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Table 3 Key implementation and evolution factors using Grol and Wensing's Characteristics of Innovations Framework [32].

From: Tailoring an intervention to the context and system redesign related to the intervention: A case study of implementing shared medical appointments for diabetes

Characteristic of Innovation ~Degree to which innovation provides or is: Promoting Factor for SMA Implementation Hindering Factor for SMA Implementation Addressing the Issues to Facilitate Implementation and Sustainability
Relative advantage or utility over existing or other methods Advantage of seeing several experts at same time, especially for behavioral barriers No clear evidence; questioned value and whether patients would accept group format Proved not to be a major issue
Compatibility with existing norms and values Consistent with norm and values of achieving process measures Inconsistent with norm and value of sacred primary care provider-patient relationship; Different roles of healthcare professionals filling in-difficult switching from traditional to multidisciplinary team approach Had a few team building and motivational interviewing learning sessions-lecture versus facilitation of patient info
Complexity of explaining, understanding and using   Too vague and many unknowns; not easy to explain Explain and sell it and take advantage of a trial period with small numbers of patients to highlight success and have observers (it was easier for providers to see it first hand)
Costs relative to benefits and level of investment   Efficacy questioned regarding clinical physiological outcomes and uncertain level of investment for various stakeholders 1. Reorganizing flow allowed up to 18 patients to be seen in one SMA
    2. Change in way patient data distributed in order to reduce prep time of Clinical Pharmacist and overall cost
    3. Introduced use of templated notes that included documentation of SMA activities at a general group level and also permitted individualized patient level documentation
Risks related to uncertainty regarding results and consequences   High-risk – no conceptual model for designing or plan for diffusion The organizational culture supported risk taking
Flexibility, adaptability to situation/needs of local context/target group Vagueness provided options for adapting to local context and needs Key non-flexible components not consistent with micro-system and mesosystem silo design Recognition of additional patient needs prompted addition of a nutritionist to the team
Involvement of target group in development High involvement of the core team only Existing structure impeding additional staff involvement Unanticipated impact on staff not involved feeling left out addressed by creating opportunities for these staff to observe and get feedback/up dates
Divisibility so able to try out parts separately   Low divisibility of shared appointments (i.e., can't try out various parts) Unable to address; we have kept the basic model of SMAs
Trialability, reversibility without risk if doesn't work High and approached as a trial period   Because of early successes, this proved not to be a major issue
Visibility, observability of results by other people High – part of local culture is feedback High – part of local culture is feedback Patient successes led to increased referral of patients close to performance measure goals overloading the clinic and prompting the redirection of resources
Centrality of impact on daily working routine   High Impact of patients' stories has contributed to team finding meaning in their work, negating the effects of the changes in work routine
Pervasiveness, scope, impact on total work, people involved, time it takes and relationships   High: fear more work and would jeopardize primary care provider-patient relationships Proved not to be a major issue
Magnitude, disruptiveness, radicalness   High The core team was made up of individuals willing to take risk and were unafraid of the potential disruption
Duration for when innovation/change must take place Not a pressing factor   
Form, physical properties of innovation: material or social; technical or administrative, etc.)   High: material change, space requirements, schedule changes, administrative and technical adjustments Continues to provide challenges
Collective action related to decisions Low collective action Strong core team (3–5 members) Unanticipated impact on staff not involved feeling left out. Some of these staff were recruited to participate in other types of SMAs where they were involved in the decision-making.
Nature of Presentation: length, clarity, attractiveness High attractiveness Low clarity Began projects to share knowledge and experience with others