Author: Candace DeMatteis
Melanie Livet is a specialist in Implementation Science working within the Center for Medication Optimization in her role as Research Assistant Professor. Her expertise enriches research efforts at the Center from conception and development through implementation, evaluation, and reporting. Her work helps to assure that the Center’s research yields results that are not only impactful, but also are replicable, sustainable, and scalable.
Q: Hi, Melanie. What’s your role and what do you do at the Center for Medication Optimization (CMOPP)?
A: I am an applied researcher with specialized expertise in implementation science, technology validation, and program evaluation. My role at CMOPP is to infuse and test relevant principles and best practices from these disciplines into our projects, to facilitate their success and optimize their real-world impact.
As an applied methodologist and implementation professional, I am really interested in understanding what it takes for a practice setting to adopt and implement an evidence-based innovation and do it well enough to drive its effectiveness…regardless of what that innovation is (e.g., intervention, process, technology, set of guidelines).
Q: What were you doing before joining the CMOPP team?
A: Prior to joining CMOPP, I worked in both the private and academic sectors, in applied research and management roles, for a behavioral health technology R&D firm, a public health government contracting organization, and a university-based Center. Over the past 13 years, I have been engaged with more than 40 projects in a number of different areas, including behavioral health, chronic disease prevention, violence prevention, HIV/AIDS prevention, emergency preparedness, and now pharmacy practice. While the content of these projects range widely, they all involved application and/or testing of implementation science and evaluation methodologies to solve real-world health challenges.
Q: What exactly is implementation science and what does it involve?
A: Implementation science is defined as the study and application of strategies to facilitate uptake of evidence-based research and practices into routine use. Its ultimate purpose is to improve the quality and impact of services and interventions for the patients on the receiving end. Previous research has demonstrated that a well-implemented service produces better patient outcomes than that those that have been poorly implemented.
In a nutshell, implementation science involves understanding and applying the knowledge generated from the synergistic effect of three streams of activities within the discipline: implementation science frameworks, which anchor the discipline and can guide your implementation efforts; implementation practice, which facilitates our understanding and tailoring of the implementation process, its components, its facilitators and barriers, and its impact on service effectiveness through application in real-world settings; and implementation research, which seeks to understand best practices and measurement strategies to enhance implementation quality.
Q: Why is implementation science so important?
A: In my opinion, implementation science plays an important role in our quest to help patients in need for three reasons. First, because this help often takes the shape of a health service or intervention that is offered to the patient, we need to ensure that this service is implemented with quality. If the service is implemented as intended, it should increase its likelihood of having a beneficial impact on the patient. Second, previous research has highlighted the fact that without proactive implementation, it takes an average of 17 years for research evidence to reach clinical practice. Use of an active implementation strategy can significantly accelerate this process. Finally, implementation science is instrumental in generating practical learnings, strategies, and tools needed for successful replication, sustainability, and scaling of the services that have been found to be effective in small-scale field tests. If a service has been found to significantly impact patients, we obviously want to be able to replicate success over a much larger scale.
Q: If a new practice or discovery works well, won’t people adopt it anyway?
A: No, not necessarily. The process of implementation is much more complex than one would think. For instance, we have identified 8 different components of implementation, at least 4 implementation stages, more than 20 multi-level influences on implementation, 14 steps or activities necessary to increase implementation effectiveness, 8 implementation outcomes, and 73 implementation strategies. All of these elements play a significant role in the implementation process. We also know from previous research studies that simply introducing a new innovation is not sufficient for it to be used effectively. We need to be purposeful, systematic, proactive, and evidence-informed in our implementation efforts for the service to work as intended.
Q: What does implementation science do to accelerate the adoption of what is learned from research to practice?
A: Implementation science promotes an approach to implementation that is systematic, proactive, and evidence-informed. Its principles and activities are all designed to facilitate uptake and enhance the intervention clinical and humanistic outcomes. In brief, these include: encouraging the translation of evidence into usable and well-defined interventions; attending to the needs of the practice setting; recognizing and addressing potential implementation challenges; engaging all key stakeholders; using proactive implementation strategies; and promoting ongoing monitoring of the implementation process to ensure that the intervention is being implemented as intended. Using this approach will not only drive initial success of the intervention in real-world practice, but it will also prepare stakeholders for replication, sustainability, and scaling of that intervention. This fosters the greatest impact possible of an effective intervention on those who need it.
Q: The Center for Medication Optimization (CMOPP) has multiple projects underway designed to test how optimizing medication use improves outcomes and impacts overall costs. Why use Implementation Science when trying to improve outcomes?
A: Implementation science is key to understanding improved service outcomes for two reasons. First, because of the positive relationship between quality implementation and intervention effectiveness, monitoring implementation to ensure that the intervention is implemented as intended will increase your likelihood of achieving the desired clinical outcomes. If you find that the service is not being delivered as intended, you can make the necessary course corrections before it is too late. Second, if your service does not produce the intended clinical outcomes, your implementation data will allow you to determine the reason for this failure: was the intervention itself not effective (assuming that it was implemented properly) or was the lack of results due to poor implementation?
Keeping this in mind, we build both implementation practice and implementation research into all of our projects.
Q: How is implementation science being built into the CMOPP projects?
A: Implementation practice, with its roadmaps, stepwise approach, and practical strategies and activities, allows us to ensure that implementation science best practices are being infused into the rollout of any medication optimization intervention. This allows us to be systematic, proactive, and attend to the diverse aspects of quality implementation.
Because we actively monitor quality implementation and want to ensure implementation success, we also make use of implementation research principles, by selecting appropriate designs, implementation indicators, and implementation measures. For instance, we use the hybrid implementation effectiveness design frequently. This type of design combines elements of clinical effectiveness and implementation research to enhance the intervention impact. This dual focus supports more rapid translation, implementation, and scaling of models and interventions. In addition, we always include implementation outcomes as part of our measurement strategy, alongside the more traditional clinical outcomes. These implementation outcomes (e.g., acceptability, fidelity) serve as indicators of both implementation progress and success.
Q: Do you have any new papers coming out that describes these efforts at CMOPP?
A: Yes, we have several manuscripts in preparation that will be highlighting some of the implementation science work that CMOPP is involved with. We recently published an implementation science primer in Pharmacotherapy that provides an overview of implementation science principles for pharmacists and other health professionals interested in accelerating practice transformation to improve health care delivery. We are also working on a number of articles that describe and investigate different aspects, processes, and tools related to the implementation process, that we believe will be foundational for advancing pharmacy practice.
Q: Any advice for decision-makers evaluating different programs to determine what could work for them?
A: I would encourage any stakeholder to make it a habit to incorporate implementation science data into their decision-making process about the effectiveness of a particular intervention or service. If an intervention is implemented as intended, and consistently produces positive effectiveness outcomes as a result, it should strengthen your level of confidence in the impact that the intervention can have on patients. In addition, because implementation science generates learnings that are key to successful replication, sustainability, and scaling, decision-makers should actively seek to incorporate implementation science into their research-to-practice projects. Understanding the implementation recipe (i.e., ingredients, directions, tools) for a successful intervention, that is, an intervention that has a significant impact on its intended beneficiaries, provides some assurance that this success can be replicated and scaled.