Using Implementation Teams to Inform a More Effective Response to Future Pandemics

Emerging viral pandemics place extraordinary and sustained demands on health, social care, and economic systems across the globe. The Centers for Disease Control and Prevention recommends a combination of evidence-based interventions for the active and rapid extinction of local outbreaks. ¹ To use these interventions in various contexts, concerted, coordinated action is needed within and across countries. The variable response to the coronavirus disease 2019 (COVID-19) pandemic raises a critical question about the existence of the necessary mechanisms to coordinate these types of complex responses to humanitarian crises. ² With each threat that substantially disrupts large, dispersed populations, the arguments for investing in the development and integration of needed capacity within health and social care systems have been strengthened. The field of implementation science can make a meaningful contribution by guiding how to build the capacity to use measures for prevention, containment, and elimination of disease outbreaks and other humanitarian crises. ^3,4

The National Institute of Health defines implementation science as “the study of methods to promote the adoption and integration of evidence-based practices, interventions, and policies into routine health care and public health settings.” ⁵ Comprehensive reviews of dissemination and implementation evaluation literature have identified implementation strategies in the form of applied models and frameworks. ^6,7 The Active Implementation Frameworks (AIFs), for example, provide a roadmap of how to build ongoing capacity that supports effective implementation of innovations and how to influence policy and funding to create an enabling context for sustaining the use of evidence-based interventions in practice. ^{8 -13} The AIF consists of 6 core components that function in an integrated manner.

1. Usable innovation: It ensures the development of operational descriptions of innovations and assessments of fidelity. ⁸

2. Implementation drivers: They ensure the development of innovation-related competencies, organization policy and procedure changes, and involved leadership that supports the use of innovation in practice. ⁸

3. Implementation stages: The stages support the iterative stage-based implementation of innovations that eventually leads to their institutionalization. ⁸

4. Systemic change: It supports the change in structures, policies, and processes to create an aligned and integrated system through bottom-up, top-down, and lateral communication so that implementation strategies are used to maximize the intended outcomes at scale. ⁸

5. Improvement cycles: They guide rapid and purposeful problem solving and continuous improvement through the use of plan-do-study-act cycles and usability testing. ⁸

6. Implementation teams: These groups are highly skilled in using implementation strategies and effecting organization and systemwide change. These teams put all the aforementioned AIFs to use. ⁸

Beyond AIF, 68% of implementation frameworks have identified implementation teams as a critical strategy to ensure quality implementation. ^{14 -19} Moreover, the implementation strategies identified by Kirchner et al ²⁰ and Leeman et al ²¹ include teaming, collaboration, and community engagement, which is consistent with the role of implementation teams. The purpose of this commentary is to highlight the need to build implementation capacity in the form of linked implementation teams that align various systems to enable a more streamlined and coordinated response to pandemics. ⁸

Local response teams engage individuals, families, and communities to ensure that evidence-based interventions for prevention and treatment are carried out (Figure). The team members, collectively, have the needed content expertise. These teams may include contact-tracing teams and treatment teams. The contact-tracing teams are responsible for identifying and isolating the diagnosed and exposed populations. The treatment teams comprise clinicians, nurses, laboratory staff members, and pharmacists who are responsible for testing, treating, and vaccinating the population.

Figure

Linked implementation teams at various administrative levels, based on implementation capacity development. Data source: Fixsen et al. ⁸

A local implementation team supports each local response team. The local implementation teams are a critical part of a system and are accountable for adapting the evidence-based interventions to the local context and ensuring that the necessary infrastructure (eg, data systems, competent workforce, resources, leadership buy-in, partnerships) is in place and is functioning as intended. ^22,23 These teams may comprise implementation science experts in hospitals, local health departments, or other ambulatory and non-ambulatory settings to facilitate and support the implementation of new evidence or guidelines. Local implementation teams are developed and supported by implementation teams at higher administrative levels (eg, county, state, and national implementation teams in the United States). The implementation teams at higher administrative levels are responsible for coordinating efforts with researchers so that the best evidence is disseminated to local implementation teams and response teams as it becomes available. These teams have collective expertise in fields such as epidemiology, implementation, science, public health, health economics, and health policy. For example, the team at CDC or the US Department of Health and Human Services can be a national implementation team, and a team from a state department of health can be a state department of health. These linked implementation teams enable the establishment of communication between the practice level and the policy level so that there is a bidirectional, top-down, bottom-up flow of timely information, which is mutually beneficial. For example, implementation teams ensure that policy makers are promptly made aware of the consequences of their policies and guidelines so that rapid adjustments and improvements can be made. ⁸ This infrastructure creates a coherent learning system by promoting centralized dissemination of the best available evidence and procurement and distribution of resources, while allowing an organized approach to adapting the evidence to local context and use of resources to meet unique local needs. ⁸ Implementation team structure, selection criteria, and detailed practice and competency profiles have been described. ^24,25 Forming an implementation team does not require hiring new staff members who engage in the implementation of innovations. Often, existing staff members or teams are carefully selected for and repurposed to fulfill the task of implementation teams (Box).

Box

Implementation team structure and collective competencies ^a based on active implementation practitioner: practice profile ^a

Implementation team structure

• 3 to 5 members who serve as an accountable structure for implementation

• Members are mutually selected into their roles

• Members may include program developers or purveyors

• Terms of reference and communication protocol must be put in place

Implementation team competencies

Knowledge of intervention/strategy

• Ability to operationalize well-defined interventions/strategies

• Ability to operationalize less well-defined interventions/strategies

• Ability to measure implementation outcomes, such as fidelity

Implementation science knowledge and skills

• Ability to apply implementation best practices

• Ability to develop and sustain implementation infrastructure (eg, drivers)

• Ability to apply adaptive leadership skills

• Ability to use improvement cycles for problem solving and usability testing

• Ability to use data for decision making

• Ability to design an action plan

Interpersonal and communication skills

• General communication skills and abilities

• Ability to receive feedback

• Ability to provide conceptual feedback to promote advanced, nuanced thinking

• Ability to institutionalize feedback loops

Systemic change knowledge and skills

• Ability to understand the context, including mindsets, and connections within the system

• Ability to engage and influence stakeholders (eg, policy makers, funding agencies)

^aAdapted from Van Dyke ²⁴ and Fixsen et al. ⁸

During the past 3 decades, implementation teams have been built in education, child and social welfare, and behavioral health sectors. ^26,27  For example, the nationwide implementation of Parent Management Training–Oregon Model (PMTO) in Norway was supported by a research team that was responsible for building the skills of implementation teams in Norway. The national implementation team comprised 6 regional coordinators who were trained in PMTO. They adapted the US model to the Norwegian context, designed and conducted training, and established a comprehensive system of supervision to maintain treatment fidelity and oversee clinical competence of local teams. ²⁸ The results showed significant improvement in the children receiving treatment through PMTO compared with children who received regular (ie, non-PMTO) services. ²⁷ The measurement of implementation outcomes for this nationwide implementation effort showed a moderate and consistent association between implementation outcomes and the integration of the PMTO program. ²⁹

To create systemic change, the education system in Kentucky implemented the State Systemic Improvement Plan with the goal of improving math scores among children with disabilities. The center of this plan was to develop linked implementation teams with the support of implementation science experts from the National Implementation Research Network. These experts worked with the Kentucky Department of Education leadership teams to develop the readiness and capacity of teams at the district and school levels to use the best available evidence from implementation science research and practice. Experts from the National Implementation Research Network measured this cascading system of supports from the state level to the school level through periodic capacity assessments. This structure helped implementation teams solve systemic barriers and meet school and district goals for improved student outcomes. The preliminary results showed that the percentage of students meeting the benchmark in math at the elementary and middle school levels increased from 21.5% in fall 2017 to 51.0% in spring 2018. ²⁶

Using implementation teams to support change efforts has led to better outcomes more quickly than traditional change efforts. For example, a randomized controlled trial study across 60 sites in Ohio and California tested one of the models of the local implementation teams: the community development team. The study found that sites with a community development team showed effective implementation and higher rates of foster care placement than sites without a community development team. ³⁰ Moreover, systematic reviews have been conducted to understand the role of facilitation by teams to support learning, collaboration, problem-solving, consensus building, and quality improvement in health care settings. ^31,32 Overall, these reviews showed a substantial positive effect on the implementation of clinical guidelines in clinical settings.

Recent history shows how the eradication of smallpox was accomplished because of a strong health care system that supported the replication of teams across regions and countries to support the high-fidelity use of surveillance and containment strategies. The teams ensured that these strategies were used as intended, used data to make timely decisions, and communicated with the leadership team at the policy level to drive actions—the best practices of implementation. ³³

Most recently, the University of California, San Diego Health, created an ambulatory COVID-19 team to manage the outbreak. ³⁴ This local response team comprised physicians, nurses, and epidemiologists. The team worked with the clinical informatics team to adapt the electronic health record system to incorporate tools for updating evolving clinical requirements, generating real-time data analytics, and providing services through telemedicine. The multidisciplinary team ensured open communication with institutional leaders and conducted a readiness assessment to determine their capacity to respond to the COVID-19 pandemic. They faced challenges along the way, such as ongoing iterations to requirements and unanticipated disruption to workflow, but their teaming structures facilitated their effort to resolve issues as they emerged.

Collectively, recent literature reflects the importance of implementation teams as an essential strategy for successful implementation of evidence-based interventions. However, the number of research studies examining the effectiveness of the various models and types of implementation teams in health care settings is limited. Nevertheless, the available evidence from research and practice is promising. Using the implementation strategy of cascading implementation teams can help build a more robust and coordinated infrastructure to tackle future pandemics with the commitment and support of political leaders, policy makers, and communities within and across countries.