Distortion of implementation techniques in health care: The case of "facilitation"

Background: When applied to solving real-world problems of health care, service improvement approaches are likely to evolve over time in response to the context of their implementation. The temporal dynamics of this evolution and its underlying processes, however, remain under-researched. To address this gap, we explore the evolution of facilitation, an implementation approach that can be broadly defined as enabling the processes of learning in group contexts and is often deployed to mobilize research knowledge into clinical practice.

Methods: The prospective longitudinal case study was conducted in a five-year UK-based collaborative research programme involving a university, a tertiary-care hospital and a number of local general practices. The programme aimed to increase the identification of chronic kidney disease (CKD) and improve the management of blood pressure in CKD patients by facilitating the mobilization of existing health research in day-to-day clinical practice. A purposive sampling strategy was used, with 40 research participants drawn both from the programme 'core' team and participating general practices. 45 semi-structured interviews (30-95 minutes in duration) served as the main method of data collection and were conducted (face-to-face or by phone) in three rounds (2010-2011, 2012-2013 and 2013-2014) to enable longitudinal analysis.

Findings: We argue that an uncritical and uncontrolled adaptation of implementation techniques may lead to their gradual distortion, undermining their promise to positively affect organizational learning processes and masking the unsustainable nature of the resulting improvement outcomes captured by conventional performance measurement. We describe the following three parallel and overlapping micro-processes underpinning the gradual distortion of facilitation over time: (1) prioritization of (measurable) outcomes over the (interactive) process; (2) reduction of (multiprofessional) team engagement and (3) erosion of the facilitator role.

Implications for D&I Research: Our findings emphasize the lack of attention to the sustainability of change once the short-term outcomes of facilitated implementation projects have been attained, measured and reported. An exploration of new ways of maintaining context-sensitive adaptation of implementation techniques without losing their core elements could provide a useful direction for future empirical inquiry.