in the form of ‘key success factors’. These underpinned our earlier evaluation and the subsequent refinement into ‘principles of practice change’; both of these developments align neatly with the multi-level framework outlined above.^{67 68} The targeted literature review of community care knowledge translation activities (See Appendix 1) undertaken to inform this latest round of projects revealed additional factors that need to be taken into account, providing a variation on the above but with a more explicit focus on addressing the fractured and fragmented context of community care. These include a greater need for services to work in partnership and in collaboration, the need for the alignment of philosophical ideas and policies, organisational design factors that address administrative and clinical factors, and coordination and boundary spaning linkage mechanisms.⁶⁹

Projects involved in implementing innovations therefore need to include a range of strategies and interventions to ensure the relevant factors are appropriately addressed. Table summarises the interventions utilised by the projects, building on the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy of interventions known to be effective to improve health care systems and health care delivery.⁷⁰ These are discussed in more detail within the Project Delivery and Project Impacts sections (Sections 3 and 4).

Table EBPAC projects and EPOC taxonomy of interventions

Intervention	CL1	CL2	CC1	CC2	CC3	CC4	CC5	CC6	RC1	RC2	RC3
Educational materials distributed										
Educational meetings/ workshops											
Local consensus processes (action research, PDSA cycles)											
Educational outreach visits e.g. academic detailing			
Local opinion leaders including ‘champions’ or ‘mentors’											
Quality improvement processes e.g., audit and feedback										
Collection of new clinical / care material								
Reminders & prompts to recall information							
Institutional incentives e.g. backfill, equipment						
Revision of professional roles e.g. carer providing nursing care											
Introduction of multidisciplinary teams											
Changes to improve continuity of care (e.g., follow-up, pathways, case management)										
*Linkage, cooperation and communication with external services providers							
*Philosophical and policy alignment e.g. model of care, CDC								
*Organisational readiness for change incl. administrative arrangements								
*Coordination and boundary spanning linkage mechanisms						

* Particularly important for community care interventions

During the second national workshop project teams and members of their consortium and participating organisations were asked to reflect on a version of the above (minus the final four community care interventions) with the view to identifying what interventions worked best. Interestingly, in contrast to the evaluation team summary above, all ten projects in attendance indicated that they had incorporated each intervention into their project design (with the exception of ‘revision of professional roles’ in residential aged care). The extent to which these were all explicit interventions, or incidental as the project activities unfolded, was not clear; the evaluation team formulated its views on the evidence provided in the project plans, reports and evaluation findings.

In addition to using evidence based interventions, stakeholder engagement is a central component of a planned approach to implementing change. All projects demonstrated an understanding of this in their project plans and the stakeholder engagement and/or governance processes. The extent to which this impacted on the overall project activities, however, varied according to the nature, context and primary target audience of the projects. As expected, the leadership and change projects were more explicit in incorporating multiple factors as they addressed care staff, management as well as organisational and strategic imperatives. Likewise, the community care projects tended to directly engage clients and staff, but were less focused on organisational or system level stakeholders. While the national roll-out projects included resources for a multi-level implementation at the local service level, their primary activities were staff educational workshops and dissemination of resources.

Of particular concern is the relatively low level of consumer engagement in the design of projects overall. Only two projects explicitly sought consumer input, perhaps not surprisingly given that CC4 was focussed on consumer directed care, and CC6 was conducted by a consumer organisation. The vast majority of projects were led by teams of academics, health care professionals and/or service providers, whose traditional relationship with clients is one of ‘doing to’ rather than ‘doing with’. While the aged care reforms were viewed as a great enabler by a number of project leads, with its focus on person centred and consumer directed care, wellness and enablement, this approach was not evident in the project activities. Consideration needs to be given to the best means of ensuring consumer input underpins all future sector improvement initiatives and they fulfil their role as ‘partners’ in the development of a sector designed to meet their needs, as indicated in the recently released Aged Care Sector Statement of Principles:

The Statement of Principles recognises the benefit in consumers, providers, the workforce and the Australian Government collaborating to realise an aged care system that will meet the needs of Australia’s ageing population.⁷¹