Commentary on “A climate for evidence-based practice implementation in the patient-centered medical home. Journal of Evaluation in Clinical Practice. 2018: 1-11”
The month’s featured article by Sklar and colleagues1 examines the implementation climate and attitudes about evidence-based practices (EBPs) within two patient-centered medical home (PCMH) clinics. The construct of implementation climate is increasingly identified as a critical organizational determinant of healthcare innovation implementation success. Implementation climate is the shared perception among targeted organizational members of the extent to which their use of a specific innovation is rewarded, supported, and expected within an organization. A strong climate is shaped by the collective influence of multiple implementation policies and practices. The stronger the climate, the greater likelihood the innovation (e.g., an EPB) will be implemented consistently and with high quality.
Sklar et al. used a mixed methods approach to understand the context and climate for implementation of EBPs within the PCMH model at two clinics (family and internal medicine). They conducted 60 surveys assessing EBP implementation climate and 19 in-depth interviews with physicians. They found a generally strong implementation climate for EBPs in both clinics. For example, surveys indicated a strong presence of educational support for EBPs, recognition for EBPs, and general openness towards EBPs. Several facilitators for EBP use were also identified in the interviews, including availability of information technology resources (e.g., electronic health record, online databases), lectures, and trainings. However, a number of barriers were also noted in both clinics, including lack of time/resources to address patient needs and variation in clinical practice guidelines. The interviews identified several ways physicians cope with these barriers, including more informal communication and interactions among clinical staff. As one physician stated: “And that’s where your attendings come in handy, because they have more anecdotals than you do as a resident, so their experience outweighs yours.” This last finding is not surprising and underscores the importance of the role of informal implementation policies and practices. For instance, my colleagues and I recently conducted a mixed-methods study2 guided by the Organizational Theory of Innovation Implementation and found support for several informal implementation policies and practices (e.g., spontaneous communication, on-the-job training, “bottom-up” approach) in shaping a strong climate for palliative care consultations in an inpatient oncology setting. To date, this role of informal policies and practices in innovation implementation has been largely overlooked in the field of implementation science. Most of the focus has been on the role of more formal implementation policies and practices, such as training programs or guidelines. It is important to expand this area of research.
In sum, Marisa Sklar and colleagues provide us with an interesting look at an implementation climate for EBPs within the PCMH model and raises several important points with regard to shaping a context and climate that is ripe for innovation implementation in healthcare settings. As the authors acknowledge, critical questions remain about the development of policies and practices to strengthen implementation climate, and subsequence use of EBPs in health care organizations.
Read the full abstract.
1Sklar, M., Hatch, M. R., & Aarons, G. A. (2018). A climate for evidence-based practice implementation in the patient-centred medical home. J Eval Clin Pract. doi:10.1111/jep.13050.
2DiMartino LD, Birken SA, Hanson LC, Trogdon JG, Clary AS, Weinberger M, Reeder-Hayes K, Weiner BJ. The Influence of Formal and Informal Policies and Practices on Healthcare Innovation Implementation: A Mixed-Methods Analysis. Health Care Management Review. 2018 Jul/Sep;43(3): 249-260.