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Table 2 Key themes related to the success or failure of implementation of complex interventions

From: Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews

  Primary themes Secondary themes Sources Example quotations from included reviews Domain
      G M E PU I PR
External context Policy Presence and form of policy [14, 15, 31, 34, 43, 5155, 58, 86, 101] B: A lack of a national mandate within countries to coordinate fall prevention interventions [86]
F: Legislative mandates are also potent motivators [51]
 
   Presence of stated goals and objectives [41, 57, 67] B: Lack of clear national objectives [57]
F: Convey a clear statement of the goals for and anticipated benefits of electronic medical records implementation [41]
   
   Fit with local or national agenda [16, 32, 55] B/F: Compatibility (contextual appropriateness, fit, congruence, match)—extent to which the intervention fits with an organisation’s mission, priorities and values [32]    
   Presence of regulatory framework [41, 51, 53, 54, 56, 58, 65, 67, 85, 94] B: Restrictive regulatory framework [54]
F: Federal mandates and a common framework that provides standards and procedures that allow systems to exchange information, regardless of whether both support highly coded data [58]
   
   Presence of code of practice [34, 41, 43, 51, 58, 61, 67, 85] F: New practice standards, guidelines and routines must be established for how work gets done [41]   
  Infrastructure   [14, 15, 42, 53, 58, 67, 72, 74, 75, 82, 86, 101, 104] B: Inadequate employment contracts, practice facilities and functioning of the primary care team [85]
F: Mechanism of support and infrastructure to support health care professionals [85]
 
  Economic and financing   [5355, 58, 66, 67] B: Lack of investment by health authorities [66]   
  Incentives Financial awards [3, 1416, 31, 33, 35, 37, 39, 43, 51, 53, 5659, 6163, 66, 6870, 74, 77, 79, 81, 8386, 89, 90, 101, 103, 104, 107, 110] B: No financial gain in using evidence-based medicine [66]
F: Other incentive schemes include quality and outcomes framework, which offers incentive payments linked to several prescribing targets; risk-sharing schemes [33]
   Non-financial awards [1416, 31, 53, 5961, 64, 68, 74, 89] B: Lack of incentives to change practice [68]
F: Access to training are important incentives for general practitioners [61]
 
  Dominant paradigm   [15, 16, 33, 54, 63, 77, 86, 94] B/F: NICE (The National Institute for Health and Care Excellence) and other guidelines [33]
  Public awareness   [34, 55, 67, 105] B: Inadequate public awareness of advanced practice nursing roles [55]
F: Widespread dissemination is important to create awareness among stakeholders, either by impersonal channels or mass media, to motivate the introduction and usage of telemedicine [34]
   
  Stakeholder buy-in   [15, 16, 31, 41, 42, 44, 5355, 57, 60, 64, 94, 103] B: Conflict potential: Lack of consensus, decision power, and commitment among key stakeholders. It includes the inadequate distribution of decision-making power (or ownership) among stakeholders [94]
F: Board members are aligned with implementation plan [16]
 
  Technological advances   [65, 67] B/F: Those responsible for Clinical Decision Support System implementation are typically administrators, information technology managers, and clinicians, all of whom are increasingly pushed by technology [65]     
Organisation Culture Organisational planning and readiness [3, 14, 15, 32, 34, 38, 40, 41, 51, 5456, 58, 60, 61, 6567, 69, 71, 77, 83, 94, 103, 105, 109, 110] B/F: Receptiveness of the whole organisation [56]  
   Leadership [1416, 31, 32, 34, 41, 5256, 58, 65, 6769, 71, 75, 94, 103, 109, 110] B: Lack of organisational, nursing and physician leadership and support frequently reported as a barrier to role implementation for all types of advanced practice nurse roles [55]  
   Hierarchy structure [44, 54, 67] B/F: Hierarchical structure in the setting [54]    
  Processes and systems   [14, 17, 31, 32, 34, 37, 39, 40, 4244, 51, 52, 57, 59, 65, 66, 69, 7174, 77, 84, 90, 105] B: Even when the practitioners have access, guidelines are often insufficiently integrated into current behavioural, organisational and communication routines [52]
F: Process—Work process was the most important factor of this theme (24 elements). When e-prescribing was integrated, work process was facilitated and work flow was improved [14]
  
  Relationships Inter-professional [3, 1416, 3133, 41, 5355, 60, 67, 71, 72, 75, 86, 105, 108, 110] B/F: The organisational aspect of professional interaction, including team spirit, relation between different health professionals [14]
   Professional and patients [31, 41, 58, 61, 72, 75, 78] B/F: Interaction: patient-physician encounters [58]   
  Resources   [3, 14, 16, 17, 3136, 3841, 43, 5157, 59, 60, 6272, 7577, 79, 80, 82, 8487, 90, 94, 106, 107, 109] B: The lack of resources such as time, money and personnel constitutes a significant barrier [71]
F: Administrative support, adequate resources and manpower, dedicated or protected time [67]
  Skill mix Clarity about responsibility/role [14, 16, 32, 44, 54, 55, 58, 61, 67, 71, 72, 85, 110] B: Lack of clarity pertaining to the responsibility inherent in the role of care manager (often a nurse) when it comes to promoting the patient’s self-management ability [71]
F: Procedures that contain clear roles and responsibilities relative to task accomplishments [32]
   
   Division of labour [34, 41, 44, 51, 55, 56, 58, 60, 61, 67, 71, 77, 79, 95, 103, 110] B: Lack of organisation and skill mix among support staff [67]
F: Different skill mix (interdisciplinary approach) [77]
  
  Involvement Support from team members and management [14, 31, 32, 39, 41, 54, 55, 58, 60, 61, 66, 67, 90, 104, 105, 109, 110] B: Lack of managerial support [61]
F: Organisational support and management [31]
 
   Collaborative working [1416, 32, 34, 41, 54, 55, 67, 71, 72, 78, 82, 94, 104, 109] B: Lack of team approach to change [16]
F: Collaborative process is characterised by non-hierarchical relationships among participants, mutual trust and open communication, shared responsibilities for competing important tasks and efforts to reach consensus when disagreements arise [32]
 
   Shared vision [16, 32, 41, 54, 55, 60, 67, 71, 72, 77, 110] B/F: Shared vision (shared mission, consensus, commitment, staff buy-in)—extent to which organisational members are united regarding the value and purpose of the innovation [32]   
Professional Role Professionalism [14, 16, 31, 35, 39, 5355, 6567, 72, 85, 89, 102, 110] B: Fear of loss of autonomy [35]
F: General practitioners provided practice nurses with considerable autonomy in managing clients with chronic conditions with defined practice guidelines and protocols [85]
 
   Sense of self-efficacy [1416, 32, 33, 38, 39, 61, 63, 68, 78, 79, 101, 104, 107, 109] B/F: Sense of self-efficacy [15]  
   Peer influences [14, 31, 38, 66] B/F: The opinion/attitudes of colleagues about evidence-based medicine [66]     
   Authority/influence [33, 38, 67, 101, 103] B: “Not having enough authority to change patient care procedures” (nurses) [38]    
  Underlying philosophy of care Personal style [42, 54, 61, 69, 72, 76, 78, 79, 105, 107] B/F: Physician personality and philosophy [54]   
   Relationship between professional and patient [3, 14, 33, 39, 42, 60, 62, 7780, 107] B/F: Perception of inconsistency of recommendations with patient values and preferences [3]  
  Attitudes to change Attitudes and beliefs (general) [3, 1417, 3136, 3841, 43, 44, 52, 57, 58, 6072, 7580, 82, 83, 85, 87, 89, 90, 100102, 105109] B: Staff attitudes to advanced care planning have adversely affected uptake [101]
F: Agreement with the particular information and communication technologies (general attitude) [31]
   Motivation and priority [31, 36, 39, 42, 57, 59, 6163, 67, 68, 70, 82, 107] B: Physicians may not have the motivation to change. Results suggest that close to half of physicians surveyed were in a pre-contemplation stage and not ready to change behaviour [39]   
   Prior experience [15, 34, 54, 61, 66, 67, 77, 107] B/F: Users’ previous experiences with health information system affected their experience with a new system both positively and negatively [77]  
   Workload/competing demands [16, 17, 31, 44, 54, 55, 61, 66, 67, 71, 72, 74, 77, 79, 84, 105] B: As the professionals seemed overburdened with papers and administrative tasks, they had difficulty allocating time to help people with depression [71]  
   Perception of time [3, 1417, 31, 36, 3840, 43, 44, 61, 62, 66, 70, 72, 74, 75, 77, 79, 83, 86, 90, 101, 107] B: “Having insufficient time on the job to implement new ideas” (nurses) [38]
F: Saves clinicians time or requires minimal time to use [74]
  
  Competencies   [3, 1417, 3136, 3843, 51, 54, 5658, 6062, 6670, 72, 7580, 82, 8487, 90, 100, 101, 105109][55] B: Non-existent or inadequate training [31]
F: Electronic medical record (EMR) implementation was found to be most effective when training for EMR system users was adequate, timely, tailored to meet the specific needs and experience of the users and available on an ongoing, as-needed basis [41]
Intervention Nature and characteristics Complexity [3, 16, 35, 37, 39, 67, 68, 70, 72, 8789] B: Confusing and complex recommendations [3]
F: Not overly complex [68]
  
   Evidence of benefit [3, 16, 31, 33, 34, 38, 39, 42, 43, 51, 55, 56, 59, 62, 63, 67, 68, 70, 7476, 85, 89, 103, 106, 107] B: Lack of evidence regarding benefits of Information Technology [43]
F: Improved quality of care, e.g. better health outcomes, reduce medical errors [51]
   Applicability and relevance [14, 16, 31, 34, 35, 3739, 44, 55, 6669, 82, 89, 94, 105] B: Evidence has a limited scope/focus or limited to particular populations [68]  
   Clarity [4, 9, 18, 19, 26, 35, 42, 52, 59, 101] B: Uncertainty about when to initiate advanced care planning discussions—timing [101]
F: Good clarity [35]
  
   Costs [16, 84, 94] B: Generating indicators is costly [16]     
   Cost-effectiveness [33, 34, 42, 51, 57, 58, 65, 67, 69] B: Cost-effectiveness relation perceived as unfavourable [57]
F: Improved cost-effectiveness and efficiency [67]
  
   Practicality and utility [3, 1416, 31, 34, 35, 37, 3942, 44, 52, 5658, 6570, 7274, 77, 82, 84, 87, 89, 91, 94, 101] B/F: Ease of use of the system [68]   
   Adaptability [15, 32, 34, 77, 94] B/F: Adaptability of interventions to local circumstances (program modification, reinvention, flexibility), extent to which the proposed program can be modified to fit provider preferences, organisational practices, and community needs, values, and cultural norms [32]     
   IT compatibility [14, 16, 31, 42, 56, 6769, 71, 73] B: Interoperability—Inadequate interfacing with other IT systems [14]
F: IT is current or resources available for upgrading [16]
   
  Implementability Complexity of implementation [31, 57, 68] B: Too complex project organisation [57]
F: Do not require a great deal of time or effort to implement [68]
   
   Benefit/harm of implementation [14, 41, 43, 51, 56, 58, 76] B: Implementation results in lower provider productivity and inconsistent error reduction [43]
F: More efficient workflow, e.g. less time spent handling lab results, improved access to clinical data, streamlined referral processes, reduced staff time [51]
     
   Resources requirements [15, 34, 42, 43, 56, 68, 71, 77] B: Too costly to implement [68]    
  Safety and data privacy   [3, 14, 31, 33, 34, 3943, 51, 55, 56, 67, 69, 70, 73, 76, 77, 84, 90, 101, 105107] B: Concerns over data protection and security [106]
F: Benefit of anonymity for sensitive health topics [90]
  1. B barriers, F facilitators G guideline, M management of care, E e-health, PU public health and preventative medicine, I integration of new roles, PR prescribing