Implementation science communications最新文献

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.

Background: Schools have the potential to promote equitable health from early life onwards yet require sufficient organizational capacity to achieve sustained action. Structured improvement approaches, such as PDSA cycles, may help strengthen this capacity by guiding systematic implementation processes. However, their potential in school health promotion remains insufficiently understood, particularly regarding the heterogeneous contextual factors shaping their application. This study examined which contextual determinants shape schools' perceived implementability of the PDSA cycle for health promotion and how these conditions differ across schools.

Methods: Nine German primary schools participating in a holistic health promotion program were purposively sampled to capture heterogeneity across federal states, socioeconomic contexts, and urban-rural settings. Semi-structured qualitative group interviews in a workshop format were conducted with school principals, teachers, and parents and analyzed using the framework method guided by the CFIR. To facilitate cross-case comparison, color-coded valence ratings (facilitator/barrier/mixed) were visualized in a Matrix Heat Map, enabling identification of contextual tendencies.

Results: Fifteen contextual factors emerged across the CFIR domains of Outer Setting, Inner Setting, and Individual. Schools with prior experience using structured processes similar to PDSA cycles reported more facilitators, such as established communication structures, while schools without such experience perceived more barriers, notably financial constraints. Common barriers across schools included limited parental engagement and staff shortages, whereas leadership support and compatibility of program components were consistent facilitators. Some factors interacted dynamically, with resource constraints reinforcing other barriers or with strong mission alignment amplifying engagement.

Conclusion: Schools' prior structured experience seemed to be associated with how they perceived the implementability of PDSA cycles for health promotion implementation, with more experienced schools anticipating more facilitators and fewer barriers. While causality cannot be inferred, these exploratory findings are hypothesis-generating and suggest that prior structured experience may be an important factor to consider for tailoring implementation support and building organizational capacity. Beyond these insights, extending the framework method with a color-coded Matrix Heat Map proved valuable for visualizing contextual heterogeneity and revealing tendencies across cases. This combined approach may inspire further research on how contextual configurations shape the use of structured processes in complex, multi-site implementation settings.

Background: Nearly 300 US municipalities have enacted policies regulating cigar pack size and price to reduce youth access to and use of inexpensive cigars. This study characterizes the policy implementation processes of these local policies and identifies associated barriers and facilitators.

Methods: Between June and November 2023, we conducted 36 semi-structured qualitative interviews with professionals involved in adopting and implementing local cigar regulations. Interview transcripts were coded and thematically analyzed using a template organizing style and iterative immersion-crystallization analysis of coded segments. Themes were categorized using the Inventory of Factors Assessing Successful Implementation and Sustainment determinant framework, encompassing domains such as external factors, internal organizational factors, retailer-specific factors, and policy-specific factors.

Results: Participants described distinct education and enforcement activities post-policy adoption, often managed by separate, autonomous organizations and individuals. Key facilitators identified included state funding (external), interagency collaborations and unofficial capacity-building efforts (internal), and clear, enforceable ordinances with less retailer pushback (policy-specific). Conversely, significant barriers included state-level influences (external), lack of standardized protocols, resource disparities, and varied implementer perspectives (internal). Retailer-specific barriers included limited English proficiency and a willingness to risk violations. Policy-specific challenges involved confusing cigar definitions and insufficient deterrent penalties.

Conclusions: Local cigar policy implementation often involves multiple autonomous organizations and individual implementers. The salience of identified barriers across various contexts may have important implications for policy impact. Understanding the facilitators and barriers to policy implementation may enable other localities to proactively develop strategies to increase success.

Background: Current standards advise starting HIV antiretroviral therapy (ART) as soon as possible with the goal of achieving viral suppression. Applying the domains of a sustainability framework as a roadmap, we examine factors and strategies impacting readiness to sustain Rapid Start ART (RS-ART) across 14 sites participating in a national initiative that successfully implemented this intervention to link people with HIV to initiate ART treatment within seven days after linkage or re-engagement in care. While sustainability entails the ongoing delivery of a previously implemented intervention, factors and strategies for sustaining RS-ART have not been well-defined or studied.

Methods: We conducted one-on-one semi-structured interviews with a purposeful sample of key informants from each of the 14 sites. Data were organized using Dedoose and analyzed using thematic analysis.

Results: We conducted a total of 27 interviews with decision-makers and key staff implementing RS-ART. We identified a continuum across the sites, reflecting three different stages of readiness to sustain RS-ART. "Well-oiled machine" sites had comprehensive sustainability plans in place with RS-ART established as their current standard practice, supported by secured funding and organizational capacity. "On track" sites demonstrated a clear vision toward sustaining RS-ART, with progress contingent on securing funding and finalizing staffing plans. "To be determined" sites faced challenges, expressing uncertainty about obtaining necessary funding and determining sufficient human resources to sustain RS-ART. While feasibility and acceptability of RS-ART, driven by improved service and patient outcomes, were high across all sites, available funding and the necessary human resources were the two critical, interrelated factors impacting readiness to sustain RS-ART.

Conclusions: Sites positioned to sustain RS-ART were able to secure funding for the necessary staff positions to effectively integrate it as standard of care. Future funding of HIV care programs must provide sufficient resources for all individuals to be offered RS-ART services to improve life expectancy, manage HIV as a chronic disease and prevent transmission to others. Given the dynamic nature of sustainability, future longitudinal studies are needed to evaluate RS-ART sustainability outcomes and its long-term effectiveness after it has been sustained.