Implementation of Patient-Reported Outcomes in a Medical Oncology Setting (the iPROMOS Study): Type II Hybrid Implementation Study.

BACKGROUND: Clinical trials have demonstrated that patient-reported outcome measures (PROMs) can improve mortality and morbidity outcomes when used in clinical practice. OBJECTIVE: This study aimed to prospectively investigate the implementation of PROMs in routine oncology. Outcomes measured included improved symptom detection, clinical response to symptom information, and health service outcomes. METHODS: Two of 12 eligible clinics were randomized to implement symptom PROMs in a medical oncology outpatient department in Australia. Randomization was carried out at the clinic level. Patients in control clinics continued with usual care; those in intervention clinics completed a symptom PROM at presentation. This was a pilot study investigating symptom detection, using binary logistic models, and clinical response to PROMs investigated using multiple regression models. RESULTS: A total of 461 patient encounters were included, consisting of 242 encounters in the control and 222 in the intervention condition. Patients in these clinics most commonly had head and neck, lung, prostate, breast, or colorectal cancer and were seen in the clinic for surveillance and oral or systemic treatments for curative, metastatic, or palliative cancer care pathways. Compared with control encounters, the proportion of symptoms detected increased in intervention encounters (odds ratio 1.05, 95% CI 0.99-1.11; P=.08). The odds of receiving supportive care, demonstrated by nonroutine allied health review, increased in the intervention compared with control encounters (odds ratio 3.54, 95% CI 1.26-9.90; P=.02). CONCLUSIONS: Implementation of PROMs in routine care did not significantly improve symptom detection but increased the likelihood of nonroutine allied health reviews for supportive care. Larger studies are needed to investigate health service outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000398202; https://tinyurl.com/3cxbemy4.

'It opened my eyes, my ears, and my heart': Codesigning a substance use disorder treatment programme.

BACKGROUND: Pregnant and parenting women have low engagement and poor retention in substance use disorder (SUD) treatment. The aim of this study was to analyse the implementation of an adapted experience-based codesign (EBCD) process involving SUD treatment staff and pregnant or parenting women with lived experience (WWLE) of SUD to launch a residential treatment service where women could coreside with their children and receive long term comprehensive treatment for dual diagnosis of SUD and mental illness. METHODS: A process evaluation was conducted utilising five data sources: two sets of semistructured interviews with WWLE and SUD treatment staff, ethnographic observation and transcripts from group events, and meeting minutes. Based on the Integrated Promoting Action on Research in Health Services framework constructs (context, recipients, facilitation, innovation) researchers applied thematic analysis to determine main themes within each construct. RESULTS: The full sample across the implementation totalled 34 individuals (WWLE = 13 and SUD staff = 21). The EBCD process engaged both cohorts and supported group cohesion and collaborative brainstorming. WWLE felt respected, emotionally safe to share, and empowered by participation. A cohesive, multidisciplinary codesign planning group, inclusive of WWLE, supported a more equitable codesign process. The need for a virtual platform due to the COVID-19 pandemic impeded human connection and relationship building. The complex environment of residential regulations and uncertainties during start-up phase of an organisation presented implementation challenges. CONCLUSION: These results highlight the feasibility of, and challenges to, effectively engaging WWLE in a codesign process. The findings also demonstrated a positive influence on WWLE's feelings of empowerment. Identified themes reinforce the purposeful components within EBCD that enhance participation, along with new insights to inform successful codesign with a vulnerable population. The author's team included a WWLE who collaborated throughout the full scope of the research process, enriching the overall research and ensuring the authenticity of the presentation of women in recovery's perspective. Utilising the codesign approach to design and implement new services should improve health equity by enhancing patient engagement and retention in care. PATIENT CONTRIBUTION: Parenting WWLE of residential SUD treatment were involved in the full scope of the research process and the implementation being evaluated. For the actual codesign work WWLE were key members of the codesign planning team that met weekly throughout the implementation to plan, implement, problem solve and adapt the process over an 18 month timeframe. As is appropriate for codesign the actual ongoing workgroup participants had average 50% WWLE participation. For the research team, this research is a culmination of the lead author's doctoral dissertation. One member of the five-person dissertation committee was a recovery coach and a WWLE. She was an active participant across the entire research process overseeing and influencing the research design, conduct of the study, analysis, interpretation of findings and approval of the final manuscript. The findings were member checked with the larger codesign planning group that had additional WWLE members.

Navigating the facilitation journey: a qualitative, longitudinal evaluation of 'Eat Walk Engage' novice and experienced facilitators.

BACKGROUND: The Promoting Action on Research Implementation in Health Services (PARIHS) and integrated-PARIHS (i-PARIHS) frameworks position facilitation as an overarching strategy to enable implementation. In the revised i-PARIHS framework, facilitation is operationalised through a multi-level model with novice, experienced and expert facilitators working together in a network structure to build facilitation knowledge and skills along a continuum. To date, there has been limited evaluation of this facilitation model in practice, which is the aim of the study reported here. METHODS: A descriptive, qualitative longitudinal study was undertaken to track a team of four novice and two experienced facilitators involved in facilitating the implementation of an intervention known as 'Eat Walk Engage' to improve multidisciplinary team delivery of age-friendly care principles in hospital. Over an 18-month period, repeat interviews were conducted to explore the learning, development, and evolving roles of novice facilitators and the roles of the experienced facilitators in providing support and mentoring. Interview data were analysed using a descriptive qualitative approach and findings were interpreted in collaboration with the participating facilitators. RESULTS: The findings demonstrated experiential learning in both the novice and experienced facilitator groups as they enacted their roles in practice. The novice facilitators progressively transitioned to becoming more experienced facilitators and the experienced facilitators became increasingly expert, in line with the i-PARIHS concept of a facilitation journey from novice to expert. Strategies to support this development included a staggered approach to learning, regular meetings between the experienced and novice facilitators, reflective writing and informal peer support and networking. However, the roles were not without challenge and these challenges changed over time, from a more specific focus on the demands of the facilitator role to concerns about embedding and sustaining improvements in practice. CONCLUSIONS: Within a network of peers and a mentored relationship with more experienced facilitators, individuals who are new to an implementation facilitator role can transition along a continuum to become experienced facilitators. Building implementation facilitation capability in this way takes time and requires tailored support and mentorship using a mix of structured and flexible approaches incorporating opportunities for reflection to support individual and group learning.

Building effective engagement for implementation with i-PARIHS: a collaborative enquiry into paediatric pain care in the emergency department.

BACKGROUND: Pain is a central and distressing experience for children in the emergency department (ED). Despite the harmful effects of pain, ED care often falls short of providing timely and effective pain relief. Knowledge translation research targeting systems of care holds potential to transform paediatric pain care. This article reports on the first stages of an implementation project aimed at embedding effective and sustainable practice change in an Australian children's hospital ED. METHODS: The integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework underpinned a cooperative process of engagement to establish a practitioner-led, interprofessional research collaborative. The Kids Pain Collaborative (KPC) aimed to co-design innovation in paediatric ED pain care, facilitating an extensive reconnaissance of research evidence, clinician and family experiences, and local evaluation data. This critical appraisal of the context and culture of pain management generated foci for innovation and facilitation of implementation action cycles. RESULTS: Engaging in a complex process of facilitated critical reflection, the KPC unpacked deeply embedded assumptions and organisational practices for pain care that worked against what they wanted to achieve as a team. A culture of rules-based pain management and command and control leadership produced self-defeating practices and ultimately breakdowns in pain care. By raising a critical awareness of context, and building consensus on the evidence for change, the KPC has established a whole of ED shared vision for prioritising pain care. CONCLUSIONS: In-depth key stakeholder collaboration and appraisal of context is the first step in innovation of practice change. The KPC provided a space for collaborative enquiry where ED clinicians and researchers could develop context-specific innovation and implementation strategy. We provide an example of the prospective application of i-PARIHS in transforming ED pain care, using a collaborative and participatory approach that has successfully enabled high levels of departmental engagement, motivation and ownership of KPC implementation as the facilitation journey unfolds.

Using i-PARIHS to assess implementation of the Surgical Safety Checklist: an international qualitative study.

BACKGROUND: Strategies selected to implement the WHO's Surgical Safety Checklist (SSC) are key factors in its ability to improve patient safety. Underutilization of implementation frameworks for informing implementation processes hinders our understanding of the checklists' varying effectiveness in different contexts. This study explored the extent to which SSC implementation practices could be assessed through the i-PARIHS framework and examined how it could support development of targeted recommendations to improve SSC implementation in high-income settings. METHODS: This qualitative study utilized interviews with surgical team members and health administrators from five high-income countries to understand the key elements necessary for successful implementation of the SSC. Using thematic analysis, we identified within and across-case themes that were mapped to the i-PARIHS framework constructs. Gaps in current implementation strategies were identified, and the utility of i-PARIHS to guide future efforts was assessed. RESULTS: Fifty-one multi-disciplinary clinicians and health administrators completed interviews. We identified themes that impacted SSC implementation in each of the four i-PARIHS constructs and several that spanned multiple constructs. Within innovation, a disconnect between the clinical outcomes-focused evidence in the literature and interviewees' patient-safety focus on observable results reduced the SSC's perceived relevance. Within recipients, existing surgical team hierarchies impacted checklist engagement, but this could be addressed through a shared leadership model. Within context, organizational priorities resulting in time pressures on surgical teams were at odds with SSC patient safety goals and reduced fidelity. At a health system level, employing surgical team members through the state or health region resulted in significant challenges in enforcing checklist use in private vs public hospitals. Within its facilitation construct, i-PARIHS includes limited definitions of facilitation processes. We identified using multiple interdisciplinary champions; establishing checklist performance feedback mechanisms; and modifying checklist processes, such as implementing a full-team huddle, as facilitators of successful SSC implementation. CONCLUSION: The i-PARIHS framework enabled a comprehensive assessment of current implementation strategies, identifying key gaps and allowed for recommending targeted improvements. i-PARIHS could serve as a guide for planning future SSC implementation efforts, however, further clarification of facilitation processes would improve the framework's utility. TRIAL REGISTRATION: No health care intervention was performed.

Health workers' experiences of implementation of Helping Mothers Survive Bleeding after Birth training in Tanzania: a process evaluation using the i-PARIHS framework.

BACKGROUND: In-service training, including the competency-based Helping Mothers Survive Bleeding After Birth (HMS BAB) is widely implemented to improve the quality of maternal health services. To better understand how this specific training responds to the needs of providers and fits into the existing health systems, we explored health workers' experiences of the HMS BAB training. METHODS: Our qualitative process evaluation was done as part of an effectiveness trial and included eight focus group discussions with 51 healthcare workers in the four districts which were part of the HMS BAB trial. We employed deductive content analysis informed by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) construct of context, recipients, innovation and facilitation. RESULTS: Overall, health workers reported positive experiences with the training content and how it was delivered. They are perceived to have improved competencies leading to improved health outcomes. Interviews proposed that peer practice coordinators require more support to sustain the weekly practices. Competing tasks within the facility in the context of limited time and human resources hindered the sustainability of weekly practices. Most health facilities had outlined the procedure for routine learning environments; however, these were not well operational. CONCLUSION: The HMS BAB training has great potential to improve health workers' competencies around the time of childbirth and maternal outcomes. Challenges to successful implementation include balancing the intervention within the routine facility setting, staff motivation and workplace cultures.

An implementation science approach for developing and implementing a dietitian-led model of care for gestational diabetes: a pre-post study.

BACKGROUND: There is strong evidence that women with gestational diabetes mellitus (GDM) who receive a minimum of three appointments with a dietitian may require medication less often. The aim of this study was to evaluate the impact of a dietitian-led model of care on clinical outcomes and to understand the utility of the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework as a prospective tool for implementation. METHODS: This was a pre-post intervention study measuring outcomes before-and-after changing a gestational diabetes (GDM) model of care and included women with GDM managed at a large, regional hospital in Queensland, Australia. The i-PARIHS framework was used to develop, implement and evaluate a dietitian-led model of care which increased dietetic input for women with GDM to a minimum of one initial education and two review appointments. The outcomes were adherence to the schedule of appointments, clinician perspective of the implementation process, pharmacotherapy use, gestational age at commencement of pharmacotherapy and birth weight. Pre- and post- comparisons of outcomes were made using t-tests and chi-squared tests. RESULTS: Adherence to the dietetic schedule of appointments was significantly increased from 29 to 82% (p < 0.001) but pharmacotherapy use also increased by 10% (p = 0.10). There were significantly more women in the post-intervention group who were diagnosed with GDM prior to 24 weeks gestation, a strong independent predictor of pharmacotherapy use. Infant birthweight remained unchanged. The i-PARIHS framework was used as a diagnostic tool and checklist in the model of care development phase; a facilitation tool during the implementation phase; and during the evaluation phase was used as a reflection tool to identify how the i-PARIHS constructs and their interactions that may have impacted on clinical outcomes. CONCLUSIONS: The i-PARIHS framework was found to be useful in the development, implementation and evaluation of a dietitian-led model of care which saw almost 90% of women with GDM meet the minimum schedule of dietetic appointments.

Experiences of using the i-PARIHS framework: a co-designed case study of four multi-site implementation projects.

BACKGROUND: The integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework is an implementation framework that has been developed and refined over the last 20 years. Its underlying philosophy is that implementing research into healthcare practice is complex, unpredictable and non-linear which therefore requires a flexible and responsive approach to implementation. Facilitation is recognized as the central ingredient of this approach, and i-PARIHS now provides a Facilitation Guide with associated tools. This multiple case study of four implementation projects explored how the i-PARIHS framework has been practically operationalized by diverse implementation project teams. METHODS: A co-design approach was used to elicit the experiences of four implementation project teams who used the i-PARIHS framework to guide their implementation approach. We conducted the established co-design steps of (i) setting up for success, (ii) gathering the experience, and (iii) understanding the experience. In particular we explored teams' approaches to setting up their projects; why and how they used the i-PARIHS framework and what they learnt from the experience. RESULTS: We found both commonalities and differences in the use of i-PARIHS across the four implementation projects: (i) all the projects used the Facilitation Checklist that accompanies i-PARIHS as a starting point, (ii) the projects differed in how facilitation was carried out, (iii) existing tools were adapted for distinct phases: pre-implementation, during implementation, and post-implementation stages; and (iv) project-specific tools were often developed for monitoring implementation activities and fidelity. CONCLUSIONS: We have provided a detailed overview of how current users of i-PARIHS are operationalising the framework, which existing tools they are using or adapting to use, and where they have needed to develop new tools to best utilise the framework. Importantly, this study highlights the value of existing tools from the published i-PARIHS Facilitation Guide and provides a starting point to further refine and add to these tools within a future Mobilising Implementation of i-PARIHS (or "Mi-PARIHS") suite of resources. Specifically, Mi-PARIHS might include more explicit guidance and/or tools for developing a structured implementation plan and monitoring fidelity to the implementation plan, including recording how strategies are tailored to an evolving context.

Evaluation of a three-phase implementation program in enhancing e-mental health adoption within Indigenous primary healthcare organisations.

BACKGROUND: A three-phase implementation program was carried out to support Indigenous primary healthcare organisations in Australia to integrate e-mental health approaches into the day-to-day practice. The present study aimed to evaluate the process and the effectiveness of the program. METHODS: A concurrent triangulation design was employed to collect and compare quantitative and qualitative data from organisations that participated in the implementation program (case studies) to those that participated in training only (non-case studies). Quantitative methods, i.e., t-tests and descriptive statistics, were used to measure outcomes relating to the frequency of e-mental health usage and levels of organisational readiness. Qualitative data were analysed separately, using theoretical thematic analysis, to gain an in depth understanding of the implementation process. The findings were integrated and interpreted within the implementation science literature. RESULTS: The case studies evidenced greater use of e-mental health approaches than the non-case studies. They also demonstrated increased organisational readiness over the course of the implementation program. The program helped organisations to work and improve on essential aspects within the organisation so that they better supported e-mental health adoption. The key areas addressed were Information Technology resources and infrastructure, leadership and support, policy and protocols around e-mental health utilisation and its integration into practice. CONCLUSIONS: By addressing and improving essential aspects relating to e-mental health implementation, the program helped organisations to increase organisational readiness and enhance uptake of e-mental health approaches.

External facilitators' perceptions of internal facilitation skills during implementation of collaborative care for mental health teams: a qualitative analysis informed by the i-PARIHS framework.

BACKGROUND: Facilitation is a key strategy that may contribute to successful implementation of healthcare innovations. In blended facilitation, external facilitators (EFs) guide and support internal facilitators (IFs) in directing implementation processes. Developers of the i-PARIHS framework propose that successful facilitation requires project management, team/process, and influencing/negotiating skills. It is unclear what IF skills are most important in real-world settings, which could inform recruitment and training efforts. As prior qualitative studies of IF skills have only interviewed IFs, the perspectives of their EF partners are needed. Furthermore, little is known regarding the distribution of implementation tasks between IFs and EFs, which could impact sustainability once external support is removed. In the context of an implementation trial, we therefore: 1) evaluated IFs' use of i-PARIHS facilitation skills, from EFs' perspectives; 2) identified attributes of IFs not encompassed within the i-PARIHS skills; and 3) investigated the relative contributions of IFs and EFs during facilitation. METHODS: Analyses were conducted within a hybrid type II trial utilizing blended facilitation to implement the collaborative chronic care model within mental health teams of nine VA medical centers. Each site committed one team and an IF to weekly process design meetings and additional implementation activities over 12 months. Three EFs worked with three sites each. Following study completion, the EFs completed semi-structured qualitative interviews reflecting on the facilitation process, informed by the i-PARIHS facilitation skill areas. Interviews were analyzed via directed content analysis. RESULTS: EFs emphasized the importance of IFs having strong project management, team/process, and influencing/negotiating skills. Prior experience in these areas and a mental health background were also benefits. Personal characteristics (e.g., flexible, assertive) were described as critical, particularly when faced with conflict. EFs discussed the importance of clear delineation of EF/IF roles, and the need to shift facilitation responsibilities to IFs. CONCLUSIONS: Key IF skills, according to EFs, are aligned with i-PARIHS recommendations, but IFs' personal characteristics were also emphasized as important factors. Findings highlight traits to consider when selecting IFs and potential training areas (e.g., conflict management). EFs and IFs must determine an appropriate distribution of facilitation tasks to ensure long-term sustainability of practices. TRIAL REGISTRATION: Clinicaltrials.gov, September 7, 2015, #NCT02543840.

Sustainability of a rural volunteer program (Nav-CARE): a case study.

INTRODUCTION: Nav-CARE (Navigation: Connecting, Accessing, Resourcing and Engaging) is an evidence-based program that was implemented over 1 year in a rural community in western Canada. Nav-CARE uses volunteers who are trained in navigation to facilitate access to resources and provide social support to older persons living in the community with serious illness such as cancer, congestive heart failure and chronic obstructive pulmonary disease. Following implementation in which Nav-CARE was found to be feasible, acceptable and have positive outcomes, Nav-CARE was integrated into the local community-based hospice society program. Two years after a successful implementation, it continued to be sustainable in this same rural community. The purpose of this study was to explore the key factors that facilitated the sustainability of Nav-CARE in a rural hospice society. METHODS: A qualitative single case study design was used with data from several sources collected at different times: (a) pre-implementation, (b) Nav-CARE program implementation (1-year time period), (c) immediately after implementation and (d) 6 months to 2 years after implementation). Data included individual interviews with community stakeholders (n=9), the study volunteer coordinator (n=1), hospice society coordinator (n=1) and Nav-CARE volunteers (n=9). It also included meeting notes of volunteer debriefing sessions and meetings with stakeholders planning for sustainability of Nav-CARE that were held during the 1-year implementation. Data were organized using the i-PARIHS (integrated Promoting Action on Research Implementation in Health Services) framework (a well known implementation framework). Data were analyzed using Yin's qualitative case study approach. RESULTS: The findings from this case study suggested that key factors in facilitating sustainability of a rural community intervention (Nav-CARE) were the organizational context (inner context) and facilitation (facilitator and facilitation processes). Additionally, the inner context included the fit of Nav-CARE with the organization's priorities, the absorptive capacity of the organization, and organizational structure and mechanisms to integrate Nav-CARE into current programs. The hospice society was well established and supported by the rural community. The role of the facilitator and the planned facilitation processes (training of volunteer navigators, ongoing support and planning events) were key factors in the sustainability of the Nav-CARE program. The findings found that the formal role of the facilitator in the implementation and sustainability of Nav-CARE in this rural community required skills and knowledge, as well as ongoing mentorship. As well, the facilitation process for Nav-CARE included formal sustainability planning meetings involving stakeholders. CONCLUSION: Using the i-PARIHS framework and a case study approach, key factors for facilitating sustainability were identified. The role of the facilitator, the facilitation processes and the characteristics of the organizational context were important for the sustainability of Nav-CARE. Future research is needed to understand how to assess and enhance an organization's sustainability capacity and the impact of additional facilitator training and mentoring. This study provides a foundation for future research and adds to the discussion of the issue of sustainability of evidence-based interventions in rural community settings.

Facilitating the implementation of clinical technology in healthcare: what role does a national agency play?

BACKGROUND: Accelerating the implementation of new technology in healthcare is typically complex and multi-faceted. One strategy is to charge a national agency with the responsibility for facilitating implementation. This study examines the role of such an agency in the English National Health Service. In particular, it compares two different facilitation strategies employed by the agency to support the implementation of insulin pump therapy. METHODS: The research involved an empirical case study of four healthcare organisations receiving different levels of facilitation from the national agency: two received active hands-on facilitation; one was the intended recipient of a more passive, web-based facilitation strategy; the other implemented the technology without any external facilitation. The primary method of data collection was semi-structured qualitative interviews with key individuals involved in implementation. The integrated-PARIHS framework was applied as a conceptual lens to analyse the data. RESULTS: The two sites that received active facilitation from an Implementation Manager in the national agency made positive progress in implementing the technology. In both sites there was a high level of initial receptiveness to implementation. This was similar to a site that had successfully introduced insulin pump therapy without facilitation support from the national agency. By contrast, a site that did not have direct contact with the national agency made little progress with implementation, despite the availability of a web-based implementation resource. Clinicians expressed differences of opinion around the value and effectiveness of the technology and contextual barriers related to funding for implementation persisted. The national agency's intended roll out strategy using passive web-based facilitation appeared to have little impact. CONCLUSIONS: When favourable conditions exist, in terms of agreement around the value of the technology, clinician receptiveness and motivation to change, active facilitation via an external agency can help to structure the implementation process and address contextual barriers. Passive facilitation using web-based implementation resources appears less effective. Moving from initial implementation to wider scale-up presents challenges and is an issue that warrants further attention.

Application of the i-PARIHS framework for enhancing understanding of interactive dissemination to achieve wide-scale improvement in Indigenous primary healthcare.

BACKGROUND: Participatory research approaches improve the use of evidence in policy, programmes and practice. Few studies have addressed ways to scale up participatory research for wider system improvement or the intensity of effort required. We used the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to analyse implementation of an interactive dissemination process engaging stakeholders with continuous quality improvement (CQI) data from Australian Indigenous primary healthcare centres. This paper reports lessons learnt about scaling knowledge translation research, facilitating engagement at a system level and applying the i-PARIHS framework to a system-level intervention. METHODS: Drawing on a developmental evaluation of our dissemination process, we conducted a post-hoc analysis of data from project records and interviews with 30 stakeholders working in Indigenous health in different roles, organisation types and settings in one Australian jurisdiction and with national participants. Content-analysed data were mapped onto the i-PARIHS framework constructs to examine factors contributing to the success (or otherwise) of the process. RESULTS: The dissemination process achieved wide reach, with stakeholders using aggregated CQI data to identify system-wide priority evidence-practice gaps, barriers and strategies for improvement across the scope of care. Innovation characteristics influencing success were credible data, online dissemination and recruitment through established networks, research goals aligned with stakeholders' interest in knowledge-sharing and motivation to improve care, and iterative phases of reporting and feedback. The policy environment and infrastructure for CQI, as well as manager support, influenced participation. Stakeholders who actively facilitated organisational- and local-level engagement were important for connecting others with the data and with the externally located research team. Developmental evaluation was facilitative in that it supported real-time adaptation and tailoring to stakeholders and context. CONCLUSIONS: A participatory research process was successfully implemented at scale without intense facilitation efforts. These findings broaden the notion of facilitation and support the utility of the i-PARIHS framework for planning participatory knowledge translation research at a system level. Researchers planning similar interventions should work through established networks and identify organisational- or local-level facilitators within the research design. Further research exploring facilitation in system-level interventions and the use of interactive dissemination processes in other settings is needed.

The influence of contextual factors on an intervention for people with disabilities from support persons' and health personnel's perspectives: a focus group study.

Introduction: Contextual factors influence interventions in healthcare and pose a particular challenge in interventions designed for people with profound intellectual and multiple disabilities (PIMD). Exploring support persons' and health personnel's experience of an intervention may improve our understanding of the influence of contextual factors. Such exploration is important for revealing areas and focus points for future implementations. Therefore, the aim of this study is to explore support persons' and health personnel's experience of contextual factors during involvement in an intervention for people with PIMD. Methods: This focus group study includes eight groups, comprising a total of 34 support persons and health personnel, at habilitation centres at four regions in central Sweden. Data were analysed inductively using a content analysis approach. Results: Three themes emerged from the analysis of the informants' perspectives on the contextual factors: (1) structure and support enhances intervention feasibility; (2) an intervention's benefit for people with PIMD increases its acceptability; and (3) being engaged and involved increases support persons' and health personnel's motivation. Our findings show that the implementation of an intervention for people with PIMD should focus on the recipients of the intervention in its context, forming a clear communication plan. A training programme should be provided for the recipients and providers of the intervention. Discussion: Finally, the implementation process can be facilitated by creating space for staff to contribute and by encouraging participation and ownership for everyone involved. Using a co-design strategy can enable a shared responsibility to solve the identified challenges, while contributing to the development and design of future interventions for people with disabilities.

Implementing evidence-based practices in rural settings: a scoping review of theories, models, and frameworks.

Background: Rural healthcare has unique characteristics that affect the dissemination and implementation of evidence-based interventions. Numerous theories, models, and frameworks have been developed to guide implementation of healthcare interventions, though not specific to rural healthcare. The present scoping review sought to identify the theories, models, and frameworks most frequently applied to rural health and propose an approach to rural health research that harnesses selected constructs from these theories, models, and frameworks. This resulting synthesis can serve as a guide to researchers, policy makers, and clinicians seeking to employ commonly used theories, models, and frameworks to rural health. Methods: We used the Scopus abstract indexing service to identify peer-reviewed literature citing one or more of theories, models, or frameworks used in dissemination and implementation research and including the word "rural" in the Title, Abstract, or Keywords. We screened the remaining titles and abstracts to ensure articles met additional inclusion criteria. We conducted a full review of the resulting 172 articles to ensure they identified one or more discrete theory, model, or framework applied to research or quality improvement projects. We extracted the theories, models, and frameworks and categorized these as process models, determinant frameworks, classic theories, or evaluation frameworks. Results: We retained 61 articles of which 28 used RE-AIM, 11 used Community-Based Participatory Research (CBPR) framework, eight used the Consolidated Framework for Implementation Research (CFIR), and six used the integrated-Promoting Action on Research Implementation in Health Services (iPARIHS). Additional theories, models, and frameworks were cited in three or fewer reports in the literature. The 14 theories, models, and frameworks cited in the literature were categorized as seven process models, four determinant frameworks, one evaluation framework, and one classic theory. Conclusions: The RE-AIM framework was the most frequently cited framework in the rural health literature, followed by CBPR, CFIR, and iPARIHS. A notable advantage of RE-AIM in rural healthcare settings is the focus on reach as a specified outcome, given the challenges of engaging a geographically diffuse and often isolated population. We present a rationale for combining the strengths of these theories, models, and frameworks to guide a research agenda specific to rural healthcare research. Systematic Review Registration: https://osf.io/fn2cd/.

Exploring stakeholders' perspectives on antibiogram use, development, and implementation in residential aged care settings.

BACKGROUND: Knowledge of local antibiotic resistance data provided by antibiograms (cumulative-antimicrobial-susceptibility-tests) can assist prescribers to make appropriate empirical antibiotic choices. OBJECTIVE: This study explored the perceptions and knowledge of key stakeholders about the role of antibiograms in residential aged care facilities (RACF), and to understand barriers and enablers of antibiogram development and implementation in this setting. METHOD: Semi-structured interviews were conducted with aged-care health professionals ('end-users') and antibiogram content experts. This study was conducted in Queensland, Australia in 2023. Using qualitative techniques, framework thematic analysis was used to identify themes, which were mapped to the 'Integrated Promoting Action on Research Implementation in Health Services' framework constructs. RESULTS: Twenty interviews were conducted comprising of five 'content-experts' and fifteen 'end-users'. Five themes were identified which indicated lack of knowledge about how to use antibiograms, and its availability. Potential insufficient data was the primary issue identified by content experts with regards to feasibility of annual antibiograms. Pragmatic solutions were offered, such as pooling pathology data from facilities in the same geographical location, extending antibiogram data to two-or three-yearly, or utilising local hospital antibiograms. Presenting antibiogram data in a mode and format suiting preferences of individual users would encourage uptake and improve usability. Antimicrobial stewardship (AMS) champions and pharmacists were highlighted as drivers of educating and promoting antibiogram use. CONCLUSION: Clinicians recognised the potential role of antibiograms in improving empirical antibiotic prescribing choices. Establishing their baseline knowledge provides an essential starting point for the education needs of this group. This study provides practical recommendations regarding the presentation of antibiograms to ensure appropriate use and uptake as an AMS tool in RACFs. Pragmatic solutions suggested to overcome challenges of antibiogram development for RACFs should be applied and evaluated to determine feasibility of RACF-specific antibiograms.

Protocol for a parallel cluster randomized trial of a participatory tailored approach to reduce overuse of antibiotics at hospital discharge: the ROAD home trial.

BACKGROUND: Antibiotic overuse at hospital discharge is common, costly, and harmful. While discharge-specific antibiotic stewardship interventions are effective, they are resource-intensive and often infeasible for hospitals with resource constraints. This weakness impacts generalizability of stewardship interventions and has health equity implications as not all patients have access to the benefits of stewardship based on where they receive care. There may be different pathways to improve discharge antibiotic prescribing that vary widely in feasibility. Supporting hospitals in selecting interventions tailored to their context may be an effective approach to feasibly reduce antibiotic overuse at discharge across diverse hospitals. The objective of this study is to evaluate the effectiveness of the Reducing Overuse of Antibiotics at Discharge Home multicomponent implementation strategy ("ROAD Home") on antibiotic overuse at discharge for community-acquired pneumonia and urinary tract infection. METHODS: This 4-year two-arm parallel cluster-randomized trial will include three phases: baseline (23 months), intervention (12 months), and postintervention (12 months). Forty hospitals recruited from the Michigan Hospital Medicine Safety Consortium will undergo covariate-constrained randomization with half randomized to the ROAD Home implementation strategy and half to a "stewardship as usual" control. ROAD Home is informed by the integrated-Promoting Action on Research Implementation in Health Services Framework and includes (1) a baseline needs assessment to create a tailored suite of potential stewardship interventions, (2) supported decision-making in selecting interventions to implement, and (3) external facilitation following an implementation blueprint. The primary outcome is baseline-adjusted days of antibiotic overuse at discharge. Secondary outcomes include 30-day patient outcomes and antibiotic-associated adverse events. A mixed-methods concurrent process evaluation will identify contextual factors influencing the implementation of tailored interventions, and assess implementation outcomes including acceptability, feasibility, fidelity, and sustainment. DISCUSSION: Reducing antibiotic overuse at discharge across hospitals with varied resources requires tailoring of interventions. This trial will assess whether a multicomponent implementation strategy that supports hospitals in selecting evidence-based stewardship interventions tailored to local context leads to reduced overuse of antibiotics at discharge. Knowledge gained during this study could inform future efforts to implement stewardship in diverse hospitals and promote equity in access to the benefits of quality improvement initiatives. TRIAL REGISTRATION: Clinicaltrials.gov NCT06106204 on 10/30/23.

Perceptions of Barriers and Facilitators to a Pilot Implementation of an Algorithm-Supported Care Navigation Model of Care: A Qualitative Study.

We aimed to explore managerial and project staff perceptions of the pilot implementation of an algorithm-supported care navigation model, targeting people at risk of hospital readmission. The pilot was implemented from May to November 2017 at a Victorian health service (Australia) and provided to sixty-five patients discharged from the hospital to the community. All managers and the single clinician involved participated in a semi-structured interview. Participants (n = 6) were asked about their perceptions of the service design and the enablers and barriers to implementation. Interviews were transcribed verbatim and analysed according to a framework approach, using inductive and deductive techniques. Constructed themes included the following: an algorithm alone is not enough, the health service culture, leadership, resources and the perceived patient experience. Participants felt that having an algorithm to target those considered most likely to benefit was helpful but not enough on its own without addressing other contextual factors, such as the health service's capacity to support a large-scale implementation. Deductively mapping themes to the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework highlighted that a formal facilitation would be essential for future sustainable implementations. The systematic identification of barriers and enablers elicited critical information for broader implementations of algorithm-supported models of care.

Mobilising Implementation of i-PARIHS (Mi-PARIHS): development of a facilitation planning tool to accompany the Integrated Promoting Action on Research Implementation in Health Services framework.

BACKGROUND: Facilitation makes the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework a popular framework in the field of implementation science. Facilitation allows for flexible application of the i-PARIHS framework by encouraging the iterative tailoring of implementation strategies to a dynamic context. However, successfully harnessing this flexibility can be challenging to navigate, particularly for novice facilitators. Therefore, to support and promote more widespread use of the i-PARIHS framework, and to make it easier for people who are already using i-PARIHS, we have undertaken the Mi-PARIHS Project-Mobilising Implementation of i-PARIHS, focused on developing a suite of practical and pragmatic i-PARIHS resources. METHODS: Through a co-design approach drawing on end-users' experiences, we developed the Mi-PARIHS Facilitation Planning Tool, and this article reports on the final end-user feedback via an online survey. RESULTS: A total of 58 participants completed the online survey. The survey focused on participants' previous experiences with i-PARIHS, their feedback on the background information provided with the Mi-PARIHS Tool, and their feedback on the tool itself (e.g. clarity, use, satisfaction, improvements). This feedback resulted in the development of a comprehensive 34-item Mi-PARIHS Facilitation Planning Tool that supports i-PARIHS users in their (1) assessment of the i-PARIHS framework's innovation, context, and recipient constructs; (2) development of a tailored facilitation plan; and (3) repeated use over time to evaluate the effectiveness of facilitation strategies. CONCLUSIONS: The Mi-PARIHS Facilitation Planning Tool makes framework-guided implementation more accessible and reliable to a wider range of systems and stakeholders, thereby contributing to more consistent implementation of evidence-based practices and other innovations. It addresses the challenge of systematically assessing core constructs of the i-PARIHS framework to develop tailored facilitation strategies. The Mi-PARIHS Facilitation Planning Tool is freely available for use at the website https://www.flinders.edu.au/caring-futures-institute/Mi-PARIHS-tool .

A facilitated social innovation: stakeholder groups using Plan-Do-Study-Act cycles for perinatal health across levels of the health system in Cao Bang province, Vietnam.

BACKGROUND: Universal coverage of evidence-based interventions for perinatal health, often part of evidence-based guidelines, could prevent most perinatal deaths, particularly if entire communities were engaged in the implementation. Social innovations may provide creative solutions to the implementation of evidence-based guidelines, but successful use of social innovations relies on the engagement of communities and health system actors. This proof-of-concept study aimed to assess whether an earlier successful social innovation for improved neonatal survival that employed regular facilitated Plan-Do-Study-Act meetings on the commune level was feasible and acceptable when implemented on multiple levels of the health system (52 health units) and resulted in actions with plausibly favourable effects on perinatal health and survival in Cao Bang province, northern Vietnam. METHODS: The Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework guided the implementation and evaluation of the Perinatal Knowledge-Into-Practice (PeriKIP) project. Data collection included facilitators' diaries, health workers' knowledge on perinatal care, structured observations of antenatal care, focus group discussions with facilitators, their mentors and representatives of different actors of the initiated stakeholder groups and an individual interview with the Reproductive Health Centre director. Clinical experts assessed the relevance of the identified problems and actions taken based on facilitators' diaries. Descriptive statistics included proportions, means, and t-tests for the knowledge assessment and observations. Qualitative data were analysed by content analysis. RESULTS: The social innovation resulted in the identification of about 500 relevant problems. Also, 75% of planned actions to overcome prioritised problems were undertaken, results presented and a plan for new actions to achieve the group's goals to enhance perinatal health. The facilitators had significant roles, ensuring that the stakeholder groups were established based on principles of mutual respect. Overall, the knowledge of perinatal health and performance of antenatal care improved over the intervention period. CONCLUSIONS: The establishment of facilitated local stakeholder groups can remedy the need for tailored interventions and grassroots involvement in perinatal health and provide a scalable structure for focused efforts to reduce preventable deaths and promote health and well-being.