Clinical policies, procedures, and documents outlining “best practices” abound. How do we sort them out and package them into usable and focused knowledge bundles for practical clinical implementation?
Implementation research (IR) is the scientific study of methods used to systematize the incorporation of research findings and other evidence-based practices into routine clinical practice. It incorporates the study of quality and effectiveness of health services delivery1 and examines the organizational dynamics, leadership, and processes used to implement a given treatment or practice.1,2 Implementation research is characterized as a broad term that focuses on the question of “what is happening?” Examining what takes place in the research process from implementations to outcomes, IR also asks, “Is it what is expected or desired?” and “Why is it happening as it is?” As Chopra and Sanders3 state, “Over the past 2 decades, experienced health policymakers and practitioners have noted a widening gap between scientific knowledge and policies on the one hand and their implementation on the other.” One of the issues intrinsic to IR is the recurrent argument that scholars of IR pose about the timing of IR. Two questions are paramount: Should the policy analysis be tested during the development of the policy itself or, as in most cases, after the policy has been developed? This is called forward mapping, backward mapping, and concept mapping4–6 and has also been termed critical path development.4–6
One of the core competencies of a practicing wound care clinician is the mastery of “health systems-based practice,” which can be summarized as “what do I need to know about the system of care and how it works” to provide the appropriate and safe care for my patient. Health systems research is concerned with operations of the system and is structured to satisfy the interrogative of how the process is completed. Remme et al7 describe several research domains or a framework to understand the context of defining research to improve health systems. The research domains begin at the local level with operations (healthcare providers), and the second level research domain is at the implementation level (program managers). The third domain is the health system (health system managers and policy makers), where the research results that were achieved at the provider level ultimately have the potential to be implemented as policy.7
In order to see the logical place for health systems research (HSR) in wound care, the following schema may be helpful by outlining how health systems research fits into the system of care.
Biomedical research is concerned with the biomechanical extrinsic and intrinsic factors that lead to pressure ulcers (PrUs), anatomy, physiology, and tissue mechanics. This may also be termed along a continuum from basic research to “translational research (bench to bedside).”8,9
Clinical research determines the efficacy of various treatments for chronic wounds, PrUs, and secondary functional impairments. This phase may also be termed “patient-oriented research.”10
Epidemiological research estimates the number of new and current cases of chronic wounds and PrUs (incidence and prevalence). This type of research also identifies certain risk factors and determines the distribution of the disease (age, sex, race, disease process, and level or transitions of care).11
Health systems research examines the way the health system functions to ensure that effective and evidence-based treatment protocols are delivered to those who need it7 (turning protocols, wound bed preparation, and wound care dressings and biologics). And, HSR is concerned with wound care quality improvement bundles where the denominator is representative of the number of improvements or failures of the patients served, and the numerator represents the total of the cohort in the system of care that were targeted for the treatment protocols.12
The continuing education feature (page 280) examines another framework model for quality improvement in PrU research.
Richard “Sal” Salcido, MD, EdD
1. Walker AE, Grimshaw J, Johnston M, Pitts N, Steen N, Eccles M. PRIME—PRocess modelling in ImpleMEntation research: selecting a theoretical basis for interventions to change clinical practice. BMC Health Serv Res 2003; 3: 22.
3. Chopra M, Sanders D. Asking “how?” rather than “what, why, where, and who?” BMJ 2000; 321: 832.
4. Elmore RF. Backward mapping: implementation research and policy decisions. Polit Sci Q 1979; 94: 601–16.
5. Schuster PM. Concept Mapping: A Critical Thinking Approach to Care Planning. Philadelphia, PA: FA Davis; 2011.
6. Heacock D, Brobst RA. A multidisciplinary approach to critical path development: a valuable CQI tool. J Nurs Care Qual 1994; 8: 38–41.
7. Remme JH, Adam T, Becerra-Posada F, et al. Defining research to improve health systems. PLoS Med 2010; 7 (11): e1001000.
8. Sweitzer SM, Fann SA, Borg TK, Baynes JW, Yost MJ. What is the future of diabetic wound care? Diabetes Educ 2006; 32: 197–210.
9. Sacristán JA. Patient-centered medicine and patient-oriented research: improving health outcomes for individual patients. BMC Med Inform Decis Mak 2013; 13: 6.
10. Rubio DM, Schoenbaum EE, Lee LS, et al. Defining translational research: implications for training. Acad Med 2010; 85: 470–5.
11. Berlowitz D. Incidence and prevalence of pressure ulcers. In: Thomas DR, Compton GA, eds. Pressure Ulcers in the Aging Population. New York, NY: Humana Press Inc; 2014: 19–26.