Facilitating implementation of the Decision-Making Capacity Assessment (DMCA) Model: senior leadership perspectives on the use of the National Implementation Research Network (NIRN) Model and frameworks

Objective Abstract Dementia and other chronic conditions can compromise a person’s ability to make independent personal and financial decisions. In the wake of an ageing population and rising incidence of chronic conditions, the number of persons who may require Decision-Making Capacity Assessments (DMCAs) is likely to increase. Legislation (e.g., Trusteeship, Guardianship, Medical Assistance in Dying) also necessitates that DMCAs adhere to legislative requirements and principles. An intentional, explicit and systematic means of implementing standardized DMCA best-practices is advisable. This single exploratory case-study examined the perspectives of senior leaders and clinical experts regarding the utility of using the National Implementation Research Network (NIRN) Model to facilitate implementation, spread and sustainability of a DMCA Model. Participants learned about the NIRN Model and discussed its application during working and focus groups, all of which were audio-recorded, transcribed, and analyzed using thematic analysis. Results Participants found that the NIRN Model aligned well with the DMCA Model, and offered utility to support implementation, spread and sustainability of DMCA best-practices. Participants also noted barriers related to its language, inability to capture personal change, resource requirements, and complexity. It was recommended that a NIRN-informed DMCA-specific implementation framework and toolkit be developed and NIRN-champions be available to guide implementation. Electronic supplementary material The online version of this article (10.1186/s13104-018-3714-x) contains supplementary material, which is available to authorized users.


Introduction
Adults are presumed to be independent decision-makers regarding their personal (e.g., health, housing, associations, legal) and financial affairs. When a person's decision-making capacity (DMC) in specific domains, however, comes into question due to diseases such as dementia and other chronic conditions, standardized Decision-Making Capacity Assessment (DMCA) processes aligned with legislation are needed. In the wake of an ageing population, increasing incidence of chronic conditions and legislative requirements (e.g., Guardianship and Trusteeship, Medical Assistance in Dying), DMCA best-practices and processes need to be standardized and better-integrated into routine care. Adherence to such processes best-positions healthcare professionals to determine person-centred outcomes that are least restrictive and intrusive, and that maximize autonomy.
The DMCA Model [1,2] is an innovative learning and development model created in 2006 by an acute care interprofessional (IP) team. The DMCA Model aims to enable independent practitioners, IP teams, organizations, and large-scale systems to effectively conduct DMCAs. The Model outlines a standardized process aligned with provincial legislation. Its aim is to support screening and pre-assessment, facilitate problem-solving, support documentation, facilitate education and mentoring, and enable widespread implementation, spread and sustainability of DMCA best-practices.
Despite attempts to implement the DMCA Model across the continuum of care and service sectors, successful uptake, spread and sustainability of the Model has had varying results. Use of intentional, systematic, "active and planned efforts to mainstream innovation" [3, p. 582] may result in more effective DMCA Model implementation. While various implementation frameworks might be utilized [4][5][6][7][8][9], the DMCA Model most closely aligns with the National Implementation Research Network (NIRN) Model [5,[10][11][12] and its five overarching Active Implementation Frameworks (AIFs) [10,[12][13][14][15][16][17]. The purpose of this study was to explore the perspectives of senior leaders and clinical experts regarding the applicability of using the NIRN Model and AIFs to implement the DMCA Model in healthcare organizations.

Methodology Design
A single exploratory case-study design was employed to document participant perspectives regarding the utility of applying the NIRN Model and AIFs to the DMCA Model. As the study was exploratory, small-scale data collection was found to be appropriate before determining specific research questions and hypotheses [18].

Participants
Senior leaders and clinical experts (i.e., managers, senior leaders, physicians, social workers, occupational therapists, nurse practitioners, professional practice leads) from health-related organizations across Alberta with expertise conducting DMCAs were invited to participate in a NIRN Working Group (a committee formed to examine a specific question and provide recommendations) (WGs), a NIRN Bootcamp (an intensive 2-day training workshop designed to introduce participants to use of the NIRN Model and its tools), and a focus group (FG

Data collection
Working Groups, which included eight, 1-h biweekly teleconferences held between June 20th and September 26th, 2016, aimed to introduce and review NIRN tools/ processes and AIFs and consider their utility in facilitating implementation, spread and sustainability of DMCA processes. In advance of the WGs, participants reviewed selected resources on NIRN's Active Implementation (AI) Hub [17].

Data analysis
Working Groups and the FG were audio-recorded, transcribed, and entered into NVivo 11. Thematic analysis, which was conducted by research assistants following methodology outlined by Braun and Clarke [19], employed both an inductive and deductive approach.

Results
Participants identified facilitators, barriers and recommendations regarding the use of NIRN tools/processes with the DMCA Model. These are described and tabulated in the following section. (See Tables 1, 2, 3 for  themes and related quotes).

The NIRN Model, Active Implementation Frameworks (AIFs) and Tools [5, 10-17]
Participants valued resources and tools available through the AI Hub, finding them to be accessible, powerful, and useful. They anticipated that use of the tools would  We are going to implement the policy anyways, so it will be in place. " (2016-11-25) "I think the most important thing that has happened is education…" "The training went well.
The implementation of the training afterwards not so much, because we are not doing this everyday so it is going to be a process and take longer to get everyone up to speed. " (2016-11-25) "Having meetings scheduled made implementation possible". (2016-11-25) "Buy in from managers and administrators. " (2016-11-25) Implementation of best-practices is a process "I'm just happy that were actually putting best-practices into place. " (2016-11-25) Making the process explicit is helpful "It is interesting to see at an organization level how it has been implemented, so how that background work gets done as well and how person-centred care has been at the forefront. Mentorship and consultants are essential during implementation "We always had someone to go to or a resource when they were stumped. " (2016-11-25) positively impact adoption and practice change, clarify and give credibility to implementation processes, and improve fidelity to DMCA best-practices.

The DMCA Model aligns well with the NIRN Model and AIFs
Participants recognized that the DMCA Model includes an implementation strategy and capacity-building processes. They concluded that the NIRN tools would support adoption of the DMCA Model at the provider, "Adds clarity regarding the individual responsible and who is the next step to assign accountability. " (2016-08-15) organizational, and system levels, and ensure fidelity to DMCA best-practices.

The DMCA Model [1-3] is a usable innovation [20]
Participants appreciated the DMCA Model's personcentred approach, alignment with provincial legislation, problem-solving strategies, and emphasis on determination of least restrictive and least intrusive solutions to declining DMC. Participants acknowledged the need for further discussion among service providers to better define critical components of DMCAs and gold or acceptable standards so as to ensure consistency of DMCA administration.

Implementation stages [5]
Participants indicated that the NIRN's stages of implementation and accompanying analysis tool is valuable for assessing and communicating an organization's current state of delivery of DMCA services. Participants evaluated implementation and sustainability processes proand retrospectively using the Analysis Tool, considering reasons that implementation, spread and sustainability of the DMCA may have been less effective and ways to mitigate barriers.

Implementation drivers [21, 22]
Participants discussed the applicability of implementation drivers (leadership, competency and organizational) to the DMCA Model: Leadership drivers-participants emphasized that senior leader buy-in/support and the availability of champions is critical to successful implementation; Competency drivers-clinician competencies were noted to be essential to effective DMCA practice. Knowledge experts with a dedicated role, protected time, and critical attributes (i.e., confident, knowledgeable, credible, trusted, collaborative), were seen as being best-able to advance DMCA practice. Resources and ongoing education are also critical to the sustainability of the DMCA Model; Organizational drivers-successful DMCA Model implementation requires that organizational drivers be put in place including intake and documentation processes, mentoring teams, education/ training, and medico-legal-ethical supports.

Implementation teams [5]
Participants identified parallels between NIRN implementation teams and DMCA Advisory Committees and Mentoring Teams. Engagement of key players early in the implementation process was noted to maximize success.

Improvement and communication cycles [5, 23]
Plan-Do-Study-Act (PDSA) and policy-practice communication cycles were routinely employed by participants implementing the DMCA Model. More deliberate communication efforts would be helpful. NIRN tools may support such efforts.

Evaluation [5, 24]
Participants appreciated that a systematic implementation framework can make successes and potential gaps more explicit. The NIRN tools and AIFs helped participants identify what was/was not going well regarding the implementation of DMCA best-practices.

Barriers to use of the NIRN Model and AIFs
Participants identified barriers related to language, resources and complexity. Some participants struggled to interpret the NIRN and AIF resources (often education-specific) into the healthcare context. They suggested adapting the language to be DMCA-specific and developing a NIRN-informed Implementation Framework and Toolkit for the DMCA Model inclusive of a Practice Profile. They also commented on the time needed to learn and apply the NIRN Model and AIFs. Participants felt that partnering with a NIRN implementation specialist or establishing a NIRN interest-group would be valuable. As implementation can be lengthy and demanding, (requiring an average of 2-4 years), strong buy-in, commitment, and a clear process is needed. To increase the likelihood of success, use of the NIRN implementation process in its entirety is advisable.

Recommendations regarding use of the NIRN Model with the DMCA Model
Participants insisted that use of and training in the NIRN Model and AIFs is needed, coupled with senior leader buy-in and access to a NIRN champion or implementation team.

Discussion
This paper reports on a single-exploratory case study that considered the perspectives of senior leaders and clinical experts regarding the applicability of the NIRN Model and AIFs in supporting implementation, spread and sustainability of the DMCA Model. The emerging themes suggest that a NIRN-informed DMCA-specific implementation framework and toolkit would be helpful in guiding independent healthcare professionals, IP teams, and organizations when attempting to embed DMCA processes into routine practice. Participants also identified challenges associated with use of such a framework to support DMCA Model implementation. Consensus from the participants was that the NIRN Model, AIFs and tools were valuable and aligned well with the DMCA Model and best-practices. They indicated that implementing the DMCA Model would be better managed using such an explicit, intentional, and systematic framework. The NIRN tools helped participants identify readiness for DMCA Model adoption, implementation stages and strategies, and successes, barriers and gaps related to previous implementation attempts. Examination of the NIRN tools stimulated reflection on the importance of champions, fidelity to DMCA practices, and evaluation and sustainability of the best-practice. Participants anticipated that utilization of the NIRN AIFs would increase credibility of the implementation and the evaluation processes. Overall, the NIRN Model was found to provide a clear framework for implementing DMCAs.
Barriers were also identified. The NIRN implementation process was found to be resource-intensive and its lengthy timeline was concerning for those who felt that staff turnover may compromise the process. Some participants also indicated that it would be difficult to apply the NIRN tools and AIFs without the support of dedicated implementation specialists. Participants further noted that, while the NIRN Model facilitates evaluation at the system and process levels, it is less effective in so doing at the service provider level. Outcome measures to evaluate the effectiveness of implementation were also found to be lacking. Finally, the language is more specific to educational rather than healthcare environments.
Specific to the DMCA Model, participants highlighted commonality and variability regarding DMCA bestpractices. Terminology regarding, conceptualization and The language of the NIRN frameworks is not specific to healthcare "Language-need it to be specified from education to healthcare and DMCA. " (2016-08-15) Usability is a potential concern "I couldn't use these tools and figure it out by myself. " (2016-08-15)  the intent of the DMCA Model was a point of discussion and at times sensitivity. "Process" appeared to be a more agreeable term than "Model" when referring to DMCAs. Further, although similar concepts were used by participants regarding DMCA processes, inconsistencies appeared. For example, it was challenging to define DMCA processes, and isolate assessment components, essential information to be gathered and by whom, and gold standard indicators. Reflections on DMCA processes stimulated through consideration of the NIRN Model and tools facilitated greater dialogue, collaboration, DMCA Model development, and consistency of DMCA practice at organizational, zonal and provincial levels.
Participants recognized the utility of the NIRN Model, AIFs and tools. As the NIRN Model provides a clear process and framework for implementing DMCA bestpractices, organizations might utilize it to support implementation of the DMCA Model and processes. Such use may support local as well as widespread adoption of the DMCA best-practice processes and ensure fidelity. Commitment to its use, however, would necessitate buy-in at the leadership levels and access to NIRN-specific resources. Sustainability efforts are needed throughout implementation and spread efforts "It' s important not to underestimate the need to think ahead to consider sustainability planning while in initial implementation, although you don't get to that until the full implementation stage. " (2016-08-15) "We need site leaders that are actually engaged and attached to the mentoring team otherwise it will not sustain or implement. " (2016-11-25)

Conclusions
The goal of the DMCA Model is to effectively integrate DMCA best-practices into routine service provision. Study findings support the future development and evaluation of a DMCA-specific NIRN-informed implementation framework and toolkit to facilitate implementation. Decreased resource requirements would result from development of such an implementation framework and toolkit and support best-practice uptake. Access to a dedicated NIRN-champion or implementation team would further enable the uptake of DMCA and other evidence-based practices, drive change and offer leadership. With respect to the implementation of the DMCA Model, it is recommended that organizations consider using the NIRN Model, AIFs and tools to support the uptake of DMCA processes, and ensure sustainability of and fidelity to DMCA best-practices. Employing the NIRN Model as a framework for implementation, sustainability and spread of the DMCA Model would offer an explicit, intentional, and systematic process for implementing and sustaining DMCA processes. While time and resources are required to do so, not employing an implementation model can result in failure to implement or sustain the best-practice, demoralization of staff, and loss of time and resources. Rather than being focused on costs associated with the use of an implementation framework, however, perhaps the better question is whether or not organizations can afford not to use a process and tools that can best-position teams for integrated, sustained and successful implementation of DMCA best-practices.

Limitations
This study has a number of limitations. While a number of organizations from across the continuum of care participated in this project, the results focus on the perspectives of 13 senior leaders and clinical experts who voluntarily attended some, though not all of, the working and focus groups, and a NIRN Bootcamp; perspectives of frontline staff were not captured. As a result, reported findings are not necessarily representative of all organizations that have implemented the DMCA Model, nor are they generalizable to other organizations.

Additional file
Additional file 1: Table S1. Project Activities and Participants. This table includes the number of participants that attended each of the working groups, NIRN Bootcamp and focus group. Also included is the aim and focus of each of the project activities.