Table 2 Domains and determinants adapted from the Integrated Sustainability Framework (ISF), along with key quotes from included audit and feedback trials

Outer/policy context

The external landscape, including policies, regulations, and guidelines. The availability of funding to maintain the intervention, the role of external partnerships, broader environmental support, and alignment with broader values, priorities, and needs.

ISF determinants:

    • Policy and legislation

    • Sociopolitical context

    • Funding environment

    • Leadership

    • Values, priorities, needs

    • Community ownership

Since 2009, China has enacted national health policy reforms to regulate antibiotic prescribing. … Our recent study showed that, at the county hospital level, the policy might be associated with reducing inappropriate antibiotic prescribing in outpatients. [18]

Limitations include our focus on commercially insured patients within a single integrated delivery system that had the ability to mobilize resources even in the absence of external funding. Systems that are smaller, are located in other geographic regions, or serve primarily publicly insured patients may have fewer resources or may face different challenges in reaching vaccine providers. [19]

Hospitals were expected to implement the national perioperative safety guidelines. However, it is not easy to implement new guidelines and sustain change. [20]

Several structural and environmental barriers for implementing evidence-based practices within LTC [Long Term Care] homes have been identified including a high proportion of unregulated staff, absence of a learning culture, high turnover in management, heavy regulatory and documentation demands, routinized care rituals, and lack of familiarity with clinical practice guidelines. [21]

Inner/organizational context

The impact of the organizational structure, leadership/support, readiness of change, resources available, and organizational stability, including staff turnover.

ISF determinants:

    • Funding/resources

    • Leadership/support

    • Climate/culture

    • Staffing turnover

    • Structural characteristics

    • Capacity

    • Champion

    • Polices (alignment)

    • Mission

The implementation packages were tested under ‘real-world’ conditions, increasing confidence in wider applicability to routine general practice settings. [22]

Adequate infrastructure such as information and communications technology was often lacking. [20]

Consideration should be given to the intervention ‘fit’ with existing systems and staff skills, and patient groups, including how best to facilitate local tailoring and embed the intervention within routine care. [23]

It is possible that staff turnover led to loss of ‘corporate memory’ about chlamydia, contributing to reduced testing. [24]

The findings illustrate that there may be different factors at play during initial implementation compared to those that are needed to influence sustained use of the intervention. There appear to be spheres of influence that when aligned enhance normalisation of the intervention into routine practice. The first broadly relates to the mission of the site, its organisational culture and the antecedents to participating in this project. The second related to the leadership structures and the role of influential leaders in changing the activities of others. Third relates to the team environment and the extent to which certain actors within the team influence the activity of others. The fourth relates to the tools themselves and the degree to which they are fit-for-purpose from content, workflow and technical perspectives. [25] forward citation from [26]

Implementation processes

Description of how the intervention is implemented, including the role of key decision makers, the training and support provided to the implementation team, the mechanisms for evaluating the program and collecting data, if, and how, the program can be adapted to meet the continually changing needs of the patients and organization, and the strategic planning for the future of the intervention.

ISF determinants:

    • Partnership/engagement

    • Training/support/ supervision

    • Fidelity

    • Adaptation

    • Planning

    • Team/board functioning

    • Program evaluation/data

    • Communication

    • Technical assistance

    • Capacity building

    • Implementation science* (new)

By integrating this intervention into routine care and making all material freely available at the end of the intervention, the [name] study strives to be sustainable and self-promoting and, thereby, implemented in primary care in Ireland beyond the intervention period. [27] protocol of [28]

The tool components were synergistically incorporated into the practice with the manager taking ownership of the audit tool and the GP focusing on the in-consultation decision support tool. This facilitated initial adoption of the intervention; however, sustained engagement of the research team was required suggesting a lack of normalisation beyond the trial setting. [25] forward citation from [26]

The implementation packages embedded behaviour change techniques within audit and feedback, educational outreach and (for risky prescribing) computerised prompts. [29]

We set out to design and apply an implementation package that could be delivered sustainably using resources typically available to primary care. We involved health professionals, commissioners and patients in structured deliberations to prioritise and develop a set of ‘high-impact’, evidence-based Qis associated with scope for improvement and that could be measured using routinely collected data. [29]

The pragmatic optimization approach featured in this aim was designed in close partnership with our research collaborators to model the considerations healthcare decision-makers told us they actually use when making decisions about adopting and sustaining evidence-based practices. [30] forward citation of [31]

Tailored interventions appeared to lead to more sustainable compliance increases. [32]

Each practice was allowed to consider how to best integrate the referrals into their workflow, allowing variation in implementation fidelity. [33]

Provider/implementer characteristics

Specific provider and implementer characteristics, such as roles, motivations, attitudes, benefits, stressors, skills, and expertise.

ISF determinants:

    • Provider/implementer characteristics

    • Implementation skills/expertise

    • Implementer attitudes

    • Implementer motivation

    • Population characteristics (removed)

Many participants were insufficiently motivated to change established behaviour patterns and procedures. [34]

The formation and maintenance of site-based quality improvement teams that aimed to lead local barrier identification, solution generation, solution implementation, and goal setting were notable deficiencies at many intervention sites. [29]

When discussing the indicators and associated clinical behaviours, primary care professionals generally viewed the workload and burden associated with adherence as accepted and embedded components of general practice. [21]

Participants considered that researchers did not have a good understanding of the way general practice operates, suggesting a number of reasons why the research might be difficult to sustain within the general practice environment. [35]

Characteristics of the intervention

How much the intervention can be adapted, how it fits within the context, population or organization, the perceived benefits or impact of the intervention and the need for this benefit within the community or setting where it is being implemented. The burden and complexity of the intervention is also covered as well as the cost.

ISF determinants:

    • Adaptability

    • Fit with population and context

    • Benefits/need

    • Burden/complexity

    • Trialability

    • Cost

Hospitals are complex dynamic systems, and shifting behavior may take longer than expected. Despite multiple modalities targeting system and individual factors in an active and interactive way, it was only in the past 4 months of the 16-month intervention period that a shift in implementation was evident. [36]

The [name] intervention is feasible in primary care and preliminary results suggest a positive impact on uptake. However, consideration should be given to the intervention ‘fit’ with existing systems and staff skills, and patient groups, including how best to facilitate local tailoring and embed the intervention within routine care. [23]

While most staff (86%, n = 19) agreed the intervention was doable, only 71% (n = 15) agreed it was easy to use…. Intervention delivery was feasible during the study period, but the intervention was an ‘extra thing’, and there were mixed views on the sustainability of specific components. [23]

Because multilevel interventions require substantial investments of personnel and time in the short-term, demonstrating that intervention effects continue in the post intervention period is important when clinical and policy decision makers consider upfront costs. [37]

There is a high-cost barrier for one-off audit and feedback interventions. [38]

This is consistent with evidence that adherence to clinical recommendations that are more complex or disruptive to routine practice is lower compared with simpler recommendations. [22]