Table 2 Number of level 1 and level 2 strategies by CFIR barrier

Intervention source

Stakeholders have a negative perception of the innovation because of the entity that developed it and/or where it was developed.

Evidence strength and quality

Stakeholders have a negative perception of the quality and validity of evidence supporting the intervention.

Relative advantage

Stakeholders do not see the advantage of implementing the innovation compared to an alternative solution or keeping things the same.

Adaptability

Stakeholders do not believe that the innovation can be sufficiently adapted, tailored, or re-invented to meet local needs.

Trialability

Stakeholders believe they cannot test the innovation on a smaller scale within the organization or undo implementation if needed.

Complexity

Stakeholders believe that the innovation is complex based on their perception of duration, scope, radicalness, disruptiveness, centrality, and/or intricacy and number of steps needed to implement.

Design quality and packaging

Stakeholders believe the innovation is poor quality based on the way it is bundled, presented, and/or assembled.

Cost

Stakeholders believe the innovation costs and/or the costs to implement (including investment, supply, and opportunity costs) are too high.

Patient needs and resources

Patient needs, including barriers and facilitators to meet those needs, are not accurately known and/or this information is not a high priority for the organization.

Cosmopolitanism

The organization is not well networked with external organizations.

Peer pressure

There is little pressure to implement the innovation because other key peers or competing organizations have not already implemented the innovation nor is the organization doing this in a bid for a competitive edge.

External policy and incentives

External policies, regulations (governmental or other central entity), mandates, recommendations or guidelines, pay-for-performance, collaborative, or public or benchmark reporting do not exist or they undermine efforts to implement the innovation.

Structural characteristics

The social architecture, age, maturity, and size of an organization hinder implementation.

Networks and communications

The organization has poor quality or non-productive social networks and/or ineffective formal and informal communications.

Culture

Cultural norms, values, and basic assumptions of the organization hinder implementation.

Implementation climate

There is little capacity for change, low receptivity, and no expectation that the use of the innovation will be rewarded, supported, or expected.

Tension for change

Stakeholders do not see the current situation as intolerable nor do not believe they need to implement the innovation.

Compatibility

The innovation does not fit well with existing workflows nor with the meaning and values attached to the innovation, nor does it align well with stakeholders’ own needs and/or it heightens the risk for stakeholders.

Relative priority

Stakeholders perceive that the implementation of the innovation takes a backseat to other initiatives or activities.

Organizational incentives and rewards

There are no tangible (e.g., goal-sharing awards, performance reviews, promotions, salary raises) or less tangible (e.g., increased stature or respect) incentives in place for implementing the innovation.

Goals and feedback

Goals are not clearly communicated or acted upon, nor do stakeholders receive feedback that is aligned with goals.

Learning climate

The organization has a climate where (a) leaders do not express their own fallibility or need for stakeholders’ assistance or input; (b) stakeholders do not feel that they are essential, valued, and knowledgeable partners in the implementation process; (c) stakeholders do not feel psychologically safe to try new methods; and (d) there is not sufficient time and space for reflective thinking or evaluation.

Readiness for implementation

There are few tangible and immediate indicators of organizational readiness and commitment to implement the innovation.

Leadership engagement

Key organizational leaders or managers do not exhibit commitment and are not involved, nor are they held accountable for the implementation of the innovation.

Available resources

Resources (e.g., money, physical space, dedicated time) are insufficient to support the implementation of the innovation.

Access to knowledge and information

Stakeholders do not have adequate access to digestible information and knowledge about the innovation nor how to incorporate it into work tasks.

Knowledge and beliefs about the intervention

Stakeholders have negative attitudes toward the innovation, they place low value on implementing the innovation, and/or they are not familiar with facts, truths, and principles about the innovation.

Self-efficacy

Stakeholders do not have confidence in their capabilities to execute courses of action to achieve implementation goals.

Individual stage of change

Stakeholders are not skilled or enthusiastic about using the innovation in a sustained way.

Individual identification with organization

Stakeholders are not satisfied with and have a low level of commitment to their organization.

Planning

A scheme or sequence of tasks necessary to implement the intervention has not been developed or the quality is poor.

Opinion leaders

Opinion leaders (individuals who have a formal or informal influence on the attitudes and beliefs of their colleagues with respect to implementing the intervention) are not involved or supportive.

Formally appointed internal implementation leaders

A skilled implementation leader (coordinator, project manager, or team leader), with the responsibility to lead the implementation of the innovation, has not been formally appointed or recognized within the organization.

Champions

Individuals acting as champions who support, market, or “drive-through” implementation in a way that helps to overcome indifference or resistance by key stakeholders are not involved or supportive.

External change agents

Individuals from an outside entity formally facilitating decisions to help move implementation forward are not involved or supportive.

Key stakeholders

Multifaceted strategies to attract and involve key stakeholders in implementing or using the innovation (e.g., through social marketing, education, role modeling, training) are ineffective or non-existent.

Patients/customers

Multifaceted strategies to attract and involve patients/customers in implementing or using the innovation (e.g., through social marketing, education, role modeling, training) are ineffective or non-existent.

Executing

Implementation activities are not being done according to plan.

Reflecting and evaluating

There is little or no quantitative and qualitative feedback about the progress and quality of implementation nor regular personal and team debriefing about progress and experience.