Implementation Science Theories
The ability to successfully implement quality improvement programs in healthcare settings will continue to be an important part of the mission of any healthcare organization. The need for proven methodologies and theoretical constructs on which to base these efforts is therefore imperative. Several robust theories conjointly serve as the foundational pillars for this Implementation Science (IS) system, for example, the Precede/Proceed (Green, Kreuter, Deeds, & Partridge, 1980) and Diffusion of Innovation theories (Rogers, 1962). Other implementation-based theories such as the Simpson TCU treatment model (Simpson, 2004), as well as social marketing theory (Kotler & Zaltman, 1971), examine ways in which both individuals and programs interact together to influence outcomes, such as treatment engagement and health promotion. A more unified IS theory is Greenhalgh's framework (Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou, 2004), which synthesizes previous theoretical and empirical findings on organizational change. According to this view, there are both organizational and individual elements, which relate to effective and sustainable uptake of an innovation or policy directive. In this conception, the innovation to be adopted, the organization, and individual actors each play crucial roles in the successful implementation and sustainability of an innovation. However, these theories can be confusing to the uninitiated, and do not present the most concise and practical approach to adopting implementation-based theories in real-world settings. In addition, some of these theories by themselves are not fully comprehensive, in that some theories focus heavily on formative approaches (e.g., Precede/Proceed) while others focus on the process of implementation through an organization (e.g., Rogers, 1962). In the case where an IS-based theory does offer a more comprehensive understanding of IS (Greenhalgh et al., 2004), the theoretical underpinnings of this model are broad and nonspecific enough that it does not present a practical (nor easy to adopt) working model of conducting real-world implementation of systems or knowledge.
The goal of this paper is to integrate relevant elements of these theories into a simple and parsimonious six-step approach for conducting real-world implementation. We have utilized this practical model to carry out a number of successful implementation-based healthcare quality improvement interventions in a variety of clinical and nonclinical settings. An overview of this model is presented in Table 1.
Table 1. ADAPTS Implementation Science Model
| ||• Gather appropriate information to determine the need and how to best address the need.|
| ||Social diagnosis|
| ||• Identify the need within the environment via quantitative/qualitative data, surveys, interviews, focus groups, archival data, observations, etc.|
| ||• Assess the strengths, weaknesses, resources, readiness/resistance to change.|
| ||Assessment of|
| ||• epidemiological factors—identify the (strongest) healthcare needs among competing priorities.|
| ||• behavioral factors—identify exacerbating/ameliorating behaviors.|
| ||• environmental factors—identify factors that extend beyond the individual that could negatively/positively influence the implementation.|
| ||Assessment of|
| ||• predisposing factors—identify the characteristics endemic to each individual.|
| ||• enabling factors—identify the change-facilitating resources.|
| ||• reinforcing factors—identify the elements that facilitate change sustainment.|
| ||Administrative and policy diagnosis|
| ||• Gather administrative support.|
| ||• Modify/create policies conducive to implementation.|
| || |
|II: Deliverables||Fabricate deliverables|
| ||• Acquire, adapt or create the resources necessary to carry out the implementation based on the findings from the assessment (Step I).|
| ||Implementation guide|
| ||• Document the instructions for carrying out the implementation.|
| || |
| ||• Communicate the identified need (Step I) and expected beneficence of the proposed deliverable (Step II) to the prospective champion.|
| ||• Prospective champion makes a determination to proceed or not based on expected feasibility and advantages/disadvantages of the proposed implementation.|
| || |
|IV: Pretraining||Administrative and policy diagnosis|
| ||• Champion coordinates with administration and relevant departments to lay the groundwork for a successful implementation.|
| ||• Champion may propose new or modified policy to facilitate implementation.|
| ||• Champion engages in social marketing, conferring with front-line staff to promote upcoming intervention and gather feedback.|
| ||• Champion refines the proposed implementation per findings.|
| || |
| ||• Present implementation (change) to staff via briefing/hands-on training.|
| || |
| ||• Champion and colleagues take charge of sustaining the implementation.|
| ||• Champion exhibits exemplary behavior and explicitly encourages others.|
| ||• Implementation team may provide periodic supportive contact, gather performance data, and offer audit feedback reports documenting the effectiveness of the implementation.|
| ||• Champion gathers key opinions and tunes the implementation accordingly.|
| ||• Champion and facility stakeholders decide to continue/modify/abandon the implementation.|
The six-step ADAPTS (Assessment, Deliverables, Activate, Pretraining, Training, Sustainability) model is populated with substeps, facilitating a concisely robust guide for carrying out even the most complex implementations. Admittedly, there is no such thing as a typical implementation; it is advised that you familiarize yourself with each substep of the proposed model and selectively utilize the elements that are best suited to each situation.
Step I: Assessment
The process begins with conducting a comprehensive formative evaluation to determine the nature of what service or resource is needed, which is described in the Precede/Proceed process (Green et al., 1980):
This involves identifying and assessing the need within the selected environment. This is accomplished via a variety of means including gathering and analyzing qualitative/quantitative data, surveys, interviews, focus groups, archival data, observations, etc. The goal is to gain a comprehensive understanding of the strengths, weaknesses, resources, and readiness to change.
This involves determining what specific issues are to be the focus of the intervention based on competing priorities. This might involve standard quality improvement activities, an expressed need, emergence of new technology, etc. The interventional change may also be propagated by administrative factors such as a new or modified policy, staffing changes, or other organizational changes.
This sheds light on specific behaviors that could have a negative or positive impact on the implementation.
Environmental factors involve elements that are beyond the control of any individual person, which (negatively or positively) affect their work. Identifying and resolving environmental roadblocks serves to clear the pathway to improved performance.
Educational and ecological diagnosis
Based on the assessment carried out thus far, the aim is to identify Predisposing Factors, Enabling Factors, and Reinforcing Factors.
Predisposing Factors involve elements endemic to each individual such as knowledge, skills, ethics, beliefs, values, and attitudes.
Enabling Factors are anything that helps to facilitate the change; these may be tangible (e.g., readily available consent forms, supplies) or intangible (e.g., implementing enabling policies, streamlining a process).
Reinforcing Factors consist of anything that helps to sustain the process over the course of time (e.g., resupply protocol for consumables, actively acknowledging quality performance, etc.). As part of these Reinforcing Factors, an additional and important consideration to address is the organizational (or cultural) dynamics necessary to engender positive and sustainable change throughout a facility or organization. This has been addressed in many instances in the IS literature; the main impetus for any behavior change required to sustain a new intervention rests squarely with the identification and long-term engagement with a local champion (see Rogers, 1962; Step III: Activate).
Administrative and policy diagnosis
In order to facilitate a successful implementation, appropriate administrative support must be garnered in the form of resource acquisition, budget allocation, identifying and clearing organizational barriers (e.g., new or modified policy), and coordination with relevant departments.
Step II: Deliverables
Based on the findings of the Assessment, fabricate the Deliverable package. The deliverable may contain a wide variety of media depending on the nature of the implementation. This package may consist of concrete items (e.g., supplies, handouts, promotional/informational pocket cards, buttons, stickers, posters, notepads, pens, etc.), or less tangible yet valuable resources (e.g., training programs, presentations, policies, practice changes, software, etc.). Resources may be acquired, modified, combined, or if necessary, created from scratch.
It is also helpful to construct an Implementation Guide, which serves as written instructions describing how to carry out the implementation. This guide should include details such as the personnel involved, their roles, procedures, resources, policies, and other relevant information (e.g., resupply algorithm, reporting instructions, emergency procedures, training/certification, etc.).
Step III: Activate
Identify and coordinate with a local site champion. Per the Rogers Diffusion of Innovation theory (Rogers, 1962), ideally, the site champion should be a local Opinion Leader. This staff member needs to be someone who is influential in the domain of interest, capable of spreading constructive information about an innovation within the targeted site.
In instances where the implementation is to take place at multiple sites, this site champion may be identified via snowball method; one influential site champion may know of similarly influential colleagues at other sites. The less preferable alternative involves seeking the site champions via (informed) cold-calls.
If the initial introduction is nondirect (e.g., e-mail or other digital messaging, memo), make an effort for the next contact to be more personable (e.g., phone call, video chat, in-person meeting, etc.). This will help to build the rapport and personal alliance to facilitate engagement, interest, and motivation of the potential site champion. As one might intuit, Persuasion and Decision are next (Green et al., 1980).
In the Persuasion process, the goal is to convincingly communicate who you are, the need that you have identified (at the targeted site), the Deliverable package that you have fabricated to address that need, how the proposed implementation will benefit those at the targeted site (e.g., staff, patients), and an overview of how the actual implementation would proceed. It is important to provide the potential site champion with the Implementation Guide, detailing the comprehensive package that they would receive if they were to opt for this implementation.
Realistically acknowledge the potential site champion as the local expert on their facility; solicit their opinion regarding the suitability and quality of the deliverable, and be prepared to customize selected items in your deliverable package. Flexibility and responsiveness to the needs articulated by the potential champion are essential—if the potential site champion sees the deliverable as ill fitting to the unique real-world characteristics of their facility, and efforts to customize the deliverable are unsuccessful, this could adversely affect the persuasive process. Depending on the site, it may be prudent to edit, drop, or create an item. Ultimately, this process may serve to upgrade the (base) fabricated package, which can be useful in multisite implementations. Be prepared to present evidence-based rationale to support the proposed implementation (e.g., efficiency, cost savings, fulfilling gaps in service, etc.).
The Decision process involves the potential site champion contemplating the expected feasibility of the project, ultimately weighing the advantages and disadvantages of adopting (or rejecting) the proposed innovation.
Step IV: Pretraining
Upon reaching this step, the proposed site champion has committed to lead the implementation process at their site. During this step, the implementation team works collaboratively with the site champion to lay the groundwork for the actual implementation. The formative evaluation process progresses per the Precede/Proceed—Administrative and Policy Diagnosis (Green et al., 1980). The site champion coordinates with appropriate administrative staff to accommodate the proposed innovation, addressing the concerns that will facilitate an effective adoption of the intervention. Issues to be addressed may include resource development, budget allocation, policies, staffing, training, and identifying and resolving organizational barriers.
To help facilitate the process, coordinate with the site champion to provide, and if necessary, customize as many of these resources as possible (e.g., model policies, letters of support from key stakeholders, administrative proposal presentation(s), etc.).
Additionally, the site champion may engage in social marketing (Kotler & Zaltman, 1971) in the form of formal/informal peer education, essentially providing a “preview of coming attractions” to help build a fertile basis for the planned change. Such dialogues should highlight the (multiple) benefits reasonably anticipated, and also actively address any concerns that may emerge.
Step V: Training
The initiation of the intervention should optimally involve a presentation at a regularly scheduled staff meeting so as not to interrupt (clinical) duties. A member of the implementation team should present training that provides a cohesive overview of the implementation, detailing the rationale, allocated resources, and new or revised policies and practices; this corresponds to the Implementation phase in Rogers theory. The local site champion may opt to copresent to lend credence to the implementation. Depending on the nature of the implementation, this may take the form of a traditional slideshow presentation with narrative, or in cases where the implementation is more complex, it may be appropriate to provide more formal training(s).
In instances wherein more detailed training or certification is involved, it is recommended that a member of the implementation team deliver the initial trainings and have the site champion sit-in on these session(s) so as to acquire the appropriate skills to carry out future trainings independent of the implementation team. Alternatively, the champion may delegate this training responsibility to a qualified colleague.
When it comes to adopting a new skill, research suggests that experiential (hands-on) learning, which involves seeing and doing (visual and kinesthetic) facilitates better retention compared with passively listening to a traditional lecture (Frankel, 2009; Sternberg & Zhang, 2000).
Per Rogers, after the training, each individual is in the (actual) Implementing phase, wherein s/he will carry out the innovation to a varying degree. During this stage, each individual determines the usefulness of the innovation, and may search for further information about it.
In addition to launch-related activities, an important component to consider is the use of real-time data to support and sustain the implementation activity you are interested in. This type of real-time data usage has traditionally been utilized for the purposes of process evaluation activities, and has primarily been used by the researcher/implementation team to assist with tailoring an intervention to overcome obstacles to implementation. There is another use for real-time data that is consistent with feedback-loop mechanisms. Real-time feedback-loop processes serve two main purposes. The first is to capture a “snapshot” of an individual's or teams’ progress in instituting the intervention; the second is to more longitudinally evaluate and highlight progress over time in instituting the change that is being adopted. By use of a feedback loop, this real-time evaluation can serve as both an external team motivator and at the same time act as a monitor to gauge sustainability of an intervention in the long run.
Step VI: Sustainability
The final step involves the implementation team handing over the continuation of the project to the site champion and their staff, who will take responsibility for sustaining the implementation. The site champion should consistently model exemplary behavior to encourage compliance with the new implementation, as well as provide explicit encouragement to promote the intervention.
The implementation team may opt to provide periodic (remote) supportive contact and monitor the progress to perform process evaluations or outcome evaluations, providing audit feedback reports detailing performance (improvement) based on information gathered from digital systems, logs, charts, surveys, interviews with key stakeholders, conversations, (anonymous) suggestion box comments, or meetings held with relevant staff members, garnering their impressions of the implementation. A summary of these findings can be disseminated to staff and stakeholders to acknowledge and encourage quality engagement. Additionally, such findings may be useful in tuning the implementation to function more effectively within each setting. This is not a mandated activity; this can be at the discretion of the implementation team, but it is assumed that sustainability activities will be the responsibility of the intervention site(s).
Per Rogers, the local champion and stakeholders enter the Confirmation stage, wherein they will finalize their decision to continue utilizing the innovation, modify it, or abandon it.
The motivation behind this manuscript is to provide a pragmatic and streamlined guide, which can be used to facilitate implementation of new techniques or knowledge within an organization. One of the main themes implicit in this new theoretical approach is the need to engender a real and sustainable environment for change. Previous work on this topic has shown how issues such as creating urgency within an organization are crucial to setting the foundation for lasting change (Kotter, 2008). In our formula, we address the issue of urgency through a pathway that begins with an Assessment to identify the problem, fabricating the Deliverables, which provides a tangible solution to the problem, concluding with Activating (the champion) in which we identify and provide evidence to champions as to the positive impact the intervention in question can provide.
We have successfully employed this succinct model to carry out implementation projects at more than 25 sites throughout the nationwide VA system, including several sites outside the VA (Anaya et al., 2012; Goetz et al., 2008; Knapp, Anaya, & Goetz, 2010; Anaya et al., under review). These implementations have largely been characterized by successful deployment and independent sustainability over time, streamlining healthcare delivery at these sites.
It is our hope that this concise ADAPTS model will serve as a robust and readily understandable guide for those embarking on implementations aimed at introducing or improving a variety of processes.
Journal for Healthcare Quality is pleased to offer the opportunity to earn continuing education (CE) credit to those who read this article and take the online posttest at http://www.nahq.org/education/content/jhq-ce.html. This continuing education offering, JHQ 239, will provide 1 contact hour to those who complete it appropriately.
Core CPHQ Examination Content Area
III. Performance Measurement & Improvement