Challenges of implementation and implementation research: Learning from an intervention study designed to improve tumor registry reporting

Abstract

Objectives:Implementation of interventions designed to improve the quality of medical care often proceeds differently from what is planned. Improving existing conceptual models to better understand the sources of these differences can help future projects avoid these pitfalls and achieve desired effectiveness. To inform an adaptation of an existing theoretical model, we examined unanticipated changes that occurred in an intervention designed to improve reporting of adjuvant therapies for breast cancer patients at a large, urban academic medical center.Methods:Guided by the complex innovation implementation conceptual framework, our study team observed and evaluated the implementation of an intervention designed to improve reporting to a tumor registry. Findings were assessed against the conceptual framework to identify boundary conditions and modifications that could improve implementation effectiveness.Results:The intervention successfully increased identification of the managing medical oncologist and treatment reporting. During implementation, however, unexpected external challenges including hospital acquisitions of community practices and practices’ responses to government incentives to purchase electronic medical record systems led to unanticipated changes and associated threats to implementation. We present a revised conceptual model that incorporates the sources of these unanticipated challenges.Conclusion:This report of our experience highlights the importance of monitoring implementation over time and accounting for changes that affect both implementation and measurement of intervention impact. In this article, we use our study to examine the challenges of implementation research in health care, and our experience can help future implementation efforts.

Innovation implementation in the context of hospital QI: lessons learned and strategies for success

“…At the organizational level, several articles have [25][26][27][28][29]36,37 Other studies that have used frameworks like the Barriers Scale and Middle Manager's role in innovation implementation have also found support for individual components of the Innovation Implementation Framework, like "presence of a champion" and "support from management." [30][31][32][33][34] At the clinician level, applications of frameworks like Disruptive Innovation theory, Deskilling and Adaptation, and Sense-Making theory, among others, have helped to demonstrate the crucial role of "innovation-values fit" for enabling behavior change and innovation implementation among frontline clinicians.…”

Prevention of Adolescent Depression in Primary Care

“…Implementation of an intervention may be affected by political, organizational, and behavioral factors—both external and internal to healthcare organizations—that may delay or inhibit administration. Examples of external barriers include unanticipated events such as economic downturn, strict healthcare regulations, and terrorist attacks; these factors may restrict the time available for clinics to participate in an intervention or force a clinic to redistribute resources (McAlearney, Walker, Livaudais-Toman, Parides, & Bickell, 2016). Governmental policy regulations such as the Affordable Care Act of 2010 and the Health Insurance Portability and Accountability Act of 1996 may have complex overlapping policies and regulations that are designed to protect patient policy but actually impede the ability of policy makers to implement interventions (Bova, Drexler, & Sullivan-Bolyai, 2012; Midkiff et al, 2016; Ness, 2007).…”

Evaluation and implementation of highly challenging balance training in clinical practice for people with Parkinson’s disease: protocol for the HiBalance effectiveness-implementation trial

“…Table 2 provides an overview of the process outcomes as well as the subdomains of the CFIR constructs outlines above, which will guide data collection of the process evaluation and in the assessment of barriers and facilitators to implementation. However, we also acknowledge such frameworks do not conceptualize the role of unexpected events [ 37 ] and we aim therefore for flexibility in the data collection to allow for emergent factors concerning barriers and facilitators to be explored during the qualitative interview process [ 21 ].…”