Implementation science communications最新文献

Background: Team-based rheumatology care, with rheumatologists and interdisciplinary health professionals (IHPs) working collaboratively, is a promising solution to improve service capacity and patient outcomes. However, increasing the number of team members does not mean a team successfully improves care quality. We sought to identify the key ingredients of a successful team-based rheumatology model to inform spread and scale of effective team-based rheumatology care.

Methods: Informed by implementation science frameworks, we used a case study approach to construct the program theory of a leading example of team-based rheumatology care in Ontario, Canada. We completed semi-structured interviews (patients [n = 15], health professionals [n = 11]), naturalistic observations (n = 3), and document reviews. We conducted framework analysis and iteratively developed an Implementation Research Logic Model, linking determinants of optimal team-based rheumatology care to implementation strategies, mechanisms of action, and outcomes.

Results: Diverse skill sets of team members enabled comprehensive, person-centered care. IHPs assumed expanded responsibilities, engaging in all aspects of rheumatology care, increasing care capacity and timely access. Training and mentorship were essential for IHP skill development to implement expanded responsibilities at the highest professional scope. Continuous evaluation and adaptations of the model were essential to address evolving care needs. Stable funding was critical for initiation and sustainability.

Conclusion: Successful team-based rheumatology care involves a patient-centered, adaptable care model supported by sustainable funding, skilled workforce, strong leadership and continuous evaluation. By identifying key components and understanding how they achieve their impact, we have gained valuable insights to inform implementation, spread, and scale of such models.

Introduction: Single site quasi-experimental implementation studies provide opportunities to learn about implementation in context. There is limited guidance on how to best utilise these studies to maximise opportunities for learning at scale. This study evaluated the use of a consensus process to develop and implement standardised perioperative pathways, and aimed to provide practical insights on conducting rigorous, theory-informed evaluations that can generate transferable insights for implementation science.

Methods: A multi-method quasi-experimental study was conducted in a private hospital in Australia. Six consensus-based surgical care pathways were developed and implemented by different clinical teams, following a four-stage implementation process using the Exploration, Preparation, Implementation and Sustainment (EPIS) framework. Implementation outcomes were explored through participant observations (16 h) and semi-structured interviews (n = 9), which were analysed thematically using an interpretive descriptive approach. Normalisation Process Theory (NPT) was then applied to understand the mechanisms of change in greater depth. Pathway fidelity was assessed via medical record audits from a random patient sample (n = 90) from four surgical cohorts.

Results: Implementing standardised perioperative pathways using a multi-faceted consensus-based implementation plan was perceived as acceptable, appropriate, and feasible. However, fidelity to clinical actions improved in only two of four surgical cohorts. Implementation was operationalised through the four generative mechanisms of NPT and was influenced by factors that related to all four constructs and 12/16 elements of the EPIS framework. Factors relating to the Inner Context and the Innovation were most frequently identified as having a greater influence on implementation across all EPIS phases. The implementation plan targeted Collective Action and Coherence to a greater extent than other mechanisms. Participants linked greater uptake and implementation to the importance of co-designing implementation strategies with frontline staff (improving Legitimation and Coherence) and tailoring strategies to specific disciplines.

Conclusions: This project provides a practical case study for how to undertake theory-informed, implementation evaluations in real-world contexts. It offers valuable insights for others seeking to operationalise implementation science principles in everyday healthcare settings including how individual strategies may work to drive local change.

Background: Implementing the evidence-based Individual Placement and Support (IPS) model in welfare states like Sweden faces contextual challenges that often necessitate local adaptations to enhance fit and effectiveness. While fidelity assessments aim to ensure effective outcomes, adaptations may lead to unintended drift from core components. The Model for Adaptation Design and Impact (MADI) help analyse the characteristics of adaptations and their ripple effects. This study explores the interplay between implementation, adaptations and fidelity in mental health services using the MADI framework.

Methods: An embedded case study design was used, involving five mental health services in a major Swedish city. Data from 26 key informants, field notes, and meeting protocols were analysed using content analysis and interpreted through the MADI framework.

Results: The adaptations were both planned and unplanned, some adaptations supported the integration of IPS and others negatively impacted core components, revealing unintended impacts on implementation and intervention outcomes.

Conclusions: To understand adaptations and its pathways when implementing IPS in mental health services, and other stakeholders, the MADI framework is valuable. Excessive adaptations can compromise core values and fidelity assessments must account for adaptations and their consequences. To ensure IPS remains effective, some practices within mental health services and other organisations may need to be revised or adapt to the method itself to support IPS implementation and outcomes. The findings offer valuable insights for professionals and user organisations adopting evidence-based practices in mental health services.

Background: Adaptations are expected when complex public health interventions are implemented in dynamically and rapidly changing real-world settings. Systematic documentation of adaptations to intervention components and strategies are critical when assessing their impact on implementation. The purpose of this paper is to describe our approach to systematically tracking, documenting, and evaluating adaptations made during the CO-CREATE-Ex project, which aimed to address COVID-19 testing disparities in the San Ysidro US/Mexico border community.

Methods: The study utilized a longitudinal, prospective, multi- method approach to systematically document and assess adaptations across the pre-implementation, early and mid/late-implementation, and maintenance phases of the project. Adaptations were aggregated from a combination of sources (i.e., meeting notes, Advisory Board transcripts, and periodic reflections). Adaptations were entered weekly into an electronic database that captured information on 16 characteristics and were validated by study staff. Descriptive statistics were used to describe adaptation characteristics. Adaptation impact was evaluated using a combination of objective and subjective measures aligned with the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) outcomes.

Results: Eighty-four unique adaptations were included in this analysis. Adaptations were organized by study phase with most occurring during pre-implementation. Most adaptations (n = 79, 94.04%) were planned (i.e., proactive) and expected (n = 63, 75%), and (n = 21, 25.0%) adaptations were considered unexpected (e.g., reactive). Across all adaptations, 71.2% were perceived as positive (i.e., had a positive impact on RE-AIM implementation outcomes) and 19.1% were perceived to be negative (i.e., worsened implementation outcome or decreased implementation). Unexpected adaptations, though reactive in nature, generally had a positive impact on implementation outcomes. For instance, 14.3% of unexpected adaptations were perceived to increase reach and effectiveness. Within maintenance, 19% of unexpected adaptations were perceived to increase this outcome. Lastly, adaptations were generally small in scope with less than a tenth of adaptations affecting 50% or more of core elements.

Conclusion: Our systematic approach to documenting and analyzing adaptations has highlighted the importance of understanding the impact of adaptations on implementation outcomes. These insights underscore the need for continued research to refine methods for adaptation documentation and impact evaluation, ensuring interventions remain effective, equitable, and responsive to real-world challenges.

Trial registration: ClinicalTrials.gov, NCT05894655, Registered 8 June 2023.

Background: Clinical champions can be effective for increasing uptake of evidence-based interventions. However, little is known about how to prepare them to be impactful, particularly within large healthcare systems. We present a conceptual model, grounded in the Awareness, Desire, Knowledge, Ability, Reinforcement (ADKAR®) change management framework, to guide training for clinical champions.

Methods: In 2021, the U.S. Department of Veterans Affairs implemented clinical champions in primary care and mental health services to facilitate uptake of Whole Health, a person-centered holistic approach to healthcare. Our conceptual model was created through iterative team discussions about learnings from our evaluation of Whole Health clinical champion implementation. This evaluation included two rounds of interviews with clinical champions, and three rounds of a practice reflection survey (aligned with ADKAR) administered to champions.

Results: Drawing on these data and ADKAR, we developed a conceptual model of how clinical champions can be supported through two complementary and sequential change management processes. The first process is related to their practice change. Clinical champions must start by gaining awareness of and interest in the new practice. They can then develop foundational knowledge and skills to enact it. Finally, they will only maintain the practice if they observe benefits of its use. Once they have progressed through the ADKAR stages in relation to the practice change, the second process they must undertake is in relation to the clinical champion role. They must first understand why clinical champions are needed and have an interest in the role. They then need training and skills for the role (e.g., overcoming barriers, mentorship). Finally, to continue the role over time they must see that champions are making a difference. Only after champions have gone through both processes can they effectively support their colleagues in progressing through the ADKAR stages to implement the change in their practice.

Conclusions: Given that clinical champions are a widely used implementation strategy, this work holds promise for improving its impact on implementation and effectiveness outcomes. By supporting tailoring training to where champions are in the change management processes, our data-driven conceptual model can improve champions' effectiveness as change agents.

Objective: The Clinical Sustainability Assessment Tool (CSAT) is designed to capture determinants of sustainable clinical practices over time. Although the full 49-item CSAT instrument has demonstrated strong psychometric properties, the 21-item short form has had limited evaluation. This study aimed to assess the CSAT short form (CSAT Short) across different respondent characteristics and care delivery settings.

Methods: We evaluated the CSAT Short in a sample of healthcare personnel (N = 256 respondents) drawn from across three hybrid effectiveness-implementation studies in a research consortium, all of which tested routine symptom surveillance and integration of symptom management interventions in ambulatory oncology care settings in the US. Confirmatory factor analyses (CFA) and mIRT were conducted to assess the CSAT Short's fit to the hypothesized factor structure. Multiple-group CFA was used to test for measurement invariance across groups of respondents with different professional roles, years in current role, and different work settings.

Results: The hypothesized seven factor structure of the CSAT Short exhibited good fit to the data and strong internal consistency in our sample of healthcare personnel drawn from across three large pragmatic trials (CFI = .99,TLI = .98,X²(182) = 658.99,p < .001;SRMR = .031,RMSEA = .10). Tests of measurement invariance indicated the respondent's role in the clinical setting (i.e., clinician vs. non-clinician) and years in current role (< 10 years vs. ≥10 years) were invariant. However, significant variance was found between respondents from three different Research Centers within the IMPACT consortium. The second-order mIRT model demonstrated acceptable fit based on most indices (M2(56) = 148.69, p < .001; RMSEA = 0.059, 90% CI[0.048, 0.071];SRMSR = 0.057; CFI = 0.917), though the TLI (0.845) was below the recommended threshold. Item-level fit varied, with RMSEA S-X² values indicating six items had acceptable fit, nine items had marginal fit, and five items had poor fit.

Conclusions: The CSAT Short is recommended to assess sustainability in oncology settings, though users should be cautious when comparing scores across different healthcare systems. Tests of invariance were nonsignificant except for variance by Research Center. Despite some items exhibiting suboptimal fit in mIRT, the overall model fit and reliability were strong. This study advances our understanding of sustainability measurement and the applicability of the CSAT Short across implementation settings and respondents.

This critique responds to Eldh et al.'s (Implement Sci Commun 6:113, 2025) commentary on Nilsen et al.'s proposal to distinguish between implementation efficacy and effectiveness along an ideal-to-real-world continuum. While acknowledging the constructive intent of Eldh et al.'s reflections, we clarify that our framework was never intended as a simplistic, one-dimensional model but as a pragmatic heuristic to enhance design transparency. Eldh et al.'s proposed two-axis alternative is conceptually overlapping, as both axes reflect contextual variation rather than independent constructs. Our adaptation of the PRECIS framework - long validated in clinical and health services research - already incorporates multidimensional nuance through distinct domains. We emphasize that the "ideal" end of the continuum denotes highly supported conditions, not normative perfection. Moreover, the proposed "Implementation PRECIS" tool is intended to stimulate integration of contextual transparency and economic evaluation within implementation research. While we concur with Eldh et al.'s emphasis on facilitation, co-production, and contextual complexity, their critique ultimately reinforces our core premise: that explicitly positioning studies along an efficacy-effectiveness spectrum strengthens interpretability, transparency, and real-world relevance in implementation science.

Background: While fidelity is a significant implementation outcome, the balance with adaptation has gained prominence when scaling up evidence-based interventions, to ensure equity in meeting local community needs within the resources available. Before undertaking adaptation of an evidence-based intervention, many fidelity/adaptation frameworks concur with the need to identify intervention 'core components' to facilitate replication. However, how to do this less clear. By creating a 'plug-in' tool, we sought to add value to existing theories, models and frameworks. The aim of this study was to co-design a plug-in tool - Core-FAST (Fidelity and Adaptation for Scaling up Tool)-to facilitate identification of core components when scaling up cancer care.

Methods: We employed a sequential, exploratory, multi-phase qualitative study in the context of cancer care to elicit in-depth perspectives from different collaborator groups: informed consumers (n = 10); cancer clinicians (n = 11); and implementation researchers (n = 11). Following a review of the literature, we used an inductive approach with two sequential activities: 1. Online workshops followed by 2. Tool development and review of Core-FAST. We employed inductive content analysis.

Results: Eight themes were identified from the workshops ranging from core components to warranted variations of these components: 1)Establishing the implementation context; 2) Retaining active ingredients; 3) Patient safety; 4) Compliance with regulatory frameworks; 5) Alignment with organizations policy and regulatory frameworks; 6) Compatibility with local infrastructure; 7) Equity and; 8) Acceptability. A draft version of Core-FAST was developed and following review, the final version comprised of seven questions to ask of each intervention component to identify core components and those open to adaptation.

Conclusions: Core-FAST proposes a pro-active method to prospectively identify which intervention components are non-negotiable, and must be retained, and those amenable to change, to support the equitable scale up and replication of evidence-based interventions. Future research is required to evaluate the extent to which Core-FAST enables efficient adaptation and identification of impact on intervention outcomes. The feasibility of applying Core-FAST to support decision-making should be investigated in further work including the co-design of an accessible version e.g., digital for use in practice.

Background: We implemented a centralized colorectal cancer (CRC) screening program with navigation to follow-up colonoscopy for community health center (CHC) patients with positive stool-based test screening results. Navigation increased six-month colonoscopy completion by 24 percentage points compared with usual care. Here, we describe how we applied a functions and forms framework alongside causal loop diagramming (CLD) to understand the effectiveness of our navigation program and explore its potential for implementation in other settings.

Methods: We first identified barriers to colonoscopy completion in our primarily rural sample and detailed the navigation services provided. Next, we classified our program into core functions (key components contributing to success) and corresponding forms (elements detailing how the functions were carried out and adapted to the local context). To inform classification, we reviewed program documentation (e.g., implementer notes, call logs, and protocol). We refined findings collaboratively in workshops with the navigation team and leadership. We also conducted CLD sessions to document and visualize how the functions addressed the problems affecting colonoscopy completion, refining our list of functions and forms based on these findings.

Results: We identified nine key functions of our navigation program - bridging across patients, providers, and systems; reaching and engaging patients; building rapport and trust; identifying and alleviating concerns; developing readiness and self-efficacy; linking to resources; monitoring progress; enhancing communication; and providing consistent, high-quality navigation services. We documented 29 distinct forms operationalizing these functions within our local context (e.g., motivational interviewing to address barriers and support self-efficacy). We developed a causal loop diagram to explore interactions among the multi-level factors affecting colonoscopy completion and how the navigation program addressed those factors.

Discussion: Organizing functions and forms clarified core elements of success and aspects adaptable for scale-up or replication across different contexts. CLD provided insights into how the functions contributed to the program's success and helped identify additional forms. Findings will guide efforts to translate this navigation model to varied contexts.

Study registration: ClinicalTrials.gov Identifier: NCT04406714.

Background: Regular assessments of Patient Safety Culture (PSC) are recommended by the World Health Organization to strengthen healthcare systems. In Brazil, despite national campaigns, hospital adherence to PSC assessments has remained low. This study aimed to design a tailored implementation strategy to improve the uptake of PSC assessments in Brazilian hospitals, addressing the key barriers faced in previous national efforts.

Methods: We conducted a sequential exploratory mixed-methods study in three phases. First, a qualitative survey with 82 patient safety center coordinators identified perceived barriers and facilitators to implementing PSC assessments. Then, a quantitative survey with 297 coordinators prioritized the most relevant barriers. Finally, we used the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementation Change (ERIC) to guide the design of a tailored implementation strategy aligned with the prioritized barriers.

Results: The main barriers included insufficient dissemination of PSC assessments, lack of training for staff, resistance to completing the survey, the excessive length of the questionnaire, and technical limitations of the data collection platform. The co-design implementation strategy includes 16 actions such as improving communication, offering training, adapting the technology platform, and revising roles and responsibilities within hospitals. These actions were aligned with the identified barriers and aim to enhance organizational readiness, reduce complexity, and promote engagement.

Conclusions: Our findings highlight critical factors limiting the adoption of PSC assessments in Brazil and offer a data-driven, context-sensitive implementation strategy to overcome them. These results provide actionable recommendations for policymakers, healthcare managers, and regulators aiming to strengthen patient safety culture in large-scale, resource-constrained health systems.