BioMed Central Page 1 of 11 (page number not for citation purposes) Implementation Science Open Access Methodology An organizational framework and strategic implementation for system-level change to enhance research-based practice: QUERI Series Cheryl B Stetler* 1 , Lynn McQueen 2 , John Demakis 3 and Brian S Mittman 4 Address: 1 Independent Consultant, Amherst, Massachusetts, USA, 2 Office of Quality and Performance, U.S. Department of Veterans Affairs, Washington DC, USA, 3 (Retired) Health Services Research and Development Service, U.S. Department of Veterans Affairs, Washington, DC, USA and 4 VA Center for the Study of Healthcare Provider Behavior, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA Email: Cheryl B Stetler* - Cheryl.Stetler@comcast.net; Lynn McQueen - Lynn.McQueen@va.gov; John Demakis - jgd11@erols.com; Brian S Mittman - Brian.Mittman@va.gov * Corresponding author Abstract Background: The continuing gap between available evidence and current practice in health care reinforces the need for more effective solutions, in particular related to organizational context. Considerable advances have been made within the U.S. Veterans Health Administration (VA) in systematically implementing evidence into practice. These advances have been achieved through a system-level program focused on collaboration and partnerships among policy makers, clinicians, and researchers. The Quality Enhancement Research Initiative (QUERI) was created to generate research-driven initiatives that directly enhance health care quality within the VA and, simultaneously, contribute to the field of implementation science. This paradigm-shifting effort provided a natural laboratory for exploring organizational change processes. This article describes the underlying change framework and implementation strategy used to operationalize QUERI. Strategic approach to organizational change: QUERI used an evidence-based organizational framework focused on three contextual elements: 1) cultural norms and values, in this case related to the role of health services researchers in evidence-based quality improvement; 2) capacity, in this case among researchers and key partners to engage in implementation research; 3) and supportive infrastructures to reinforce expectations for change and to sustain new behaviors as part of the norm. As part of a QUERI Series in Implementation Science, this article describes the framework's application in an innovative integration of health services research, policy, and clinical care delivery. Conclusion: QUERI's experience and success provide a case study in organizational change. It demonstrates that progress requires a strategic, systems-based effort. QUERI's evidence-based initiative involved a deliberate cultural shift, requiring ongoing commitment in multiple forms and at multiple levels. VA's commitment to QUERI came in the form of visionary leadership, targeted allocation of resources, infrastructure refinements, innovative peer review and study methods, and direct involvement of key stakeholders. Stakeholders included both those providing and managing clinical care, as well as those producing relevant evidence within the health care system. The organizational framework and related implementation interventions used to achieve contextual change resulted in engaged investigators and enhanced uptake of research knowledge. QUERI's approach and progress provide working hypotheses for others pursuing similar system-wide efforts to routinely achieve evidence-based care. Published: 29 May 2008 Implementation Science 2008, 3:30 doi:10.1186/1748-5908-3-30 Received: 22 August 2006 Accepted: 29 May 2008 This article is available from: http://www.implementationscience.com/content/3/1/30 © 2008 Stetler et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons Practice strategic laziness Practice strategic laziness Bởi: Joe Tye “Relaxation can be achieved in many different ways, and learning what works best may be a process that takes time This may be some of the most productive time and effort you will ever put into managing anxiety for a lifetime.” Margaret Wehrenberg: The 10 Best-Ever Anxiety Management Techniques: Understanding How Your Brain Makes You Anxious & What You Can Do to Change it The late C.W Metcalf, author of the book Lighten Up, was one of the funniest – and most insightful – speakers I ever heard When he spoke at one of my Never Fear, Never Quit conferences, he commented on how people would often say that it must be a riot working in his office because he had such a great sense of humor His response was that after a week on the road, he came to work with a lapel button that said “Back off, fish breath” then hid in the closet for the rest of the day We all need days like that I think of it as strategic laziness By giving yourself permission to take some time off, you recharge your batteries The lion is the king of beasts, but he spends most of his days lyin’ around We all need our lyin’ round days! 1/1 BioMed Central Page 1 of 19 (page number not for citation purposes) Implementation Science Open Access Research article Institutionalizing evidence-based practice: an organizational case study using a model of strategic change Cheryl B Stetler* 1 , Judith A Ritchie 2 , Jo Rycroft-Malone 3 , Alyce A Schultz 4 and Martin P Charns 5,6 Address: 1 Health Services Department, Boston University School of Public Health, Independent Consultant, 321 Middle St, Amherst, MA 01002, USA, 2 McGill University Health Centre & School of Nursing, McGill University, Montreal, Quebec, CA, 3 Centre for Health-Related Research, School of Healthcare Sciences, Bangor University, UK, 4 Alyce A Schultz and Associates, LLC, 5747 W Drake Court, Chandler, AZ 85226, USA, 5 VA HSR&D Center for Organization, Leadership and Management Research, Boston, MA, 02130 USA and 6 Health Policy and Management Department, Boston University School of Public Health, Boston, MA, 02118 USA Email: Cheryl B Stetler* - cheryl.stetler@comcast.net; Judith A Ritchie - judith.ritchie@muhc.mcgill.ca; Jo Rycroft-Malone - j.rycroft- malone@bangor.ac.uk; Alyce A Schultz - alyceme@cox.net; Martin P Charns - mcharns@bu.edu * Corresponding author Abstract Background: There is a general expectation within healthcare that organizations should use evidence-based practice (EBP) as an approach to improving the quality of care. However, challenges exist regarding how to make EBP a reality, particularly at an organizational level and as a routine, sustained aspect of professional practice. Methods: A mixed method explanatory case study was conducted to study context; i.e., in terms of the presence or absence of multiple, inter-related contextual elements and associated strategic approaches required for integrated, routine use of EBP ('institutionalization'). The Pettigrew et al. Content, Context, and Process model was used as the theoretical framework. Two sites in the US were purposively sampled to provide contrasting cases: i.e., a 'role model' site, widely recognized as demonstrating capacity to successfully implement and sustain EBP to a greater degree than others; and a 'beginner' site, self-perceived as early in the journey towards institutionalization. Results: The two sites were clearly different in terms of their organizational context, level of EBP activity, and degree of institutionalization. For example, the role model site had a pervasive, integrated presence of EBP versus a sporadic, isolated presence in the beginner site. Within the inner context of the role model site, there was also a combination of the Pettigrew and colleagues' receptive elements that, together, appeared to enhance its ability to effectively implement EBP- related change at multiple levels. In contrast, the beginner site, which had been involved for a few years in EBP-related efforts, had primarily non-receptive conditions in several contextual elements and a fairly low overall level of EBP receptivity. The beginner site thus appeared, at the time of data collection, to lack an integrated context to either support or facilitate the institutionalization of EBP. Conclusion: Our findings provide evidence of some of the key contextual elements that may require attention if institutionalization of EBP is to be realized. They also suggest the need for an integrated set of receptive contextual elements to achieve EBP institutionalization; and they further support the importance of specific interactions among these elements, including ways in which leadership affects other contextual elements positively or negatively. Published: 30 November 2009 Implementation Science 2009, 4:78 doi:10.1186/1748-5908-4-78 Received: 23 October 2008 Accepted: 30 November 2009 This article is available from: http://www.implementationscience.com/content/4/1/78 © 2009 Stetler et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the BioMed Central Page 1 of 13 (page number not for citation purposes) Implementation Science Open Access Study protocol Improving quality of care through routine, successful implementation of evidence-based practice at the bedside: an organizational case study protocol using the Pettigrew and Whipp model of strategic change Cheryl B Stetler* 1 , Judith Ritchie 2 , Joanne Rycroft-Malone 3 , Alyce Schultz 4 and Martin Charns 5 Address: 1 Health Services Department, Boston University School of Public Health, Boston, MA, USA; (office) 321 Middle St., Amherst, MA 01002, USA, 2 McGill University Health Centre, Montreal, Quebec, CA, 3 Centre for Health-Related Research, University of Wales, Bangor, UK, 4 Center for Advancement of Evidence-based Practice, Arizona State University, Tempe, AZ, USA and 5 Veterans Administration HSR&D Center for Organization, Leadership & Management Research, Boston, MA, USA; Program on Health Policy & Management, Health Services Department, Boston University School of Public Health, Boston, MA, USA Email: Cheryl B Stetler* - cheryl.stetler@comcast.net; Judith Ritchie - judith.ritchie@muhc.mcgill.ca; Joanne Rycroft-Malone - j.rycroft- malone@bangor.ac.uk; Alyce Schultz - Alyce.Schultz@asu.edu; Martin Charns - Martin.Charns@va.gov * Corresponding author Abstract Background: Evidence-based practice (EBP) is an expected approach to improving the quality of patient care and service delivery in health care systems internationally that is yet to be realized. Given the current evidence-practice gap, numerous authors describe barriers to achieving EBP. One recurrently identified barrier is the setting or context of practice, which is likewise cited as a potential part of the solution to the gap. The purpose of this study is to identify key contextual elements and related strategic processes in organizations that find and use evidence at multiple levels, in an ongoing, integrated fashion, in contrast to those that do not. Methods: The core theoretical framework for this multi-method explanatory case study is Pettigrew and Whipp's Content, Context, and Process model of strategic change. This framework focuses data collection on three entities: the Why of strategic change, the What of strategic change, and the How of strategic change, in this case related to implementation and normalization of EBP. The data collection plan, designed to capture relevant organizational context and related outcomes, focuses on eight interrelated factors said to characterize a receptive context. Selective, purposive sampling will provide contrasting results between two cases (departments of nursing) and three embedded units in each. Data collection methods will include quantitative tools (e.g., regarding culture) and qualitative approaches including focus groups, interviews, and documents review (e.g., regarding integration and “success”) relevant to the EBP initiative. Discussion: This study should provide information regarding contextual elements and related strategic processes key to successful implementation and sustainability of EBP, specifically in terms of a pervasive pattern in an acute care hospital-based health care setting. Additionally, this study will identify key contextual elements that differentiate successful implementation and sustainability of EBP efforts, both within varying levels of a hospital-based clinical setting and across similar hospital settings interested in EBP. Published: 31 January 2007 Implementation Science 2007, 2:3 doi:10.1186/1748-5908-2-3 Received: 21 August 2006 Accepted: 31 January 2007 This article is available from: http://www.implementationscience.com/content/2/1/3 © 2007 Stetler et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original BioMed Central Page 1 of 19 (page number not for citation purposes) Implementation Science Open Access Research article Institutionalizing evidence-based practice: an organizational case study using a model of strategic change Cheryl B Stetler* 1 , Judith A Ritchie 2 , Jo Rycroft-Malone 3 , Alyce A Schultz 4 and Martin P Charns 5,6 Address: 1 Health Services Department, Boston University School of Public Health, Independent Consultant, 321 Middle St, Amherst, MA 01002, USA, 2 McGill University Health Centre & School of Nursing, McGill University, Montreal, Quebec, CA, 3 Centre for Health-Related Research, School of Healthcare Sciences, Bangor University, UK, 4 Alyce A Schultz and Associates, LLC, 5747 W Drake Court, Chandler, AZ 85226, USA, 5 VA HSR&D Center for Organization, Leadership and Management Research, Boston, MA, 02130 USA and 6 Health Policy and Management Department, Boston University School of Public Health, Boston, MA, 02118 USA Email: Cheryl B Stetler* - cheryl.stetler@comcast.net; Judith A Ritchie - judith.ritchie@muhc.mcgill.ca; Jo Rycroft-Malone - j.rycroft- malone@bangor.ac.uk; Alyce A Schultz - alyceme@cox.net; Martin P Charns - mcharns@bu.edu * Corresponding author Abstract Background: There is a general expectation within healthcare that organizations should use evidence-based practice (EBP) as an approach to improving the quality of care. However, challenges exist regarding how to make EBP a reality, particularly at an organizational level and as a routine, sustained aspect of professional practice. Methods: A mixed method explanatory case study was conducted to study context; i.e., in terms of the presence or absence of multiple, inter-related contextual elements and associated strategic approaches required for integrated, routine use of EBP ('institutionalization'). The Pettigrew et al. Content, Context, and Process model was used as the theoretical framework. Two sites in the US were purposively sampled to provide contrasting cases: i.e., a 'role model' site, widely recognized as demonstrating capacity to successfully implement and sustain EBP to a greater degree than others; and a 'beginner' site, self-perceived as early in the journey towards institutionalization. Results: The two sites were clearly different in terms of their organizational context, level of EBP activity, and degree of institutionalization. For example, the role model site had a pervasive, integrated presence of EBP versus a sporadic, isolated presence in the beginner site. Within the inner context of the role model site, there was also a combination of the Pettigrew and colleagues' receptive elements that, together, appeared to enhance its ability to effectively implement EBP- related change at multiple levels. In contrast, the beginner site, which had been involved for a few years in EBP-related efforts, had primarily non-receptive conditions in several contextual elements and a fairly low overall level of EBP receptivity. The beginner site thus appeared, at the time of data collection, to lack an integrated context to either support or facilitate the institutionalization of EBP. Conclusion: Our findings provide evidence of some of the key contextual elements that may require attention if institutionalization of EBP is to be realized. They also suggest the need for an integrated set of receptive contextual elements to achieve EBP institutionalization; and they further support the importance of specific interactions among these elements, including ways in which leadership affects other contextual elements positively or negatively. Published: 30 November 2009 Implementation Science 2009, 4:78 doi:10.1186/1748-5908-4-78 Received: 23 October 2008 Accepted: 30 November 2009 This article is available from: http://www.implementationscience.com/content/4/1/78 © 2009 Stetler et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the BioMed Central Page 1 of 11 (page number not for citation purposes) Implementation Science Open Access Methodology An organizational framework and strategic implementation for system-level change to enhance research-based practice: QUERI Series Cheryl B Stetler* 1 , Lynn McQueen 2 , John Demakis 3 and Brian S Mittman 4 Address: 1 Independent Consultant, Amherst, Massachusetts, USA, 2 Office of Quality and Performance, U.S. Department of Veterans Affairs, Washington DC, USA, 3 (Retired) Health Services Research and Development Service, U.S. Department of Veterans Affairs, Washington, DC, USA and 4 VA Center for the Study of Healthcare Provider Behavior, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA Email: Cheryl B Stetler* - Cheryl.Stetler@comcast.net; Lynn McQueen - Lynn.McQueen@va.gov; John Demakis - jgd11@erols.com; Brian S Mittman - Brian.Mittman@va.gov * Corresponding author Abstract Background: The continuing gap between available evidence and current practice in health care reinforces the need for more effective solutions, in particular related to organizational context. Considerable advances have been made within the U.S. Veterans Health Administration (VA) in systematically implementing evidence into practice. These advances have been achieved through a system-level program focused on collaboration and partnerships among policy makers, clinicians, and researchers. The Quality Enhancement Research Initiative (QUERI) was created to generate research-driven initiatives that directly enhance health care quality within the VA and, simultaneously, contribute to the field of implementation science. This paradigm-shifting effort provided a natural laboratory for exploring organizational change processes. This article describes the underlying change framework and implementation strategy used to operationalize QUERI. Strategic approach to organizational change: QUERI used an evidence-based organizational framework focused on three contextual elements: 1) cultural norms and values, in this case related to the role of health services researchers in evidence-based quality improvement; 2) capacity, in this case among researchers and key partners to engage in implementation research; 3) and supportive infrastructures to reinforce expectations for change and to sustain new behaviors as part of the norm. As part of a QUERI Series in Implementation Science, this article describes the framework's application in an innovative integration of health services research, policy, and clinical care delivery. Conclusion: QUERI's experience and success provide a case study in organizational change. It demonstrates that progress requires a strategic, systems-based effort. QUERI's evidence-based initiative involved a deliberate cultural shift, requiring ongoing commitment in multiple forms and at multiple levels. VA's commitment to QUERI came in the form of visionary leadership, targeted allocation of resources, infrastructure refinements, innovative peer review and study methods, and direct involvement of key stakeholders. Stakeholders included both those providing and managing clinical care, as well as those producing relevant evidence within the health care system. The organizational framework and related implementation interventions used to achieve contextual change resulted in engaged investigators and enhanced uptake of research knowledge. QUERI's approach and progress provide working hypotheses for others pursuing similar system-wide efforts to routinely achieve evidence-based care. Published: 29 May 2008 Implementation Science 2008, 3:30 doi:10.1186/1748-5908-3-30 Received: 22 August 2006 Accepted: 29 May 2008 This article is available from: http://www.implementationscience.com/content/3/1/30 © 2008 Stetler et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons