PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Med Care Res Rev. Author manuscript; available in PMC Apr 1, 2013.
Published in final edited form as:
PMCID: PMC3524416
NIHMSID: NIHMS424595
A Compilation of Strategies for Implementing Clinical Innovations in Health and Mental Health
Byron J. Powell, AM,1* J. Curtis McMillen, PhD,2 Enola K. Proctor, PhD,1 Christopher R. Carpenter, MD, MSc,3 Richard T. Griffey, MD, MPH,3 Alicia C. Bunger, PhD,4 Joseph E. Glass, MSW,1 and Jennifer L. York, MD5
1George Warren Brown School of Social Work, Washington University in St. Louis, Campus Box 1196, One Brookings Drive, St. Louis, MO 63130
2The School of Social Service Administration, The University of Chicago, 969 E. 60th, Chicago, IL 60637
3Department of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8072, St. Louis, MO 63130
4Cecil G. Sheps Center for Health Services Research, University of North Carolina, Campus Box 7590, 725 Martin Luther King J. Blvd., Chapel Hill, NC 27599
5Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8116, St. Louis, MO 63130
*BJP (Corresponding Author): bjpowell/at/wustl.edu, (630) 730-1703
JCM: cmcmillen/at/uchicago.edu, (773) 702-1155
CRC: carpenterc/at/wustl.edu, (314) 362-4362
RTG: griffeyr/at/wustl.edu, (314) 362-4362
ACB: bunger/at/schsr.unc.edu, (919) 843-6103
JEG: jeglass/at/wustl.edu, (314) 935-6660
JLY: york_j/at/wustl.edu, (314) 454-2527
EKP: ekp/at/wustl.edu, (314) 935-6660
Efforts to identify, develop, refine, and test strategies to disseminate and implement evidence-based treatments have been prioritized in order to improve the quality of health and mental healthcare delivery. However, this task is complicated by an implementation science literature characterized by inconsistent language use and inadequate descriptions of implementation strategies. This article brings more depth and clarity to implementation research and practice by presenting a consolidated compilation of discrete implementation strategies, based upon a review of 205 sources published between 1995 and 2011. The resulting compilation includes 68 implementation strategies and definitions, which are grouped according to six key implementation processes: planning, educating, financing, restructuring, managing quality, and attending to the policy context. This consolidated compilation can serve as a reference to stakeholders who wish to implement clinical innovations in health and mental healthcare and can facilitate the development of multifaceted, multilevel implementation plans that are tailored to local contexts.
Keywords: implementation research, implementation strategies, evidence-based practice, health, mental health
Internationally, there is a substantial gap between innovations in health and mental healthcare and their delivery in routine practice (Institute of Medicine, 2001, 2006; Madon, Hofman, Kupfer, & Glass, 2007). Implementation research has emerged as a promising way of bridging this “quality chasm” (Institute of Medicine, 2001) by advancing knowledge about how to adopt and integrate evidence-based health interventions (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004; Grol, Wensing, & Eccles, 2005; Proctor, et al., 2009; Straus, Tetroe, & Graham, 2009). Implementation research has been defined as “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices” to improve the quality of service delivery in routine care (Eccles, et al., 2009; Eccles & Mittman, 2006).
From the beginning, implementation scientists have stressed the use of specific strategies to accomplish this translational work (Lomas, 1993), and recently, the identification, development, refinement, and testing of strategies to implement evidence-based innovations has been prioritized (National Institutes of Health, 2010). In fact, the Institute of Medicine (2009) recently identified the assessment of dissemination and implementation strategies as a top-quartile priority for comparative effectiveness research. Yet, leaders in the field have identified critical challenges that inhibit the conduct of implementation research and practice. For instance, Michie and colleagues (2009) bemoan the fact that implementation strategies are rarely defined and are often poorly described. When they are described, the terminology used is inconsistent (Michie, et al., 2009). For example, multiple terms are used for implementation processes (e.g., knowledge translation, diffusion, dissemination, translation) and strategies (e.g., methods, interventions, models) resulting in a literature that McKibbon and colleagues (2010) describe as a “Tower of Babel.” These variations in terminology and description inhibit scientific replication and meta-analyses (Michie, et al., 2009) and reduce the value of the literature for stakeholders (e.g., researchers, administrators, etc.) who seek implementation guidance, making it difficult for them to identify and select strategies that have the potential to promote the implementation and sustainability of clinical innovations.
We define an implementation strategy as a systematic intervention process to adopt and integrate evidence-based health innovations into usual care. Our view of health innovations is relatively broad, and includes evidence-based treatments, practice guidelines, and empirically-supported multi-component intervention programs that focus on prevention and treatment in health and mental health. We differentiate discrete, multifaceted and blended implementation strategies. Discrete strategies are the most recognizable and commonly cited implementation actions (e.g., reminders, educational meetings) and involve one process or action. A multifaceted implementation strategy (Grimshaw, et al., 2001; Grol & Grimshaw, 2003) uses two or more discrete strategies (e.g., training plus technical assistance). We reserve the term blended strategy for instances in which a number of discrete strategies, addressing multiple levels and barriers to change, are interwoven and packaged as a protocolized or branded implementation intervention. Blended strategies are inherently multifaceted; however, all multifaceted strategies are not blended. There are several examples of such models, including the Translating Research Into Practice intervention, the Availability, Responsibility and Continuity model, and the Institute for Healthcare Improvement’s Framework for Spread (Brooks, Titler, Ardery, & Herr, 2009; Glisson & Schoenwald, 2005; Glisson, Schoenwald, Hemmelgarn, Green, Dukes, Armstrong, & Chapman, 2010; Massoud, et al., 2006; Titler, et al., 2009).
Discrete implementation strategies can be identified and extracted from empirical evaluations of implementation efforts; descriptions of blended implementation models; review articles, compilations, and taxonomies; and a limited number of texts pertinent to implementation research and practice (Grol, et al., 2005; Straus, et al., 2009). For illustrative purposes, we provide brief summaries of 41 reviews and compilations of implementation strategies in Table 1.
Table 1
Table 1
The foci of prior compilations of implementation strategies
Many of these source documents represent seminal contributions to the field, but none were intended to be a consolidated menu of potential implementation options for a broad range of stakeholders in health and mental healthcare, thus the strategies included in each are limited. For instance, the most influential compilation to date, the Cochrane Collaboration’s Effective Practice and Organisation of Care (EPOC) group’s Data Collection Checklist (Cochrane Effective Practice and Organisation of Care Group, 2002), was created to guide systematic reviews on professional, financial, organizational, or regulatory interventions to improve healthcare practice. Thus, in addition to implementation strategies, it includes many interventions that apply to improving the quality of care more generally (e.g., case management, arrangements for follow-up, telemedicine). Other sources are purposely narrow in scope, focusing on: strategies with known evidence on effectiveness (e.g., Bero, et al., 1998; Grimshaw, et al., 2006; Grol & Grimshaw, 2003; Shojania, et al., 2006); specific medical conditions, fields of practice or disciplines (e.g., Cabana, Rushton, & Rush, 2002; Gilbody, Whitty, Grimshaw, & Thomas, 2003; Stone, et al., 2002); strategies that were employed in a specific setting or study (e.g., Hysong, Best & Pugh, 2007; Magnabosco, 2006); “exemplar” programs or strategies (e.g., Katon, Zatzick, Bond, & Williams, 2006; McHugh & Barlow, 2010); one level of target such as consumers or practitioners (e.g., Ryan, Lowe, Santesso, & Hill, 2010); or one type of strategy such as educational or organizational strategies (e.g., Gilbody, Whitty, Grimshaw, & Thomas, 2003; Raghavan, Bright & Shadoin, 2008). The characteristics of some of these reviews and compilations may lead healthcare stakeholders to believe that there are relatively few strategies from which to choose. Additionally, many of these compilations do not provide definitions or provide definitions that do not adequately describe the specific actions that need to be taken by stakeholders.
New Contributions
This review follows and extends previous reviews and compilations by presenting a consolidated compilation of discrete implementation strategies. We attempt to advance clarity within the field by defining each discrete strategy and providing referenced examples. While it is impossible to develop a comprehensive compilation, we intend to improve upon existing compilations by providing a reference tool that more closely reflects the full range of implementation actions that are available to those who wish to adopt, implement, and sustain innovations in routine care.
A consolidated compilation of implementation strategies will benefit a number of healthcare stakeholders by highlighting available options and allowing them to thoughtfully plan and execute programs of implementation using multiple strategies tailored to specific settings, needs, and timetables. For example, researchers and practitioners who develop and test clinical innovations; administrators and clinical managers considering the adoption of an innovation; funders who wish to maximize their investment in clinical innovations; and healthcare consumers, their families, and advocates who desire access to effective services all stand to benefit from a consolidated menu of discrete implementation strategies.
We focus on both health and mental health, because while many strategies described in the literature are relevant to both broad fields, we have found that they both emphasize a different array of strategies and stand to be enhanced through “dialogue” with the other. Unlike reviews and compilations that focus on a narrow sector of health or mental healthcare, our aim is to develop a compilation that is essentially generic and broadly applicable, so that stakeholders could use the compilation to tailor their implementation plans depending upon the innovation being implemented and the specific barriers and facilitators of their implementation context. The strategies employed will likely differ depending upon the practice being implemented (and a myriad of contextual factors). For example, increasing the frequency of hand washing in medical settings may require different strategies (e.g. audit and feedback, reminders) than would the implementation of a complex cognitive-behavioral psychosocial treatment in a community mental health clinic (which would likely require training, supervision, consultation). Though we focus on the implementation of clinical innovations, some of the included strategies may also be useful in reducing bad practices (e.g. poor hand hygiene) and critical incidences (e.g. infections, unexpected death in heart surgery). Finally, we classify discrete strategies under taxonomic headings that highlight their usefulness vis-à-vis six broad implementation processes, though we caution against reducing these discrete strategies to their taxonomic headings.
Conceptual Model
We used the Consolidated Framework for Implementation Research (CFIR) to guide this review (Damschroder, et al., 2009). Starting with Greenhalgh et al.’s (2004) “Conceptual model for considering the determinants of diffusion, dissemination, and implementation of innovations in health service delivery and organization” (Greenhalgh, et al., 2004), the CFIR consolidates 19 different conceptual frameworks pertinent to implementation research and practice. In doing so, the CFIR highlights the many commonalities between different models, theories, and frameworks; and expands our conceptual understanding by ensuring that the unique contributions of each model are represented. The CFIR suggests that implementation is influenced by: 1) intervention characteristics (evidentiary support, relative advantage, adaptability, trialability, and complexity), 2) the outer setting (patient needs and resources, organizational connectedness, peer pressure, external policy and incentives), 3) the inner setting (structural characteristics, networks and communications, culture, climate, readiness for implementation), the 4) characteristics of the individuals involved (knowledge, self-efficacy, stage of change, identification with organization, etc.), and 5) the process of implementation (planning, engaging, executing, reflecting, evaluating). This model informed our review process by capturing the complex, multi-level nature (Shortell, 2004) of implementation, which compelled us to consider implementation strategies in a holistic manner. The CFIR suggests that successful implementation may necessitate the use of an array of strategies that exert their effects at multiple levels of the implementation context. Indeed, each mutable aspect of the implementation context that the CFIR highlights is potentially amenable to the application of targeted and tailored implementation strategies. Though we were limited to the strategies represented in the health and mental health literature, we attempted to extract and define strategies that had the potential to impact any of the components specified in the CFIR.
Review Method
In order to identify sources that describe active efforts to implement clinical innovations in health and mental health service settings we conducted a narrative review (Dijkers, 2009). This approach was chosen due the breadth of our research question and the diffuse nature of the literature focusing on implementation strategies (McKibbon, et al., 2010). Indeed, Hamersley notes that narrative reviews are well suited for research questions that are broad and don’t necessarily benefit from a pre-determined protocol that sets forth procedures to be followed (Hammersley, 2002). Narrative reviews involve a more inductive approach (Hammersley, 2002), and are effective in capturing diversities and pluralities of understanding (Jones, 2004). Some elements of our process are more often associated with systematic reviews (Zed, Rowe, Loewen, & Abu-Laban, 2003), such as the specification of databases and search terms and querying experts to identify important references. However, we made no effort to assess or exclude sources based upon methodological quality, nor was it within our scope to evaluate the empirical evidence of the strategies we identify, lending further support to the appropriateness of a narrative approach. McPheeters and colleagues (2006) note that narrative reviews are best conducted in a team; thus, we leveraged the expertise of an implementation research workgroup.
Workgroup Composition
We formed an eight member multidisciplinary workgroup comprised of physicians and social workers/mental health services researchers with both clinical and research backgrounds in general heath, emergency medicine, mental health, and substance abuse treatment. Members of the group maintain leadership positions and associations with an NIMH-funded research center, an NIH-funded research core, and an NIMH-funded training institute, all of which focus on implementation research in health and/or mental health. Each workgroup member had experience conducting or consulting on implementation research in health or mental health settings, including the conduct of NIH R01s and other federally funded research. The workgroup also included appointed leaders in quality, safety, and evidence-based medicine at an academic medical center. Finally, nearly all members of the workgroup had experience conducing narrative or systematic reviews/meta-analyses.
Data Sources
Books, articles, reports, and websites describing implementation strategies were drawn from three sources: (1) workgroup members’ suggestions of compilations and blended models (steps one & two), (2) a database search (step three), and an expert query (step four). These steps are described in more detail below.
(1) Compilations and lists
We started by examining compilations (n = 17) that were known to members of the workgroup. We began by reviewing the EPOC Data Collection Checklist, as it is the most frequently referenced source document in reviews of implementation strategies (e.g., Chaillet, et al., 2006; Gilbody, et al., 2003; Grimshaw, et al., 2006; Grimshaw, et al., 2004; Shojania, et al., 2006; Stone, et al., 2002).
(2) Blended models
We reviewed blended implementation models (n = 12) known to our group.
(3) Database searches
A database search was conducted with the aid of an academic librarian. To target health and mental health literature, we searched for articles in English language published between 1995 and 2011 in CINAHL Plus, Global Health, MEDLINE, PsycINFO, Social Work Abstracts, and SocINDEX using the EBSCO database host. The search strategy is described in detail in Table 2.
Table 2
Table 2
Search strategy
This search yielded 553 abstracts. These abstracts were reviewed, and we eliminated those that did not describe active implementation efforts (e.g., studies of diffusion), did not involve health or mental health service settings, or that were obviously unrelated to implementation. The first and second author reviewed a sample of 50 abstracts, and obtained excellent agreement (kappa = .88), after which the first author reviewed the remaining abstracts. Ultimately, this yielded 142 full-text articles to review.
(4) Expert query
Sixty-four implementation researchers were contacted and asked if they could “provide us leads toward finding existing compilations, lists or taxonomies of implementation strategies, and/or bundled or blended implementation strategies.” Our list of scholars included the editorial board of Implementation Science and the Dissemination and Implementation Research in Health Study Section of the National Institutes of Health. We received responses from 16 experts (13 from the Implementation Science editorial board and 3 from individuals that they prompted to contact us) who identified 33 additional sources.
Sources Identified
In total, 205 sources were identified (one article was identified by a reviewer of this article). This included 41 compilations, taxonomies, or reviews of multiple strategies; 15 descriptions of blended strategies; and 149 empirical, descriptive, and conceptual articles. A full list of references for all 205 sources is available from the lead author upon request.
Data Extraction Process
Two workgroup members reviewed the full-text sources (n = 205) sequentially, beginning with compilations and blended models known to the workgroup members, and proceeding to review sources identified through the database search and expert query. Any information pertaining to the form or substance of an implementation strategy or its definition was extracted. When a source described a multifaceted or blended implementation strategy, an attempt was made to reduce them to their discrete strategy components. A provisional compilation of discrete implementation strategies and working definitions was developed. The provisional compilation was edited in an iterative fashion when source materials included strategies or definitions that were novel or more nuanced than those already represented.
Group Review Process
The eight-member workgroup gathered for seven face-to-face meetings over the course of one year. The first three meetings were dedicated to discussions of the state of the implementation literature and formulating a strategy to compile and define strategies that have been utilized in health and mental health. In subsequent meetings, we utilized a modified Delphi process (Fink, Kosecoff, Chassin, & Brook, 1984; Jones & Hunter, 1995) to develop consensus regarding the discrete strategies and definitions that were extracted from the literature by the primary reviewers. Prior to each of the four meetings, workgroup members were emailed the current provisional taxonomy, and were asked to review it to determine their agreement with each of the strategies and definitions listed. Each group member was to consider whether each entry: a) met our definition of an implementation strategy, b) was (or could be) sufficiently defined to provide guidance to users, c) was sufficiently distinct from other implementation strategies included in the provisional compilation, and d) could be applied to implementation of health and mental health treatments. Group meetings were used to discuss members’ concerns about the soundness of strategies and definitions, and to move towards consensus. Every work group member’s views were elicited about every strategy decision. This process occurred over the course of several meetings; thus, the workgroup members had multiple opportunities to express concern regarding the inclusion of specific strategies and definitions. Figure 1 depicts each stage of our iterative review process and details the number of strategies that were identified and incorporated into our final compilation.
Figure 1
Figure 1
Flowchart for building the compilation of implementation strategies
Finally, we discussed categories and subcategories to adequately represent the range of strategies presented.
Illustrations of Decision-Making and Synthesis Processes
To provide a better understanding of the decision-making and synthesis processes, we provide several examples. Several actions fell short of our definition of an implementation strategy by failing to emphasize deliberate actions to integrate health innovations. For example, we eliminated activities that occur far before a decision to adopt an evidence-based innovation occurs, such as identifying high risk and high volume diseases or assessing the evidence for a given innovation (Stetler, McQueen, Demakis, & Mittman, 2008). Though these activities are clearly important, the purpose of this article is not to identify ways to determine what innovations should be adopted, but to show how they can be implemented through the use of specific strategies. Other potential strategies were not sufficiently defined to provide guidance to those who might use them. For instance, EPOC lists “boost morale” (Cochrane Effective Practice and Organisation of Care Group, 2002) and the VA’s QUERI model lists “regular encouragement” (Stetler, et al., 2008) as implementation interventions. These activities were also not sufficiently specific to implementing health innovations, although they may remain important components of implementation processes. Several other activities such as “build teamwork,” “resolve conflicts,” and “develop relationships” were excluded for the same reason. Our decisional work also included merging strategies when they were not conceptually distinct. For example, the financial strategy “forgive loans” (Raghavan, Bright, & Shadoin, 2008) is simply one type of financial inducement to adopt a clinical innovation; thus, it was subsumed under the strategy “alter incentive and allowance structures.” Other times, we decided to split what others might have seen as one strategy in order to remain consistent with our focus on discrete strategies. For example, the EPOC taxonomy combines the identification of barriers to implementation and designing strategies to overcome them in one intervention they called “marketing” (Cochrane Effective Practice and Organisation of Care Group, 2002). We split them into two categories (“assess for readiness and identify barriers” and “tailor strategies to overcome barriers and honor preferences”) to emphasize the distinctiveness and importance of both processes.
The definitions for 68 implementation strategies that emerged from our process are presented in Table 3. For presentation purposes the workgroup classified the strategies into six categories that represent larger implementation processes: planning, educating, restructuring, financing, managing quality, and attending to the policy context. Although several strategies could be placed into more than one group, we attempted to assign a primary group to each strategy. Plan strategies (n = 17) can help stakeholders gather data, select strategies, build buy-in, initiate leadership, and develop the relationships necessary for successful implementation. The educate (n = 16) category includes strategies of various levels of intensity that can be used to inform a range of stakeholders about the innovation and/or implementation effort. A number of finance strategies (n = 9) can be leveraged to incentivize the use of clinical innovations and provide resources for training and ongoing support. Strategies to restructure (n = 7) facilitate implementation by altering staffing, professional roles, physical structures, equipment, and data systems. Quality management strategies (n = 16) can be adopted to put data systems and support networks in place to continually evaluate and enhance quality of care, and ensure that clinical innovations are delivered with fidelity. Finally, strategies that attend to the policy context (n = 3) can encourage the promotion of clinical innovations through accrediting bodies, licensing boards, and legal systems. A “quick view” of the taxonomic headings, subheadings, and 68 discrete implementation strategies can be seen in Figure 2.
Table 3
Table 3
Compilation of discrete implementation strategies (N = 68)
Figure 2
Figure 2
“Quick view” of the compilation of discrete implementation strategies
Strategy definitions are presented without attention to the type of actor who would typically perform the strategy. For example, some strategies are most likely enacted by a payer of clinical services, whereas others are enacted by administrators, clinicians, etc. Each of the strategies included in Table 3 includes references to some of the sources that named, defined, or discussed them. These references are meant to be illustrative. In most cases, we do not provide every reference that mentioned the use of a given strategy, as doing so would result in an unwieldy list of references for the most commonly used strategies. In a small number of cases, the cited source could be considered inspirational, in that not enough information was provided on the strategy to determine with certainty what the authors meant; the definition listed is our best guess of what was intended.
This compilation contributes to implementation practice and research by highlighting the range of available strategies and clarifying their description. It can help facilitate the development of multifaceted, multilevel implementation plans that are tailored to local contexts. Though implementation scholars have noted the importance of addressing multiple barriers to change at multiple levels of the implementation context (Grol & Grimshaw, 2003; Solberg, 2000; Solberg, et al., 2000; Wensing, Bosch, & Grol, 2009), the literature is only beginning to describe processes to help innovators build comprehensive blueprints for implementation from known strategies. Grol and Wensing (Grol & Wensing, 2005a, 2005b) suggest an approach tailored to the implementation situation, linking specific strategies to known features of the innovation, the setting, and the target of behavior change. They encourage implementers to think in terms of phases (Grol & Wensing, 2005b), starting with strategies that make stakeholders aware of the innovation and moving toward those that integrate and maintain the innovation in usual care. They caution that “a balance must be reached between the possibility of reaching the desired effects and the amount of money, time, effort and personal commitment invested and the commotion they may cause” (Grol & Wensing, 2005a, p. 53). Ultimately, implementation research is an applied science, and strategies will need to be adapted to local situations and contexts. We hope this compilation will aid in that process.
This compilation may also facilitate the conduct of implementation research. For instance, it can help researchers to develop multifaceted “enhanced implementation strategies” that can be compared to more standard approaches to implementation. Similarly, the compilation may highlight strategies that have not been empirically evaluated in a given context (in isolation or in combination), which would serve to stimulate comparative effectiveness research. Furthermore, specifying the discrete components of such approaches will allow researchers to develop protocols that outline the elements that must be present if the strategies are to be delivered with fidelity. Indeed, assessing the frequency, intensity, and fidelity in which implementation strategies are developed may be an important next step in implementation research as we struggle to understand the variability in the effectiveness of specific implementation strategies. Finally, the compilation could be adapted to serve as an audit tool to assess the types of strategies that are being employed in “real world” care and/or in implementation research.
Limitations
This effort to compile implementation strategies is limited in several ways. If we had started our iterative process with different source documents, our strategy titles and definitions may have differed. Similarly, a different composition of workgroup members could have led to different decisions. Despite our efforts to improve the consistency and clarity of the description of strategies, this compilation represents only a step toward achieving that goal. Addressing the “Tower of Babel” problem identified by McKibbon and colleagues (McKibbon, et al., 2010) would likely require an international consensus group of leaders in implementation research. Certainly, we would be among the first to support such an effort; however, in absence of that, we believe this compilation contributes to the advancement of clarity in the field.
There are also limitations inherent to our search strategy. A broader search strategy that included non-English language sources may have revealed a greater number of strategies. Nevertheless, our purpose was not to capture every possible strategy that could be used in health and mental health, but to highlight the range of available strategies by consolidating and extending other compilations and reviews.
This compilation does not address geographical variations in the organization and financing of health and mental healthcare, and we were unable to identify regional-level implementation strategies, which deserve further attention in the literature. Thus, it is possible that some of the strategies included in the compilation are more readily applicable to the U.S. healthcare system, and that some strategies that are particularly relevant within other nations’ healthcare systems are absent. Nevertheless, our expert query involved an international body of scholars, and we believe that the majority of the strategies included in the compilation are broadly applicable.
This compilation does not address the empirical evidence for included strategies. Though future work could certainly address this element, our priority here was to highlight the range of options available to stakeholders rather than perpetuate the notion that there are a limited number of options available by focusing on those with the most empirical support.
Finally, it was beyond the scope of this article to discuss the explicit theoretical underpinnings of each included strategy (though there are implicit links to the dimensions of the CFIR). While some scholars have debated the utility of theory (Bhattacharyya, Reeves, Garfinkel, & Zwarenstein, 2006), many have emphasized the use of behavioral change theories and broader theoretical models of implementation in the design and selection of implementation strategies (Damschroder, et al., 2009; Grol, Bosch, Hulscher, Eccles, & Wensing, 2007; The Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG), 2006). Future work could make the theoretical underpinnings of each individual strategy more explicit.
Conclusion
It is our hope that this consolidated compilation will play a role in expanding the range of strategies that are both utilized and tested empirically. Yet, the list of strategies and definitions compiled here should not be considered the last word. There are likely strategies in use that are not represented in our compilation. Furthermore, this is a new field, with substantial need and promise for innovation. We welcome suggestions for additions to this list.
  • Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA. Getting research findings into practice: Closing the gap between research and practice: An overview of systematic reviews of interventions to promote the implementation of research findings. British Medical Journal. 1998;317(7156):465–468. [PMC free article] [PubMed]
  • Bhattacharyya O, Reeves S, Garfinkel S, Zwarenstein M. Designing theoretically-informed implementation interventions: Fine in theory, but evidence of effectiveness in practice is needed. Implementation Science. 2006;1(5) [PMC free article] [PubMed]
  • Biegel DE, Kola LA, Ronis RJ, Boyle PE, Reyes CMD, Wieder B, et al. The Ohio substance abuse and mental illness coordinating center of excellence: Implementation support for evidence-based practice. Research on Social Work Practice. 2003;13(4):531–545.
  • Brooks JM, Titler MG, Ardery G, Herr K. Effect of evidence-based acute pain management practices on inpatient costs. Health Services Research. 2009;44(1):245–263. [PMC free article] [PubMed]
  • Cabana MD, Rushton JL, Rush AJ. Implementing practice guidelines for depression: Applying a new framework to an old problem. General Hospital Psychiatry. 2002;24(1):35–42. [PubMed]
  • Carpinello SE, Rosenberg L, Stone J, Schwager M, Felton CJ. New York State’s campaign to implement evidence-based practices for people with serious mental disorders. Psychiatric Services. 2002;53(2):153–155. [PubMed]
  • Chaillet N, Dube E, Dugas M, Audibert F, Tourigny C, Fraser WD, et al. Evidence-based strategies for implementing guidelines in obstetrics: A systematic review. Obstetrics & Gynecology. 2006;108(5):1234–1245. [PubMed]
  • Chamberlain P, Price J, Reid J, Landsverk J. Cascading implementation of a foster and kinship parent intervention. Child Welfare. 2008;87(5):27–48. [PMC free article] [PubMed]
  • Chorpita BF, Daleiden EL, Weisz JR. Modularity in the design and application of therapeutic interventions. Applied and Preventive Psychology. 2005;11:141–156.
  • Clark DM, Layard R, Smithies R, Richards DA. Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour Research and Therapy. 2009;47:910–920. [PMC free article] [PubMed]
  • Cochrane Effective Practice and Organisation of Care Group Data Collection Checklist. 2002:1–30.
  • Corrigan PW, Steiner L, McCracken SG, Blaser B, Barr M. Strategies for disseminating evidence-based practices to staff who treat people with serious mental illness. Psychiatric Services. 2001;52(12):1598–1606. [PubMed]
  • Curry SJ. Organizational interventions to encourage guideline implementation. Chest. 2000;118(2):40S–46S. [PubMed]
  • Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science. 2009;4(50):1–15. [PMC free article] [PubMed]
  • Davis D, Davis N. Educational interventions. In: Straus S, Tetroe J, Graham ID, editors. Knowledge translation in health care: Moving from evidence to practice. Wiley-Blackwell; Oxford, UK: 2009. pp. 113–123.
  • Dijkers M. The task force on systematic reviews and guidelines: The value of traditional reviews in the era of systematic reviewing. Am J Phys Med Rehabil. 2009;88:423–430. [PubMed]
  • Eccles MP, Foy R. Linkage and exchange interventions. In: Straus S, Tetroe J, Graham ID, editors. Knowledge translation in health care: Moving from evidence to practice. Wiley-Blackwell; Oxford, UK: 2009. pp. 123–126.
  • Eccles MP, Mittman BS. Welcome to Implementation Science. Implementation Science. 2006;1(1)
  • Eccles MP, Armstrong D, Baker R, Cleary K, Davies H, Davies S, et al. An implementation research agenda. Implementation Science. 2009;4(18) [PMC free article] [PubMed]
  • Ferlie E. Organizational intervention. In: Straus S, Tetroe J, Graham ID, editors. Knowledge translation in health care: Moving from evidence to practice. Wiley-Blackwell; Oxford, UK: 2009. pp. 144–150.
  • Fink A, Kosecoff J, Chassin M, Brook RH. Consensus methods: Characteristics and guidelines for use. American Journal of Public Health. 1984;74(9):979–983. [PubMed]
  • Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F. Implementation research: A synthesis of the literature (No. FMHI Publication #231) University of South Florida, Louis de la Parte Florida Mental Health Institute, National Implementation Research Network; Tampa, FL: 2005.
  • Flynn FM, Cafarelli M, Petrakos K, Christophersen P. Improving outcomes for acute coronary syndrome patients in the hospital setting: Successful implementation of the American Heart Association “get with the guidelines” program by phase I cardiac rehabilitation nurses. The Journal of Cardiovascular Nursing. 2007;22(3):166–176. [PubMed]
  • Foy R, Eccles MP. Audit and feedback interventions. In: Straus S, Tetroe J, Graham ID, editors. Knowledge translation in health care: Moving from evidence to practice. Wiley: Blackwell; Oxford, UK: 2009. pp. 126–131.
  • Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: A systematic review. JAMA. 2003;289(23):3145–3151. doi: 10.1001/jama.289.23.3145. [PubMed]
  • Glisson C, Schoenwald SK. The ARC organizational and community intervention strategy for implementing evidence-based children’s mental health treatments. Mental Health Services Research. 2005;7(4):243–259. [PubMed]
  • Glisson C, Schoenwald SK, Hemmelgarn A, Green P, Dukes D, Armstrong KS, Chapman JE. Randomized trial of MST and ARC in a two-level evidence-based treatment implementation strategy. Journal of Consulting and Clinical Psychology. 2010;78(4):537–550. [PubMed]
  • Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: Systematic review and recommendations. The Milbank Quarterly. 2004;82(4):581–629. [PubMed]
  • Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, et al. Changing provider behavior: An overview of systematic reviews of interventions. Medical Care. 2001;39(8, Supplement 2):II-2–II-45. [PubMed]
  • Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment. 2004;8(6) [PubMed]
  • Grimshaw J, Eccles M, Thomas R, MacLennan G, Ramsay C, Fraser C, et al. Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966-1998. Journal of General Internal Medicine. 2006;21(Suppl 2):S14–20. doi: JGI357 [pii] 10.1111/j.1525-1497.2006.00357.x. [PMC free article] [PubMed]
  • Grol R. Beliefs and evidence in changing clinical practice. BMJ. 1997;315:418–425. [PMC free article] [PubMed]
  • Grol R. Improving the quality of medical care. JAMA. 2001;284:2578–2585. [PubMed]
  • Grol R, Grimshaw J. From best evidence to best practice: Effective implementation of change in patients’ care. Lancet. 2003;362:1225–1230. [PubMed]
  • Grol R, Wensing M. Effective implementation: A model. In: Grol R, Wensing M, Eccles M, editors. Improving patient care: The implementation of change in clinical practice. Elsevier; Edinburgh: 2005a. pp. 41–57.
  • Grol R, Wensing M. Selection of strategies. In: Grol R, Wensing M, Eccles M, editors. Improving patient care: The implementation of change in clinical practice. Elsevier; Edinburgh: 2005b. pp. 122–134.
  • Grol R, Bosch MC, Hulscher MEJL, Eccles MP, Wensing M. Planning and studying improvement in patient care: The use of theoretical perspectives. The Milbank Quarterly. 2007;85(1):93–138. [PubMed]
  • Grol R, Wensing M, Eccles M, editors. Improving patient care: The implementation of change in clinical practice. Elsevier; Edinburgh: 2005.
  • Gupta S, McKibbon KA. Informatics interventions. In: Straus S, Tetroe J, Graham ID, editors. Knowledge translation in health care: Moving from evidence to practice. Wiley-Blackwell; Oxford, UK: 2009. pp. 131–137.
  • Hammersley M. Systematic or unsystematic, is that the question? Some reflections on the science, art, and politics of reviewing research evidence; Paper presented at the Public Health Evidence Steering Group of the Health Development Agency; 2002; www.nice.org.uk/download.aspx?o=508244.
  • Hysong SJ, Best RG, Pugh JA. Clinical practice guideline implementation strategy patterns in veterans affairs primary care clinics. Health Services Research. 2007;42(1):84–103. [PMC free article] [PubMed]
  • Institute for Healthcare Improvement The Breakthrough Series: IHI’s collaborative model for achieving breakthrough improvement. Institute for Healthcare Improvement; Cambridge, Massachusetts: 2003.
  • Institute of Medicine Crossing the quality chasm: A new health system for the 21st century. National Academy Press; Washington, DC: 2001.
  • Institute of Medicine Improving the quality of health care for mental and substance-use conditions. National Academy Press; Washington, DC: 2006.
  • Institute of Medicine Initial national priorities for comparative effectiveness research. The National Academies Press; Washington, DC: 2009.
  • Jones J, Hunter D. Consensus methods for medical and health services research. BMJ. 1995;311:376–380. [PMC free article] [PubMed]
  • Jones K. Mission drift in qualitative research, or moving toward a systematic review of qualitative studies, moving back to a more systematic narrative review. The Qualitative Report. 2004;9(1):95–112.
  • Kato WJ, Zatzick D, Bond G, Williams J. Dissemination of evidence-based mental health interventions: Importance to the trauma field. Journal of Traumatic Stress. 2006;19(5):611–623. [PubMed]
  • Leeman J, Baernholdt M, Sandelowski M. Developing a theory-based taxonomy of methods for implementing change in practice. Journal of Advanced Nursing. 2007;58(2):191–200. [PubMed]
  • Lehman WEK, Greener JM, Simpson DD. Assessing organizational readiness for change. Journal of Substance Abuse Treatment. 2002;22:197–209. [PubMed]
  • Lomas J. Diffusion, dissemination, and implementation: Who should do what? Annals of the New York Academy of Sciences. 1993;703:226–237. [PubMed]
  • Madon T, Hofman KJ, Kupfer L, Glass RI. Public health. Implementation science. Science. 2007;318:1728–1729. [PubMed]
  • Magnabosco JL. Innovations in mental health services implementation: A report on state-level data from the U.S. evidence-based practices project. Implementation Science. 2006;1(13) [PMC free article] [PubMed]
  • Markiewicz J, Ebert L, Ling D, Amaya-Jackson L, Kisiel C. Learning collaborative toolkit. National Center for Child Traumatic Stress; Los Angeles, CA and Durham, NC: 2006.
  • Marshall T, Solomon P, Steber SA. Implementing best practice models by using a consensus-building process. Administration and Policy in Mental Health. 2001;29(2):105–116. [PubMed]
  • Massoud M, Nielsen G, Nolan K, Nolan T, Schall M, Sevin C. A framework for spread: From local improvements to system-wide change IHI Innovation Series white paper. Institute for Healthcare Improvement; Cambridge, Massachusetts: 2006.
  • McHugh RK, Barlow DH. The dissemination and implementation of evidence-based psychological treatments. American Psychologist. 2010;65(2):73–84. [PubMed]
  • McKibbon KA, Lokker C, Wilczynski NL, Ciliska D, Dobbins M, Davis DA, et al. A cross-sectional study of the number and frequency of terms used to refer to knowledge translation in a body of health literature in 2006: A Tower of Babel? Implementation Science. 2010;5(16) [PMC free article] [PubMed]
  • McMaster University Health systems evidence. Retrieved November 13, 2010, from http://www.healthsystemsevidence.org/
  • McPheeters ML, Briss P, Teutsch SJ, Truman B. Systematic reviews in public health. In: Brownson RC, Petitti DB, editors. Applied epidemiology: Theory to practice. 2nd ed. Oxford University Press; New York: 2006. pp. 99–124.
  • Medves J, Godfrey C, Turner C, Paterson M, Harrison M, MacKenzie L, Durando P. Systematic review of practice guideline dissemination and implementation strategies for healthcare teams and team-based practice. International Journal of Evidence-Based Healthcare. 2010;8(2):79–89. [PubMed]
  • Michie S, Fixsen D, Grimshaw JM, Eccles MP. Specifying and reporting complex behaviour change interventions: the need for a scientific method. Implementation Science. 2009;4(40) [PMC free article] [PubMed]
  • Moulding NT, Silagy CA, Weller DP. A framework for effective management of change in clinical practice: Dissemination and implementation of clinical practice guidelines. Quality in Health Care. 1999;8(3):177–183. [PMC free article] [PubMed]
  • Mueser KT, Torrey WC, Lynde D, Singer P, Drake RE. Implementing evidence-based practices for people with severe mental illness. Behavior Modification. 2003;27(3):387–411. [PubMed]
  • National Institutes of Health Dissemination and implementation research in health. 2010 from http://grants.nih.gov/grants/guide/pa-files/PAR-10-038.html.
  • Norton WE, Amico KR, Cornman DH, Fisher WA, Fisher JD. An agenda for advancing the science of implementation of evidence-based HIV prevention interventions. AIDS and Behavior. 2009;13(3):424–429. [PubMed]
  • O’Connor AM. Patient-mediated interventions. In: Straus S, Tetroe J, Graham ID, editors. Knowledge translation in health care: Moving from evidence to practice. Wiley-Blackwell; Oxford, UK: 2009. pp. 137–144.
  • Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation strategies: A synthesis of systematic review findings. Journal of Evaluation in Clinical Practice. 2008;14:888–897. [PubMed]
  • Proctor EK. Implementing evidence-based practice in social work education: Principles, strategies, and partnerships. Research on Social Work Practice. 2007;17(5):583–591.
  • Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman B. Implementation research in mental health services: An emerging science with conceptual, methodological, and training challenges. Adm Policy Ment Health. 2009;36:24–34. [PubMed]
  • Rabin BA, Brownson RC, Joshu-Haire D, Kreuter MW, Weaver NL. A glossary of dissemination and implementation research in health. Journal of Public Health Management. 2008;14(2):117–123. [PubMed]
  • Rabin BA, Glasgow RE, Kerner JF, Klump MP, Brownson RC. Dissemination and implementation research on community-based cancer prevention: A systematic review. American Journal of Preventative Medicine. 2010;38(4):443–456. [PubMed]
  • Raghavan R, Bright CL, Shadoin AL. Toward a policy ecology of implementation of evidence-based practices in public mental health settings. Implementation Science. 2008;3(26) [PMC free article] [PubMed]
  • Rapp CA, Etzel-Wise D, Marty D, Coffman M, Carlson L, Asher D, et al. Evidence-based practice implementation strategies: Results of a qualitative study. Community Mental Health Journal. 2008;44(3):213–224. [PubMed]
  • Reed RG, Fong SY, Pearson TA. Role of a central laboratory in implementing national cholesterol education panel guidelines in rural practices: Model system for managed care. Clinical Chemistry. 1995;41(2):271–274. [PubMed]
  • Rugs D, Hills HA, Moore KA, Peters RH. A community planning process for the implementation of evidence-based practice. Evaluation and Program Planning. 2011;34(1):29–36. [PubMed]
  • Rx for Change Rx for Change interventions database. Retrieved November 13, 2010, from http://rxforchange.ca/index.php/en/home.
  • Ryan R, Lowe D, Santesso N, Hill S. Development of a taxonomy of interventions directed at consumers to promote evidence-based prescribing and medicines use: A tool for evidence-based decision-making; Paper presented at the National Medicines Symposium; Melbourne, Australia. 2010.
  • Sanders MR, Turner KMT. The role of the media and primary care in the dissemination of evidence-based parenting and family support interventions. The Behavior Therapist. 2002;25(9):156–166.
  • Schoenwald SK. From policy pinball to purposeful partnership: The policy contexts of multisystemic therapy transport. In: Weisz JR, Kazdin AE, editors. Evidence-based psychotherapies for children and adolescents. 2nd ed. Guilford Press; New York: 2010. pp. 538–553.
  • Shapiro SE, Donaldson NA. Evidence-based practice for advanced practice emergency nurses, part III: Planning, implementing, and evaluating an evidence-based small test of change. Advanced Emergency Nursing Journal. 2008;30(3):222–232.
  • Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, Sundaram V, Rushakoff RJ, et al. Effects of quality improvement strategies for Type 2 Diabetes on Glycemic Control: A meta-regression analysis. JAMA. 2006;296(4):427–440. [PubMed]
  • Shojania K, McDonald K, Wachter R, Owens D. Technical Review 9. Agency for Healthcare Research and Quality; Rockville, MD: 2004. Closing the quality gap: A critical analysis of quality improvement strategies, Volume 1-Series overview and methodology.
  • Shortell SM. Increasing value: A research agenda for addressing the managerial and organizational challenges facing health care delivery in the United States. Medical Care Research Review. 2004;61:12S–30S. [PubMed]
  • Sisk JE, Greer AL, Wojtowycz M, Pincus LB, Aubry RH. Implementing evidence-based practice: Evaluation of an opinion leader strategy to improve breast-feeding rates. American Journal of Obstetrics & Gynecology. 2004;190(2):413–421. [PubMed]
  • Slavin RE, Madden NA. Disseminating success for all: Lessons for policy and practice. Center for Research on the Education of Students Placed At Risk; Baltimore: 1999.
  • Solberg LI. Guideline implementation: What the literature doesn’t tell us. Journal on Quality Improvement. 2000;26(9):525–537. [PubMed]
  • Solberg LI, Brekke ML, Fazio CJ, Fowles J, Jacobsen DN, Kottke TE, et al. Lessons from experienced guideline implementers: Attend to many factors and use multiple strategies. Journal on Quality Improvement. 2000;26(4):171–188. [PubMed]
  • Sosna T, Marsenich L. Community development team model: Supporting the model adherent implementation of programs and practices. California Institute for Mental Health; Sacramento, CA: 2006.
  • Spoth R, Clair S, Greenberg M, Redmond C, Shin C. Toward dissemination of evidence-based family interventions: Maintenance of community-based partnership recruitment results and associated factors. Journal of Family Psychology. 2007;21(2):137–146. [PMC free article] [PubMed]
  • Stetler CB, McQueen L, Demakis J, Mittman BS. An organizational framework and strategic implementation for systems-level change to enhance research-based practice: QUERI series. Implementation Science. 2008;3(30) [PMC free article] [PubMed]
  • Stone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, Grimshaw JM, et al. Interventions that increase use of adult immunization and cancer screening services: A meta-analysis. Annals of Internal Medicine. 2002;136:641–651. [PubMed]
  • Straus S, Tetroe J, Graham ID, editors. Knowledge translation in health care: Moving from evidence to practice. Wiley-Blackwell; Hoboken, NJ: 2009.
  • The Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG) Designing theoretically-informed implementation interventions. Implementation Science. 2006;1(4) [PMC free article] [PubMed]
  • Thompson RS, Taplin SH, McAfee TA, Mandelson MT, Smith AE. Primary and secondary prevention services in clinical practice: Twenty years’ experience in development, implementation, and evaluation. JAMA. 1995;273(14):1130–1135. [PubMed]
  • Titler MG, Herr K, Brooks JM, Xie X-J, Ardery G, Schilling ML, et al. Translating research into practice intervention improves management of acute pain in older hip fracture patients. Health Services Research. 2009;44(1):264–287. [PMC free article] [PubMed]
  • Torrey WC, Finnerty M, Evans A, Wyzik P. Strategies for leading the implementation of evidence-based practices. Psychiatric Clinics of North America. 2003;26(4):883–897. [PubMed]
  • Walter I, Nutley S, Davies H. Developing a taxonomy of interventions used to increase the impact of research. 2003 Retrieved from http://www.ruru.ac.uk/PDFs/Taxonomy%20development%20paper%20070103.pdf.
  • Walter I, Nutley S, Davies H. What works to promote evidence-based practice? A cross-sector review. Evidence & Policy. 2005;1(3):335–363.
  • Weiner BJ, Amick H, Lee S-YD. Conceptualization and measurement of organizational readiness for change: A review of the literature in health services research and other fields. Medical Care Research and Review. 2008;65(4):379–436. [PubMed]
  • Wensing M, Grol R. Educational interventions. In: Grol R, Wensing M, Eccles M, editors. Improving patent care: The implementation of change in clinical practice. Elsevier; Edinburgh: 2005. pp. 147–157.
  • Wensing M, Bosch M, Grol R. Selecting, tailoring, and implementing knowledge translation interventions. In: Straus S, Tetroe J, Graham ID, editors. Knowledge Translation in health care: Moving from evidence to practice. Wiley-Blackwell; Oxford, UK: 2009. pp. 94–113.
  • Wensing M, Elwyn G, Grol R. Patient-mediated strategies. In: Grol R, Wensing M, Eccles M, editors. Improving patient care: The implementation of change in clinical practice. Elsevier; Edinburgh: 2005. pp. 185–196.
  • Wensing M, Klazinga N, Wollersheim H, Grol R. Organizational and financial interventions. In: Grol R, Wensing M, Eccles M, editors. Improving patient care: The implementation of change in clinical practice. Elsevier; Edinburgh: 2005. pp. 173–184.
  • Wensing M, van der Weijden T, Grol R. Implementing guidelines and innovations in general practice: Which interventions are effective? The British Journal of General Practice: The Journal of the Royal College of General Practitioners. 1998;48(427):991–997. [PMC free article] [PubMed]
  • Zed PJ, Rowe BH, Loewen PS, Abu-Laban RB. Systematic reviews in emergency medicine: Part I. Background and general principles for locating and critically appraising reviews. Can J Emerg Med. 2003;5(5):331–335. [PubMed]