Rationale The Program in Implementation Science has created a series of courses within the Training in Clinical Research Program that are designed to meet the didactic training needs of fellows and junior faculty, but lacks an experiential component.  To be effective, implementation research must accommodate the unique culture and context that define specific health care settings and communities.  An “Action Research” Program can help meet this need—which involves partnering with health care providers to improve their own practices, which in turn will enhance their working environment.  Action research’s strength lies in its focus on generating solutions to practical problems and its ability to empower health care providers, by getting them to engage with research and the subsequent development or implementation activities.  We propose an action research program to achieve at least 3 broad goals:

1. To design innovative strategies to improve health care delivery or public/community health in real-time in San Francisco by capitalizing on the experience and skills of an interdisciplinary team of UCSF implementation scientists... the goal of which is to improve health and care delivery in targeted settings using strategies that are designed to be patient-centered and to reduce total health care costs.

2. To provide a hands-on training and implementation experience for students, residents and fellows by involving them in a real-world project through all stages of development... the goal of which is to attract/encourage students to pursue careers committed to improving health care delivery, system redesign and community health programs.

3. To design an action research program that can be self-sustaining through reimbursements from stakeholder organizations and delivery systems who directly benefit financially from the impact of the action research program.

Plan

We request pilot funds for 1 year to develop and implement this program at UCSF.  It will consist broadly of 8 steps that culminate with the initial launch of a delivery system intervention. 

Step 1. Select a Partner with a “Hot Spot”. Hot spots are problem areas in clinical operations, quality or health outcomes that are identified by stakeholders (such as payors, administrators, providers or patients) as priority areas for intervention.  In our first cycle, we will focus on UCSF Medical Center ambulatory practices.  To identify potential partners, we will invite practice chiefs and administrative directors of these practices to submit brief, 1-page descriptions of Hot Spots in their practice that they would like the action research program team to help them intervene on.  Key criteria will include feasibilty of measuring and intervening on Hot Spot, engagement of clinic providers/staff, learner access to relevant data, staff, patients and providers, and degree to which addressing hot spot will help improve quality, reduce health care costs and enhance the patient experience.

Step 2.  Assemble Action Team.  Advertise volunteer/training opportunities to students and residents in medicine, pharmacy, nursing and dentistry.  Commitment of 2-4 hours per week for 4-6 months is required.  Limit to 6-8 students.  Identify key content/strategy experts from UCSF faculty and partners.

Step 3. Characterize Hot Spot with existing data sources.  Further characterize with administrative and/or medical record data to examine frequency, distribution, variability and predictors of the key process or outcome that represents the Hot Spot.

Step 4.  Conduct Literature Review of Hot Spot.  This will be performed by a combination of faculty and students.  Medical students will apply some of the principles taught in their EEBM (Epidemiology and Evidence Based Medicine) classes.

Step 5. Convene Launch Meeting and Design Workshop.  This will be a 1 or 2 day retreat in which the partner clinic (and staff) are brought together with the faculty and students on the Action Team.  The goal of the meeting will be to create a timetable with specific activities benchmarks for completing the project in a 4-6 month time frame.

Step 6. Conduct & Analyze Formative Research.  Interviews and observations will be performed to gain a greater understanding of the patient, provider, staff and system-level factors that contribute to the Hot Spot being investigated.  With close guidance from faculty, students will be charged with collecting and analyzing this data.

Step 7. Create Alpha-Version of Intervention Approach.  Combine data inputs from the literature review, the quantitative analysis of administrative/EMR data, and the formative research findings to design an intervention approach. 

Step 8. Launch First Iteration (Beta-Version) of Intervention; Collect Process Data

Criteria and metrics for success

1. Submission of Hot Spot proposals from multiple clinics—shows interest/need for service.
2. Requests to participate from multiple students/residents—shows interest/appeal to trainees.
3. Implementation of intervention that has a significant impact (>10-20% change from baseline) on Hot Spot measure.
4. Explicit plan for continued monitoring and refinement of intervention by participating clinic.

Total Budget: $70,904

Salary support for principal faculty and part-time research assistant.

Collaborators: Ralph Gonzales (Medicine); Margaret Handley (Epidemiology & Biostatistics); Sara Ackerman (Medicine); Joshua Adler (Chief Medical Officer; UCSF Medical Center)