Anne Sales – The Implementer

Anne Sales is building capacity in an emerging field that has tremendous potential to improve patient care and public health.

Ask Anne Sales about the state of science in implementation science, and she’ll give a powerful answer: “I don’t know.”

It seems counterintuitive. Shouldn’t the co-editor-in- chief and one of the founders of the emerging field’s top journals have all the answers?

But her willingness to admit that she doesn’t know isn’t a weakness — it’s a leadership skill. One that separates strong leaders from insecure ones and shows both humility and confidence. And her ability to say those three words could be the best thing for Mizzou.

A researcher with joint appointments in the Sinclair School of Nursing and the Department of Family and Community Medicine in the School of Medicine, Sales was recruited to Mizzou to build capacity in the science and practice of implementing evidence- based health interventions into routine care. In an industry with a 17-year research-to-practice gap and in a time when the university is heavily investing in translational science, Sales is saying, “Let’s figure this out together.”

The Missing Link

Nurses are key drivers to delivering safe, quality care. At the bedside day in and day out, they are often the best people to assess health care services and work toward improving them. They not only identify and bridge gaps in care but also understand how a person’s environment impacts their wellness.

Sales has always had an interest in quality improvement. Her first published papers were on the topic, and after becoming a nurse practitioner and earning a PhD in health service research, she started working in the Veteran Affairs’ Quality Enhancement Research Initiative (QUERI). Within QUERI, Sales and her colleagues worked to not only improve quality of care but also harness their health service research expertise to study gaps in the use of evidence-based practices and address them at the system level.

One early example: In 2001, they conducted a qualitative study, interviewing over 60 physicians, nurses, pharmacists, dieticians, quality managers and other clinical and nonclinical staff across six VA medical centers, to identify barriers and facilitators to the implementation of pilot interventions designed to improve the measurement and management of low-density lipoprotein cholesterol levels in coronary heart disease patients. The results, published in a 2004 paper in Worldviews on Evidence-Based Nursing, showed that developing how-to guides that teach intervention teams how to anticipate barriers and make plans to address them should be a top priority.

“Quality improvement in health care has a lot of really good features, but one of the things that it really doesn’t have is solid systematic research,” says Sales, an expert in organizational and system behavior change. “Project after project after project gets done, and we learn something that works at that time for that particular environment, but it doesn’t get captured and it doesn’t spread. Instead of really learning from it systematically, individuals learn from it momentarily and learn how to do things better the next time they do it.”

Sales and her fellow VA researchers didn’t know it, but by developing generalizable knowledge that could be widely applied beyond the VA, they were laying the foundation for implementation science as a field. “I feel like I grew up with the field in a lot of ways,” Sales says.

At the time, the term “implementation science” hadn’t even been coined yet. The flagship journal in the field wasn’t established until 2006. These days, Implementation Science receives over 800 submissions annually, 85% of which gets rejected. Its sister journal, Implementation Science Communications, which Sales co-founded in 2019, received over 100 submissions its first year.

Still, there is a lack of agreement on what implementation science really means. “When someone says, ‘I’m doing implementation science,’ often what they’re doing is implementing things. They’re not studying implementation,” she said during a recent presentation to Duke’s Department of Population Health Sciences. “It worries me if we keep saying it’s all science. It isn’t. That’s part of the problem.”

With a nod to her undergraduate degrees in sociology and anthropology, Sales defines implementation science as “the study of planned human behavior change under organizational constraints.”

“Organizations are really understanding the need for systematic approaches to how they manage the care they deliver,” she says. “And that’s one of the things that excites me about Missouri — I think there is significant organizational willingness to take this on.”

A Roadmap for Change

Before Richard Barohn was MU’s top health administrator, he saw Sales give a presentation on implementation science. It was 2019, and he was still the vice chancellor for research at the University of Kansas Medical Center and she a professor at the University of Michigan. When Barohn was tapped to become the executive vice chancellor for health affairs for MU in 2020, it became one of his goals to get her to Columbia.

“Results from conducting translational science and precision health research cannot make a difference in the lives of patients if they are not implemented,” says Barohn, who is also the executive director of the NextGen Precision Health initiative, which is dedicated to accelerating critical health care discoveries and shortening the time it takes for lab research findings to reach clinical practice.

The dean of the Sinclair School of Nursing, Sarah Thompson agrees: “Nurses can play a crucial role in making precision health solutions work in the context of patient care environments and health care delivery systems.”

Sales’ joint appointment with the nursing school and the medical school is important. Implementation research requires cross-disciplinary research involving not only your traditional health care, social work, psychology and engineering teams but also people who are not routinely part of most clinical trials such as economists, sociologists, anthropologists, administrators and patients.

“This is very much collaborative work,” Sales says.

That might look like working with the Clinical Family and Community Medicine’s Associate Professor, Robert Pierce on how to systematically implement a tool he’s developed that uses machine learning to create a risk prediction score for the probability that someone who is admitted to a hospital is likely to die within the next 30 to start providing services sooner.

Or it might look like collaborating with Richelle Koopman, the director of Family Medicine Research, to better staff primary care clinics to affect the quality and efficiency of care and improve access for patients. “We don’t have nurse researchers on our faculty in family medicine, so being able to easily incorporate that perspective is an advantage,” says Koopman, the Jack M. and Winifred S. Colwill Endowed Professor in Family & Community Medicine. “For example, the demand for primary care far exceeds the amount of capacity that we have. Figuring out ways that we can stretch physicians by having more of a team approach and then showing that actually leads to improved care and is a better value for the health system and payers — that is where we need rigorous evaluation, and Dr. Sales can really help us.”

It also looks like sitting in monthly Percolating Proposals meetings with the School of Nursing’s interim assistant dean of research, Deidre Wipke-Tevis, BSN’85, and helping postdoctoral fellows and early career faculty learn how to look beyond the individual and implement best practices into the clinical setting across health systems. “She is a very gracious scholar,” says Wipke-Tevis, who directs the PhD Program. “She’s very giving of her time. It’s not just about what she can do to make her own program of research move forward. She really is invested in developing those behind her — not only budding nurse scientists but young physician researchers and other interdisciplinary scientists — to improve health care.”

The Next Generation

One of the reasons why there is such an implementation gap is that there simply aren’t enough implementation scientists. So, when Sales says, “I have no idea,” what she’s really doing is inviting others in the room to become part of the problem-solving process.

A mentor to numerous National Institutes of Health Career Development (K) Award recipients, she launched Implementation Science Communications so junior faculty would have a place to submit their work. Her primary focus, both at Mizzou and the University of Michigan, is helping people learn how to move things from demonstration to widespread acceptance and use.

“The thing that matters the most to me is the success of the people I worked with,” Sales says.

One of those people is Ted Skolarus, associate professor of Urology at the University of Michigan and the VA Ann Arbor Healthcare System who is trying to eliminate low- value practices in prostate cancer care. His mentor from 2011 to 2018, Sales met with Skolarus almost weekly and played a pivotal role in his career progression.

“She was very much committed to my success in an unselfish way,” Skolarus says. “Her commitment to capacity building in the field of implementation research over the past decade has impacted the careers and lives of many people and, in turn, patients. Dr. Sales has had a broad impact here in terms of exposing students and faculty to implementation science and helping them realize that implementation is key to systematically promoting individual and organizational behavior change to improve health care delivery and value.”

Sales is just getting started at Mizzou, but she says Mizzou is already further along than most universities.

“There are other precision health initiatives around the country, but none of them include implementation science as a core component at this point,” Sales says. “At Mizzou, people are thinking ahead to what it’s going to take to get this new discovery that has so much promise and so much opportunity for saving lives and improving quality of life into practice. This is where nursing as a whole comes in. Nurses are agents of making that kind of change happen.”

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