Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions

Implementing absolute cardiovascular disease risk assessment into pathology collection services

BACKGROUND

Pathology services represent an ideal setting to integrate absolute cardiovascular disease (CVD) risk estimation when patients attend for routine cholesterol testing. This study aimed to explore the process of implementing CVD risk estimation into point-of-care service delivery by pathology staff to inform future implementation and sustainability.

METHODS

A new service for CVD risk estimation via a self-directed screening station was implemented into 14 pathology service sites across Tasmania, Australia. Before implementation, observations at pathology services (n = 26) and semi-structured interviews were undertaken with 26 pathology staff (88% female, 77% aged 41-60 years) to identify factors that could impact implementation of the service. The process of implementation was then evaluated using participant observations and clinical trial recruitment data. Transcripts and field notes were analysed thematically according to the Medical Research Council Framework and used to develop a programme logic model to understand how the service could be adapted to be successfully integrated into routine workflow at pathology services.

RESULTS

Eight key themes were identified during the pre-implementation phase as important factors that could impact upon integration of CVD risk estimation into pathology services. Themes related to factors within the organisation, including available resources, logistics and workflow, as well as having sufficient time to complete the intervention. Additional factors related to the individual motivations of staff, collaborative leadership and patient characteristics. Success of implementation varied among sites, requiring the trialling of different strategies to support uptake of the service and patient recruitment.

CONCLUSIONS

Implementing CVD risk estimation into point-of-care pathology services required an understanding of the core implementation components specific to each context, and for implementation strategies to be targeted to the individual and organisational contexts. The generated programme logic model may be useful in guiding future implementation endeavours within these services and aiding the selection of apt implementation strategies.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04896021, registered 19/05/2021, https://clinicaltrials.gov/study/NCT04896021.

Implementation and Impact of Perinatal Food Is Medicine Programs: A Qualitative Research Study

BACKGROUND

Improving social determinants of health, such as access to nutritious food, is crucial for achieving health equity. Nutrition insecurity, especially during pregnancy and postpartum, can lead to poor maternal and birth outcomes. Food is Medicine (FIM) programs, which integrate food into the health care system to prevent or manage disease, have the potential to improve nutrition insecurity, but research about perinatal FIM programs is limited.

OBJECTIVE

The purpose of this study was to explore perceptions of public health impacts of perinatal FIM programs from the perspectives of both program implementers and program supporters and implementation strategies used to enhance program adoption, implementation, and maintenance.

DESIGN

Qualitative data were collected through semi-structured interviews. The interview guide was based on the Reach, Effectiveness, Adoption, Implementation, Maintenance framework.

PARTICIPANTS/SETTING

Program implementers (n = 16) and program supporters (n = 20) were recruited across the United States through purposive sampling in 2022 and 2023.

ANALYSIS

Data were analyzed using deductive thematic analysis and an iterative feedback loop with the project partner.

RESULTS

Interviews were completed with program implementers and program supporters and generated meaning units (n = 1,942), which were coded into themes aligned with each Reach, Effectiveness, Adoption, Implementation, Maintenance dimension. Perinatal FIM programs reached multiple priority populations who were mainly recruited through health care systems. Effectiveness measures typically included nutrition patterns and practices, as well as return on investment. Motivations for adopting programs primarily included partnerships and connections, financing, and policies and laws. Program components varied and were adapted to meet participants and setting needs. Policy, evidence, funding, and partnerships could lead to program maintenance. Implementation strategies applied by the program supporters included financial strategies and infrastructure changes.

CONCLUSIONS

There is a need to identify the core functions and adaptable forms of perinatal FIM programs, which could lead to identification of standard evaluation metrics. This could result in greater uptake by potential delivery agents, increased funding and policy support, and enhanced benefits for perinatal population experiencing health disparities.

Hospital variation in adoption of balanced transfusion practices among injured patients requiring blood transfusions

BACKGROUND

This study sought to measure hospital variability in adoption of balanced transfusion following the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) guidelines. We hypothesized hospital adoption rates of balanced transfusion would be low, and vary significantly among hospitals after controlling for patient, injury and hospital characteristics.

STUDY DESIGN AND METHODS

This was an observational cohort study of injured adult patients (≥16 years) in Trauma Quality Improvement Program hospitals 2016-2021. Inclusion criteria were hypotensive patients receiving one transfusion of packed red blood cells, fresh frozen plasma, platelets, or cryoprecipitate. Balanced transfusion was defined as ≥1 ratio of plasma to packed red blood cells or platelets to packed red blood cells or whole blood use at 4 hours. Hierarchical multivariable logistic regression quantified residual hospital-level variability in balanced transfusion rates after adjusting for patient and hospital characteristics.

RESULTS

Among 172,457 injured patients who received transfusions, 30,386 (17.6%) underwent balanced transfusion. Patient-level balanced transfusion rates were 11% in 2016, rose to 14.0% in 2019, and jumped up once whole blood transfusions were measured to 24.0% in 2020 and to 25.9% in 2021. Approximately 26% of the variability in balanced transfusion rates was attributable to the hospital. Verified level I hospitals had a 2.09 increased adjusted odds of balanced transfusion (95% CI 1.88-2.21) compared to nonverified hospitals. University teaching status had a 1.29 increased adjusted odds of balanced transfusion (95% CI 1.08-1.54) compared with community hospitals. Overall, 150 (23.5%) hospitals were high outliers (high performing) in balanced transfusion adoption and 124 (19.4%) hospitals were low outliers.

CONCLUSION

There was significant variability in hospital adoption of balanced transfusion.

Dynamic Changes Toward Reflective Practice: Documented Shifts in Speech-Language Pathologists' Evaluation Practices

PURPOSE

This qualitative study explored the experiences of speech-language pathologists (SLPs) in professional learning communities (PLCs) during a year-long virtual professional development (PD) opportunity using an implementation science (IS) framework in an urban public school district for dynamic assessment (DA) training. The DA presented in the PD was modified based on ongoing discussions with key stakeholders in the district, so that it could be reasonably implemented in clinical practice while preserving the integrity of the DA's purpose.

METHOD

SLPs in an urban district were trained virtually using DA over the course of the school year. PD topics focused on decreasing bias and incorporating evidence-based practice into SLP approaches to speech-language evaluations. The SLPs underwent three training sessions and three separate PLC sessions. The SLPs were assigned a series of case studies to complement PLC sessions. An IS framework informed each step of the PD and PLCs to ensure applicability and integration of the content. Of the 366 SLPs working in the district, 209 consented and filled out two questionnaires and three exit slips to gather information on their experiences with the DAs and PLC models.

RESULTS

SLPs reported new insights into their practice, including changes in assessment practices, awareness of bias in assessment practices, and increased confidence in working with families during the evaluation process. Two additional themes emerged: increased collaboration and enhanced group problem-solving skills when working with peers in PLC groups, and expanded proficiencies and heightened skills when applying DA practices to evaluations. The two challenges faced by SLPs included time constraints and confidence in the mastery of DA.

CONCLUSION

This study offers an approach to shifting evaluation practices in large districts to incorporate more evidence-based approaches.

Bundling implementation strategies supports outcome measure adoption in stroke rehabilitation: preliminary findings

BACKGROUND

Over 80% of people who experience a stroke present with residual impairment of the upper extremity, such as the shoulder, elbow, wrist, and hand. However, rarely do stroke rehabilitation practitioners (e.g., occupational therapists) use standardized outcome measures to objectively evaluate upper extremity function. Accordingly, the purpose of this project was to develop a bundle of implementation strategies that supports practitioners' adoption of the Fugl-Meyer Assessment of the Upper Extremity in stroke rehabilitation practice.

METHODS

We used tenets of Implementation Mapping to guide the development of our implementation strategy bundle. We partnered with one, large academic health system serving over 200 stroke patients annually through intensive rehabilitation care. Strategies were selected and developed through a multi-method process that included a review of the literature, qualitative input from our health system's practitioners and managers, and expert consultation. We also specified the hypothesized implementation "mechanisms" our strategies intended to change. Practitioners' adoption (yes/no) of the Fugl-Meyer Assessment was calculated by analyzing electronic health record documentation of the 6-month time frame before strategies were deployed compared to the 6-month time frame after deployment.

RESULTS

Practitioners were exposed to the following implementation strategies to support Fugl-Meyer adoption: conduct educational meetings, prepare outcome measure champions, provide equipment, develop training materials, and adapt documentation systems. In the 6-months before deployment of our implementation strategies, practitioners implemented the Fugl-Meyer with 14.8% of stroke patients. In the six months after deployment, adoption of the Fugl-Meyer increased to 73.8% (p < .001).

CONCLUSIONS

When systematically developed in collaboration with health system partners, a bundle of implementation strategies may support outcome measure adoption in stroke rehabilitation. Improving the use of standardized outcome measures is of paramount importance in stroke rehabilitation to objectively monitor patients' progress or decline, to demonstrate the value of rehabilitation services for enhancing patients' recovery, and to advocate for continued reimbursement for rehabilitation care. Future opportunities lie in further specifying the mechanisms through which implementation strategies are intended to work and how those mechanisms contribute to strategy effectiveness.

TRIAL REGISTRATION

NCT registration: NCT04888416; May 06, 2021.

Reducing Iatrogenic Blood Losses in Premature Infants

OBJECTIVE

Iatrogenic blood losses from repetitive laboratory testing are a leading cause of anemia of prematurity and blood transfusions. We used an implementation science approach to decrease iatrogenic blood losses during the first 3 postnatal weeks among very low birth weight infants.

METHODS

We performed qualitative interviews of key stakeholders to assess implementation determinants (ie, barriers and facilitators to reducing iatrogenic blood losses), guided by the Consolidated Framework for Implementation Research. Next, we selected implementation strategies matched to these implementation determinants to de-implement excess laboratory tests. The number of laboratory tests, amount of blood taken (ml/kg), and laboratory charges were compared before and after implementation using quasi-Poisson and multi-variable regression models.

RESULTS

Qualitative interviews with 14 clinicians revealed implementation-related themes, including provider-specific factors, recurring orders, awareness of blood loss and cost, and balance between over- and under-testing. Implementation strategies deployed included resident education, revised order sets, blood loss and cost awareness, audit and feedback, and the documentation of blood out. There were 184 and 170 infants in the pre- and postimplementation cohorts, respectively. There was an 18.5% reduction in laboratory tests (median 54 [36 - 80] versus 44 [29 - 74], P = .01) in the first 3 postnatal weeks, a 17% decrease in blood taken (mean 18.1 [16.4 - 20.1] versus 15 [13.4 - 16.8], P = .01), and an overall reduction of $290 328 in laboratory charges. No difference was noted in the number of blood transfusions. Postimplementation interviews showed no adverse events attributable to implementation strategies.

CONCLUSIONS

An implementation science approach combining qualitative and quantitative methods reduced laboratory tests, blood loss, and charges.

Building a culture of safety in Australian residential aged care facilities: protocol for a longitudinal mixed methods research programme

INTRODUCTION

The quality and safety of care within residential aged care facilities (RACFs) have been linked to their organisational culture. However, evidence for understanding and improving culture in this setting is limited. This research programme aims to validate a survey to measure organisational culture and determine the relationship of culture with safety and quality of care, then to evaluate an organisational culture change programme in Australian RACFs.

METHODS AND ANALYSIS

This is a longitudinal mixed methods programme of research conducted across four studies in collaboration with a national aged care provider that cares for more than 5000 residents:Study 1: Cross-sectional staff survey of organisational culture in >50 RACFs with concurrent collection of data on quality and safety of care, and staff outcomes, to explore their associations with culture.Study 2: Ethnographic fieldwork in eight RACFs sampled to achieve maximum variation. Data from interviews, observations and documents will be analysed to identify the underlying assumptions and how cultural assumptions influence the enactment of safety and quality.Study 3: Evaluation of the implementation of the Speak Up for Safety culture change programme, focusing on its contextualisation for RACFs, implementation determinants and outcomes. Data will be collected through semistructured interviews, complimented with secondary data from program training and feedback system usage.Study 4: Evaluation of the effectiveness of the culture change programme using baseline data from study 1 and a follow-up survey of organisational culture postimplementation to assess changes in organisational culture and staff behaviour.

ETHICS AND DISSEMINATION

The study has received approval from the Macquarie University Human Research Ethics Committee. Informed consent will be sought from all participants. Findings will be disseminated through journal articles, conference presentations and reports to the collaborating provider and RACFs. Survey data will be deposited into a data repository for use by others working on related research.

A research agenda to advance the study of implementation mechanisms

BACKGROUND

Implementation science scholars have made significant progress identifying factors that enable or obstruct the implementation of evidence-based interventions, and testing strategies that may modify those factors. However, little research sheds light on how or why strategies work, in what contexts, and for whom. Studying implementation mechanisms-the processes responsible for change-is crucial for advancing the field of implementation science and enhancing its value in facilitating equitable policy and practice change. The Agency for Healthcare Research and Quality funded a conference series to achieve two aims: (1) develop a research agenda on implementation mechanisms, and (2) actively disseminate the research agenda to research, policy, and practice audiences. This article presents the resulting research agenda, including priorities and actions to encourage its execution.

METHOD

Building on prior concept mapping work, in a semi-structured, 3-day, in-person working meeting, 23 US-based researchers used a modified nominal group process to generate priorities and actions for addressing challenges to studying implementation mechanisms. During each of the three 120-min sessions, small groups responded to the prompt: "What actions need to be taken to move this research forward?" The groups brainstormed actions, which were then shared with the full group and discussed with the support of facilitators trained in structured group processes. Facilitators grouped critical and novel ideas into themes. Attendees voted on six themes they prioritized to discuss in a fourth, 120-min session, during which small groups operationalized prioritized actions. Subsequently, all ideas were collated, combined, and revised for clarity by a subset of the authorship team.

RESULTS

From this multistep process, 150 actions emerged across 10 priority areas, which together constitute the research agenda. Actions included discrete activities, projects, or products, and ways to shift how research is conducted to strengthen the study of implementation mechanisms.

CONCLUSIONS

This research agenda elevates actions to guide the selection, design, and evaluation of implementation mechanisms. By delineating recommended actions to address the challenges of studying implementation mechanisms, this research agenda facilitates expanding the field of implementation science, beyond studying what works to how and why strategies work, in what contexts, for whom, and with which interventions.

Gaps in communication theory paradigms when conducting implementation science research: qualitative observations from interviews with administrators, implementors, and evaluators of rural health programs

BACKGROUND

Communication is considered an inherent element of nearly every implementation strategy. Often it is seen as a means for imparting new information between stakeholders, representing a Transaction orientation to communication. From a Process orientation, communication is more than information-exchange and is acknowledged as being shaped by (and shaping) the individuals involved and their relationships with one another. As the field of Implementation Science (IS) works to strengthen theoretical integration, we encourage an interdisciplinary approach that engages communication theory to develop richer understanding of strategies and determinants of practice.

METHODS

We interviewed 28 evaluators, 12 implementors, and 12 administrators from 21 Enterprise-Wide Initiatives funded by the Department of Veteran Affairs Office of Rural Health. Semi-structured interviews focused on experiences with implementation and evaluation strategies. We analyzed the interviews using thematic analysis identifying a range of IS constructs. Then we deductively classified those segments based on a Transaction or Process orientation to communication.

RESULTS

We organized findings using the two IS constructs most commonly discussed in interviews: Collaboration and Leadership Buy-in. The majority of segments coded as Collaboration (n = 34, 74%) and Leadership Buy-in (n = 31, 70%) discussed communication from a Transaction orientation and referred to communication as synonymous with information exchange, which emphasizes the task over the relationships between the individuals performing the tasks. Conversely, when participants discussed Collaboration and Leadership Buy-in from a Process orientation, they acknowledged both constructs as the result of long-term efforts to develop positive relationships based on trust and respect, and emphasized the time costliness of such strategies. Our findings demonstrate that participants who discussed communication from a Process orientation recognized the nuance and complexity of interpersonal interactions, particularly in the context of IS.

CONCLUSIONS

Efficient, reliable information exchange is a critical but often overemphasized element of implementation. Practitioners and researchers must recognize and incorporate the larger role of communication in IS. Two suggestions for engaging a Process orientation to communication are to: (a) use interview probes to learn how communication is enacted, and (b) use process-oriented communication theories to develop interventions and evaluation tools.

Identifying Barriers and Implementation Strategies to Inform TBI Screening Adoption in Behavioral Healthcare Settings

OBJECTIVE

Identify barriers to the adoption of the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) in behavioral healthcare organizations and match these barriers to implementation strategies to inform future implementation efforts.

PARTICIPANTS

Twenty behavioral health providers.

DESIGN

Qualitative study involving individual, semi-structured interviews regarding barriers to adopting the OSU TBI-ID. Data were thematically analyzed around constructs from the Consolidated Framework for Implementation Research (CFIR). Results were matched to strategies using the Expert Recommendations for Implementing Change (CFIR/ERIC) matching tool.

RESULTS

Ten barriers were identified across 4 CFIR domains. Inner-Setting barriers were inadequate leadership engagement, priorities, resources, and organizational incentives. Individual-Characteristics barriers were insufficient knowledge about the connection between TBI and behavioral health and how to conduct the OSU TBI-ID with fidelity, low self-efficacy to conduct screening, and inadequate motivation and buy-in to conduct screening. Outer-Setting barriers were lack of state-level mandates and inadequate incentives to conduct screenings. The Process domain barrier was an insufficient engagement of key personnel. Strategy recommendations include: identify and prepare champions; alter incentive and allowance structures; inform local opinion leaders; build a coalition; access new funding; conduct local consensus discussions; involve executive boards; capture/share local knowledge; conduct educational meetings; assess for readiness and identify determinants; identify early adopters; fund and contract for the clinical innovation; create a learning collaborative; and conduct a local needs assessment.

CONCLUSIONS

This is the first study to examine barriers to adopting the OSU TBI-ID in real-world practice settings. Our results suggest that multilevel implementation strategies addressing mechanisms of change are necessary at the provider, organizational, and systems levels to overcome the complex barriers affecting TBI screening adoption and implementation. Future research is needed to test these strategies and their mechanisms of action on the adoption, implementation, and sustainment of TBI screening, as well as their effect on client-level outcomes.

Pre-implementation planning to enhance integration of HIV and behavioral health care services at two Ryan White-funded HIV care centers

Behavioral health conditions are disproportionately experienced by people living with Human immunodeficiency virus (HIV), including young Black gay, bisexual, and other men who have sex with men (GBMSM). Left unaddressed, these symptoms can adversely impact HIV care outcomes. Improving the integration of behavioral health and HIV care services has been proposed as a strategy to address this challenge. To conduct a pre-implementation study exploring barriers and facilitators to improving HIV and behavioral health care integration at two HIV clinics in Atlanta, Georgia. We conducted a mixed-methods study guided by the Consolidated Framework for Implementation Research (CFIR). Sixty (60) HIV care providers, behavioral health care providers, and social service providers participated in cross-sectional surveys, and a subset of survey participants (15) also participated in a qualitative in-depth interview to explore CFIR constructs in greater depth. We focused on Intervention Characteristics, Outer Setting, and Inner Setting as the most relevant CFIR domains. Within each of these domains, we identified both facilitators and barriers to improving HIV and behavioral care integration in the two clinics. Participants agreed that enhancing integration would provide a relative advantage over current practice, would address young Black GBMSM and other patient needs, and would be compatible with the organizational mission. However, they also expressed concerns about complexity, resource availability, and priority relative to other clinic initiatives. Participants were enthusiastic about improving care integration but also invoked practical challenges to translating this idea into practice. Future research should test specific implementation strategies and their potential effectiveness for improving the integration of behavioral health and HIV care, as a strategy for improving well-being among young Black GBMSM and other people living with HIV.

"Physical Activity Is Not the Answer to Everything, but It Is to a Lot": Stakeholders' Perceived Determinants of Implementing Physical Activity Interventions for Older Adults

Although many physical activity (PA) interventions for older adults have proven effective in controlled research settings, optimal implementation in real life remains challenging. This study identifies determinants perceived by stakeholders when implementing community-based PA interventions for older adults. We interviewed 31 stakeholders guided by the Consolidated Framework for Implementation Research (CFIR). Results showed that stakeholders are very specific about the role they can play in implementation, making collaboration between stakeholders crucial. Barriers and motivators were identified in the CFIR intervention characteristics domain (relative advantage, complexity and costs, evidence quality and strength, and adaptability and trialability), in the outer setting domain (cosmopolitism, patient needs, and external policy and incentives), in the inner setting domain (implementation climate, relative priority, compatibility and organizational incentives and rewards) and in the individual characteristics domain (knowledge and beliefs, and other personal attributes). An overarching theme was the stakeholders' emphasis on aiming for broad health goals in interventions, as they perceive PA as a means to reach these goals rather than an end in itself. Another overarching theme requiring attention in future implementation efforts is the need to tailor implementation efforts to the specific needs of older adults as the end users of the intervention.

Optimization of implementation strategies using the Multiphase Optimization STratgey (MOST) framework: Practical guidance using the factorial design

The Multiphase Optimization STrategy (MOST) is a framework that uses three phases-preparation, optimization, and evaluation-to develop multicomponent interventions that achieve intervention EASE by strategically balancing Effectiveness, Affordability, Scalability, and Efficiency. In implementation science, optimization of the intervention requires focus on the implementation strategies-things that we do to deliver the intervention-and implementation outcomes. MOST has been primarily used to optimize the components of the intervention related to behavioral or health outcomes. However, innovative opportunities to optimize discrete (i.e. single strategy) and multifaceted (i.e. multiple strategies) implementation strategies exist and can be done independently, or in conjunction with, intervention optimization. This article details four scenarios where the MOST framework and the factorial design can be used in the optimization of implementation strategies: (i) the development of new multifaceted implementation strategies; (ii) evaluating interactions between program components and a discrete or multifaceted implementation strategies; (iii) evaluating the independent effects of several discrete strategies that have been previously evaluated as a multifaceted implementation strategy; and (iv) modification of a discrete or multifaceted implementation strategy for the local context. We supply hypothetical school-based physical activity examples to illustrate these four scenarios, and we provide hypothetical data that can help readers make informed decisions derived from their trial data. This manuscript offers a blueprint for implementation scientists such that not only is the field using MOST to optimize the effectiveness of an intervention on a behavioral or health outcome, but also that the implementation of that intervention is optimized.

Implementation of a digital diary in the intensive care unit; understanding the facilitators and barriers: A qualitative exploration

BACKGROUND

In the recent years, digital intensive care unit (ICU) diaries have emerged as more advantageous than paper diaries. Despite the advantages of digital diaries, the successful implementation and maintenance of this digital intervention present significant challenges in clinical practice. Therefore, understanding the facilitators and barriers among stakeholders influencing this process becomes imperative for devising a tailored strategy to integrate digital diaries effectively within ICU settings.

AIM/OBJECTIVE

The aim of this study was to explore facilitators and barriers for implementation of a digital ICU diary from the perspectives of ICU professionals, ICU survivors, and their relatives.

METHODS

A qualitative design was used, incorporating focus-group interviews with professionals from four Dutch ICUs, along with individual interviews with ICU survivors and relatives. The study spanned from October 2022 to April 2023. Data analysis utilised a mixed inductive-deductive approach, particularly through directed content analysis. The Consolidated Framework for Implementation Research 2.0 guided both data collection and analysis processes.

FINDINGS

We conducted five focus-group interviews among ICU professionals (n = 32) and 10 individual or dual interviews involving five ICU survivors and nine relatives. Key facilitators for implementing a digital diary according to ICU professionals encompassed a user-friendly interface accessible independent of time and place, with a seamless login process requiring minimal steps, comprehensive training covering all aspects of its use, and feedback from the experiences of both patients and relatives. Barriers for ICU professionals included many steps required to access the digital diary, as well as resistance to (co)writing diary entries. In contrast, professionals' involvement in writing diary entries was highly appreciated among ICU survivors and relatives. An ambiguous factor arose regarding sharing the digital diary with others; both ICU survivors and relatives found it valuable, yet it also raised privacy concerns.

CONCLUSIONS

This study offers insights into the most important factors influencing the implementation of a digital ICU diary. Strikingly, some factors serve as both barriers and facilitators. When developing the implementation strategy, the identified facilitators can be used to overcome the barriers faced by ICU professionals, ICU survivors, and their relatives in adopting a digital diary.

Implementing a Clinical Pathway for Needs Assessment and Supportive Care Interventions

Despite advances in clinical cancer care, cancer survivors frequently report a range of persisting issues, unmet needs, and concerns that limit their ability to participate in life roles and reduce quality of life. Needs assessment is recognized as an important component of cancer care delivery, ideally beginning during active treatment to connect patients with supportive services that address these issues in a timely manner. Despite the recognized importance of this process, many health care systems have struggled to implement a feasible and sustainable needs assessment and management system. This article uses an implementation science framework to guide pragmatic implementation of a needs assessment clinical system in cancer care. According to this framework, successful implementation requires four steps including (1) choosing a needs assessment tool; (2) carefully considering the provider level, clinic level, and health care system-level strengths and barriers to implementation and creating a pilot system that addresses these factors; (3) making the assessment system actionable by matching needs with clinical workflow; and (4) demonstrating the value of the system to support sustainability.

Let it go, let it go: Stop measuring child maltreatment as a binary yes/no

Numerous methods are used in the measurement of child maltreatment (CM) exposure. As a science, it is necessary that the field of CM research evaluate its measurement approaches periodically to ensure that the common approaches are the best approaches. A prominent method for measuring CM in research as a predictor variable is to conceptualize CM as a two-level, yes/no binary variable (e.g., 0 = No CM exposure, 1 = CM exposure). While there is no consensus on what method is the best approach for measuring CM, empirical evidence suggests that the binary measurement approach to CM has significant limitations. The current paper sought to progress the field of CM and trauma research forward by reviewing several lines of research demonstrating why the use of a binary yes/no CM measurement approach is problematic. As evidence for why a binary measurement of CM should be halted, this paper reviews research on: why the characteristics or details of CM exposure matter, risk of CM "contamination," and CM's relation with environmental or systemic factors. The ethical and clinical implications of a CM binary measurement approach are also discussed. Several recommendations for the field are provided on how researchers can improve the measurement of CM and ensure accurate and replicable studies are being published.

Identifying anticipated challenges when implementing group care: Context-analyses across seven countries to develop an anticipated challenges framework

PROBLEM

Despite increasing interest in Group Care worldwide, implementation is challenging.

BACKGROUND

Group Care is an evidence-based perinatal care model including three core components: health assessment, interactive learning, and community building. It has several advantages for service users and providers compared to individual perinatal care.

AIM

We aimed to identify anticipated challenges when implementing Group Care, and to develop a supporting tool based on these challenges.

METHODS

Context analyses through Rapid Qualitative Inquiries were conducted in 26 sites in seven countries to gain insight into the anticipated challenges when implementing Group Care. Data triangulation and investigator triangulation were applied. The context analyses generated 330 semi-structured interviews with service users and other stakeholders, 10 focus group discussions, and 56 review meetings with the research teams.

FINDINGS

We identified six surface structure anticipated challenges categories (content, materials, facilitators, timing, location, group composition), and five deep structure anticipated challenges categories (health assessment, scheduling Group Care into regular care, enrolment, (possible) partner organisations, financials) occurring in all participating sites, leading to the development of the Anticipated Challenges Framework.

CONCLUSION

Completing the Anticipated Challenges Framework raises awareness of anticipated challenges if sustainable Group Care implementation is to succeed and encourages the initiation of a concrete action plan to tackle these challenges. Application of the framework may offer important insights to health systems administrators and other key stakeholders before implementing Group Care. In the medium- and long-term, insights gained may lead to greater possibilities for sustainability and to the most cost-effective approaches for implementing Group Care.

Identification of implementation enhancement strategies for national comprehensive care standards using the CFIR-ERIC approach: a qualitative study

BACKGROUND

Comprehensive care is important for ensuring patients receive coordinated delivery of healthcare that aligns with their needs and preferences. While comprehensive care programs are recognised as beneficial, optimal implementation strategies in the real world remain unclear. This study utilises existing implementation theory to investigate barriers and enablers to implementing the Australian National Safety and Quality Health Service Standard 5 - Comprehensive Care Standard in acute care hospitals. The aim is to develop implementation enhancement strategies for work with comprehensive care standards in acute care.

METHODS

Free text data from 256 survey participants, who were care professionals working in acute care hospitals across Australia, were coded using the Consolidated Framework for Implementation Research (CFIR) using deductive content analysis. Codes were then converted to barrier and enabler statements and themes using inductive theme analysis approach. Subsequently, CFIR barriers and enablers were mapped to the Expert Recommendations for Implementing Change (ERIC) using the CFIR-ERIC Matching Tool, facilitating the development of implementation enhancement strategies.

RESULTS

Twelve (n = 12) CFIR barriers and 10 enablers were identified, with 14 barrier statements condensed into 12 themes and 11 enabler statements streamlined into 10 themes. Common themes of barriers include impact of COVID-19 pandemic; heavy workload; staff shortage, lack of skilled staff and high staff turnover; poorly integrated documentation system; staff lacking availability, capability, and motivation; lack of resources; lack of education and training; culture of nursing dependency; competing priorities; absence of tailored straties; insufficient planning and adjustment; and lack of multidisciplinary collaboration. Common themes of enablers include leadership from CCS committees and working groups; integrated documentation systems; established communication channels; access to education, training and information; available resources; culture of patient-centeredness; consumer representation on committees and working groups; engaging consumers in implementation and in care planning and delivery; implementing changes incrementally with a well-defined plan; and regularly collecting and discussing feedback. Following the mapping of CFIR enablers and barriers to the ERIC tool, 15 enhancement strategies were identified.

CONCLUSION

This study identified barriers, enablers, and recommended strategies associated with implementing a national standard for comprehensive care in Australian acute care hospitals. Understanding and addressing these challenges and strategies is not only crucial for the Australian healthcare landscape but also holds significance for the broader international community that is striving to advance comprehensive care.

Twelve-Month Sustainment of IPV Screening and Response Programs in Primary Care: Contextual Factors Impacting Implementation Success

PURPOSE

The Veterans Health Administration (VHA) employed implementation facilitation (IF) as a strategy to boost uptake of intimate partner violence (IPV) screening programs in primary care. This study examined the sustainment of screening uptake 1 year after IF and identified factors impacting sustainment success.

METHODS

A mixed-methods evaluation using quantitative and qualitative data was conducted. IPV screening rates from the conclusion of the IF period (i.e., initial adoption) through the 1-year sustainment period served as the primary outcome. We categorized sites into four groups of screening adoption and sustainment success (high adoption and high sustainment, moderate adoption and moderate sustainment, low adoption and low sustainment, and no adoption and/or no sustainment). Qualitative analysis of key informant interviews was used to identify contextual factors affecting screening 12 months post-IF. A mixed sustainment analysis matrix integrated quantitative and qualitative findings and enabled the identification of cross-site patterns.

MAIN FINDINGS

Seven of the nine sites sustained IPV screening at the most basic level (saw static or increased screening rates). High adopting and high sustaining sites (n = 3) were marked by consistently supportive medical center leadership, ongoing training for clinicians, clear protocols for responding to positive screens, and robust referral options for women experiencing IPV. Nonsustaining sites (n = 2) were marked by a host of barriers including staffing shortages, competing priorities, and inconsistent messaging from leadership regarding the importance of IPV screening.

CONCLUSIONS

Knowing barriers and facilitators to successful IPV screening sustainment can inform health care systems to tailor IF and other implementation strategies to sustain IPV screening in primary care. Sustainment of IPV screening requires attention to a combination of facilitators (e.g., consistent leadership support and robust referral options) as well as addressing key barriers (e.g., staff turnover and competing priorities).

Promoting the implementation of a computer-tailored physical activity intervention: development and feasibility testing of an implementation intervention

BACKGROUND

Although there are many proven effective physical activity (PA) interventions for older adults, implementation in a real world setting is often limited. This study describes the systematic development of a multifaceted implementation intervention targeting the implementation of an evidence-based computer-tailored PA intervention and evaluates its use and feasibility.

METHODS

The implementation intervention was developed following the Intervention Mapping (IM) protocol, supplemented with insights from implementation science literature. The implementation intervention targets the municipal healthcare policy advisors, as an important implementation stakeholder in Dutch healthcare system. The feasibility of the implementation intervention was studied among these stakeholders using a pretest-posttest design within 8 municipal healthcare settings. Quantitative questionnaires were used to assess task performance (i.e. achievement of performance objectives), and utilization of implementation strategies (as part of the intervention). Furthermore, changes in implementation determinants were studied by gathering quantitative data before, during and after applying the implementation intervention within a one-year period. Additionally, semi-structured interviews with stakeholders assessed their considerations regarding the feasibility of the implementation intervention.

RESULTS

A multi-faceted implementation intervention was developed in which implementation strategies (e.g. funding, educational materials, meetings, building a coalition) were selected to target the most relevant identified implementation determinants. Most implementation strategies were used as intended. Execution of performance objectives for adoption and implementation was relatively high (75-100%). Maintenance objectives were executed to a lesser degree (13-63%). No positive changes in implementation determinants were found. None of the stakeholders decided to continue implementation of the PA intervention further, mainly due to the unforeseen amount of labour and the disappointing reach of end-users.

CONCLUSION

The current study highlights the importance of a thorough feasibility study in addition to the use of IM. Although feasibility results may have demonstrated that stakeholders broadly accepted the implementation intervention, implementation determinants did not change favorably, and stakeholders had no plans to continue the PA intervention. Yet, choices made during the development of the implementation intervention (i.e. the operationalization of Implementation Mapping) might not have been optimal. The current study describes important lessons learned when developing an implementation intervention, and provides recommendations for developers of future implementation interventions.

Barriers and facilitators to using a clinical decision support tool for the management of osteoarthritis pain in patients undergoing hemodialysis: a qualitative study

BACKGROUND

While osteoarthritis is a significant issue within the hemodialysis population and contributes to reduced quality of life, pain related to osteoarthritis is poorly managed by healthcare professionals (HCPs) in hemodialysis settings due to the absence of clinical guidance applicable to this population. The purpose of this study was to explore the perceptions of HCPs on the barriers and facilitators to using a clinical decision support tool for osteoarthritis pain management in the hemodialysis setting.

METHODS

A qualitative descriptive study was conducted. Purposeful and snowball sampling techniques were used to recruit hemodialysis clinicians from academic and community settings across multiple Canadian provinces. One-to-one interviews were conducted with clinicians using a semi-structured, open ended interview guide informed by the Theoretical Domains Framework, a behavior change framework. A general inductive approach was applied to identify the main themes of barriers and facilitators.

RESULTS

A total of 11 interviews were completed with 3 nephrologists, 2 nurse practitioners and 6 pharmacists. Findings revealed 6 main barriers and facilitators related to the use of the clinical decision support tool. Alignment of the tool with practice roles emerged as a key barrier and facilitator. Other barriers included challenges related to the dialysis environment, varying levels of clinician comfort with pain medications, and limited applicability of the tool due to patient factors. An important facilitator was the intrinsic motivation among clinicians to use the tool.

CONCLUSIONS

Most participants across the included hemodialysis settings expressed satisfaction with the clinical decision support tool and acknowledged its overall potential for improving osteoarthritis pain management among patients on hemodialysis. Future implementation of the tool may be limited by existing roles and practices at different institutions. Increased collaboration among hemodialysis and primary care teams may promote uptake of the tool.

Implementing early feeding after liver transplant using implementation frameworks: A multimethod study

BACKGROUND

Evidence-based guidelines (EBGs) in the nutrition management of advanced liver disease and enhanced recovery after surgery recommendations state that normal diet should recommence 12-24 h following liver transplantation. This study aimed to compare postoperative nutrition practices to guideline recommendations, explore clinician perceptions regarding feeding after transplant surgery, and implement and evaluate strategies to improve postoperative nutrition practices.

METHODS

A pre-post multimethod implementation study was undertaken, guided by the knowledge-to-action framework. A retrospective chart audit of postoperative dietary practice and semistructured interviews with clinicians were undertaken. Implementation strategies were informed by the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool and then evaluated.

RESULTS

An evidence-practice gap was identified, with the median day to initiation of nutrition (free-fluid or full diet) on postoperative day (POD) 2 and only 25% of patients aligning with the EBGs. Clinician interviews identified belief in the importance of nutrition, with variation in surgical practice in relation to early nutrition, competing clinical priorities, and vulnerabilities in communication contributing to delays in returning to feeding. An endorsed postoperative nutrition protocol was implemented along with a suite of theory- and stakeholder-informed intervention strategies. Following implementation, the median time to initiate nutrition reduced to POD1 and alignment with EBGs improved to 60%.

CONCLUSION

This study used implementation frameworks and strategies to understand, implement, and improve early feeding practices in line with EBGs after liver transplant. Ongoing sustainability of practice change as well as the impact on clinical outcomes have yet to be determined.

Reducing asthma attacks in disadvantaged school children with asthma: study protocol for a type 2 hybrid implementation-effectiveness trial (Better Asthma Control for Kids, BACK)

BACKGROUND

Asthma is a leading cause of children's hospitalizations, emergency department visits, and missed school days. Our school-based asthma intervention has reduced asthma exacerbations for children experiencing health disparities in the Denver Metropolitan Area, due partly to addressing care coordination for asthma and social determinants of health (SDOH), such as access to healthcare and medications. Limited dissemination of school-based asthma programs has occurred in other metropolitan and rural areas of Colorado. We formed and engaged community advisory boards in socioeconomically diverse regions of Colorado to develop two implementation strategy packages for delivering our school-based asthma intervention - now termed "Better Asthma Control for Kids (BACK)" - with tailoring to regional priorities, needs and resources.

METHODS

In this proposed type 2 hybrid implementation-effectiveness trial, where the primary goal is equitable reach to families to reduce asthma disparities, we will compare two different packages of implementation strategies to deliver BACK across four Colorado regions. The two implementation packages to be compared are: 1) standard set of implementation strategies including Tailor and Adapt to context, Facilitation and Training termed, BACK-Standard (BACK-S); 2) BACK-S plus an enhanced implementation strategy, that incorporates network weaving with community partners and consumer engagement with school families, termed BACK-Enhanced (BACK-E). Our evaluation will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, including its Pragmatic Robust Implementation Sustainability Model (PRISM) determinants of implementation outcomes. Our central hypothesis is that our BACK-E implementation strategy will have significantly greater reach to eligible children/families than BACK-S (primary outcome) and that both BACK-E and BACK-S groups will have significantly reduced asthma exacerbation rates ("attacks") and improved asthma control as compared to usual care.

DISCUSSION

We expect both the BACK-S and BACK-E strategy packages will accelerate dissemination of our BACK program across the state - the comparative impact of BACK-S vs. BACK-E on reach and other RE-AIM outcomes may inform strategy selection for scaling BACK and other effective school-based programs to address chronic illness disparities.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT06003569, registered on August 22, 2023, https://classic.

CLINICALTRIALS

gov/ct2/show/NCT06003569 .

Pre-implementation planning for a new personalised, dementia post-diagnostic support intervention: exploring the perspective of professional stakeholders

BACKGROUND

Only a third of people with dementia receive a diagnosis and post-diagnostic support. An eight session, manualised, modular post-diagnostic support system (New Interventions for Independence in Dementia Study (NIDUS) - family), delivered remotely by non-clinical facilitators is the first scalable intervention to improve personalised goal attainment for people with dementia. It could significantly improve care quality.

AIMS

We aimed to explore system readiness for NIDUS-family, a scalable, personalised post-diagnostic support intervention.

METHOD

We conducted semi-structured interviews with professionals from dementia care services; the Consolidated Framework for Implementation Research guided interviews and their thematic analysis.

RESULTS

From 2022 to 2023, we interviewed a purposive sample of 21 professionals from seven English National Health Service, health and social care services. We identified three themes: (1) potential value of a personalised intervention - interviewees perceived the capacity for choice and supporting person-centred care as relative advantages over existing resources; (2) compatibility and deliverability with existing systems - the NIDUS-family intervention model was perceived as compatible with service goals and clients' needs, but current service infrastructures, financing and commissioning briefs constraining resources to those at greatest need were seen as barriers to providing universal, post-diagnostic care; (3) fit with current workforce skills - the intervention model aligned well with staff development plans; delivery by non-clinically qualified staff was considered an advantage over current care options.

CONCLUSIONS

Translating evidence for scalable and effective post-diagnostic care into practice will support national policies to widen access to support and upskill support workers, but requires a greater focus on prevention in commissioning briefs and resource planning.

Factors influencing older adult community fall prevention exercise implementation: a scoping review

BACKGROUND

Exercise that challenges balance is the most effective fall prevention intervention in community-dwelling older adults. Identifying factors influencing implementation of community fall prevention exercise programs is a critical step in developing strategies to support program delivery.

OBJECTIVE

To identify implementation facilitators, barriers, and details reported in peer-reviewed publications on community fall prevention exercise for older adults.

DESIGN

Scoping review.

METHODS

We searched multiple databases up to July 2023 for English-language publications that reported facilitators and/or barriers to implementing an evidence-based fall prevention exercise program in adults aged 50+ years living independently. At least two reviewers independently identified publications and extracted article, implementation, and exercise program characteristics and coded barriers and facilitators using the Consolidated Framework for Implementation Research (CFIR).

RESULTS

We included 22 publications between 2001 and July 2023 that reported factors influencing implementation of 10 exercise programs. 293 factors were reported: 183 facilitators, 91 barriers, 6 described as both a facilitator and barrier, and 13 unspecified factors. Factors represented 33 CFIR constructs across all five CFIR domains: implementation inner setting (n = 95 factors); innovation (exercise program) characteristics (n = 84); individuals involved (n = 54); implementation process (n = 40) and outer setting (n = 20). Eight publications reported implementation strategies used; 6 reported using a conceptual framework; and 13 reported implementation outcomes.

CONCLUSION

The high number of factors reflects the complexity of fall prevention exercise implementation. The low reporting of implementation strategies, frameworks and outcomes highlight the ongoing need for work to implement and sustain community fall prevention exercise programs.

Transforming Healthcare with Nanomedicine: A SWOT Analysis of Drug Delivery Innovation

Objective

Nanomedicine represents a transformative approach in biomedical applications. This study aims to delineate the application of nanomedicine in the biomedical field through the strengths, weaknesses, opportunities, and threats (SWOT) analysis to evaluate its efficacy and potential in clinical applications.

Methods

The SWOT analysis framework was employed to systematically review and assess the internal strengths and weaknesses, along with external opportunities and threats of nanomedicine. This method provides a balanced consideration of the potential benefits and challenges.

Results

Findings from the SWOT analysis indicate that nanomedicine presents significant potential in drug delivery, diagnostic imaging, and tissue engineering. Nonetheless, it faces substantial hurdles such as safety issues, environmental concerns, and high development costs. Critical areas for development were identified, particularly concerning its therapeutic potential and the uncertainties surrounding long-term effects.

Conclusion

Nanomedicine holds substantial promise in driving medical innovation. However, successful clinical translation requires addressing safety, cost, and regulatory challenges. Interdisciplinary collaboration and comprehensive strategic planning are crucial for the safe and effective application of nanomedicine.

Expert consensus on multilevel implementation hypotheses to promote the uptake of youth care guidelines: a Delphi study

BACKGROUND

The implementation of youth care guidelines remains a complex process. Several evidence-based frameworks aid the identification and specification of implementation determinants and strategies. However, the influence of specific strategies on certain determinants remains unclear. Therefore, we need to clarify which active ingredients of strategies, known as behaviour change techniques (BCTs), elicit behaviour change and improve implementation outcomes. With this knowledge, we are able to formulate evidence-based implementation hypotheses. An implementation hypothesis details how determinants and in turn, implementation outcomes might be influenced by specific implementation strategies and their BCTs. We aimed to identify (1) determinants relevant to the implementation of youth care guidelines and (2) feasible and potentially effective implementation hypotheses.

METHODS

A four-round online modified Delphi study was conducted. In the first round, experts rated the implementation determinants based on their relevance. Next, experts formulated implementation hypotheses by connecting BCTs and implementation strategies to determinants and were asked to provide a rationale for their choices. In round three, the experts reconsidered and finalised their hypotheses based on an anonymous overview of all formulated hypotheses, including rationales. Finally, the experts rated the implementation hypotheses based on their potential effectiveness and feasibility.

RESULTS

Fourteen experts completed the first, second, and third rounds, with 11 completed the final round. Guideline promotion, mandatory education, presence of an implementation leader, poor management support, knowledge regarding guideline use, and a lack of communication skills were reported as most relevant determinants. In total, 46 hypotheses were formulated, ranging from 6 to 9 per determinant. For each determinant, we provide an overview of the implementation hypotheses that were most commonly deemed feasible and potentially effective.

CONCLUSION

This study offers valuable insights into youth care guideline implementation by systematically identifying relevant determinants and formulating hypotheses based on expert input. Determinants related to engagement and to knowledge and skills were found to be relevant to youth care guideline implementation. This study offers a set of hypotheses that could help organisations, policymakers, and professionals guide the implementation process of youth care guidelines to ultimately improve implementation outcomes. The effectiveness of these hypotheses in practice remains to be assessed.

Implementation Strategies for Quality Improvement in Palliative Care: A Scoping Review

BACKGROUND

Quality improvement (QI) programs based on person-centred outcome measures (PCOMs) play an important role in promoting optimal palliative care. However, routine use of PCOMs has been slow and difficult to implement, including within QI programs.

OBJECTIVE

This study aimed to identify implementation strategies that support the implementation of PCOMs as routine practice in hospital-based palliative care, as well as the implementation theories, models and frameworks (TMFs) guiding the design of these implementation strategies.

METHODS

A scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) Scoping Review framework. Four databases (Medline, CINAHL, Scopus and PubMed) were systematically searched for literature published between 1 January 1990 and 8 March 2024.

RESULTS

One hundred and fifteen unique implementation strategies, identified from 11 included studies, were mapped onto the 73 Expert Recommendations for Implementing Change (ERIC) discrete implementation strategies, covering 52% of the ERIC strategies. The most commonly used categories were train and educate stakeholders, and support clinicians, followed by develop stakeholder interrelationships and use evaluation and iterative strategies. Three key themes emerged: what to do; how to do it; and who to do it with. Only four studies employed TMFs to guide the design of the implementation strategies in this review.

CONCLUSIONS

To promote the implementation of PCOM-based QI programs, strategies should be developed based on identified/potential barriers and facilitators by using rigorous TMFs. The components of the implementation strategies must be reported transparently and consistently to enable replication and measurement in future research and practice.

PATIENT AND PUBLIC CONTRIBUTION

This scoping review does not directly involve patients or the general public in its design or execution. However, it is part of an implementation study aimed at integrating the Palliative Care Outcome Collaboration (PCOC) model into routine clinical practice at a cancer hospital in China. Before the formal implementation, palliative care professionals from this hospital highlighted the need for a comprehensive analysis of existing evidence to support the effective adoption of the PCOC model in their specific clinical setting.

Artificial intelligence for diabetes care: current and future prospects

Artificial intelligence (AI) use in diabetes care is increasingly being explored to personalise care for people with diabetes and adapt treatments for complex presentations. However, the rapid advancement of AI also introduces challenges such as potential biases, ethical considerations, and implementation challenges in ensuring that its deployment is equitable. Ensuring inclusive and ethical developments of AI technology can empower both health-care providers and people with diabetes in managing the condition. In this Review, we explore and summarise the current and future prospects of AI across the diabetes care continuum, from enhancing screening and diagnosis to optimising treatment and predicting and managing complications.

Between acute medicine and municipal alcohol treatment: Cross-sectoral collaborations regarding patients with alcohol problems

Aim: The aim was to examine cross-sectoral collaborations of a Danish emergency department (ED) and two municipal treatment centres in the uptake area regarding patients with alcohol problems. Methods: The study was a qualitative exploratory study. We conducted individual interviews with ED nurses and secretaries (n = 21) and group interviews (n = 2) in municipal alcohol treatment centres with three and four participants, respectively. Interviews were analysed, first with qualitative content analysis, then by applying the analytical concept "boundary object". Results: Three themes emerged: (1) Responsibilities in practice; (2) Professional contrasts; and (3) The social nurse in a unique position. Themes illuminated a low degree of collaboration characterising the intersectoral work. Blurred responsibilities, challenged communication and acute versus long-term focus were some of the factors not supporting cross-sector collaborations. However, the function of the social nurse was highly appreciated in both sectors and plays a central role. Nonetheless, implicit limitations of this function entail that not all patients with alcohol problems are referred and handled within an ED setting. Conclusions: Overall, we found a lack of collaborative work between healthcare professionals in ED and municipalities for patients with alcohol problems. However, the "social nurse" function was greatly valued in both sectors due to a mediating role, since healthcare professionals in both sectors experienced lack of organisational structures supporting collaborative network, perceived temporal barriers, limited knowledge exchange and differences in approaches to patients.

Building an implementation strategy for community-based rehabilitation for mental health in Colombia

INTRODUCTION

Scientific evidence indicates that the community-based rehabilitation (CBR) model is recommended for recovery from mental disorders. However, this approach encounters barriers and often lacks implementation strategies.

AIM

The aim of this study was to create a strategy for the implementation of CBR for mental health in Colombia through the identification of barriers and facilitators, together with the expected outcomes, from the perspective of mental health decision-makers in Colombia.

METHODS

This study adopts a qualitative descriptive approach, using focus group data collection methods and thematic analysis to code and analyze the data.

RESULTS

A total of 208 individuals participated in the study, including mental health decision-makers and health care professionals. Intersectoral collaboration, contextualization, financial resources, and community commitment and autonomy were identified as barriers and facilitators. The element that was considered a priority for successful implementation was the contextualization of strategies.

CONCLUSIONS

CBR needs to be strengthened through implementation science if these strategies are to be successfully developed and implemented in various contexts.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A210.

Implementation of a Cancer Rehabilitation Navigation Program: a qualitative analysis of implementation determinants and strategies

BACKGROUND

Cancer rehabilitation navigation (CRNav) is a care delivery model that expedites identification and management of symptom-related functional morbidity for individuals undergoing cancer treatment. A CRNav program is unique in that it embeds a cancer rehabilitation professional in the cancer center for patient screening and assessment. The implementation of CRNav programs has not been studied and doing so could facilitate greater uptake of these programs.

METHODS

Using implementation science frameworks, we conducted a qualitative, post-implementation analysis of a CRNav program that was implemented in 2019. Semi-structured, 1:1 interviews were guided by the Consolidated Framework for Implementation Research (CFIR) and a combination of deductive and inductive analyses, using a priori established codes, was used to assess the implementation context, and identify emergent themes of barriers and facilitators to implementation. Participant described implementation strategies were characterized and defined using the Expert Consensus Recommendations for Implementing Change (ERIC) taxonomy.

RESULTS

Eleven stakeholders including physicians, administrators, clinical staff, and patients, involved with program development and the implementation effort, participated in interviews. Predominant barriers to implementation included developing the program infrastructure, and lack of awareness of rehabilitation services among oncology professionals, predominant facilitators of implementation included; physical co-location of the navigator in the cancer center, individual characteristics of the navigator, and unique characteristics of the program. Strategies described that supported implementation included developing stakeholder interrelationships, evaluating and iteratively adapting the program, creating infrastructure, training and education, and supporting clinicians.

CONCLUSION

This analysis uses implementation science to methodically analyze and characterize factors that may contribute to successful implementation of a CRNav program. These findings could be used alongside a prospective context-specific analysis to tailor future implementation efforts.

IMPLICATIONS FOR CANCER SURVIVORS

Implementing a CRNav program expedites a patient's direct contact with a rehabilitation provider complementing the cancer care delivery team, and providing an additive and often missing service.

Implementation contexts and strategies for alternative peripherally inserted central catheter material and design selection: A qualitative exploration using CFIR/ERIC approach

AIM

To explore the implementation contexts and strategies that influence the uptake and selection of alternative peripherally inserted central catheter (PICC) materials and design.

DESIGN

Qualitative evaluation of end user perspectives within a randomized control trial of different PICC materials and design.

METHODS

Semi-structured interviews with key stakeholders were undertaken via an adapted, rapid-analytic approach using the Consolidated Framework for Implementation Research. Outcomes were mapped against the Expert Recommendations for Implementing Change (ERIC) tool for strategies to guide innovation in PICC practice.

RESULTS

Participants (n = 23) represented a combination of users and inserters/purchasers, from adult and paediatric settings. Dominant themes included intervention characteristics (intervention source), inner setting (structural characteristics) and individuals involved (self-efficacy). Strategies emerging to support a change from ERIC mapping (n = 16) included promotion of intervention adaptability, inclusion of staff and consumer perspectives and sufficient funding. Implementation contexts such as inner setting and individuals involved equally impacted PICC success and implementation effectiveness and enabled a greater understanding of barriers and facilitators to intervention implementation in this trial.

CONCLUSION

Trial evidence is important, but healthcare decision-making requires consideration of local contexts especially resourcing. Implementation contexts for Australian healthcare settings include a practical, strategic toolkit for the implementation of alternative PICC materials and designs.

REPORTING METHOD

This study adhered to COREQ guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Mapping regional implementation of 'Making Every Contact Count': mixed-methods evaluation of implementation stage, strategies, barriers and facilitators of implementation

BACKGROUND

The Making Every Contact Count (MECC) programme provides training and materials to support public-facing workers to encourage health-promoting behaviour change by using the day-to-day interactions between organisations and individuals. This project aimed to analyse MECC implementation through a comparative analysis of implementation stage, strategies used for implementation and enablers/barriers of the implementation process within a region in England-the North East and North Cumbria (NENC).

METHODS

A mixed-methods process evaluation was conducted applying normalisation process theory and theoretical domains framework. MECC programme documents were reviewed and mapped against specific criteria (eg, implementation strategies). An online mapping survey was conducted to establish current implementation/delivery of MECC within NENC settings (eg, local government, healthcare and voluntary community sector). Qualitative research, using individual interviews and group discussions, was conducted to establish further understanding of MECC implementation.

RESULTS

Our findings were informed by reviewing documents (n=5), surveying participants (n=34), interviews (n=18) and group discussions (n=48). Overall, the implementation of MECC within the region was at an early stage, with training mostly delivered between, rather than within, organisations. Qualitative findings highlighted factors that influence stakeholders to implement MECC (eg, organisational goals that were facilitated by MECC implementation, including the prevention agenda), supported resources that facilitate the implementation of MECC (eg, logic models) and enabling factors that promote MECC sustainability across the region (eg, buy-in from leadership and management).

CONCLUSIONS

The NENC MECC programme is built around regional leadership that supports the implementation process. This process evaluation identified key influences of MECC implementation across the region. We discuss evidence-based recommendation for policy and practice that can be taken forward to develop targeted strategies to support future MECC implementation. For example, a co-ordinated infrastructure and strategy is needed to combat delivery and implementation issues identified.

"Sometimes it can be like an icebreaker": A mixed method evaluation of the implementation of the Refugee Health Screener-13 (RHS-13)

Background

Forced migrants are at risk of developing mental illness, yet challenges remain with underutilization of mental healthcare among this population. This study examined the implementation of the Refugee Health Screener-13 (RHS-13) in the health assessment for forced migrants in eight primary health care centres in Stockholm Region, Sweden.

Methods

A mixed-methods convergent parallel design was used, combining nurses self-reported quantitative data on the levels and reasons for RHS-13 use in the health assessment with qualitative interview data on the barriers and facilitators for RHS-13 use. The Consolidated Framework for Implementation Research (CFIR) was used as a coding framework for the qualitative analysis.

Results

Levels of RHS-13 use varied between primary health care centres, resulting in two groups: three centres with high-level (65-92%) and five centres with low-level (0-36%) implementation. Factors related to the tool itself, as well as the inner and outer context, influenced the use of RHS-13. Language barriers, insufficient time, and lack of trust in the validity and utility of RHS-13 were the main barriers, while its availability in many languages and that it was perceived as an important complement to the health assessment were the main facilitators.

Conclusion

RHS-13 contributes to the standardization of assessing mental health in the health assessment. Identifying context-based implementation strategies and addressing language and time issues as well as nurses trust in the tool's utility are recommended to enhance the use of RHS-13.

Implementing evidence-based practices to improve primary care for high-risk patients: study protocol for the VA high-RIsk VETerans (RIVET) type III effectiveness-implementation trial

BACKGROUND

Patients with significant multimorbidity and other factors that make healthcare challenging to access and coordinate are at high risk for poor health outcomes. Although most (93%) of Veterans' Health Administration (VHA) patients at high risk for hospitalization or death ("high-risk Veterans") are primarily managed by primary care teams, few of these teams have implemented evidence-based practices (EBPs) known to improve outcomes for the high-risk patient population's complex healthcare issues. Effective implementation strategies could increase adoption of these EBPs in primary care; however, the most effective implementation strategies to increase evidence-based care for high-risk patients are unknown. The high-RIsk VETerans (RIVET) Quality Enhancement Research Initiative (QUERI) will compare two variants of Evidence-Based Quality Improvement (EBQI) strategies to implement two distinct EBPs for high-risk Veterans: individual coaching (EBQI-IC; tailored training with individual implementation sites to meet site-specific needs) versus learning collaborative (EBQI-LC; implementation sites trained in groups to encourage collaboration among sites). One EBP, Comprehensive Assessment and Care Planning (CACP), guides teams in addressing patients' cognitive, functional, and social needs through a comprehensive care plan. The other EBP, Medication Adherence Assessment (MAA), addresses common challenges to medication adherence using a patient-centered approach.

METHODS

We will recruit and randomize 16 sites to either EBQI-IC or EBQI-LC to implement one of the EBPs, chosen by the site. Each site will have a site champion (front-line staff) who will participate in 18 months of EBQI facilitation.

ANALYSIS

We will use a mixed-methods type 3 hybrid Effectiveness-Implementation trial to test EBQI-IC versus EBQI-LC versus usual care using a Concurrent Stepped Wedge design. We will use the Practical, Robust Implementation and Sustainability Model (PRISM) framework to compare and evaluate Reach, Effectiveness, Adoption, Implementation, and costs. We will then assess the maintenance/sustainment and spread of both EBPs in primary care after the 18-month implementation period. Our primary outcome will be Reach, measured by the percentage of eligible high-risk patients who received the EBP.

DISCUSSION

Our study will identify which implementation strategy is most effective overall, and under various contexts, accounting for unique barriers, facilitators, EBP characteristics, and adaptations. Ultimately this study will identify ways for primary care clinics and teams to choose implementation strategies that can improve care and outcomes for patients with complex healthcare needs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05050643. Registered September 9th, 2021, https://clinicaltrials.gov/study/NCT05050643 PROTOCOL VERSION: This protocol is Version 1.0 which was created on 6/3/2020.

Comparing Two Training Modalities Supporting the Adoption of the SEEK Approach in Pediatric Primary Care 6/30/24

OBJECTIVE

To compare the impact of two common continuing medical education training modalities - independent online training (IND) and a Maintenance of Certification-4 activity (MOC) - on primary care professionals' (PCPs') thinking and practice behavior regarding the Safe Environment for Every Kid (SEEK) approach. This was part of an implementation science study scaling up the evidence-based practice, SEEK.

METHODS

This is a longitudinal, multi-site, mixed methods, cluster randomized controlled trial comparing 21 pediatric primary care practices across the U.S. randomized to one of two training modalities. Two hundred and ten PCPs completed surveys up to 4 times over a two-year period to assess their thinking and practice regarding SEEK; a subset was interviewed up to 3 times.

RESULTS

Training led to significant and sustained improvements in PCPs' thinking and behavior related to SEEK, with no significant differences between the IND and MOC groups. PCPs mostly viewed their training positively, but several described shortcomings. PCP characteristics, such as age and sex, did not moderate the impact of the training, nor did the presence of a behavioral health professional.

CONCLUSIONS

The lack of significant differences between the training modalities favors the simpler IND modality. This was despite the MOC training employing key principles of adult education. Of note, MOC-4 credits are required for pediatric board certification. More research is needed to optimize continuing medical education and to tailor approaches for different learners.

Overcoming Barriers: Strategies for Implementing Pharmacist-Led Pharmacogenetic Services in Swiss Clinical Practice

There is growing evidence that pharmacogenetic analysis can improve drug therapy for individual patients. In Switzerland, pharmacists are legally authorized to initiate pharmacogenetic tests. However, pharmacogenetic tests are rarely conducted in Swiss pharmacies. Therefore, we aimed to identify implementation strategies that facilitate the integration of a pharmacist-led pharmacogenetic service into clinical practice. To achieve this, we conducted semi-structured interviews with pharmacists and physicians regarding the implementation process of a pharmacist-led pharmacogenetic service. We utilized the Consolidated Framework for Implementation Research (CFIR) to identify potential facilitators and barriers in the implementation process. Additionally, we employed Expert Recommendations for Implementing Change (ERIC) to identify strategies mentioned in the interviews and used the CFIR-ERIC matching tool to identify additional strategies. We obtained interview responses from nine pharmacists and nine physicians. From these responses, we identified 7 CFIR constructs as facilitators and 12 as barriers. Some of the most commonly mentioned barriers included unclear procedures, lack of cost coverage by health care insurance, insufficient pharmacogenetics knowledge, lack of interprofessional collaboration, communication with the patient, and inadequate e-health technologies. Additionally, we identified 23 implementation strategies mentioned by interviewees using ERIC and 45 potential strategies using the CFIR-ERIC matching tool. In summary, we found that significant barriers hinder the implementation process of this new service. We hope that by highlighting potential implementation strategies, we can advance the integration of a pharmacist-led pharmacogenetic service in Switzerland.

Overcoming barriers to implementation: mapping implementation strategies in four hospital in home programs within the Veterans Health Administration

The Hospital at Home model, called Hospital-in-Home (HIH) in the Department of Veterans Affairs, delivers coordinated, high-value care aligned with older adult and caregiver preferences. Documenting implementation barriers and corresponding strategies to overcome them can address challenges to widespread adoption. To evaluate HIH implementation barriers and identify strategies to address them, we conducted interviews with 8 HIH staff at 4 hospitals between 2010 and 2013. We utilized qualitative directed content analysis guided by the Consolidated Framework for Implementation Research (CFIR) and mapped identified barriers to possible strategies using the CFIR-Expert Recommendations for Implementing Change (ERIC) Matching Tool. We identified 11 barriers spanning 5 CFIR domains. Three implementation strategies - identifying and preparing champions, conducting educational meetings, and capturing and sharing local knowledge - achieved high expert endorsement for each barrier. A mix of strategies targeting resources, organizational readiness and fit, and leadership engagement should be considered to support the sustainability and spread of HIH.

Strategies to Improve Emergency Transitions From Long-Term Care Facilities: A Scoping Review

BACKGROUND AND OBJECTIVES

Older adults residing in residential aged care facilities (RACFs) often experience substandard transitions to emergency departments (EDs) through rationed and delayed ED care. We aimed to identify research describing interventions to improve transitions from RACFs to EDs.

RESEARCH DESIGN AND METHODS

In our scoping review, we included English language articles that (a) examined an intervention to improve transitions from RACF to EDs; and (b) focused on older adults (≥65 years). We employed content analysis. Dy et al.'s Care Transitions Framework was used to assess the contextualization of interventions and measurement of implementation success.

RESULTS

Interventions in 28 studies included geriatric assessment or outreach services (n = 7), standardized documentation forms (n = 6), models of care to improve transitions from RACFs to EDs (n = 6), telehealth services (n = 3), nurse-led care coordination programs (n = 2), acute-care geriatric departments (n = 2), an extended paramedicine program (n = 1), and a web-based referral system (n = 1). Many studies (n = 17) did not define what "improvement" entailed and instead assessed documentation strategies and distal outcomes (e.g., hospital admission rates, length of stay). Few authors reported how they contextualized interventions to align with care environments and/or evaluated implementation success. Few studies included clinician perspectives and no study examined resident- or family/friend caregiver-reported outcomes.

DISCUSSION AND IMPLICATIONS

Mixed or nonsignificant results prevent us from recommending (or discouraging) any interventions. Given the complexity of these transitions and the need to create sustainable improvement strategies, future research should describe strategies used to embed innovations in care contexts and to measure both implementation and intervention success.

Integrating a mental health intervention into PrEP services for South African young women: a human-centred implementation research approach to intervention development

INTRODUCTION

Adolescent girls and young women (AGYW) who may benefit from HIV pre-exposure prophylaxis (PrEP) face high levels of common mental disorders (e.g. depression, anxiety). Common mental disorders can reduce PrEP adherence and increase HIV risk, yet mental health interventions have not been well-integrated into PrEP delivery.

METHODS

We conducted a four-phase human-centred design process, from December 2020 to April 2022, to understand mental health challenges among AGYW in Johannesburg, South Africa and barriers to integrated mental health and PrEP services. In the "Discover" phase, we conducted in-depth interviews with AGYW and key informants (KIs) in Johannesburg. We conducted a rapid qualitative analysis, informed by the Consolidated Framework for Implementation Research (CFIR), to identify facilitators and barriers of integrated mental health and PrEP services and mapped barriers to potential implementation strategies. In the "Design" and "Build" phases, we conducted stakeholder workshops to iteratively adapt an evidence-based mental health intervention, the Friendship Bench, and refine implementation strategies for South African PrEP delivery settings. In the "Test" phase, we piloted our adapted Friendship Bench package.

RESULTS

Interviews with 70 Discover phase participants (48 AGYW, 22 KIs) revealed the importance of integrated mental health and PrEP services for South African AGYW. Interviewees described barriers and implementation strategies for mental health and PrEP services around the CFIR domains: intervention characteristics (e.g. challenges with AGYW "opening up"); outer Johannesburg setting (e.g. community stigma); inner clinic setting (e.g. judgemental healthcare providers); characteristics of counsellors (e.g. training gaps); and the implementation process (e.g. need for demand creation). The Design and Build workshops included 13 AGYW and 15 KIs. Implementation barriers related to the quality and accessibility of public-sector clinic services, lay counsellor training, and community education and demand creation activities were prioritized. This led to 12 key Friendship Bench adaptations and the specification of 10 implementation strategies that were acceptable and feasible in initial pilot testing with three AGYW.

CONCLUSIONS

Using a human-centred approach, we identified determinants and potential solutions for integrating mental health interventions within PrEP services for South African AGYW. This design process centred stakeholders' perspectives, enabling rapid development of an adapted Friendship Bench intervention implementation package.

Optimizing implementation: elucidating the role of behavior change techniques and corresponding strategies on determinants and implementation performance: a cross-sectional study

INTRODUCTION

Behavior change techniques (BCTs) are considered as active components of implementation strategies, influencing determinants and, ultimately, implementation performance. In our previous Delphi study, experts formulated 'implementation hypotheses', detailing how specific combinations of BCTs and strategies (referred to as BCT-strategy combinations) might influence determinants and guideline implementation within youth care. For example, educational meetings providing instructions on guideline use were hypothesized to enhance practitioners' knowledge and, consequently, guideline implementation. However, these hypotheses have not been verified in practice yet.

METHOD

We conducted a cross-sectional study involving practitioners and management professionals from youth (health)care organizations. Using questionnaires, we obtained data on the presence of BCT-strategy combinations and their perceived influence on determinants and implementation performance. Chi-squared tests and regression analyses were employed to determine the influence of specific BCT-strategy combinations on determinants and implementation performance.

RESULTS

Our analyses included data from 104 practitioners and 34 management professionals. Most of the management professionals indicated that the BCT-strategy combinations positively influenced or had the potential to influence their implementation performance. At the practitioner level, half of the combinations were perceived to have a positive influence on determinants and implementation performance. Furthermore, practitioners who reported the absence of BCT-strategy combinations were more skeptical about their potential influence on determinants and implementation performance.

CONCLUSION

Several BCT-strategy combinations were perceived to improve or potentially improve implementation performance of both practitioners and management professionals. In the development and evaluation of implementation efforts, we advocate for clearly describing the implementation effort's objective and using frameworks that detail the BCTs inducing behavior change, the strategy employed, and the processes driving the observed changes. Understanding these interconnected processes is important in designing targeted, evidence-based behavior change interventions. This understanding optimizes resource allocation and contributes to the overall success of implementation efforts in youth care.

Implementation of Complex Suicide Prevention Interventions: Insights into Barriers, Facilitators and Lessons Learned

INTRODUCTION

Effective suicide prevention interventions are infrequently translated into practice and policy. One way to bridge this gap is to understand the influence of theoretical determinants on intervention delivery, adoption, and sustainment and lessons learned. This study aimed to examine barriers, facilitators and lessons learned from implementing complex suicide prevention interventions across the world.

METHODS AND MATERIALS

This study was a secondary analysis of a systematic review of complex suicide prevention interventions, following updated PRISMA guidelines. English published records and grey literature between 1990 and 2022 were searched on PubMed, CINAHL, PsycINFO, ProQuest, SCOPUS and CENTRAL. Related reports were organized into clusters. Data was extracted from clusters of reports on interventions and were mapped using the updated Consolidated Framework for Implementation Research.

RESULTS

The most frequently-reported barriers were reported within the intervention setting and were related to the perceived appropriateness of interventions within settings; shared norms, beliefs; and maintaining formal and informal networks and connections. The most frequently reported facilitators concerned individuals' motivation, capability/capacity, and felt need. Lessons learned focused on the importance of tailoring the intervention, responding to contextual needs and the importance of community engagement throughout the process.

CONCLUSION

This study emphasizes the importance of documenting and analyzing important influences on implementation. The complex interplay between the contextual determinants and implementation is discussed. These findings contribute to a better understanding of barriers and facilitators salient for implementation of complex suicide prevention interventions.

Designing strategies to support Implementation of iNtensive Therapy for Early Reach through PLAY (INTERPLAY) for young children with cerebral palsy: a study protocol

BACKGROUND

Intensive manual therapy is important for improving lifelong upper limb motor outcomes for infants and toddlers with cerebral palsy. This play-based therapy is delivered by caregivers who are coached by occupational therapists. However, access to this therapy is very limited for Canadian children with cerebral palsy younger than two years old. This project aims to first identify barriers and facilitators and then design implementation strategies to support early intensive manual therapy delivery for infants and toddlers with cerebral palsy across Canada.

METHODS

A mixed-methods sequential explanatory design will be used with four consecutive phases. The updated Consolidated Framework for Implementation Research will guide the study. Quantitative data will be collected from a survey in Phase One. Participants will be recruited from three groups: (1) Caregivers of children with cerebral palsy six years old and younger who are eligible for manual therapy; (2) occupational therapists who treat children with cerebral palsy; and (3) healthcare administrators or people responsible for managing pediatric occupational therapy programs. In Phase Two, quantitative data from the survey will be used to map to implementation strategies known to be effective at addressing the identified modifiable barriers and facilitators. Phase Three will collect qualitative data from semi-structured interviews for the purpose of explaining Phase One quantitative findings in greater depth, and for understanding the appropriateness of strategies identified in Phase Two. The participant recruitment strategy and interview guide content for Phase Three will be informed by results of Phase One. Phase Four will use a modified nominal group technique to refine and prioritize an implementation strategy toolbox. Results will be widely disseminated to knowledge users to provide them with tailorable strategies to increase delivery of early intensive manual interventions.

DISCUSSION

This study will provide a comprehensive understanding of the barriers and facilitators to implementation of early intensive manual therapy for young children with cerebral palsy in Canada. A toolbox of evidence-based and tailorable implementation strategies will be disseminated nationally to support uptake of early intensive manual therapy into clinical practice for young children with cerebral palsy.

A streamlined approach to classifying and tailoring implementation strategies: recommendations to speed the translation of research to practice

BACKGROUND

Implementation science emerged from the recognized need to speed the translation of effective interventions into practice. In the US, the science has evolved to place an ever-increasing focus on implementation strategies. The long list of implementation strategies, terminology used to name strategies, and time required to tailor strategies all may contribute to delays in translating evidence-based interventions (EBIs) into practice. To speed EBI translation, we propose a streamlined approach to classifying and tailoring implementation strategies.

MAIN TEXT

A multidisciplinary team of eight scholars conducted an exercise to sort the Expert Recommendations for Implementing Change (ERIC) strategies into three classes: implementation processes (n = 25), capacity-building strategies (n = 20), and integration strategies (n = 28). Implementation processes comprise best practices that apply across EBIs and throughout the phases of implementation from exploration through sustainment (e.g., conduct local needs assessment). Capacity-building strategies target either general or EBI-specific knowledge and skills (e.g., conduct educational meetings). Integration strategies include "methods and techniques" that target barriers or facilitators to implementation of a specific EBI beyond those targeted by capacity building. Building on these three classes, the team collaboratively developed recommendations for a pragmatic, five-step approach that begins with the implementation processes and capacity-building strategies practice-settings are already using prior to tailoring integration strategies. A case study is provided to illustrate use of the five-step approach to tailor the strategies needed to implement a transitional care intervention in skilled nursing facilities.

CONCLUSIONS

Our proposed approach streamlines the formative work required prior to implementing an EBI by building on practice partner preferences, expertise, and infrastructure while also making the most of prior research findings.

Integrating design thinking and implementation science principles in delivering a medication review service in the community pharmacy setting-An implementation testing study

BACKGROUND

Medication review (MR) services are evidenced-based practices in which a systematic assessment of a patient's medication is conducted, primarily aiming to optimize drug therapy and minimize adverse drug events through pharmacist interventions. Although studies show that MR services are effective, the implementation of MR services in Malaysia has been challenging due to several barriers. An MR services blueprint was developed to be adapted to the Malaysian community pharmacy setting as part of tailoring strategies.

OBJECTIVE

Through utilizing the design thinking triple diamond model and implementation science principles, a powerful guide for healthcare researchers and stakeholders to assist with effective service implementation, this study aimed to evaluate the implementation testing and observe the effectiveness of the developed MR service blueprint.

METHOD

The study utilizes an effectiveness-implementation Type 3 hybrid implementation science framework conducted from May 2021 to April 2022. Employing a qualitative ethnographic approach, researchers observed pharmacy study sites during the implementation of MR services. Both qualitative and quantitative data were collected across exploration, preparation, testing, and operational phases. Implementation outcomes evaluated include phases, reach, fidelity, acceptability, as well as implementation barriers and strategies. MR intervention outcomes included service characteristics and the number and type of drug-related problems and interventions offered.

RESULTS

17 community pharmacists were invited to pilot the MR service blueprint for six months in their setting. Of this, 78.5% (n = 11) of the pharmacies reached the testing phase, and 36% (n = 4) reached the implementation phase. Fifty-four patients were in the study, giving an implementation reach of 70%. The majority of surveyed patients expressed satisfaction with the service. The total DRP identified was 133, and 64 interventions were provided by the pharmacists. Facilitation strategies such as "Engage stakeholders by creating ownership of the change" and "Equip stakeholders with training" are needed to overcome the barriers.

CONCLUSION

This study marked the beginning of successful MR service implementation at Malaysian community pharmacies. Future studies with multi-level partnered strategies are required to reach full implementation and sustainability.

Evaluation of a multifaceted implementation strategy for semi-automated surveillance of surgical site infections after total hip or knee arthroplasty: a multicentre pilot study in the Netherlands

INTRODUCTION

To promote the nation-wide implementation of semi-automated surveillance (AS) of surgical site infection after hip and knee arthroplasty, the Dutch National Institute for Public Health and the Environment (RIVM) deployed a decentralised multifaceted implementation strategy. This strategy consisted of a protocol specifying minimum requirements for an AS system, supported by a user manual, education module, individual guidance for hospitals and user-group meetings. This study describes an effect evaluation and process evaluation of the implementation strategy for AS in five frontrunner hospitals.

METHODS

To evaluate the effect of the implementation strategy, the achieved phase of implementation was determined in each frontrunner hospital at the end of the study period. The process evaluation consisted of (1) an evaluation of the feasibility of strategy elements, (2) an evaluation of barriers and facilitators for implementation and (3) an evaluation of the workload for implementation. Interviews were performed as a basis for a subsequent survey quantifying the results regarding the feasibility as well as barriers and facilitators. Workload was self-monitored per profession. Qualitative data were analysed using a framework analysis, whereas quantitative data were analysed descriptively.

RESULTS

One hospital finished the complete implementation process in 240 person-hours. Overall, the elements of the implementation strategy were often used, positively received and overall, the strategy was rated effective and feasible. During the implementation process, participants perceived the relative advantage of AS and had sufficient knowledge about AS. However, barriers regarding complexity of AS data extraction, data-infrastructure, and validation, lack of capacity and motivation at the IT department, and difficulties with assigning roles and responsibilities were experienced.

CONCLUSION

A decentralised multifaceted implementation strategy is suitable for the implementation of AS in hospitals. Effective local project management, including clear project leadership and ownership, obtaining commitment of higher management levels, active involvement of stakeholders, and appropriate allocation of roles and responsibilities is important for successful implementation and should be facilitated by the implementation strategy. Sufficient knowledge about AS, its requirements and the implementation process should be available among stakeholders by e.g. an education module. Furthermore, exchange of knowledge and experiences between hospitals should be encouraged in user-group meetings.

Gastroenterologist and surgeon perceptions of recommendations for optimal endoscopic localization of colorectal neoplasms

National consensus recommendations have recently been developed to standardize colorectal tumour localization and documentation during colonoscopy. In this qualitative semi-structured interview study, we identified and contrast the perceived barriers and facilitators to using these new recommendations according to gastroenterologists and surgeons in a large central Canadian city. Interviews were analyzed according to the Consolidated Framework for Implementation Research (CFIR) through directed content analysis. Solutions were categorized using the Expert Recommendations for Implementing Change (ERIC) framework. Eleven gastroenterologists and ten surgeons participated. Both specialty groups felt that the new recommendations were clearly written, adequately addressed current care practice tensions, and offered a relative advantage versus existing practices. The new recommendations appeared appropriately complex, applicable to most participants, and could be trialed and adapted prior to full implementation. Major barriers included a lack of relevant external or internal organizational incentives, non-existing formal feedback processes, and a lack of individual familiarity with the evidence behind some recommendations. With application of the ERIC framework, common barriers could be addressed through accessing new funding, altering incentive structures, changing record systems, educational interventions, identifying champions, promoting adaptability, and employing audit/feedback processes. Future research is needed to test strategies for feasibility and effectiveness.

Ultrasound in Cardiopulmonary Arrest and Resuscitation: Constructing Comprehensive Implementation Frameworks in High-Risk Settings

OBJECTIVES

Information obtained from point-of-care ultrasound during cardiopulmonary arrest and resuscitation (POCUS-CA) can be used to identify underlying pathophysiology and provide life-sustaining interventions. However, integration of POCUS-CA into resuscitation care is inconsistent. We used expert consensus building methodology to help identify discrete barriers to clinical integration. We subsequently applied implementation science frameworks to generate generalizable strategies to overcome these barriers.

MEASURES AND MAIN RESULTS

Two multidisciplinary expert working groups used KJ Reverse-Merlin consensus building method to identify and characterize barriers contributing to failed POCUS-CA utilization in a hypothetical future state. Identified barriers were organized into affinity groups. The Center for Implementation Research (CFIR) framework and Expert Recommendations for Implementing Change (CFIR-ERIC) tool were used to identify strategies to guide POCUS-US implementation.

RESULTS

Sixteen multidisciplinary resuscitation content experts participated in the working groups and identified individual barriers, consolidated into 19 unique affinity groups that mapped 12 separate CFIR constructs, representing all 5 CFIR domains. The CFIR-ERIC tool identified the following strategies as most impactful to address barriers described in the affinity groups: identify and prepare champions, conduct local needs assessment, conduct local consensus discussions, and conduct educational meetings.

CONCLUSIONS

KJ Reverse-Merlin consensus building identified multiple barriers to implementing POCUS-CA. Implementation science methodologies identified and prioritized strategies to overcome barriers and guide POCUS-CA implementation across diverse clinical settings.