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Our journey with Evidence-Informed Practice (EIP) in a Community Health Centre context: building a culture of reflection and collaboration

Contents

I Summary
II EIP: is it a phase?
III EIP Tools: Reflective questions we can’t afford to miss
IV EIP Procedures: Making it work within busy schedules
V EIP Help: Formal champions are essential to building a culture of EIP
VI EIP Impacts: Diverse perspectives on the value of advancing EIP
VII Conclusion: Anticipating the next phase of EIP @ Unison
VIII Resources

Submitted by Gillian Kranias and Jen Quinlan on behalf of Unison’s EIP Team             

I Summary

Evidence-Informed Practice (EIP) is an approach to program or service delivery in which service providers, program implementers and program planners are aware of the evidence relevant to our practice or program initiatives, and apply that knowledge within the scope of our work. Evidence-informed practice is applicable to both the development of new and the assessment of existing programs and services.

Unison Health and Community Services has worked for four years to build a culture of reflection and collaboration with the goal of improving EIP for our health promotion programs and initiatives. This OHPE feature article discusses our key learnings, highlights essential elements of the tools and procedures we have developed, and shares feedback we have received from different stakeholders. At the end of the article are links to an online “prezi” (zooming slideshow) which visually depicts Unison’s EIP purpose, tools and procedures, as well as direct links to our EIP tools and sample resources.

II EIP: is it a phase?

Our answer is no… it’s many phases. Several years ago, our organization took on the challenge of EIP by developing tools (a checklist of reflective questions and supporting resources) and piloting procedures to guide planning and evaluation work for group programs and community initiatives. We began a journey of collaboration between frontline and management staff to foster a culture of EIP that aligned with our organizational mission and values. We worked hard to make EIP accessible and meaningful to dozens of staff with diverse training/work backgrounds and already demanding workloads. Our ultimate goal has been to increase the relevance and quality of Unison programs and services to our clients.

So far, we have:

  • Clarified that EIP is not a destination, but a process.
  • Built a team of EIP champions (including health promoters, dietitians and diverse community workers) who support and expand the quality and scope of EIP efforts by advising their peers, collaborating on EIP resource development/revisions and acting as panel members for EIP reviews.
  • Revised our tools to be far more user-friendly with clearer language.
  • Finally pinned down procedures that seem to be working for both frontline staff and managers.
  • Expanded the scope of EIP to include not just programs (personal development groups and community initiatives), but also service delivery processes (the context through which a one-one service is delivered to clients, for example diabetes education appointments delivered through local pharmacies.)
  • Designed and implemented an organization-wide communications strategy, including regular public service announcements (PSAs) at all staff meetings, weekly “EIP office hours” (where any staff can drop by to learn basics or get focused help with EIP work), and half-day capacity-building workshops for staff/students/volunteers wanting to strengthen their skills for immediate EIP work or general professional development.

The slogan for our PSAs is “we have tools, we have procedures – you have help!” Unison’s flow diagram outlines the phases (steps) in the EIP checklist (our central tool). Each phase of the checklist (“detective”, “forecaster”, “architect”, etc.) has corresponding reflective questions, which staff work through – preferably in collaboration with colleagues, partners, clients and/or a member of Unison’s EIP team.

In the following sections, this article shares more details about our tools, our procedures, our “help” team, and the impacts of our EIP efforts.

III EIP Tools: Reflective questions we can’t afford to miss

Unison's EIP tools include the main EIP checklist as well as templates for a logic model, a promotions plan and an evaluative learning plan. All these tools are collections of questions. Some are easy to answer. Others take more time and consultation. Some of the questions are common to other EIP tools (we borrowed from them). Others we developed for our own specific context. Our tools put a strong emphasis on questions that align with Unison's key organizational values of equity, collaboration, and accountability.

EIP: Tools

 

The main checklist now has six phases, with a total of 23 questions. What all the questions have in common is that they are questions we can’t afford to miss. Discussed below are some select EIP Checklist questions where we have noticed new and important impacts:

Who is the intended client group? What are some differences within the “client group” to keep in mind?

This was a question we got from Health Nexus consultants who helped us build our initial checklist. It is the second question in the checklist and encourages us to identify differences within the client group, many of which relate to equity and accessibility concerns (e.g., literacy levels, childcare needs). We need to account for these when building our design (phase 3 – the architect phase).

Who are the relevant stakeholders, including clients, in this program and what is their role and expectations?

Depending on the nature and scope of the program being planned, this question asks us to create a list of stakeholders – always including clients as a key stakeholder group. When planning is more extensive, we employ the stakeholder wheel (http://www.thcu.ca/infoandresources/resource_display.cfm?resourceID=1235...) from The Health Communication Unit, to map out stakeholders. Another tool, the stakeholder profile, takes us deeper into exploring expectations, roles, and potential value of the program to different stakeholders. Elaborating answers deepens the “detective” work of our EIP process and better prepares us to design successful programs based on our findings.

Which elements of the community health centre (CHC) model of care can we integrate, and how?

In this case we rely on the CHC model of care http://accessalliance.ca/sites/accessalliance/files/documents/CHCModelOf..., a resource from our provincial association, that prompts us to think about how best to build programs that are comprehensive, accessible, client and community centred, interdisciplinary, integrated, inclusive of social determinants of health and grounded in a community development approach.

What do we want to learn about and document? (= objectives to guide our evaluative learning plan and evaluation activities)

We chose the term “evaluative learning” to replace “evaluation” because it denotes an ongoing, iterative process for continuous quality improvement. This first question in our evaluative learning plan template invites program leads to clarify their evaluative priorities (we can’t do it all). From there, the template encourages staff to prepare a mixture of formal and informal data gathering and feedback methods. And, in the spirit of community-based research, the template asks who will lead each method and encourages staff to find ways for clients to become more involved in all phases of evaluative learning.

What, in particular, do you most want to communicate to your manager for follow-up?

We ask lead staff if they have something in particular they want to communicate because, in some cases, the EIP review panel can consider and add a new perspective to a particular issue staff have been struggling with.

IV EIP Procedures: Making it work within busy schedules

With all those good questions, one challenge we continually face is time constraints. As noted by one program lead working on the EIP checklist: “Those questions go on and on and on.” Building clear, manageable and effective EIP procedures has been the most challenging part of Unison's EIP journey. This past summer, we finally firmed up an “EIP trajectory” that seems to meet our requirements. And based on feedback from a recent staff survey around EIP work, key stakeholders of EIP at Unison feel comfortable and confident with the new EIP procedures.

EIP: Procedures

As outlined in our EIP @ Unison “prezi” http://prezi.com/4jx8ql0edweu/eip-unison-full-path/?auth_key=88bf096407c... if staff see a problem they want to address, see an opportunity they want to advance, or know of an outside evidence-informed program they want to host, they first complete a “request form” that initiates staff/management discussion about whether to move forward with the initiative and related EIP work. Once a manager signs off on this form, lead staff will work, with help from colleagues and EIP Champions, to complete the stages of the EIP checklist. This process may take anywhere from one month to one year depending on the initiative and the staff's available time; it usually takes two to three months. Once EIP materials are completed, an EIP review panel meeting is scheduled. This two hour review panel is a peer panel (i.e., no managers present) made up of one Community Health Planner (who is an EIP lead resource staff) and two EIP champions from any site or discipline (EIP champions self-select to participate in EIP reviews). The review panels sometimes include other frontline staff who may have valuable perspectives to contribute (e.g., a clinical professional when the program has a clinical focus/aspect, or a youth worker when the program is targeting a youth audience). The panel reviews EIP materials, clarifies elements of the plan, and discusses opportunities to improve the planning (including program plans, promotion plans and evaluative learning plans) for the program or service delivery process.

Recommendations from the panel are written up in the EIP review notes which are shared back with lead staff and their manager(s). After the EIP review (anywhere between one week to one month), lead staff meet with their manager(s) and one representative from the review panel to discuss the notes and recommendations. At this meeting the manager(s) makes final decisions about changes to be made, based on the recommendations, and how to move forward.    

It is important to note that while the review panel and follow-up meeting with management represent the formal EIP procedures, the meetings and informal discussions that lead staff hold with their colleagues and EIP champions in their preparations for the review are where EIP at Unison sprouts roots, grows greenery and bears fruit (improved program quality and client/community benefits).  

V EIP Help: Formal champions are essential to building a culture of EIP

While EIP efforts have always been led by one to two coordinating staff (who contribute the bulk of EIP mentorship and EIP review panel hours), the biggest boost to building EIP culture at Unison was the recruitment and coordination (in 2011) of a team of EIP Champions. EIP Champions are from across the organization's various sites and teams. Currently, eleven champions contribute 10–80 hours a year to sitting on EIP peer review panels and/or co-leading EIP capacity-building and communications efforts. Also, in their day-to-day teamwork, at team meetings and in lunch room conversations, these EIP champions bring forth reflective questions and advocate for collaborative community-based planning and evaluation...“steeping “ Unison's work and culture with EIP.

At Unison, the acronym “EIP” alienates fewer people every year. We now make short presentations at new staff orientations, offer sound bites at monthly staff meetings, and are using bulletin boards at all sites to teach about and share samples of EIP. Although most of our organization's staff are primary health care practitioners delivering one-to-one services who will never need to use EIP tools and procedures, we want everyone to appreciate it and know it is there if they ever want to explore a group format – or pilot a new delivery process (e.g., off-site partnership) for one-to-one services.

VI EIP Impacts: Diverse perspectives on the value of advancing EIP

Unison's EIP stats:

  • Four years
  • 29 EIP reviews
  • 25 staff leads/coleads
  • 10 managers
  • 12 internal presentations to Unison staff
  • 4 external presentations to sector colleagues
  • 1 OHPE feature article

Management perspectives:

“The EIP process has really enabled me to make decisions about moving forward (or not) with program initiatives. The process has saved me time and provided me with objective data to review instead of me having to locate this information on my own.”

“I feel clearer about a process to introduce new programs and my role in it. My staff have a process that is standardized and so as a manager, I don't feel I have to make decisions about programs that are subjective.”

“EIP has allowed us to evaluate officially new programs or program components. This was a big gap previously. Meetings with health planners and other EIP champions have been extremely helpful in offering a different view to program enhancements.”

Front line (program lead/colead) staff perspectives:

“It is always good to take time to reflect. The EIP forced us to do that. Our program is going to get better as a result of this.”

“The EIP checklist was very helpful in terms of our program planning. It forced us to think more critically about our initiative and to put more focus on situational assessment.”

“The EIP review discussions were really valuable. I gained new connections around promotions. Also, the review highlighted the challenge about how people get triggered; having that highlighted in advance made me think through the support I am going to need and I will definitely arrange for that.”

“My manager knows me well and reads my plans differently; meeting with this peer panel gave me different insights... I am really happy it happened.”

“Last week I applied for a new grant for my program online. I found that all the questions they asked I had already completed for the EIP – all I had to do was cut and paste! Without the EIP, I would have felt overwhelmed and probably not found the time to apply.”

EIP champion perspectives:

“Being part of the EIP review helps me to promote the program. After two hours I have a much deeper understanding of what it is.”

“Our EIP efforts make program planning more manageable – concentrated and purposeful. Through networking and collaboration we reach increased heights.”

“This process guided the diabetes education centre to design a very successful pilot project which allowed us to outreach to hard to reach clients and brought great results for the centre.”

“I see how EIP helps increase clients' involvement in program evaluation. Our approach has become more participatory.”

VII Conclusion: Anticipating the next phase of EIP @ Unison

Set on a foundation of seasoned tools and procedures, EIP at Unison continues to evolve. The next phase of our journey includes:

  • Updating our EIP workbook to reflect changes in the EIP tools and to include new materials from recent capacity-building workshops
  • Connecting with staff at their team level to build a stronger familiarity with EIP and each team’s unique relationship to it.
  • Continuing to provide half-day capacity-building workshops, EIP consultations, and EIP reviews to foster collaborations that incorporate evidence to improve outcomes for communities.
  • Expanding EIP efforts beyond a group program planning focus to enhance other aspects of Unison's service and organizational planning.

The EIP path is fluid, rejuvenating and regenerative. We cultivate patterns of reflection and collaboration every step of the way.  And Unison’s EIP work is not in isolation – we remain open to learning from and sharing with other organizations working for community health from various vantage points.

For more information or dialogue, email gillian.kranias@unisonhcs.org and jen.quinlan@unisonhcs.org

VIII Resources

EIP @ Unison “prezi”
http://prezi.com/4jx8ql0edweu/eip-unison-full-path/?auth_key=88bf096407c...

This is a zooming slideshow that introduces Unison's EIP tools, procedures, and “help” team. The EIP checklist, our main tool, is depicted graphically; our EIP procedures are depicted as a boardgame (trajectory); and EIP templates and samples (as well as a few resources from other organizations) are embedded within the prezi.

Unison's EIP Checklist, Templates, other Tools and Samples
http://unisonhcs.org/resources/eip

Hot links on Unison's website include Word versions of Unison's EIP forms, checklist and templates. There are also samples of EIP materials for a variety of programs that have undergone EIP review. Please note that the EIP Workbook is from an earlier version of Unison's EIP tools and the checklist within this version is no longer being used (but many of the resources and links are still very current).

THCU's Stakeholder Wheel
http://www.thcu.ca/infoandresources/resource_display.cfm?resourceID=1235...

One of THCU's most popular resources, the stakeholder wheel shows that in any planning process, for any kind of health promotion intervention, stakeholders may have different levels of involvement and be from different sectors.

The CHC Model of Care
http://accessalliance.ca/sites/accessalliance/files/documents/CHCModelOf...

This resource from the Association of Ontario Health Centres prompts us to think about how best to build programs that are comprehensive, accessible, client & community centred, interdisciplinary, integrated, inclusive of social determinants of health and grounded in a community development approach.

OHPE Bulletin 706 “Building Capacity for Evidence-Informed Practice: Lessons from the Ontario Public Health Association’s Towards Evidence-Informed Practice (TEIP) Program”
http://www.ohpe.ca/node/12251

This OHPE Feature Article profiles how The Ontario Public Health Association (OPHA) supported resource development and capacity building through its Towards Evidence-Informed Practice (TEIP) program. TEIP developed processes, tools and training to strengthen capacity for evidence-informed practice and practice based learning. Unfortunately the online links to TEIP resources are no longer available.