DNP 750 Week 4 Translational and Implementation Framework Example

The Iowa Model as the Map, Plan-Do-Study-Act as the Engine: Choosing Frameworks to Carry Diabetes Distress Screening Into a Health Center's Daily Workflow

[Student Name]

University of Phoenix

DNP/750: DNP Applied Project I

Week 4 Assignment

[Instructor Name]

[Date]

The health center and staff are composites written for a model paper.

The project I am planning adds a brief distress screen to diabetes visits at one health center site, with a longer questionnaire and nurse follow-up for anyone who screens positive. Last week's evidence summary supported the change. This paper selects the frameworks that will carry it into practice. The project needs three things from a framework: a path from evidence to a practice change that lasts, a method for testing workflow changes quickly in a busy clinic, and a way to identify barriers before implementation begins.

The Revised Iowa Model

The Iowa Model of Evidence-Based Practice came out of the University of Iowa Hospitals and Clinics and was updated by the Iowa Model Collaborative (2017), which tested the new version with a survey of the people who use it. The revision kept the model's structure of steps and decision points and added emphasis on piloting, sustaining change and dissemination. Its sequence starts from a trigger, which may be a problem or an opportunity. The team then confirms that leadership sees the topic as a priority, assembles members, collects and rates the literature and judges whether that literature is strong enough to act on. If it is, the team tests the change on a small scale, decides whether to adopt it, builds it into routine care and shares what happened.

Applying the Iowa Model Step by Step

The trigger was a clinical problem identified at the site: patients whose depression screens were negative but whose diabetes control and engagement were poor, with no tool to name distress. The purpose was stated in Week 2. The priority decision point was met when the health center's medical director named diabetes control as the top quality goal for the grant year and approved the project. The team includes me as project lead, both registered nurse care managers, the behavioral health consultant, one medical assistant, the site's nurse practitioner lead and the quality coordinator who manages the electronic health record reports.

The evidence step was completed last week, and the sufficiency decision point was answered yes: the two tools are well validated, and one pragmatic trial shows that distress falls when patients receive structured follow-up. The pilot step is where this project lives: the Iowa Model asks for a small, planned trial of the change with measures before any decision about wider adoption, which matches a 12-week project at one of three sites. The adoption decision point will be made with the medical director at the end of the pilot using the outcomes defined in Week 2. Integration and sustainment would follow at the other two sites, and dissemination will occur through the DNP 752 manuscript and poster and a presentation to the health center's quality committee.

Plan-Do-Study-Act for the Pilot

The Iowa Model says to pilot the change but not how to run each small test. For that, small tests of change will follow the Plan-Do-Study-Act method. In each cycle the team writes down one change and what it expects to happen, tries the change briefly, compares the data with the expectation and then decides whether to keep the change, modify it or drop it. Taylor et al. (2014) reviewed 73 published reports of PDSA in health care and found that most departed from the method as designed; only 14 of the 73 described a series of linked cycles, and few used weekly or monthly data to choose what to try next. The project will guard against those faults by planning at least three cycles, each with a written prediction and weekly data on screening and follow-up.

The first cycle will test the DDS2 with one medical assistant and one nurse practitioner for one week, predicting that at least 70% of eligible visits will be screened. The second will add the full scale and care manager review for positive screens across all morning clinics. The third will extend to all clinicians and add phone follow-up for patients who leave before review.

Anticipating Barriers With CFIR

Damschroder et al. (2009) reviewed published implementation theories and merged their constructs into one framework with five domains, covering the change being introduced, the wider environment, the organization's internal conditions, the individuals involved and the way the work is carried out. The project will use these domains as a checklist rather than a full framework. For the intervention, complexity is low but adds time to rooming. In the outer setting, federal grant measures reward diabetes control and support the change. In the inner setting, medical assistants have heavy rooming tasks and staff turnover is high. Among individuals, care managers are enthusiastic but unsure how to respond to high distress. In the process domain, the project needs a champion among medical assistants and a clear order of steps.

Using the Frameworks in Evaluation

The frameworks also shape how success will be judged. The Iowa adoption decision point needs criteria set in advance, so the team agreed that the screen will be recommended for the other sites if at least 80% of eligible visits are screened for four consecutive weeks, at least 85% of positive screens receive timely follow-up and staff report the added time as acceptable. PDSA data will be reviewed every Friday in a 15-minute huddle, and the run charts from each cycle will become part of the evidence for that decision. CFIR barriers identified now will be revisited at the end of each cycle to see which ones appeared and which did not.

Limits of the Chosen Frameworks

The Iowa Model was built in a large academic hospital, and some of its steps assume resources, such as a dedicated evidence-based practice council, that a health center lacks. The project adapts by using the existing quality committee for decisions. PDSA can encourage many small changes that are never tied together, so each cycle will be recorded on one form that links it to the previous cycle. CFIR is broad, and applying all of its constructs would take more time than the project has, which is why only the domains are used.

Alternatives Considered

The Johns Hopkins Evidence-Based Practice Model was considered because its levels were used to rate the evidence last week. Its practice question, evidence and translation phases fit well, but the Iowa Model's explicit pilot and adoption decision points match a single-site pilot more closely. Lewin's three-stage change theory was considered for the human side of change, but it offers little guidance on measurement, and PDSA covers the cycle of change with data. A full CFIR-guided implementation study was rejected as too large for the time frame.

How the Frameworks Shape the Precis

The Iowa steps will organize the project timeline in the Week 5 design section. PDSA cycles will appear in the methods, with each cycle's measures listed. CFIR barriers will inform the feasibility and risk section in Week 7.

Conclusion

The revised Iowa Model provides the overall path from trigger to dissemination, with a pilot step that matches this project. PDSA cycles supply the method for testing workflow changes within that pilot, and CFIR domains help name barriers in advance. Together they give each part of the project a framework with a clear role.

References

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, Article 50. https://doi.org/10.1186/1748-5908-4-50

Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223

Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862