BackgroundMost implementation research focuses on understanding and changing health professionals’ work practices. While Patient and Public Involvement and Engagement (PPIE) in applied health research is recognised as best practice, and is often a requirement for funders globally, little is known about the role of patients and the public in implementation research.MethodsGuided by Arksey and O’Malley’s framework, we conducted a scoping review to categorise PPIE in the design and conduct of implementation research, including how patients and the public have been involved, the reported impact of patient and public involvement, and the reported benefits and challenges to involving patients and the public in implementation research. We searched four databases: MEDLINE, Embase, CINAHL, and SCOPUS. To be included, studies had to report some form of PPIE in the design and conduct of implementation research. Information about each study was extracted using a structured data extraction form. Data was collated and summarised.ResultsOf the 535 unique records identified, 12 were included. Analysis of the eligible studies found eight different types of PPIE activities. Researchers mostly consulted with patients and members of the public via feedback sessions, committee representation and roundtable discussions. Barriers and enablers were usually researcher related and their attempts to build, maintain, and negotiate relationships with public contributors over time. Resources and financial remuneration were also key. Most studies (n = 7) reported that engaging community members in the design and implementation of community-based programs and trials enhanced cultural appropriateness, and the likelihood of sustainability. However, there was little formal evaluation of the use of PPIE.ConclusionThis study can be used to design and guide future PPIE in implementation research. Given the inconsistent, and often absent, reporting of PPIE activities and barriers and enablers across the included studies, future studies should describe and evaluate the execution of PPIE in implementation research to advance practices in this field.RegistrationThe review was registered on Research Registry (reviewregistry1552).

BackgroundEvaluating implementation outcomes is gaining momentum in health service delivery organizations. Teams are increasingly recognizing the importance of capturing and learning from their implementation efforts, and Implementation Scientists have published extensively on implementation outcomes. However, Quality Improvement approaches and tools are more widely recognized and routinely used in healthcare to improve processes and outcomes. This article describes the development of an interactive online tool designed to help researchers and practitioners effectively design and develop appropriate evaluation plans that support the understanding of successful implementation.MethodsThere were two main development phases. Phase 1, from January to October 2020, involved several design sessions with a small group of professionals leading implementation initiatives within the provincial health delivery system. This resulted in a testable prototype. Phase 2, from November 2020 to June 2021, focused on usability testing and interviews with a broader group of researchers and professionals leading implementation initiatives across the province.ResultsThe result is the EQUIP (Evaluating QUality and ImPlementation) Tool, an interactive online tool that integrates quality measures from the Alberta Quality Matrix for Health and implementation measures from widely used outcomes frameworks, such as the one developed by Proctor and colleagues and the RE-AIM planning and evaluation framework. The tool encourages users to explore implementation outcomes and quality dimensions from different perspectives and select questions and indicators relevant to their project.ConclusionThe EQUIP tool was designed and refined in collaboration with end users to create an accessible and practical online tool. This work addresses the call for greater integration of Quality Improvement and Implementation Science by combining approaches from both fields to strengthen evaluation processes within the health system.

BackgroundMaternity triage is the emergency portal to access maternity services for pregnant or newly postnatal women experiencing unexpected complications or concerns. Traditionally women were seen in the order in which they attended maternity services without appropriate organisational and clinical systems in place to prioritise the clinical urgency of the women presenting. The Birmingham Symptom-specific Obstetric Triage System (BSOTS) is a standardised triage system co-developed by clinicians and researchers to address this need. Since its inception in 2013, BSOTS is now the recommended triage system and has been widely implemented in the UK with international adoption also occurring. This study aimed to explore the factors influencing the normalisation and sustainment of BSOTS in UK maternity units.MethodsA qualitative evaluation study involving semi-structured interviews with 43 maternity professionals across 9 sites representing a range of implementation experiences (normalised n=3, partially normalised n=3, and probably not normalised n= 3). Participants were maternity triage staff of varying levels including midwives, obstetricians and senior leaders. Interviews were held virtually, and recorded and transcribed verbatim. Analysis was based on Normalisation Process Theory.ResultsContextual factors were key to influencing implementation and sustainment of BSOTS. In sites where BSOTS was normalised and integrated into routine practice, organisational and leadership buy-in helped mobilise support for other contextual factors required for implementation fidelity and success, including establishing a clear identity of the triage department, sufficient midwifery and obstetric staffing, appropriate space, a dedicated and protected core team, adequate equipment and resources. Accommodating these factors often meant complex system-level changes were required to implement BSOTS for which strategic intentions and organisational support were integral. In some cases, such support was facilitated by Care Quality Commission regulatory recommendations.ConclusionsOur study found successful implementation and normalisation of BSOTS was driven by contextual factors, particularly organisational buy-in and leadership support. While regulatory requirements enabled the prioritisation of triage within maternity services, our evaluation emphasised the importance of both leadership and frontline staff support for effective integration and sustainment. Evaluation findings were used to inform an implementation toolkit for clinical triage teams seeking to implement or reinvigorate BSOTS in their sites.

BackgroundThe prevalence of smoking opioids and other unregulated drugs has increased across the United States (U.S.) since 2000. Improved access to safer smoking supplies may reduce the health consequences of inhalation while helping to engage more people who use drugs in syringe services programs (SSPs); however, the landscape of safer smoking supply implementation is understudied.MethodsFrom November 2023–January 2024, we surveyed representatives of U.S. SSPs to assess safer smoking supply implementation across contextual domains of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Descriptive statistics were used to describe determinants across the phases of safer smoking supply implementation. Poisson regression identified factors associated with implementation.ResultsAmong 118 organizations responding to the survey, most received state funding (83%), were community-based organizations (CBOs; 74%), and served urban jurisdictions (62%). The majority (67%) were already providing safer smoking supplies; 16% were exploring implementation and 11% were not. On average, safer smoking supply implementation occurred more recently than the provision of syringes (1–2 years ago vs. > 5 years ago), with participant request being the most common motivation for implementation (84%). Additional facilitators of safer smoking supply implementation were organizational prioritization (65%) and internal leadership support (57%). Factors significantly associated with safer smoking supply implementation included being from the Northeastern or Western regions (vs. the U.S. South), serving exurban communities, being a CBO, receiving foundation funding, receiving private donations from fundraising, and offering syringes and other injection alternatives (e.g., safer snorting supplies). Receiving federal funding, fear of external community opposition, internal leadership opposition, and respondent uncertainty about changing demand for safer smoking supplies (vs. perceiving that demand has not changed) were negatively associated with implementation.ConclusionsDeterminants in the inner context, like organizational prioritization of safer smoking supplies and internal leadership support, may facilitate safer smoking supply implementation, while specific outer context factors (e.g., funding, regional policies) may inhibit implementation. Flexible policies and funding structures and further research to build and disseminate evidence on the benefits of safer smoking supplies are needed to expand the implementation and scale-up of this prevention service within U.S. SSPs.

Variation in perioperative care persists globally. Consensus discussions may facilitate standardisation, yet the processes used to reach agreement are poorly understood. This study aimed to develop a model for conducting local consensus discussions when implementing standardised perioperative pathways. Specifically, we 1) describe how local consensus discussions are operationalised; 2) identify what guides decision making and consensus between clinicians; and 3) formulate explanatory mechanisms and identify determinants that facilitate consensus discussions. A qualitative, modified grounded theory study was conducted in one private hospital in metropolitan Sydney, Australia. Thirty-one participants from clinical disciplines and hospital management/leadership were included. Data were collected from nine semi-structured interviews and 16h of participant observations during consensus development or implementation meetings. Data collection and analysis occurred concurrently until theoretical saturation was achieved. Interviews and field notes were recorded and transcribed verbatim. Data were analysed using coding, constant comparison, detailed memo writing and data interpretation. Seven individual and contextual factors crucial for building consensus, and eight mechanisms for reaching agreement were identified and integrated into a conceptual model. Seeking evidence to support decision-making emerged as the primary driver of consensus. Strong research evidence in support of a pathway component facilitated swift agreement. Where there was ambiguous evidence for a pathway component, clinicians based their decisions on a desire for professional autonomy, consideration of how their peers practice, patient preferences, practices from external organisations, or the feasibility of implementing the pathway component. The Consensus Model for Standardising Healthcare provides a map for healthcare organisations seeking to conduct local consensus discussions to reduce variation in care. Our findings advance our understanding of how local consensus discussions are conducted and factors that impact success when standardising care amongst clinicians.

BackgroundArchetypes are representations of a group of people with shared behaviors, attitudes, and characteristics. The design and use of archetypes have potential application to increase partnership and support when embedding and scaling interventions but methodological approaches have not been developed.ObjectiveTo describe the methodology of designing archetypes for use in a pragmatic trial of advance care planning in the primary care context, SHARING Choices ((NCT04819191). We present resulting archetypes representing three key roles (primary care champion, advance care planning facilitator, and patient) in our pragmatic trial.MethodsOur process for developing archetypes involved 4 steps: 1) Identify roles for archetype development, 2) Identify Shareholders and Data Sources for Archetype Development, 3) Generate unique archetypes and their distinguishing traits, and 4) Iteratively refine archetypes through exposure, scrutiny, and shareholder input. We also developed a process map to communicate our methodology.ResultsWe created 6 distinct archetypes for the primary care champion role, 5 archetypes for the advance care planning facilitator role and 6 archetypes for the patient role. For each archetype we described strengths, challenges, prevailing emotions, and successful approaches to collaboration (e.g., “what works for me”). Unique opportunities for synergy between archetypes (such as with facilitator and champion) and potential challenges between archetypes (such as for facilitator and patient) suggest ways to improve training and support of key roles.DiscussionOur process for creating archetypes for use in implementation research was iterative and informative in discussion of implementation with shareholders. We expect this methodology to be useful for anticipating and analyzing many aspects of implementation.

BackgroundRural School Support Strategies (RS3) is a bundle of implementation supports (including training, technical assistance, and a virtual learning collaborative) designed for the scale-up of universal prevention initiatives. This study addresses mechanisms of action, exploring whether positive effects of RS3 on implementation fidelity are attributable to improvements in functioning of school implementation teams, and increases in organizational readiness.MethodsData are from a cluster-randomized hybrid Type 3 implementation-effectiveness trial of RS3 among rural Idaho schools implementing Positive Behavioral Interventions and Supports (PBIS). Forty public K-12 schools in Idaho, located in rural areas or townships, were recruited for the trial and were equally randomized to either the basic supports condition, including standard trainings, or to the RS3 condition. Condition was not masked. The mechanistic aims were hypothesized prior to the trial and tested with survey data from individuals on each school’s implementation team (n = 205). Surveys were collected in spring 2019 and 2020 regarding organizational readiness and team functioning. The outcome measure was PBIS implementation fidelity, measured by school teams during the summers of 2019 and 2020 using the Tiered Fidelity Inventory. School-level path models tested the effect of RS3 on implementation fidelity, controlling for baseline, school grade level, and school location. Multilevel (2–1-2) mediation models tested the degree to which individual team members’ perceptions of organizational readiness and team functioning mediated the relationship between school-level experimental condition and fidelity, controlling for the team members’ role.ResultsSchools receiving RS3 reported significantly greater implementation fidelity, although effects were slightly reduced (b = 8.40, p = .056, 95% CI [-0.22,17.01], β = 0.54) after inclusion of baseline and demographic controls. Models indicated a significant indirect effect of RS3 on fidelity through increased team productivity (b = 6.30, SE = 2.63, p = .017, MC 95% CI [0.83,13.86], β = 0.21), and effects through organizational readiness, change commitment, team culture, and team goal setting.ConclusionsExternal supports may improve implementation of universal prevention initiatives in rural schools through improvements in readiness and fostering teaming in organizations.Trial registrationThis research was prospectively registered on ClinicalTrials.gov (NCT03736395), on November 9, 2018.

BackgroundStudies have demonstrated that standardizing labor induction (IOL), often with the use of protocols, may reduce racial inequities in obstetrics. IOL protocols are complex, multi-component interventions. To target identified implementation barriers, audit and feedback (A&F) was selected as an implementation strategy. Here, we aimed to understand the acceptability and effect of A&F on fidelity to this complex intervention through quantitative and qualitative approaches.MethodsThis secondary analysis of a type I hybrid effectiveness-implementation trial (10/2018–12/2022) compared 2 years before (PRE) to 2 years after (POST) implementation of an IOL protocol at two sites. Fidelity to each of 8 specific protocol components was collected via chart review. During the POST period, unit-aggregated A&F reports were distributed via email every 3 months to site clinicians. Reports tracked fidelity to protocol components over time. For this analysis, we compared component fidelity PRE to POST-implementation. Additionally, during the POST period, we compared fidelity by month after each A&F (Month#1 v. Month#2/3) to evaluate the effect of A&F over time. Acceptability of A&F reports was evaluated using qualitative interviews.Results8509 labor inductions were included (PRE = 4214, POST = 4295). A&F reports were successfully distributed every 3 months for the 2-year POST period. PRE to POST-implementation, fidelity to 4 of the 8 components increased significantly (cervical Foley utilization, latent labor examination frequency, amniotomy timing, and intrauterine pressure catheter utilization), without change in the other 4 components. For 2 of those 4 components where improvement was noted, there was no difference in fidelity by month after A&F report; rather, there was sustained improvement across the POST-implementation period. On the other hand, for the remaining 2 components, fidelity peaked in the first month after each A&F report, with some decline in the following 2 months prior to the next A&F report. Qualitative analysis (n = 24) supported A&F acceptability, with A&F described as “motivating” and “helpful.”ConclusionsA&F was an effective implementation strategy to promote fidelity to certain components of this labor induction protocol. With some decline in effect after the first month POST-A&F report, increased A&F frequency should be considered in future work targeting obstetric outcomes, as well as health inequities.

BackgroundAll for Them is a theory-based and evidence-informed multilevel, multicomponent program delivered through schools to increase HPV vaccination among medically underserved youth across Texas. Given the potential logistical challenges of program implementation, understanding how to best support the implementation and sustainment of the program is critical. The overall goals of this study are twofold: 1) develop a multifaceted implementation strategy, Implementing All for Them (IM-AFT); and 2) evaluate the impact of IM-AFT on implementation outcomes for schools and healthcare providers to successfully implement All for Them in their respective settings.MethodsThis study is underpinned by a comprehensive and synergistic conceptual framework. We will use Social Cognitive Theory and the Interactive Systems Framework for Dissemination and Implementation to inform important individual and organizational factors to target as part of implementation strategy development. We will use this formative work and Implementation Mapping, a systematic, iterative process that guides the use of theories, models, and frameworks, to develop IM-AFT. The three core aims of the present study are connected to the five tasks of Implementation Mapping. For Aim 1, we will develop IM-AFT using a community-based participatory research-informed approach, including a qualitative assessment of needs and assets associated with program implementation and identification of behavioral and psychosocial objectives to determine implementation outcomes. For Aim 2, we will use a mixed-methods approach to assess user experience with the IM-AFT prototype to test its feasibility, usability, and acceptability. For Aim 3, we will use a descriptive checklist to assess the impact of IM-AFT on user fidelity of program implementation.DiscussionThis paper presents the detailed protocol for developing and evaluating IM-AFT to successfully implement All for Them, leveraging a systematic, community- and theory-based approach and user experience with the strategy prototype. This study will contribute to expanding limited scientific knowledge about using multiple sources to develop and evaluate specified implementation strategies for effective implementation of school-based vaccination programs. Theory-based IM-AFT will guide collaborations between schools and community health centers to improve HPV and other adolescent vaccination rates in underserved communities in Texas.

BackgroundThe Calgary Audit and Feedback Framework (CAFF) is a pragmatic, evidence-based approach for the design and implementation of in-person social learning interventions using Audit and Group Feedback (AGF). This report describes extension of CAFF into the virtual environment as part of a multifaceted intervention bundle to reduce redundant daily laboratory testing in hospitals. We evaluate the process of extending CAFF in the virtual environment and share resulting evidence of participant engagement with planning for practice change.MethodsWe describe an innovative virtually facilitated AGF intervention based on the CAFF. The AGF intervention was part of an intervention bundle which included individual physician laboratory test utilization reports and educational tools to reduce redundant daily laboratory testing in hospitals. We used data from recorded and transcribed virtual AGF sessions, post AGF session surveys and detailed field notes maintained by project team members. We used simple descriptive statistics for quantitative data and analyzed qualitative data according to the elements of CAFF.ResultsEighty-three physicians participated over twelve virtual AGF sessions conducted across four tertiary care hospitals during the study period. We demonstrate that all prerequisite activities for CAFF (relationship building, question choice and data representation) were present in every virtual AGF session. Virtual facilitation was effective in supporting the transition of participants through different steps of CAFF in each session to lead to change talk and planning. All participants contributed to discussion during the AGF sessions. The post AGF session surveys were filled by 66% of participants (55/83), with over 90% of respondents reporting that the session helped them improve practice. 46% of participants (38/83) completed personal commitment to change forms at the end of the sessions.ConclusionsVirtual AGF sessions, developed and implemented with fidelity to the CAFF approach, successfully engaged physicians in a group learning environment that led to change planning. Further studies are needed to determine the generalizability of our findings and to add to the literature on evidence-based virtual facilitation techniques.