The purpose of this study was to assess the relationship between baseline ORCA evidence and context subscales and implementation of practice recommendations following a training experience. Results indicated differences in the hypothesized direction between high and low implementation clinics on several ORCA subscales. The relationship between ORCA subscale scores and implementation outcomes does not appear to be related to the number of team members that were sent to the face-to-face training, the type of facility or complexity of the facility the team came from, or the number of staff employed by or number of patients served by the SUD clinic. High implementation teams included both a 'team' of one clinical nurse specialist from a community-based outpatient clinic with only 4.5 full-time equivalent staff members as well as a team from a medical center with the highest possible complexity rating and 20 full-time equivalent staff members. On the other hand, the low implementation teams included both a team from a low complexity medical center with only six full-time equivalent staff members and a team from a high complexity medical center with over 20 full-time equivalent staff members. It would appear that the ORCA subscales are capturing something about the organization's readiness to implement practice change related to hepatitis prevention that is not fully explained by the size or complexity of the SUD clinic itself or the medical center in which it resides.
The relationship of the patient preferences and leadership culture subscales to implementation of recommended practices were particularly robust, with effect sizes of 2.15 and 2.09, respectively. Based on the items in the patient preference subscales, it appears that team leaders who more strongly endorsed the idea that hepatitis services provided through the SUD treatment clinics would be accepted by patients and meet patients' needs and expectations were associated with clinics that implemented more recommended practices. Similarly, based on the items in the leadership culture subscale, it appears that team leaders who more strongly endorsed that their clinic leadership provided effective management, clearly defined staff responsibilities, and promoted team building and communication were associated with clinics that implemented more recommended practices. These findings support the hypotheses from the PARIHS model that a match between perceived patient needs and the new practice to be implemented and effective leadership facilitate implementation of new practices [17
the opinion leaders subscale was the only subscale to yield a small effect size when comparing low and high implementation clinics. This result may be explained by the recruitment method for this study. All teams volunteered to participate, which resulted in a sample of team members presumably eager to make improvements to their healthcare practices. Support for this contention is found when examining the means for high and low implementation clinics on this subscale. For high implementation clinics, the opinion leaders subscale score fell in a similar range to other subscales, whereas for low implementation clinics the opinion leader score was the highest subscale score, closer to the subscale scores of the high implementation clinics. Perhaps the low implementation team leaders felt they had supportive opinion leaders within their team but recognized that other facilitators of change were lacking in their organization.
The only subscale that did not function in the hypothesized direction was the resource subscale. This scale yielded a large effect size, with low implementation clinics reporting greater resources (e.g.
, financial, facilities, training) for change than high implementation clinics. Generally speaking, slack resources are viewed as a facilitator for implementation. However, as Wiener and colleagues pointed out in their discussion of the definition of the construct of organizational readiness to change, an organization may have all of the necessary financial and material resources to implement a change but lack the motivation or the capability to mobilize those resources [6
]. The resource subscale questions on the ORCA begin with the stem, 'In general in my organization, when there is an agreement that change needs to happen...
'. Given that the evidence subscales indicate that the team leaders from the low implementation sites expressed lower levels of support for the LHI recommendations, they may very well feel that the resources are available to them but they have not committed to mobilizing those resources to implement these particular recommendations. Another potential hypothesis is that team leaders from the low implementation sites may have had less experience with the level of resources necessary to implement a new practice and therefore may overestimate the adequacy of available resources. This could potentially lead to discouragement when initial attempts to implement practice change are unsuccessful or run into significant barriers. Interestingly, the resources subscale was also problematic when Helfrich et al
. investigated the factor structure of the ORCA in that it did not load onto the context scale as predicted [14
]. Nor did it significantly load on either of the other primary scales of the ORCA. Instead, it appears to measure information separate from the evidence, context, and facilitation scales. While a certain minimum level of slack resources is presumably necessary for successful implementation, it does not appear to be sufficient, because mobilization of those resources may be dependent on perceived need for change and the capabilities of the implementation team to capitalize on those available resources.