Understanding implementation science from the standpoint of health organisation and management: an interdisciplinary exploration of selected theories, models and frameworks

Developing a codebook to characterize barriers, enablers, and strategies for implementing learning health systems from a multilevel perspective

Introduction

Learning health systems (LHSs) play a crucial role in improving healthcare delivery and outcomes through continuous learning and data-driven decision-making. Implementation of LHSs spans individual, organization, and systemic levels of healthcare. This paper outlines a systematic approach for developing a comprehensive codebook to identify barriers, enablers, and strategies associated with the establishment and operation of LHS from a multilevel perspective.

Methods

The codebook development process was divided into two phases and employed a coding team. Phase 1 involved the synthesis of previous literature, which drove the development of initial codes. Phase 2 included the testing of the codebook with a pilot dataset to derive new codes or iterative refinement, ensuring robustness, and validity.

Results

The literature search revealed 12 papers that detailed the barriers, enablers, and strategies for LHS implementation. Micro-level codes were derived from a mixture of existing literature and our pilot dataset. Most meso-level codes barriers and enablers were derived from the literature, with some subcodes derived from participant interviews. All strategies for implementation at the meso-level were identified in the literature. At the macro-level, all codes and subcodes were from the literature.

Conclusions

The codebook contributes to the advancement of implementation science in LHS. The codebook facilitates effective analysis and understanding of the key factors influencing the success of LHS implementation, offering practical insights for policymakers, healthcare practitioners and researchers engaged in the ongoing evolution of LHS.

Implementation science and genetic testing for familial hypercholesterolemia

PURPOSE OF REVIEW

Familial hypercholesterolemia is a treatable genetic disorder of cholesterol metabolism. Genetic testing is the most specific method for diagnosing familial hypercholesterolemia, but it remains underutilized. Implementation science aims to bridge the gap between evidence and practice and, thereby, support improved familial hypercholesterolemia care. This review presents the current evidence on the use of implementation science to improve the use of genetic testing for familial hypercholesterolemia.

RECENT FINDINGS

Recent research has focused on developing implementation strategies to improve the use of genetic testing, particularly cascade testing of at-risk blood relatives of known familial hypercholesterolemia cases. Stakeholder informed strategies aimed at improving communication between families and detection of familial hypercholesterolemia in primary care have been developed and implemented. Findings demonstrate implementation science methods can help remove barriers and improve the uptake of cascade genetic testing.

SUMMARY

Significant gaps in familial hypercholesterolemia care emphasize the importance of practical and realistic approaches to improve the detection of this preventable cause of premature heart disease, and recent efforts using implementation science have shown some promising results. More implementation science studies are needed that address the considerable gaps in familial hypercholesterolemia care, including the underutilization of genetic testing, so that all individuals receive the best clinical care.

Improving hospital food and meal provision: a qualitative exploration of nutrition leaders' experiences in implementing change

BACKGROUND

Recently, numerous initiatives have been taken to improve food and meals for hospital inpatients. Research providing in-depth knowledge on leading such improvement initiatives and implementing changes, specifically through facilitation within this multilevel context, is essential. This study aims to explore nutrition leaders' experiences in implementing changes to improve food and meal provision for hospital inpatients, focusing on facilitation activities.

METHOD

This is a qualitative interview study within the social constructivist paradigm. Participants were recruited through professional networks, advertisements, and snowballing. Eighteen semi-structured interviews were conducted individually with participants in leadership roles of food and meal improvement initiatives at Swedish hospitals. The interviews were transcribed verbatim and analysed thematically through an i-PARIHS lens.

RESULTS

Three themes of facilitation activities were identified: 'Building Relationships', 'Placing Food and Meals on the Agenda', and 'Cultivating Skills'. Building relationships involved establishing connections between the service and clinical divisions. Creating common structures and multidisciplinary teamwork enabled collaboration across organisational boundaries. Placing food and meals on the agenda involved both initial and ongoing communication activities, as food and meal tasks were often considered low priority. Cultivating skills encompassed creating learning opportunities for implementing lasting changes, tailored to specific contexts and adopted within everyday practices.

CONCLUSIONS

Collaboration between foodservice and clinical professionals, along with the dissemination of knowledge, appears to be important for implementing changes. Active leadership supports successful implementations by providing structured approaches, including feedback systems, and by contributing to the recognition of improvement initiatives, according to experiences shared during interviews.

Organization Theory for Implementation Science (OTIS): reflections and recommendations

Organizations exert influence on the implementation of evidence-based practices and other innovations that are independent of the influence of organizations' individual constituents. Despite their influence, nuanced explanations of organizations' influence remain limited in implementation science. Organization theories are uniquely suited to offer insights and explain organizational influences on implementation. In this paper, we describe the efforts of the Cancer Prevention and Control Research Network's (CPCRN) Organization Theory for Implementation Science (OTIS) workgroup to equip implementation scientists with theory-guided understanding of organizational influences on implementation. We provide a set of recommendations for future efforts to enhance implementation through the use of organization theories and OTIS tools.

A new normal in primary care: the rapid normalization of a major eHealth program in public health centers

BACKGROUND

This study aimed to contribute to a better understanding of the context, mechanisms and outcomes in the implementation process of an eHealth video consultation program in primary care. The study focused on how the program is normalized in the primary care setting. The primary research question for this study is "in what ways is the implementation of video consultation normalized in primary care?".

METHODS

The qualitative design and content analysis of primary data from the transcripts were based on in-depth interviews, complemented with free-text answers to open-ended survey questions and various documents. The study focuses on the large-scale implementation of the public eHealth program Närhälsan Online, which represents more than 100 health centers in Sweden's largest region of Västra Götaland. Multiagent perspectives on how the program is normalized were drawn from expressed perceptions by professions directly linked to both strategic and functional implementation, as well as administration and clinical operation.

RESULTS

This study both confirms and enhances the field with a theoretical contribution in six ways to the reviewed previous research, as well as showing practical implications. It also provides multi-agent perspectives on the rapid normalization of the implementation program studied.

CONCLUSIONS

In relation to the rapid progression of different initiatives in eHealth, this study contributes to perspectives on specific challenges as expressed by professions directly linked to both strategic and functional implementation as well as administration and clinical operation.

Application of implementation science for improving the utilization of an international clinical practice guidance on familial hypercholesterolemia

BACKGROUND

The International Atherosclerosis Society (IAS) published an evidence-informed guidance for familial hypercholesterolemia (FH) that provides both clinical and implementation recommendations. We reference examples of strategies from the literature to explore how these implementation recommendations can be tailored into implementation strategies at the local-level for stakeholders guided by a framework proposed by Sarkies and Jones.

METHODS

Four authors of the IAS guidance selected two published exemplar implementation recommendations for detection, management, and general implementation. Each recommendation was described as an implementation strategy using Proctor's guidance for specifying and reporting implementation strategies. It recommends reporting the actor (who), action (what), action-target (who is impacted), temporality (how often), and dose (how much) for each implementation strategy.

RESULTS

Detection: A centralized cascade testing model, mobilized nurses (actor) to relative's homes, after the diagnosis of the proband (temporality), once (dose) to consent, obtain a blood sample and health information (action) on relatives (action-target).

MANAGEMENT

A primary care initiative to improve FH management included an educational session (action) with clinicians (action-target), computer-based reminder message and message to patients to have their cholesterol screened once (dose) at a visit or outreach (temporality) by researchers (actor). General: A partnership between a statewide public pathology provider, local public hospital network, primary health network, government health ministry, and an academic university (actors) was established to implement a primary-tertiary shared care model (action) to improve the detection of FH (action-target).

CONCLUSIONS

We demonstrate that implementation recommendations can be specified and reported for different local contexts with examples on monitoring, evaluation, and sustainability in practice.

When rules turn into tools: An activity theory-based perspective on implementation processes and unintended consequences

The idea that actions of people, organizations or governments may lead to Unintended Consequences (UICs) is not new. In health, UICs have been reported as a result of various interventions including quality improvement initiatives, health information technology implementation, and knowledge translation, especially those involving translation of broad policies (evidence-based medicine and patient-centred care) or system level improvement into actionable items or tools. While some unintended consequences cannot be anticipated, others may be predictable. In this article, we present a model based on cultural historical activity theory, which may help policy-makers, health leaders, and researchers better anticipate UICs resulting from implementation of new programs or technologies and take action to address them or mitigate their risk of occurrence. We support this model using examples of UICs of implementing family centred care principles, electronic health records, and computerized templates for quality improvement in chronic disease management.

Program coordinators' perspectives on implementing a transition program for newly graduated nurses: a qualitative interview study

PURPOSE

While transition programs are widely used to facilitate newly graduated nurses transition to healthcare settings, knowledge about preconditions for implementing such programs in the hospital context is scarce. The purpose of this study was to explore program coordinators' perspectives on implementing a transition program for newly graduated nurses.

DESIGN/METHODOLOGY/APPROACH

An explorative qualitative study using individual interviews. Total of 11 program coordinators at five acute care hospital administrations in a south-west region in Sweden. Data was subjected to thematic analysis, using NVivo software to promote coding.

FINDINGS

The following two themes were identified from the analysis: Create a shared responsibility for introducing newly graduated nurses, and establish legitimacy of the program. The implementation process was found to be a matter of both educational content and anchoring work in the hospital organization. To clarify the what and why of implementing a transition program, where the nurses learning processes are prioritized, was foundational prerequisites for successful implementation.

ORIGINALITY/VALUE

This paper illustrates that implementing transition programs in contemporary hospital care context is a valuable but complex process that involves conflicting priorities. A program that is well integrated in the organization, in which responsibilities between different levels and roles in the hospital organization, aims and expectations on the program are clarified, is important to achieve the intentions of effective transition to practice. Joint actions need to be taken by healthcare policymakers, hospitals and ward managers, and educational institutions to support the implementation of transition programs as a long-term strategy for nurses entering hospital care.

Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms

BACKGROUND

Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation.

METHODS

Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.

RESULTS

The program's audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.

CONCLUSIONS

Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

Barriers to and Facilitators of Implementing Guidelines for Detecting Familial Hypercholesterolaemia in Australia

BACKGROUND

Familial hypercholesterolaemia (FH) is a genetic condition that is a preventable cause of premature cardiovascular morbidity and mortality. High-level evidence and clinical practice guidelines support preventative care for people with FH. However, it is estimated that less than 10% of people at risk of FH have been detected using any approach across Australian health settings. The aim of this study was to identify the implementation barriers to and facilitators of the detection of FH in Australia.

METHODS

Four, 2-hour virtual focus groups were facilitated by implementation scientists and a clinicians as part of the 2021 Australasian FH Summit. Template analysis was used to identify themes.

RESULTS

There were 28 workshop attendees across four groups (n=6-8 each), yielding 13 barriers and 10 facilitators across three themes: (1) patient related, (2) provider related, and (3) system related. A "lack of care pathways" and "upskilling clinicians in identifying and diagnosing FH" were the most interconnected barriers and facilitators for the detection of FH.

CONCLUSIONS

The relationships between barriers and facilitators across the patient, provider, and system themes indicates that a comprehensive implementation strategy is needed to address these different levels. Future research is underway to develop a model for implementing the Australian FH guidelines into practice.

How Can Implementation Science Improve the Care of Familial Hypercholesterolaemia?

PURPOSE OF REVIEW

Describe the application of implementation science to improve the detection and management of familial hypercholesterolaemia.

RECENT FINDINGS

Gaps between evidence and practice, such as underutilization of genetic testing, family cascade testing, failure to achieve LDL-cholesterol goals and low levels of knowledge and awareness, have been identified through clinical registry analyses and clinician surveys. Implementation science theories, models and frameworks have been applied to assess barriers and enablers in the literature specific to local contextual factors (e.g. stages of life). The effect of implementation strategies to overcome these factors has been evaluated; for example, automated identification of individuals with FH or training and education to improve statin adherence. Clinical registries were identified as a key infrastructure to monitor, evaluate and sustain improvements in care. The expansion in evidence supporting the care of familial hypercholesterolaemia requires a similar expansion of efforts to translate new knowledge into clinical practice.

Conceptualising learning healthcare systems and organisations in the context of rehabilitation: a scoping review protocol

Background: Transformative system wide action is needed for healthcare systems to meet the needs of an increasing aging population and changing health needs. One idea is that health systems can become “learning organisations” (LO) or “learning healthcare systems” (LHS) that continuously generate and apply evidence, innovation, quality, and value to provide better care. This is of value to non-acute healthcare settings such as rehabilitation, which are complex, multi-dimensional and multi-disciplinary in nature. Little is known about how these frameworks have been applied to rehabilitation settings. Objective and inclusion criteria: The aim of this scoping review is to systematically map and summarise the literature conceptualising and operationalising LHS and LO in rehabilitation settings. Studies will be included which define a LO or LHS; or describe an operating LHS/LO; or include the translation of research evidence generated from LHS/LO data into healthcare improvement within a rehabilitation context will be included. Study designs such as quantitative, qualitative, mixed method studies, and case studies will be included. Methods: The guidelines from the Joanna Briggs institute methodology for scoping reviews will be used for this review. The literature search will be performed using a three-step search strategy: an initial limited search of two databases has been performed to identify relevant key words and index terms. The developed search string will be adapted and applied across the following databases: OVID MEDLINE, EMBASE, CINAHL Plus, APA PsycINFO and COCHRANE Database of Systematic Reviews. This will be followed by search of the reference lists of selected sources and relevant data-hubs. A draft data extraction framework will be used and updated iteratively to extract data. Frequency counts and qualitative content analysis will be employed to address the research question of how LHS and LO have been conceptualised and operationalised in the context of rehabilitation.

What is in a Meter? A Qualitative Exploration into the Implementation of Electricity Metering Across Mumbai Communities Using Normalisation Process Theory

Metering is fundamental in the efficient operation of electricity networks, as meters facilitate controlled usage and improve health and well-being. However, across the Global South, meters have often been found to be lacking or not fit for purpose. Therefore, this study sought to determine residents’ perceptions and access to electricity metering across a community in Mumbai, with the goal of developing recommendations to support the implementation of meters in the future. Fifty semi-structured interviews were conducted by phone, with participants from different areas and socioeconomic classes, within Greater Mumbai. The sample consisted of 20 low-income, 20 middle-income, and 10 high-income participants. The Normalisation Process Theory (NPT) was used to inform the interview schedule and to organise the thematic analysis. Meter accessibility and location was variable across the participant groups, as was the education and awareness of metering technology. Socio-political factors were found to directly affect the use of meters, specifically in the low-income group. The high cost associated with metering was a prominent finding; with a preconception that introducing meters would only increase utility expenditure. Future work should focus around ensuring meters are easy to use, practical and accessible to all residents and supporting education programmes around how to use a meter and how they can reduce utility expenditure. The cost of meters should also be investigated, to establish that the costs, associated with introducing new meters, are not passed disproportionately to consumers.

Increasing Access to Organization Theories for Implementation Science

Background

Organization theories offer numerous existing, highly relevant, yet largely untapped explanations of the organizational dynamics underlying evidence-based intervention (EBI) implementation. Rooted in ideas regarding power, autonomy, and control, organization theories can explain how and why organizations adopt, implement, and sustain EBI use. Although they have gained visibility, organization theories remain underused in implementation research, perhaps due to their inaccessibility to implementation scientists. To improve access to organization theory among implementation scientists, we summarized organization theories with relevance to implementation science.

Methods

Led by the Cancer Prevention and Control Research Network (CPCRN) Organization Theory for Implementation Science workgroup, we employed a modified Delphi process to reach a consensus among 18 experts at the intersection of organization and implementation science regarding organization theories with relevance to implementation science. From texts that described the organization theories, using standardized abstraction forms, two investigators independently abstracted information regarding constructs, propositions regarding how or why constructs might influence implementation, the potential relevance of organization theories' propositions for implementation, and overviews of each theory. The investigators then reconciled discrepancies until reaching consensus. A third investigator reviewed reconciled abstraction forms for accuracy, coherence, and completeness.

Findings

We identified nine organization theories with relevance to implementation science: contingency, complexity, institutional, network, organizational learning, resource dependence, sociotechnical, and transaction cost economics. From the theories, we abstracted 70 constructs and 65 propositions. An example proposition from institutional theory is: "Coercive, mimetic, and normative pressures contribute to organizations…within an organizational field [becoming increasingly similar]." These propositions can be operationalized as levers to facilitate EBI implementation.

Conclusions

To increase use in the field, organization theories must be made more accessible to implementation scientists. The abstraction forms developed in this study are now publicly available on the CPCRN website with the goal of increasing access to organization theories among an interdisciplinary audience of implementation scientists through the CPCRN Scholars program and other venues. Next steps include consolidating organization theory constructs into domains and translating the resulting framework for use among researchers, policymakers and practitioners, aiding them in accounting for a comprehensive set of organization theory constructs thought to influence EBI implementation.

Making implementation science more real

Implementation science in healthcare aims to understand how to get evidence into practice. Once this is achieved in one setting, it becomes increasingly difficult to replicate elsewhere. The problem is often attributed to differences in context that influence how and whether implementation strategies work. We argue that realist research paradigms provide a useful framework to express the effect of contextual factors within implementation strategy causal processes. Realist studies are theory-driven evaluations that focus on understanding how and why interventions work under different circumstances. They consider the interaction between contextual circumstances, theoretical mechanisms of change and the outcomes they produce, to arrive at explanations of conditional causality (i.e., what tends to work, for whom, under what circumstances). This Commentary provides example applications using preliminary findings from a large realist implementation study of system-wide value-based healthcare initiatives in New South Wales, Australia. If applied judiciously, realist implementation studies may represent a sound approach to help optimise delivery of the right care in the right setting and at the right time.

Using systems thinking to increase understanding of the innovation system of healthcare organisations

PURPOSE

This paper applies systems thinking modelling to enhance the dynamic understanding of how to nurture an innovative culture in healthcare organisations to develop the innovation system in practice and speed up the innovative work. The model aims to provide a holistic view of a studied healthcare organisation's innovation processes, ranging from managerial values to its manifestation in improved results.

DESIGN/METHODOLOGY/APPROACH

The study is based on empirical material from a healthcare unit that, within a few years, changed from having no innovations to repeatedly generating innovations. The study uses the modelling language of causal loop diagrams (CLDs) in the system dynamics methodology to identify the key important aspects found in the empirical material.

FINDINGS

The proposed model, based on the stories of the interviewees, explores the dynamics of inertia when nurturing an innovative culture, identifying delays attributed to the internal change processes and system relationships. These findings underscored the need for perseverance when developing an innovative culture in the entrepreneurial phases.

PRACTICAL IMPLICATIONS

The approach of using systems thinking to make empirical healthcare research results more tangible through the visual notations of CLDs and mental simulations is believed to support exploring complex phenomena to induce and nurture both individual and organisational learning.

ORIGINALITY/VALUE

The results from this approach provide deepened analysis and provoke the systems view to explain how the nurturing of the culture can accelerate the innovation processes, which helps practitioners and researchers to further expand their understanding of their healthcare contexts.

The Science of Learning Health Systems: Scoping Review of Empirical Research

BACKGROUND

The development and adoption of a learning health system (LHS) has been proposed as a means to address key challenges facing current and future health care systems. The first review of the LHS literature was conducted 5 years ago, identifying only a small number of published papers that had empirically examined the implementation or testing of an LHS. It is timely to look more closely at the published empirical research and to ask the question, Where are we now? 5 years on from that early LHS review.

OBJECTIVE

This study performed a scoping review of empirical research within the LHS domain. Taking an "implementation science" lens, the review aims to map out the empirical research that has been conducted to date, identify limitations, and identify future directions for the field.

METHODS

Two academic databases (PubMed and Scopus) were searched using the terms "learning health* system*" for papers published between January 1, 2016, to January 31, 2021, that had an explicit empirical focus on LHSs. Study information was extracted relevant to the review objective, including each study's publication details; primary concern or focus; context; design; data type; implementation framework, model, or theory used; and implementation determinants or outcomes examined.

RESULTS

A total of 76 studies were included in this review. Over two-thirds of the studies were concerned with implementing a particular program, system, or platform (53/76, 69.7%) designed to contribute to achieving an LHS. Most of these studies focused on a particular clinical context or patient population (37/53, 69.8%), with far fewer studies focusing on whole hospital systems (4/53, 7.5%) or on other broad health care systems encompassing multiple facilities (12/53, 22.6%). Over two-thirds of the program-specific studies utilized quantitative methods (37/53, 69.8%), with a smaller number utilizing qualitative methods (10/53, 18.9%) or mixed-methods designs (6/53, 11.3%). The remaining 23 studies were classified into 1 of 3 key areas: ethics, policies, and governance (10/76, 13.2%); stakeholder perspectives of LHSs (5/76, 6.6%); or LHS-specific research strategies and tools (8/76, 10.5%). Overall, relatively few studies were identified that incorporated an implementation science framework.

CONCLUSIONS

Although there has been considerable growth in empirical applications of LHSs within the past 5 years, paralleling the recent emergence of LHS-specific research strategies and tools, there are few high-quality studies. Comprehensive reporting of implementation and evaluation efforts is an important step to moving the LHS field forward. In particular, the routine use of implementation determinant and outcome frameworks will improve the assessment and reporting of barriers, enablers, and implementation outcomes in this field and will enable comparison and identification of trends across studies.