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INTRODUCTION: Implementation is influenced by factors beyond individual clinical settings. Nevertheless, implementation research often focuses on factors related to individual providers and practices, potentially due to limitations of available frameworks. Extant frameworks do not adequately capture the myriad organizational influences on implementation. Organization theories capture diverse organizational influences but remain underused in implementation science. To advance their use among implementation scientists, we distilled 70 constructs from nine organization theories identified in our previous work into theoretical domains in the Organization Theory for Implementation Science (OTIS) framework. METHODS: The process of distilling organization theory constructs into domains involved concept mapping and iterative consensus-building. First, we recruited organization and implementation scientists to participate in an online concept mapping exercise in which they sorted organization theory constructs into domains representing similar theoretical concepts. Multidimensional scaling and hierarchical cluster analyses were used to produce visual representations (clusters) of the relationships among constructs in concept maps. Second, to interpret concept maps, we engaged members of the Cancer Prevention and Control Research Network (CPCRN) OTIS workgroup in consensus-building discussions. RESULTS: Twenty-four experts participated in concept mapping. Based on resulting construct groupings coherence, OTIS workgroup members selected the 10-cluster solution (from options of 7-13 clusters) and then reorganized clusters in consensus-building discussions to increase coherence. This process yielded six final OTIS domains: organizational characteristics (e.g., size; age); governance and operations (e.g., organizational and social subsystems); tasks and processes (e.g., technology cycles; excess capacity); knowledge and learning (e.g., tacit knowledge; sense making); characteristics of a population of organizations (e.g., isomorphism; selection pressure); and interorganizational relationships (e.g., dominance; interdependence). DISCUSSION: Organizational influences on implementation are poorly understood, in part due to the limitations of extant frameworks. To improve understanding of organizational influences on implementation, we distilled 70 constructs from nine organization theories into six domains. Applications of the OTIS framework will enhance understanding of organizational influences on implementation, promote theory-driven strategies for organizational change, improve understanding of mechanisms underlying relationships between OTIS constructs and implementation, and allow for framework refinement. Next steps include testing the OTIS framework in implementation research and adapting it for use among policymakers and practitioners.

BackgroundUniversity students in Sweden routinely receive proactive mail-based alcohol Internet interventions sent from student health services. This intervention provides personalized normative feedback on alcohol consumption with suggestions on how to decrease drinking. Earlier feasibility trials by our group and others have examined effectiveness in simple parallel-groups designs. ObjectiveTo evaluate the effectiveness of electronic screening and brief intervention, using a randomized controlled trial design that takes account of baseline assessment reactivity (and other possible effects of the research process) due to the similarity between the intervention and assessment content. The design of the study allowed for exploration of the magnitude of the assessment effects per se. MethodsThis trial used a dismantling design and randomly assigned 5227 students to 3 groups: (1) routine practice assessment and feedback, (2) assessment-only without feedback, and (3) neither assessment nor feedback. At baseline all participants were blinded to study participation, with no contact being made with group 3. We approached students 2 months later to participate in a cross-sectional alcohol survey. All interventions were fully automated and did not have any human involvement. All data used in the analysis were based on self-assessment using questionnaires. The participants were unaware that they were participating in a trial and thus were also blinded to which group they were randomly assigned. ResultsOverall, 44.69% (n = 2336) of those targeted for study completed follow-up. Attrition was similar in groups 1 (697/1742, 40.01%) and 2 (737/1742, 42.31% retained) and lower in group 3 (902/1743, 51.75% retained). Intention-to-treat analyses among all participants regardless of their baseline drinking status revealed no differences between groups in all alcohol parameters at the 2-month follow-up. Per-protocol analyses of groups 1 and 2 among those who accepted the email intervention (36.2% of the students who were offered the intervention in group 1 and 37.3% of the students in group2 ) and who were risky drinkers at baseline (60.7% follow-up rate in group 1 and 63.5% in group 2) suggested possible small beneficial effects on weekly consumption attributable to feedback. ConclusionsThis approach to outcome evaluation is highly conservative, and small benefits may follow the actual uptake of feedback intervention in students who are risky drinkers, the precise target group. Trial RegistrationInternational Standard Randomized Controlled Trial Number (ISRCTN): 24735383; http://www.controlled-trials.com/ISRCTN24735383 (Archived by WebCite at http://www.webcitation.org/6Awq7gjXG)

BackgroundInteractive behavior change technology (eg, computer programs, Internet websites, and mobile phones) may facilitate the implementation of lifestyle behavior interventions in routine primary health care. Effective, fully automated solutions not involving primary health care staff may offer low-cost support for behavior change. ObjectivesWe explored the effectiveness of an electronic screening and brief intervention (e-SBI) deployed through a stand-alone information kiosk for promoting physical activity among sedentary patients in routine primary health care. We further tested whether its effectiveness differed between patients performing the e-SBI on their own initiative and those referred to it by primary health care staff. MethodsThe e-SBI screens for the physical activity level, motivation to change, attitudes toward performing the test, and physical characteristics and provides tailored feedback supporting behavior change. A total of 7863 patients performed the e-SBI from 2007 through 2009 in routine primary health care in Östergötland County, Sweden. Of these, 2509 were considered not sufficiently physically active, and 311 of these 2509 patients agreed to participate in an optional 3-month follow-up. These 311 patients were included in the analysis and were further divided into two groups based on whether the e-SBI was performed on the patient´s own initiative (informed by posters in the waiting room) or if the patient was referred to it by staff. A physical activity score representing the number of days being physically active was compared between baseline e-SBI and the 3-month follow-up. Based on physical activity recommendations, a score of 5 was considered the cutoff for being sufficiently physically active. ResultsIn all, 137 of 311 patients (44%) were sufficiently physically active at the 3-month follow-up. The proportion becoming sufficiently physically active was 16/55 (29%), 40/101 (40%), and 81/155 (52%) for patients with a physical activity score at baseline of 0, 1 to 2, and 3 to 4, respectively. The patient-initiated group and staff-referred group had similar mean physical activity scores at baseline (2.1, 95% confidence interval [CI] 1.8-2.3, versus 2.3, 95% CI 2.1-2.5) and at follow-up, (4.1, 95% CI 3.4-4.7, vs 4.2, 95% CI 3.7-4.8). ConclusionsAmong the sedentary patients in primary health care who participated in the follow-up, the e-SBI appeared effective at promoting short-term improvement of physical activity for about half of them. The results were similar when the e-SBI was patient-initiated or staff-referred. The e-SBI may be a low-cost complement to lifestyle behavior interventions in routine primary health care and could work as a stand-alone technique not requiring the involvment of primary health care staff.

BACKGROUND: Organization theories offer numerous existing, highly relevant, yet largely untapped explanations of the organizational dynamics underlying evidence-based intervention (EBI) implementation. Rooted in ideas regarding power, autonomy, and control, organization theories can explain how and why organizations adopt, implement, and sustain EBI use. Although they have gained visibility, organization theories remain underused in implementation research, perhaps due to their inaccessibility to implementation scientists. To improve access to organization theory among implementation scientists, we summarized organization theories with relevance to implementation science. METHODS: Led by the Cancer Prevention and Control Research Network (CPCRN) Organization Theory for Implementation Science workgroup, we employed a modified Delphi process to reach a consensus among 18 experts at the intersection of organization and implementation science regarding organization theories with relevance to implementation science. From texts that described the organization theories, using standardized abstraction forms, two investigators independently abstracted information regarding constructs, propositions regarding how or why constructs might influence implementation, the potential relevance of organization theories propositions for implementation, and overviews of each theory. The investigators then reconciled discrepancies until reaching consensus. A third investigator reviewed reconciled abstraction forms for accuracy, coherence, and completeness. FINDINGS: We identified nine organization theories with relevance to implementation science: contingency, complexity, institutional, network, organizational learning, resource dependence, sociotechnical, and transaction cost economics. From the theories, we abstracted 70 constructs and 65 propositions. An example proposition from institutional theory is: Coercive, mimetic, and normative pressures contribute to organizations…within an organizational field [becoming increasingly similar]. These propositions can be operationalized as levers to facilitate EBI implementation. CONCLUSIONS: To increase use in the field, organization theories must be made more accessible to implementation scientists. The abstraction forms developed in this study are now publicly available on the CPCRN website with the goal of increasing access to organization theories among an interdisciplinary audience of implementation scientists through the CPCRN Scholars program and other venues. Next steps include consolidating organization theory constructs into domains and translating the resulting framework for use among researchers, policymakers and practitioners, aiding them in accounting for a comprehensive set of organization theory constructs thought to influence EBI implementation.

BACKGROUND: Implementation science and improvement science have similar goals of improving health care services for better patient and population outcomes, yet historically there has been limited exchange between the two fields. Implementation science was born out of the recognition that research findings and effective practices should be more systematically disseminated and applied in various settings to achieve improved health and welfare of populations. Improvement science has grown out of the wider quality improvement movement, but a fundamental difference between quality improvement and improvement science is that the former generates knowledge for local improvement, whereas the latter is aimed at producing generalizable scientific knowledge. OBJECTIVES: The first objective of this paper is to characterise and contrast implementation science and improvement science. The second objective, building on the first, is to highlight aspects of improvement science that potentially could inform implementation science and vice versa. METHODS: We used a critical literature review approach. Search methods included systematic literature searches in PubMed, CINAHL, and PsycINFO until October 2021; reviewing references in identified articles and books; and the authors own cross-disciplinary knowledge of key literature. FINDINGS: The comparative analysis of the fields of implementation science and improvement science centred on six categories: (1) influences; (2) ontology, epistemology and methodology; (3) identified problem; (4) potential solutions; (5) analytical tools; and (6) knowledge production and use. The two fields have different origins and draw mostly on different sources of knowledge, but they have a shared goal of using scientific methods to understand and explain how health care services can be improved for their users. Both describe problems in terms of a gap or chasm between current and optimal care delivery and consider similar strategies to address the problems. Both apply a range of analytical tools to analyse problems and facilitate appropriate solutions. CONCLUSIONS: Implementation science and improvement science have similar endpoints but different starting points and academic perspectives. To bridge the silos between the fields, increased collaboration between implementation and improvement scholars will help to clarify the differences and connections between the science and practice of improvement, to expand scientific application of quality improvement tools, to further address contextual influences on implementation and improvement efforts, and to share and use theory to support strategy development, delivery and evaluation.

BackgroundRecent reviews of the use and application of implementation frameworks in implementation efforts highlight the limited use of frameworks, despite the value in doing so. As such, this article aims to provide recommendations to enhance the application of implementation frameworks, for implementation researchers, intermediaries, and practitioners.DiscussionIdeally, an implementation framework, or multiple frameworks should be used prior to and throughout an implementation effort. This includes both in implementation science research studies and in real-world implementation projects. To guide this application, outlined are ten recommendations for using implementation frameworks across the implementation process. The recommendations have been written in the rough chronological order of an implementation effort; however, we understand these may vary depending on the project or context: (1) select a suitable framework(s), (2) establish and maintain community stakeholder engagement and partnerships, (3) define issue and develop research or evaluation questions and hypotheses, (4) develop an implementation mechanistic process model or logic model, (5) select research and evaluation methods (6) determine implementation factors/determinants, (7) select and tailor, or develop, implementation strategy(s), (8) specify implementation outcomes and evaluate implementation, (9) use a framework(s) at micro level to conduct and tailor implementation, and (10) write the proposal and report. Ideally, a framework(s) would be applied to each of the recommendations. For this article, we begin by discussing each recommendation within the context of frameworks broadly, followed by specific examples using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.SummaryThe use of conceptual and theoretical frameworks provides a foundation from which generalizable implementation knowledge can be advanced. On the contrary, superficial use of frameworks hinders being able to use, learn from, and work sequentially to progress the field. Following the provided ten recommendations, we hope to assist researchers, intermediaries, and practitioners to improve the use of implementation science frameworks.

Healthcare settings and systems have been slow to adopt and implement many effective cancer prevention and control interventions. Understanding the factors that determine successful implementation is essential to accelerating the translation of effective interventions into practice. Many scholars have studied the determinants of implementation, and much of this research has been guided by the Consolidated Framework for Implementation Research (CFIR). The CFIR categorizes implementation determinants at five levels (characteristics of the intervention, inner setting, individual, processes, and outer setting). Of these five levels, determinants at the level of the outer setting are the least developed. Extensive research in fields other than healthcare suggest that determinants at the level of the outer setting (e.g., funding streams, contracting practices, and public policy) play a central role in shaping when and how an organization implements new structures and practices. Thus, a more comprehensive understanding of outer-setting determinants is critical to efforts to accelerate the implementation of effective cancer control interventions. The Cancer Prevention and Control Research Network (CPCRN) created a cross-center workgroup to review organizational theories and begin to contribute to the creation of a future framework of constructs related to outer setting determinants. In this paper, we report findings from the review of three organizational theories: Institutional Theory, Transaction Cost Economics, and Contingency Theory. To demonstrate the applicability of this work to implementation science and practice, we have applied findings to three case studies of CPCRN researchers' efforts to implement colorectal cancer screening interventions in Federally Qualified Health Centers.

Medication review, a systematic assessment of a patient's medicines by a health care professional, is intended to prevent medication-related harms. A critical element of medication review concerns whether medication review is conducted in a coordinated way. This article draws from a case example of implementing medication review in two surgical wards of a Swedish regional hospital and aims to analyse how medication review is being accomplished with respect to the coordination of its actions. Using a practice-based ethnographic approach, we present several coordination mechanisms by illustrating how practices are connected to materials involved in medication review. Also, we show how common orientations, ends, and understandings expressed in different medication review practices contribute to the coordination of the practices. In conclusion, this article highlights the complexity of establishing and sustaining medication review as a coordinated practice in routine health care. By closely examining sociomaterial connections, this article sheds new light on the neglected issue of artefacts and arrangements in constituting and transforming a highly complex medication practice.