Implementation Science volume 8, Article number: 139 (2013) Cite this article Show
AbstractImplementation strategies have unparalleled importance in implementation science, as they constitute the ‘how to’ component of changing healthcare practice. Yet, implementation researchers and other stakeholders are not able to fully utilize the findings of studies focusing on implementation strategies because they are often inconsistently labelled and poorly described, are rarely justified theoretically, lack operational definitions or manuals to guide their use, and are part of ‘packaged’ approaches whose specific elements are poorly understood. We address the challenges of specifying and reporting implementation strategies encountered by researchers who design, conduct, and report research on implementation strategies. Specifically, we propose guidelines for naming, defining, and operationalizing implementation strategies in terms of seven dimensions: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification. Ultimately, implementation strategies cannot be used in practice or tested in research without a full description of their components and how they should be used. As with all intervention research, their descriptions must be precise enough to enable measurement and ‘reproducibility.’ We propose these recommendations to improve the reporting of implementation strategies in research studies and to stimulate further identification of elements pertinent to implementation strategies that should be included in reporting guidelines for implementation strategies. Peer Review reports The need for better specification and reporting of implementation strategiesImplementation strategies have unparalleled importance in implementation science, as they constitute the ‘how to’ component of changing healthcare practice. Comprising the specific means or methods for adopting and sustaining interventions[1], implementation strategies are recognized as necessary for realizing the public health benefits of evidence-based care[2]. Accordingly, developing strategies to overcome barriers and increase the pace and effectiveness of implementation is a high research priority[3–7]. While the evidence for particular implementation strategies is increasing[8], limitations in their specification pose serious problems that thwart their testing and hence the development of an evidence-base for their efficiency, cost, and effectiveness. Implementation strategies are often inconsistently labelled and poorly described[9], are rarely justified theoretically[10, 11], lack operational definitions or manuals to guide their use, and are part of ‘packaged’ approaches whose specific elements are poorly understood[12]. The literature on implementation has been characterized as a ‘Tower of Babel’[13], which makes it difficult to search for empirical studies of implementation strategies, and to compare the effects of different implementation strategies through meta-analyses[9]. Worse yet, the lack of clarity and depth in the description of implementation strategies within the published literature precludes replication in both research and practice. As with all intervention research, implementation strategies need to be fully and precisely described, in detail sufficient to enable measurement and ‘reproducibility’[14] of their components. The purpose of this article is to provide guidance to researchers who are designing, conducting, and reporting studies by proposing specific standards for characterizing implementation strategies in sufficient detail. We begin by providing a brief introduction to implementation strategies, including how the broad term has been defined as well as some examples of implementation strategies. Thereafter we suggest an extension of existing reporting guidelines that provides direction to researchers with regard to naming, clearly describing, and operationalizing implementation strategies. Definitions and examples of implementation strategiesImplementation strategies can be defined as methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice[15]. A growing literature on implementation strategies provides a window into their type, range, and nature. They include ‘top down/bottom up,’ ‘push/pull,’ and ‘carrot/stick’ tactics, and typically involve ‘package’ approaches[16]. They include methods for provider training and decision support; intervention-specific tool kits, checklists, and algorithms; formal practice protocols and guidelines; learning collaboratives, business strategies and organizational interventions from management science (e.g., plan-do-study-act cycles[17] and ‘lean thinking’[18]); and economic, fiscal, and regulatory strategies. The complexity of implementation strategies can vary widely. For instance, some implementation efforts may involve a single component strategy, such as disseminating treatment guidelines in the hopes of changing clinicians’ behavior (e.g., Azocar et al.[19]). These strategies have been referred to as discrete strategies in the literature[20, 21], though they have also been called ‘implementation interventions’[22], ‘actions’[23], and ‘specified activities’[23]. A number of publications provide lists and taxonomies that attempt to reflect the range of these strategies[20, 24–26]. For example, Powell et al.[20] compiled a ‘menu’ of 68 implementation strategies, grouped by six key processes: planning (e.g., conducting a local needs assessment, developing a formal implementation plan), educating (e.g., conduct educational meetings, distribute educational materials), financing (e.g., alter incentive/allowance structures, access new funding), restructuring (e.g., revise professional roles), managing quality (e.g., provide clinical supervision, audit and feedback, reminders), and attending to policy context (e.g., creating or changing credentialing and/or licensure requirements)[20]. Michie et al.[26] focused on a more granular level in their published taxonomy of 93 behavior change techniques (e.g., punishment, prompts/cues, material reward, habit formation, etc.), many of which could be used to further specify implementation strategies as well. Most often a number of strategies are combined to form a multifaceted strategy such as training, consultation, and audit and feedback. There are also a number of manualized and branded multifaceted implementation strategies, such as the ‘ARC’ organizational implementation strategy[27, 28], the Institute for Healthcare Improvement’s learning collaborative[29] and framework for spread models[30], the Getting to Outcomes framework[31], and the Replicating Effective Programs (REP) framework[32, 33]. The REP framework for instance, includes a number of discrete or component implementation strategies across four phases: pre-conditions (e.g., identifying need, identifying barriers), pre-implementation (e.g., developing a community working group), implementation (e.g., training, technical assistance, feedback and refinement), and maintenance and evolution (e.g., re-customize delivery as need arises)[33]. Some authors have simply used the term ‘implementation strategy’ to refer to these multi-faceted implementation strategies comprised of multiple ‘implementation interventions’[15], whereas others have referred to ‘implementation programs’ to be inclusive of all of the component implementation strategies utilized in an implementation effort[34]. We have chosen to use the term ‘implementation strategy’ to be inclusive of both single component and multi-faceted implementation strategies, and we purposefully attempt to avoid the word ‘intervention’ largely to reduce the chance that clinical interventions and implementation interventions be confused[23]. That said, we acknowledge that some interventions can be used as either implementation strategies or interventions in their own right. For instance, the ‘ARC’ intervention[28, 35] was designed as an organizational improvement strategy (i.e., not necessarily as a method of implementing other clinical interventions). A randomized trial of ARC as a ‘standalone’ intervention has shown it to be effective in improving organizational culture, climate, and work attitudes as well as clinical outcomes for youth[27, 36]. However, it also has been used as a strategy to implement a psychosocial intervention (Multisystemic Therapy)[28]. In cases where a strategy may be conceptualized as an improvement intervention in its own right (i.e., independent of the clinical intervention being implemented) it may be useful to employ a 2 x 2 factorial design, in which both the implementation strategy and the clinical intervention are compared independently and in combination to a no treatment control. The complexity of even making the distinction between an implementation strategy and an independent intervention highlights the importance of carefully specifying the strategy in the manner that we describe below, so as to ensure that consumers of the resulting research understand how, when, why, and where the strategy is likely to be effective. As evidenced by many of the examples above, interest has been high and progress has been made in the identification, development, and testing of implementation strategies. However, definitions and descriptions of implementation strategies in the literature often lack the clarity required to interpret study results and build upon the knowledge gained through the replication and extension of the research. This signals the need for more guidance that would assist researchers designing, conducting, and reporting implementation studies. Prerequisites to studying implementation strategies empiricallyThe study of implementation strategies should be approached in a similar fashion as evidence-based interventions (EBIs), for strategies are in fact a type of intervention. Accordingly, their specification carries the same demands as treatment specification: If they are to be scientifically tested, communicated clearly in the literature, and accurately employed in actual healthcare practice, they must be specified both conceptually and operationally[37]. There are a number of prerequisites to the measurement of implementation strategies, many of which are detailed below. They are also listed in Table 1, along with examples, resources, or tools from the literature (when available) for advancing the state of measurement. Table 1 Prerequisites to measuring implementation strategies Full size table The complexity of implementation strategies poses one of the greatest challenges to their clear description, operational definition, and measurement. Implementation strategies are inherently complex social interventions, as they address multifaceted and complicated processes within interpersonal, organizational, and community contexts[12, 56–58]. Implementation strategies must be capable of dealing with the contingencies of various service systems, sectors, of care, and practice settings, as well as the human capital challenge of staff training and support. They must tackle a myriad of barriers to evidence-based care[59, 60] and the various properties of interventions that make them more or less amenable to implementation[52]. All these factors significantly contribute to the challenge of measuring, testing, and effectively employing implementation strategies in actual healthcare practice. We attempt to provide this guidance by discussing fundamental principles for naming, defining, and specifying implementation strategies, all of which are prerequisites to studying them empirically.
Table 2 Specification of two implementation strategies Full size table Existing reporting guidelines and suggested extensionsWe suggest that journals that routinely publish implementation studies could advance knowledge about strategies by formally adopting reporting guidelines and providing them to authors and reviewers. Applying such guidelines not only to implementation trials but also to articles that focus on the intervention being tested would pushing detail about implementation processes in treatment effectiveness trials and thus accelerate our understanding of strategies. This point is underscored by the call for ‘hybrid trials’ that advance knowledge about both the treatment and the implementation[15]. Several existing guidelines are relevant. For instance, Implementation Science and several other journals have embraced the WIDER Recommendations[9, 92], which call for authors to provide detailed descriptions of interventions (and implementation strategies) in published papers, clarify assumed change processes and design principles, provide access to manuals and protocols that provide information about the clinical interventions or implementation strategies, and give detailed descriptions of active control conditions. The Standards for Quality Improvement Reporting Excellence (SQUIRE) suggest that authors provide, among other things, a description of the intervention (in this case implementation strategy) and its component parts in sufficient detail so that others could reproduce it, an indication of the main factors that contributed to the choice of the intervention, and initial plans for how the intervention was to be implemented, including the specific steps to be taken and by whom (i.e., the intended roles, qualifications, and training of staff)[93]. The Equator Network[94] is a repository of reporting guidelines (e.g., CONSORT and STROBE) that can provide guidance to specific research designs and methodologies utilized in implementation research. However, there is a need for the development of a suite of reporting guidelines for different types of implementation research[3]. We build upon and extend existing guidelines by recommending two standards as outlined above. First, all studies of implementation should name and define the implementation strategies used. Linguistic harmony in implementation science will be advanced if authors label or describe implementation strategies using terms that already appear in a published review article, a strategy compilation or taxonomy, or another primary research article. If and when unique language is introduced to characterize a strategy, the authors should provide a rationale for the new terminology and should clarify how the new strategy label is similar to or conceptually different from labels already in the literature. Second, all strategies used should be specified or operationalized. In our view, definition and specification should include each of the seven dimensions outlined above. Ideally, descriptions of implementation strategies should be ‘packaged’ in detailed protocols or manuals describing how a given innovation is to be enacted. These manuals can be considered akin to the kinds of manuals that accompany evidence-based psychotherapies, and could then be published in online supplements and appendices to journal articles. Adopting these guidelines would address many of the current problems that make it difficult to interpret and use findings from implementation research, such as inconsistent labelling, poor descriptions, and unclear justification for specific implementation strategies[9–11, 13]. Specifically, it would facilitate meta-analysis and replication (in both research and practice), and would increase the comparability of implementation strategies by allowing them to be described in similar ways. It would also help to accelerate our understanding of how, why, when, and where they work, and our translation of those findings to real-world improvements in healthcare. We welcome dialogue regarding additional considerations for reporting research on implementation, and acknowledge room for national or international consensus processes that could formalize and extend the guidelines we present here. In the meantime, we hope that these suggestions provide much needed guidance to those endeavouring to advance our understanding of implementation strategies. Authors’ informationEKP directs the Center for Mental Health Services Research at Washington University in St. Louis (NIMH P30 MH085979), the Dissemination and Implementation Research Core (DIRC) of the Washington University Institute of Clinical and Translational Sciences (NCRR UL1RR024992), the Center for Dissemination and Implementation at the Washington University Institute for Public Health, and the Implementation Research Institute (NIMH R25 MH080916). AbbreviationsCFIR: Consolidated framework for implementation research EBIs:Evidence-based interventions NIH:National institutes of health PDSA:Plan-do-study act SQUIRE:Standards for quality improvement reporting excellence. References
Download references AcknowledgementsThe authors acknowledge their colleagues in the practice community who ask important and provocative questions about how to improve care, the kind of questions that simulated this work. Preparation of this paper was supported in part by National Center for Research Resources through the Dissemination and Implementation Research Core of Washington University in St. Louis’ Institute of Clinical and Translational Sciences (NCRR UL1 RR024992); the National Institute of Mental Health through the Center for Mental Health Services Research (NIMH P30 MH068579), the Washington University Center for Diabetes Translation Research (NIDDK/NIH P30 DK092950); the Washington University TREC (Energy Balance and Cancer Across the Lifecourse, NCI/NIH. U54 CA155496); the Implementation Research Institute (NIMH R25 MH080916), and a Ruth L. Kirschstein National Research Service Award (NIMH F31 MH098478); and a Doris Duke Charitable Foundation Fellowship for the Advancement of Child Well-Being. An earlier version of this paper was presented at the Implementation Research Institute on June 20, 2012 at Washington University in St. Louis. Author informationAuthors and Affiliations
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Corresponding authorCorrespondence to Enola K Proctor. Additional informationCompeting interestsThe authors declare that they have no competing interests. Authors’ contributionsEKP conceived the idea for this paper and wrote the initial draft. BJP, JCM, and EKP contributed to the conceptualization and writing of subsequent drafts. All authors read and approved the final manuscript. Rights and permissionsThis article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Reprints and Permissions About this articleCite this articleProctor, E.K., Powell, B.J. & McMillen, J.C. Implementation strategies: recommendations for specifying and reporting. Implementation Sci 8, 139 (2013). https://doi.org/10.1186/1748-5908-8-139 Download citation
Keywords
What is a bestA best-cost provider strategy — giving customers more value for the money by satisfying buyers' expectations on key product attributes (e.g., quality, features, performance, or service) while beating their price expectations.
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