Role of "external facilitation" in implementation of research findings: a qualitative evaluation of facilitation experiences in the Veterans Health Administration

The PARIHS framework, which was the basis for initial use of facilitation in QUERI, conceives of facilitation as one of the three factors key to successful implementation [7, 8]. The originators of the framework suggest that facilitators have a key role in helping individuals and teams understand what they need to change and how to change it to successfully implement evidence into practice [8]. As such, facilitation can be identified as a potential intervention that enables the implementation of evidence into practice [9]. However, the precise role of facilitation and its contribution to the success of implementation, particularly within multi-site projects across a health system, has yet to be thoroughly described, operationally defined, or well-evaluated.

The process of facilitation and the related role of a facilitator are evident in a number of different fields and disciplines ranging across education, counseling, management, clinical supervision, and quality improvement. Available evidence reviewed by Harvey and colleagues [9], however, illustrates variable interpretations and approaches to facilitation. For example, in practice-based learning methods, such as clinical supervision, the focus is on "facilitating experiential learning through critical reflection, dealing with psychological defensiveness and challenging cultural norms [p.580, [9]]." In contrast, in fields such as quality improvement the purpose of facilitation appears to be more oriented to task and goal achievement. The purpose of facilitation can thus vary, ranging from "providing help and support to achieve a specific goal" to "enabling individuals and teams to analyze, reflect and change their own attitudes, behaviours and ways of working [p.580, [9]]." Facilitation also may occur in variable forms, e.g., as a facilitator internal to an implementation site, an external facilitator [i.e., QUERI change agent], or a combination thereof. In the latter instance, an external facilitator might work with an internal facilitator to develop his/her facilitation skills and abilities and/or help to develop an enabling context. Finally, facilitation has been described as an appointed role that encompasses a wide range of techniques and approaches [9].

Facilitation, as described to date, is a complex and multi-faceted concept. Based on the current state of the evidence, questions exist as to both: 1) Whether facilitation is conceptually and operationally discrete from other change agent interventions, such as educational outreach, and 2) How facilitation relates to other types of interventions or processes within a multi-faceted implementation project [9]. Aspects of educational outreach, for example, appear in some facilitation models but not others, and, as Rycroft-Malone, et al[10] noted recently, there is a potential overlap of project management and facilitation. Additionally, there is a lack of common intervention definitions within the implementation field, as well as a failure at times to differentiate planned versus actual operationalization of those interventions [11, 12]. This makes comparisons across studies difficult and adds to the lack of clarity of any implementation concept, including facilitation. Further questions arise from the following:

In summary, findings from evaluative studies reflect the diverse ways in which facilitation has been conceptualized and applied. This makes it difficult to combine the findings to draw meaningful conclusions about the nature and effectiveness of facilitation as a distinct implementation intervention. According to Harvey and colleagues, the findings from qualitative and quantitative studies do suggest that a facilitator with face-to-face communication and using a "range of enabling techniques has some impact on changing clinical and organisational practice, although the effect size is variable and associated with differing costs [p.585, 9]." Exactly what enabling techniques influence change, with which type of facilitator, using what type of approach, or in what type of setting or context remains unclear.

The completion of a first wave of implementation projects within QUERI provided an opportunity to explore the concept of facilitation and highlight essential details of the facilitator role. (See additional file 1, an Adobe Acrobat 7.0 PDF document: Study Projects per QUERI Team: Related Goals and Implementation Interventions for a description of the multi-intervention strategy for each QUERI study. Although facilitation was present at varying levels in all the projects, it had not been recognized at the initiation of these projects as a distinct activity or intervention. This type of approach further highlights problems associated with making sense of multi-faceted interventions and their related effects.)

The overall purpose of this evaluation was to raise consciousness about the need to better understand the concept of facilitation – and thereby enhance its deliberative operationalization and encourage its explicit evaluation in future QUERI research. More specific evaluative objectives (see Table 2 for details) covered two aims: 1) To clarify the precise nature of facilitation as a potentially discrete versus diffuse intervention within an implementation strategy, and 2) To uncover critical issues requiring future research.

The remainder of this paper contains a description of the reflective method used to identify and analyze QUERI facilitation experiences, a set of summarized findings with detailed tables, and associated research implications.

A reflective exploration was the method chosen to gain in-depth insights into the nature of facilitation across multiple VA research projects. A reflective exploration is a process that systematically stimulates and supports recall and analysis of a past complex experience; in this case, involving interviews of a purposefully selected group of implementation research change agents. The approach was based on Kolb's experiential 4-phase learning cycle [13]. As applied to this study, learning cycle phases paralleled data collection and analysis processes, and progressed as follows:

[See additional file 2, an Adobe Acrobat 7.0 PDF document: Reflective Questions and Interviewee Preparatory Work.]

A possible fourth phase was not part of this study (i.e., testing implications of concepts in new situations). However, selected questions were framed in a future perspective. For example, what should have happened in the implementation study? What might have been more effective? And by implication, what should be done in the next implementation study?

An initial, one-to-two hour semi-structured telephone interview was conducted with each participant. An implementation expert carried out the interviews (CBS), which primarily captured qualitative data, while another team member (ML) served as the note taker (except for her own interview, the pilot) and participated in the interview if clarification was required. Guided by the Kolb framework [13], the reflective interview process focused on exploration of the following topical areas:

The initial interview was followed by a series of shorter interviews and e-mail communications over approximately 7 months to obtain the iterative participant reflections required by the learning cycle. [See additional file 2: Reflective Questions and Interviewee Preparatory Work, for the detailed interview guide.]

Seven VA researchers from six QUERI-related VA implementation projects agreed to participate in the evaluation. All participants had been involved in explicit or implicit facilitative processes, occasionally as a supporter and supervisor of a facilitator.

Each QUERI project in which these interviewees had been involved was designed with a goal of improving a specific aspect of health care for a specific group of veterans. [See additional file 1: Study Projects.] The number of clinics or study facilities involved in an individual QUERI project ranged widely – from 4 to 23. Each interviewee participated in the execution of one of these projects as a study team member and facilitator (or facilitator supervisor/supporter).

The evaluation plan was submitted to the Human Subjects Division at an organizer's home site (ML) and was considered to be a QUERI quality review. The manuscript was more recently presented to the same Human Subjects Division (HSD) relative to its proposed publication in the health care literature. In consultation with the University of Washington Institutional Review Board Chair, the HSD concluded that this work did not constitute human subjects research and, therefore, did not need a certificate of exemption. Nonetheless, specific ethical principles regarding confidentiality and protection of data were adopted. For example, it was agreed that the organizers of the evaluation (CBS, ML, JR-M) would be the collectors and analyzers of raw data and would maintain its confidentiality; individual experiential data would be synthesized across participants, so individual participant experiences and perceptions would be anonymous; and quotations used in any outputs would not include information that identified the participant.

Following each interview, a detailed process was followed to enhance reliability and trustworthiness of data acquisition, analysis and interpretation. Table 3 describes the iterative process used to affirm accuracy of recorded experiences, individual case interpretations, and cross-interview syntheses. Interviewee participants received a draft transcript of their own interview to ascertain whether they believed it to be a true record and were invited to contribute any additional thoughts since the interview. Next, interviewers organized and synopsized the raw experiential report within each finalized interview to reflect an interviewee's core, conceptual response to each question. This draft analysis was provided to the participant for further comment and affirmation or challenge.

As data were primarily qualitative, content analysis, whereby data are broken down and subsequently built up into themes, was employed following Huberman and Miles [14]. In this case, responses across interviews were clustered in relation to the pre-determined questions to identify similar or distinct perceptions and experiences. Common responses or themes across cases were identified. Interviewee quotes were linked to draft themes for illustrative and clarifying purposes, and, where relevant, distinct experiences that differed from the majority were highlighted. Throughout the analysis process, the third organizer [JR-M] acted as a critical reader, challenging emerging themes and hypotheses, and ensuring re-formulation of ideas where appropriate.

Based on consensus of the interviewers [CBS & ML] and evidence-based clarifications requested by JR-M, the draft of this cross-case analysis was circulated to all participants. Affirmation or suggestions about alternate interpretations or wording was requested during individualized phone calls. Overall, participants reviewed and affirmed the product at each step of the analysis, including the summary of the cross-case synthesis.

As experienced by these VHA implementation researchers, facilitation is a valuable and critical process of interactive problem-solving and support, which occurs in the context of a recognized need for improvement and a supportive interpersonal relationship. The recognized need is one derived through research of best practice and diagnostic analysis of a site's performance gaps [15].

In general, interviewees viewed the end goal of facilitation as helping people in health care settings modify their work to incorporate a specific evidence-based clinical practice. This "helping" effort was seen to occur in general through the support of locals' use of an evidence-based implementation strategy – originally developed by the research team (additional file 1: Study Projects) – and through provision of other assistive and encouraging activities.

More specifically, interviewees identified the objectives of external facilitation as follows:

The following individual participant comments highlight these objectives ['you' and 'them' herein refer to the internal change agents as applicable]:

A key question about facilitation is whether it is different from or part of other implementation interventions, processes or roles. Based on the experiences of these QUERI interviewees, the following observations were made about facilitation:

Facilitators also might help internal change agent/s understand and utilize audit and feedback data provided by an implementation research team, or use persuasive advocacy/championing to reinforce the need for a targeted evidence-based change in relation to local practice gaps. In terms of the latter, another participant suggested, "Facilitation is not equivalent to marketing ... or networking. But, facilitation can encompass those particular roles and be part of making these roles easier." Yet another said, "It really has a lot to do with creating buy-in/activating the sites/championing the recommendations."

Two interviewees described their view of the distinctness of facilitation as follows:

As noted above, facilitators appear to help internal change agents actualize an implementation plan and, thereby, EBP through two key components of the facilitation process, i.e., interactive problem solving and support. A summary regarding distinct behaviors and activities related to these two components of the external facilitator role are described below, with further detail provided in Tables 4, 5, and 6.

There are barriers to and enablers of external facilitation, at times reflecting either the absence or presence of the same critical factor. Table 7 depicts this relationship in terms of common themes across interviewee experiences and sample quotes illustrating contrasting circumstances.

Four key factors and related observations were described as follows:

A multi-faceted interview question was used to assess participant views regarding the degree of "success" of facilitation efforts. Data are from six interviewees, as one felt s/he couldn't judge success. Interviewee perceptions regarding the success of individually identified and critical facilitation behaviors ranged on a scale from 1 (not at all effective) to 5 (very effective/successful). In terms of the success of the overall facilitative effort, on the same scale, two individuals rated facilitation as not effective ("1" and "2" respectively), while remaining summary ratings averaged 3.25. Perceptions of the overall success of individual QUERI implementation projects were similar, with an average rating of 3.4.

In those facilitation relationships perceived by interviewees to be more successful, one or more of the following factors, consistent with the above barrier/enhancer discussion, were likely to be cited:

Some illustrative comments from three interviewees included the following: "They said I was easy to communicate with, readily available. I returned calls. I either had answers or would find them." Another was said to "...have had a great rapport," and a third felt that a facilitator had to be "...someone who is well-liked." In terms of a clinical background, one said, "With no clinical background, it is difficult to talk to MDs. You need to understand what it is like being in the trenches." While another (a clinician by background) indicated "It isn't as important as personal skills...I could always refer them to literature or an MD."

In contrast, those facilitation relationships or encounters perceived as not very successful were more likely characterized by interviewees and interviewers with one or more of the overlapping factors on the following list.

Interviewees from QUERI discussed the purpose of their facilitation efforts – actual and as desired in the future – in terms of interactive problem solving to meet specific implementation goals. This finding is consistent with Roger's definition of a change agent [5], as "an individual who influences clients' innovation decisions in a direction deemed desirable by a change agency." Therefore, it is different from facilitating a change that involves open-ended implementation goals and objectives.

The QUERI description of facilitation as a form of interactive problem solving also is consistent with a recently published concept analysis by Thompson, et al. [18] that identified the facilitator role as active, dynamic and task-oriented. Furthermore, interviewees' emphasis upon the criticality of the role's support element reinforces findings of both Harvey, et al.'s concept analysis that concluded "the facilitator role is about supporting people to change their practice [p.585,9]," as well as recent empirical work by Cheater, et al[17] and Wallin, et al. [16].

In terms of the PARIHS definition and purpose of facilitation, there is an obvious overlap with this study's findings relative to the concept of a "helping and enabling" role [7, 8]. The heuristic definition that emerged from QUERI experiences further emphasizes what PARIHS would call the "task orientated approach" but provides more explicit operational detail about the "focused process of providing help and support to achieve a specific task [p.177, [8]]." Unlike the 2002 PARIHS description, QUERI facilitators at times did use "telling or persuading," given the goal of the external change agency.

In general, QUERI interviewees felt that facilitation could be a distinct entity, but questions still remain as to exactly how this problem solving and supportive function sets facilitators apart from other change agent roles, such as educational outreach/academic detail workers, opinion leaders, or champions. To some extent the findings from this evaluation support Harvey, et al. [9] in that QUERI interviewees described their facilitation role as broader than the educational outreach model; i.e., because as facilitators they engaged in more, and differently targeted interventions. For example, interviewees described their role in diagnosing and modifying contextual factors, and in being a boundary spanner/intermediary between organizations and other stakeholders. Arguably, educational outreach workers tend not to focus their efforts on context or on providing a mediating function.

Additionally, there may be some overlap between facilitation and project management. While participants in this study viewed their facilitation role as distinct from a project management role, in reality there may at times be blurring of role boundaries and tasks undertaken. According to the findings of this evaluation and those of Harvey, et al. [9], the distinction between a facilitation intervention and project management role seems to be one of intention and scope. A facilitation intervention, for example, is concerned with enabling the implementation of evidence into practice using a wide repertoire of skills and a flexible approach to working with individuals and teams in an enabling way. On the other hand, project management is not necessarily about enabling the process of evidence implementation and is potentially more restrictive in its scope, remit and enactment. More research is obviously needed to determine the specific differences between facilitation and project management roles.

In Thompson, et al.'s concept analysis [18], various roles of "intermediaries and influentials" in the transfer of knowledge were reviewed, revealing persistent confusion regarding both standard definitions of individual roles and cross-role similarities/differences. In terms of the roles reviewed – i.e., opinion leaders, facilitators, champions, linking agents and change agents – Thompson, et al. concluded that these specific "concepts may indeed be similar phenomena with different labels [p. 691, [18]]."

A facilitator in the QUERI study clearly can be defined as a change agent [5], as well as a linking agent between the internal change agent and the broader environment. However, as Thompson, et al. also found, "there are...many differences that suggest that these [reviewed] concepts are conceptually unique [p. 691, [18]]." For example, external QUERI facilitators did not conform to various descriptions of either an opinion leader (i.e., an internal individual who is informally well-connected and has a wide peer and social network) or a champion (i.e., an individual who emerges unsolicited and has visionary qualities).

A number of individual factors were highlighted by interviewees believed critical to the success of a facilitator's role. This included flexibility, relevant experience (as facilitators or as clinical process experts within the VHA), knowledge (e.g., regarding the evidence), and the ability to build relationships through good communication. The facilitators in this study were required to be flexible by adopting different styles (e.g., directive and non-directive) depending on the projects, specific sites, related progress, and individuals involved. These findings support others' work. For example, Cheater, et al. [17] found that flexibility and the ability to draw on a repertoire of skills supported the functioning of the facilitation role in an exploratory trial. Additionally, Wallin, et al. [16] describe the positive benefits of guideline implementation facilitators having knowledge about managing change, as well as having insight into the clinical topic, which they call being 'content aware.' Furthermore, Greenhalgh, et al.'s observations regarding external change agents [6] suggest that facilitators need to have credibility and be appropriately "trained and supported to develop... interpersonal relationships with potential users [p.26]." Thompson, et al.'s review generally echoes these observations [18].

In summary, and as Harvey, et al. [9] surmise, collective findings to date, including this evaluation, indicate that to be effective, facilitators need to be flexible and possess a range of skills to be used according to the needs of those with whom they are working and the related context.

A number of facilitating and hindering factors were identified in this evaluation, including the need for protected time, leadership support, and recognition of the importance of the facilitation role. The issue of protected time is one seen frequently in the evidence into practice implementation literature [10, 19]. Clearly the resolution of such issues is not straightforward, and it would be naïve to suggest that just providing protected time for facilitators would enhance the success of projects. In the case of this evaluation, perhaps protected time was an indicator of the degree of organizational investment or support. For those project teams that did not understand or value the facilitator role, this resource was not forthcoming and, thus, was unavailable to help optimize change.