Internationally, there is a substantial gap between innovations in health and mental healthcare and their delivery in routine practice (Institute of Medicine, 2001
; 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 .
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.
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.
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.