Implementation Framework

Bree Collaborative Transformation Plan is being modeled on the Knowledge to Action (KTA) framework. This means that we conceptualize the translation of the guidelines we have created as a cyclical process that includes feedback from those who are doing the work of implementation. To that end, we have designed a self-report system and case study format to provide some tools for organizations, clinicians, health plans, and other stakeholders to provide us with information on the usefulness of the checklists, tools, metrics, and other resources we have provided and on the gaps in knowledge that still exists.

Theory of change

The Bree Collaborative Primary Care Transformation implementation is designed on the assumption that individual organizations working together create systemic change. Some of our efforts involve priming the system for change by creating common metrics, providing information to regulators and legislators, and aligning our work to address the needs and gaps in the health care system through the creation of bundled payment models and guidelines to address health topics where no guidelines exist or where there is variation among providers or organizations. In this way we hope to help create an environment where multiple stakeholders can most easily act on guidelines that support systemic change.

These assumptions are in line with Prosci’s ADKAR Change Management Model. The ADKAR model consists of 5 stages:

• Awareness of the need to change
• Desire to support change
• Knowledge of how to change
• Ability to demonstrate skills and behavior
• Reinforcement to make the change stick

To support the first two items on this list, the Bree Provides webinars, Learning Collaboratives, Learning Labs, and other opportunities to raise awareness about guidelines and to inspire the desire in health system stakeholders and organizations to change. This implementation guide is designed to provide knowledge on the “how” of change, while our self-report system was created to allow stakeholders to demonstrate skills and behaviors. Finally, our awards program is meant to act as reinforcement to help make change stick.

Each Bree report that was created after 2023 also has a theory of change that describes the way the work group envisions activities that will result in system-wide change, among those partners that implement it, for that specific topic.

Making progress on implementation

This guide has been designed to make sure that your team can answer the who, what, when, how, and why of an implementation project for each of our reports before moving into the execution phase. We have employed a strategy of implementation levels in this IG in order to provide interested parties with manageable, step-wise actions to adapt guidelines into their unique context. These levels help support the five stages of implementation, which are: 1) exploration, 2) installation, 3) initial implementation, 4) full implementation, and 5) expansion and scale-up. Below is a summary of the Bree Collaborative Implementation levels.

Level 1:

Level 1 identifies activities, processes, and competencies for each guideline topic that address a minimum standard of care. Generally speaking, these are activities, processes, and competencies that medical groups or practitioners can accomplish internally. These activities may be centered around things such as training, system upgrades or basic in-house programs or processes (exploration, installation, initial implementation).

Level 2:

Level 2 processes and activities address a standard of care for each guideline topic that reflects increased integration and coordination with external partners. These activities may include things such as team-based care, tracking patients, or using population health managements (full implementation).

Level 3:

Level 3 encompasses activities, processes, and competencies for each guideline topic which include full coordinated care, exemplary patient-centered approaches, and measurement of change in patient outcomes. These activities may include things such as coordination with multiple partners or spreading practices throughout your organization (expansion and scale-up).

The Bree Collaborative has developed a roadmap to health system transformation. This document helps stakeholder and other interested parties conceptualize how our work contributes to system wide changes in health care quality and cost for people in Washington State.

Bree Health Ecosystem Roadmap

Guideline Information

The guideline information sub-section provides a brief summary of the topic, publication date, status, etc.

Read On-line

This sub-section provides a quick link to the report

Checklists

Level 1:  identifies activities, processes, and competencies for each guideline topic that address a minimum standard of care. Generally speaking, these are activities, processes, and competencies that medical groups or practitioners can accomplish internally. These activities may be centered around things such as training, system upgrades or basic in-house programs or processes (exploration, installation, initial implementation).

Level 2: processes and activities address a standard of care for each guideline topic that reflects increased integration and coordination with external partners. These activities may include things such as team-based care, tracking patients, or using population health managements (full implementation).

Level 3:  encompasses activities, processes, and competencies for each guideline topic which include full coordinated care, exemplary patient-centered approaches, and measurement of change in patient outcomes. These activities may include things such as coordination with multiple partners or spreading practices throughout your organization (expansion and scale-up).

Resources and tools

This sub-section contains webinars, tool kits, guides, clinical resources, screening tools, and other implementation resources that are recommended by the guidelines or that have been identified as relevant to the guidelines.

Metrics and Evaluation Tools

The Metrics and evaluation tools section provide topic specific information and resources to help organizations plan and conduct the evaluation of the implementation work. These tools include things such as “score cards” that are divided by audience type, evaluation frameworks, theory of change models and more.

Examples of implementation

Examples are formal case studies and write-ups from award winners.

Awards

This sub-section lists organizations that have won awards for work on a specific topic. The implementation guide is also where organizations and individuals can start their journey towards winning awards from the Bree Collaborative or the Foundation for Health Care Quality. See the section on self-reporting and awards for more information.

The Bree Collaborative encourages providers, delivery sites, hospital systems, health plans and other guideline “audience” organizations to demonstrate their progress on guidelines implementation and their commitment to quality care.

Why report:

Self-reporting allows us to provide many services and different types of recognition. Reporting helps us craft individual support through a better understanding of an organizations environment and context. Data that is self reported is de-identified, aggregated and displayed on our dashboard to allow organizations to compare their progress to others, find partners doing similar work, or to help patients find organizations that are providing quality care.

The Foundation for Health Care Quality also uses the self-report data for awards and recognition. Please see the Awards section for a full description. The Bree Collaborative may also reach out to submitting organizations if they indicate that they are interested in developing a case study as a way to spread recognition of quality work.

How to report:

The Metrics and Evaluation section of each topic contains “score cards” to document your progress on the implementation of the Bree Collaborative Guidelines. The self-report form uses a simple measurement system for recommended actions of implementation and provides your organization with an overall score:

• 0 -No action taken;
• 1 -Actively considering adoption;
• 2 -Some/similar adoption;
• 3 -Full adoption

The overall scores are to help you and us understand barriers to implementation and gaps in use. They will be used to help identify area where organizations may need additional support or resources.

The format of the score cards is a downloadable excel workbook. To complete reporting, choose the relevant report topic (for example, LGBTQ care, Colorectal Cancer Screening, etc.) and fill out the items for each instance of implementation your organization. Each instance can mean by department or delivery site, by health plan, or for the entire organization if you are using the reports to inform care throughout your organization.

Once the data collection tool is filled out there are a variety of ways to submit it. You can either email it directly to knicholas@qualtyhealth.org or submit it through our PORTAL.

If you ave questions, please contact knicholas@qualityhealth.org or bree@qualityhealth.org.

Rational and description

The aim of these awards is to highlight and celebrate quality work being done by many different organizations.

Being Considered for Awards

Any organization that is implementing the Bree Guidelines can be considered for an award.

Types of awards

The Path Finder awards are based on the submission of the Bree Collaborative checklists and supporting documentation. There are three levels of awards for completion of the checklists for each level of implementation – Path Finder Level 1, Level 2, and Level 3. The checklists and documentation can be submitted using the self-report form in the section above. (What do they get?)

The Trail Blazer award is given in recognition for having implemented guidelines or having processes that have fidelity with Bree reports. Fidelity is determined by filling out the “score card” in the self-report section above. Anyone submitting self-report data to the Bree Collaborative who receives an overall implementation score of 2.00 or greater for a specific report will automatically receive an award. We inform each submitter by email, which includes information on how to apply for our Mountain Climber Award. (Awards may include buttons for staff, wall certificates for departments, or flags for organizations, depending on the spread of their work. Example: if they have only done it in one unit or floor, they get buttons or a certificate, if they have done it organization wide, they get a flag or banner for their entrance.)

The Mountain Climber award is given for exemplary implementation efforts that focus on EQUITY. Any organization receiving a Trailblazer award is automatically eligible for consideration. Organizations that are eligible for the Mountain Climber Award will be notified by email and receive a form to provide further information about how your work has embedded and equity lens into your implementation project.

The Mountain Climber Award is given out by the Foundation for Health Care Quality, in collaboration with the Washington Patient Safety Coalition. A panel of judges from the legislature, professional associations, or other partner organizations is convened to score all the submissions on the criteria of generalizability, innovation, overcoming barriers, breadth of implementation work, (or other qualitative concepts we think will help celebrate them and that would be useful to share with others). Awardees will receive a plaque in recognition of their work and be invited to speak on our webinars.

Award Criteria

Pathfinder awards

• Submission of proof of completion of level 1, 2 or 3 checklist

Trail Blazer awards

• Submission of self-report form, supporting documentation, and average score of 2.75 for fidelity with Bree Guidelines.

Mountain climber awards

• Recipient of Trail Blazer award.
• Submission of Mountain Climber award form