Implementation Strategies for Frontline Healthcare Professionals: People, Process Mapping, and Problem Solving

Patients in HospitalAs healthcare organizations become increasingly accountable for equity, quality, and value, attention has been directed to identifying specific implementation strategies that can accelerate the adoption of evidence-based therapies into clinical practice. In a recent perspective in Journal of General Internal Medicine, Mary Whooley, MD and colleagues offer three simple, practical strategies that can be used by frontline healthcare providers who are involved in on-the-ground implementation: people (stakeholder) engagement, process mapping, and problem solving. As a use case example, the researchers describe the iterative application of these strategies to the implementation of a new home sleep apnea testing program for patients in the Veterans Health Administration (VA) healthcare system. These three strategies are straightforward, intuitive, and do not require extensive training in implementation science. 

As a project enters the implementation phase, frontline teams play a critical role in shaping its trajectory and successful sustainment. In their experience with national implementation efforts, this approach has proven indispensable for aligning scientists, operational leaders, and frontline staff at local sites. “The many frameworks and theories developed by implementation scientists are valuable for the pre-implementation/planning and evaluation/sustainment phases of quality improvement interventions, but the actual implementation requires roll-up-your-sleeves, hands-on, problem solving,” said Whooley.  “A problem well defined is half solved.”

In the pre-implementation phase of a project, process mapping of the existing structures and practices at each site identifies potential adaptations of the intervention that may be necessary and helps delineate important metrics for future tracking. Once the current state has been determined and agreed upon by relevant stakeholders, mapping the envisioned future state articulates the change initiative to everyone involved and may identify new stakeholders who need to be engaged. Seeking input from frontline staff on the future state map communicates the importance of their roles and increases their ownership of the new process.

Just as identification of a local champion is the most critical aspect of pre-implementation, stakeholder engagement sits at the core of successful implementation. Continuous involvement of stakeholders (including ancillary and support staff) and repeated tailoring of implementation strategies to new stakeholders throughout a project are also key factors in achieving sustained adoption of evidence-based practices.

Providing brief monthly updates refreshes stakeholders about the goals of the initiative, highlights the project’s importance amidst competing demands, and reminds them that their progress is being monitored. Whenever possible, cross-training individuals for different roles such as the implementer, evaluator, and team leader can help mitigate the substantial loss of momentum resulting from unanticipated personnel changes during the fragile early stages of implementation. Finally, celebrating victories both large and small boosts moral and ensures sustained engagement.

When frontline staff are committed to an initiative, problems are recognized early and solutions are implemented quickly. Given the idiosyncrasies of local culture and customs, however, isolating a problem and identifying potential solutions often require iterative cycles of process mapping and new stakeholder engagement. Revisiting the existing process map can help localize the source, identify potential downstream consequences, and discover new processes to bypass barriers. “VA facilities were having trouble purchasing home sleep apnea testing devices due to the complexities and variability across individual contracting offices,” said Whooley. “To overcome this barrier, the implementation team was able to negotiate a single national contract to purchase Home Sleep Apnea Devices and distribute them to all 54 facilities.”

The authors hope frontline teams will be empowered to apply these tools to their daily practice and embrace continued efforts to improve the efficiency and effectiveness of Learning Healthcare Systems.

Mary WooleyMary Whooley, MD

Dr. Whooley is a primary care physician, implementation scientist, professor of Medicine, Epidemiology & Biostatistics, and Director of the Center for Healthcare Improvement and Medical Effectiveness (CHIME) at the San Francisco VA and UCSF. Her work focuses on applying health services research methods (including data science, implementation science, and program evaluation) to accelerate the adoption of evidence-based practices within the VA's national learning healthcare system

Implementation Strategies for Frontline Healthcare Professionals: People, Process Mapping, and Problem Solving.
Lu AD, Kaul B, Reichert J, Kilbourne AM, Sarmiento KF, Whooley MA. J Gen Intern Med. 2020 Sep 11. doi: 10.1007/s11606-020-06169-3. Online ahead of print.