Enola K. Proctor

Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda.

An unresolved issue in the field of implementation research is how to conceptualize and evaluate successful implementation. This paper advances the concept of “implementation outcomes” distinct from service system and clinical treatment outcomes. This paper proposes a heuristic, working “taxonomy” of eight conceptually distinct implementation outcomes—acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability—along with their nominal definitions. We propose a two-pronged agenda for research on implementation outcomes. Conceptualizing and measuring implementation outcomes will advance understanding of implementation processes, enhance efficiency in implementation research, and pave the way for studies of the comparative effectiveness of implementation strategies.

Implementation Research in Mental Health Services: an Emerging Science with Conceptual, Methodological, and Training challenges

One of the most critical issues in mental health services research is the gap between what is known about effective treatment and what is provided to consumers in routine care. Concerted efforts are required to advance implementation science and produce skilled implementation researchers. This paper seeks to advance implementation science in mental health services by over viewing the emergence of implementation as an issue for research, by addressing key issues of language and conceptualization, by presenting a heuristic skeleton model for the study of implementation processes, and by identifying the implications for research and training in this emerging field.

A compilation of strategies for implementing clinical innovations in health and mental health

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 health care 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 on 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 health care and can facilitate the development of multifaceted, multilevel implementation plans that are tailored to local contexts.

A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project

BackgroundIdentifying, developing, and testing implementation strategies are important goals of implementation science. However, these efforts have been complicated by the use of inconsistent language and inadequate descriptions of implementation strategies in the literature. The Expert Recommendations for Implementing Change (ERIC) study aimed to refine a published compilation of implementation strategy terms and definitions by systematically gathering input from a wide range of stakeholders with expertise in implementation science and clinical practice.MethodsPurposive sampling was used to recruit a panel of experts in implementation and clinical practice who engaged in three rounds of a modified Delphi process to generate consensus on implementation strategies and definitions. The first and second rounds involved Web-based surveys soliciting comments on implementation strategy terms and definitions. After each round, iterative refinements were made based upon participant feedback. The third round involved a live polling and consensus process via a Web-based platform and conference call.ResultsParticipants identified substantial concerns with 31% of the terms and/or definitions and suggested five additional strategies. Seventy-five percent of definitions from the originally published compilation of strategies were retained after voting. Ultimately, the expert panel reached consensus on a final compilation of 73 implementation strategies.ConclusionsThis research advances the field by improving the conceptual clarity, relevance, and comprehensiveness of implementation strategies that can be used in isolation or combination in implementation research and practice. Future phases of ERIC will focus on developing conceptually distinct categories of strategies as well as ratings for each strategy’s importance and feasibility. Next, the expert panel will recommend multifaceted strategies for hypothetical yet real-world scenarios that vary by sites’ endorsement of evidence-based programs and practices and the strength of contextual supports that surround the effort.

Implementation strategies: Recommendations for specifying and reporting

Implementation strategies have unparalleled importance in implementation science, as they constitute the ‘how to’ component of changing healthcare practice. Yet, implementation researchers and other stakeholders are not able to fully utilize the findings of studies focusing on implementation strategies because they are often inconsistently labelled and poorly described, are rarely justified theoretically, lack operational definitions or manuals to guide their use, and are part of ‘packaged’ approaches whose specific elements are poorly understood. We address the challenges of specifying and reporting implementation strategies encountered by researchers who design, conduct, and report research on implementation strategies. Specifically, we propose guidelines for naming, defining, and operationalizing implementation strategies in terms of seven dimensions: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification. Ultimately, implementation strategies cannot be used in practice or tested in research without a full description of their components and how they should be used. As with all intervention research, their descriptions must be precise enough to enable measurement and ‘reproducibility.’ We propose these recommendations to improve the reporting of implementation strategies in research studies and to stimulate further identification of elements pertinent to implementation strategies that should be included in reporting guidelines for implementation strategies.

Implementation of Evidence-Based Practice in Community Behavioral Health: Agency Director Perspectives

Despite a growing supply of evidence-based mental health treatments, we have little evidence about how to implement them in real-world care. This qualitative pilot study captured the perspectives of agency directors on the challenge of implementing evidence-based practices in community mental health agencies. Directors identified challenges as limited access to research, provider resistance, and training costs. Director leadership, support to providers, and partnerships with universities were leverage points to implement evidenced-based treatments. Directors’ mental models of EBP invoked such concepts as agency reputation, financial solvency, and market niche. Findings have potential to shape implementation interventions.

A Systematic Review of Strategies for Implementing Empirically Supported Mental Health Interventions

Objective: This systematic review examines experimental studies that test the effectiveness of strategies intended to integrate empirically supported mental health interventions into routine care settings. Our goal was to characterize the state of the literature and to provide direction for future implementation studies. Method: A literature search was conducted using electronic databases and a manual search. Results: Eleven studies were identified that tested implementation strategies with a randomized (n = 10) or controlled clinical trial design (n = 1). The wide range of clinical interventions, implementation strategies, and outcomes evaluated precluded meta-analysis. However, the majority of studies (n = 7; 64%) found a statistically significant effect in the hypothesized direction for at least one implementation or clinical outcome. Conclusion: There is a clear need for more rigorous research on the effectiveness of implementation strategies, and we provide several suggestions that could improve this research area.

From Knowledge Production to Implementation: Research Challenges and Imperatives

As evidence-based practice is increasingly accepted in social work, the challenges associated with its actual implementation become more apparent and pressing. This article identifies implementation as a critical issue for research; implementation itself must be better understood if evidence-based practices are to be used and resultant improvements to practice are to be realized. Social work needs to engage more fully in (a) service system research and (b) implementation research, each of which complements and has potential to extend the benefits of efficacy and effectiveness research. Service system research can enhance the fit of empirically supported treatments to the needs of real-world practice and thus facilitate their implementation. Implementation studies examine the acceptability of evidence-based interventions, the feasibility and likelihood of their sustained use, and the decision-support procedures that can help practitioners apply probabilistically based, empirically supported treatments to the individual case in real-world practice.

Methods to Improve the Selection and Tailoring of Implementation Strategies

Implementing behavioral health interventions is a complicated process. It has been suggested that implementation strategies should be selected and tailored to address the contextual needs of a given change effort; however, there is limited guidance as to how to do this. This article proposes four methods (concept mapping, group model building, conjoint analysis, and intervention mapping) that could be used to match implementation strategies to identified barriers and facilitators for a particular evidence-based practice or process change being implemented in a given setting. Each method is reviewed, examples of their use are provided, and their strengths and weaknesses are discussed. The discussion includes suggestions for future research pertaining to implementation strategies and highlights these methods’ relevance to behavioral health services and research.

Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study

BackgroundPoor terminological consistency for core concepts in implementation science has been widely noted as an obstacle to effective meta-analyses. This inconsistency is also a barrier for those seeking guidance from the research literature when developing and planning implementation initiatives. The Expert Recommendations for Implementing Change (ERIC) study aims to address one area of terminological inconsistency: discrete implementation strategies involving one process or action used to support a practice change. The present report is on the second stage of the ERIC project that focuses on providing initial validation of the compilation of 73 implementation strategies that were identified in the first phase.FindingsPurposive sampling was used to recruit a panel of experts in implementation science and clinical practice (N = 35). These key stakeholders used concept mapping sorting and rating activities to place the 73 implementation strategies into similar groups and to rate each strategy’s relative importance and feasibility. Multidimensional scaling analysis provided a quantitative representation of the relationships among the strategies, all but one of which were found to be conceptually distinct from the others. Hierarchical cluster analysis supported organizing the 73 strategies into 9 categories. The ratings data reflect those strategies identified as the most important and feasible.ConclusionsThis study provides initial validation of the implementation strategies within the ERIC compilation as being conceptually distinct. The categorization and strategy ratings of importance and feasibility may facilitate the search for, and selection of, strategies that are best suited for implementation efforts in a particular setting.