Table 5 Comparison of additional implementation strategies to EPOC taxonomy

Changes to organizational policies

Creating/adapting new policies and or adaptations or modifications to existing organizational policies to enable the implementation of evidence at a systems-level [41]

Weiss 2019:

Added components into intervention units’ operational procedures for hospital discharge

Titler 2009: Revision of institution-specific documents (e.g., documentation forms, policies, and procedures)

Organizational culture: “Strategies to change organizational culture”

ERIC Taxonomy [42]:

1. Mandate change; Have leadership declare the priority of the innovation and their determination to have it implemented

2. Alter patient/consumer fees: Create fee structures where patients/consumers pay less for preferred treatments (the clinical innovation) and more for less-preferred treatments

3. Change accreditation or membership requirements: Strive to alter accreditation standards so that they require or encourage use of the clinical innovation.

Dynamic Adaption process and EPIS implementation conceptual model: Policies, funding/resources are classified at the system-level and differ from culture/climate [41]

Organizational culture is defined as the “attitudes, experiences, beliefs, and values of the organization, acquired through social learning, that control the way individuals and groups in the organization interact with one another and with parties outside it.” [43]

The “Changes to organizational policies” strategy identified in our review differs from this definition of culture, as it relates specifically to changing practice policies and procedures to implement evidence into practice. Making changes to organizational policies is not the same as interventions to change the attitudes, experiences, beliefs, and values of an organization. As such, it requires a distinct strategy, similar to the way it has been described in other implementation science research, such as the ERIC taxonomy. While organizational policies may contribute to creating organizational culture in the long term, their goal is to provide concrete direction to staff about practice/behavior, not to simply change beliefs or attitudes.

Participatory approaches

Collaborative research approaches, such as engaged scholarship, integrated knowledge translation, co-production, participatory action research, that engage knowledge users (e.g., patients, health care providers, policy-makers) throughout the research process [44]

Von Lengerke 2017: Involved medical psychologists and performed in coordination with the leading Hospital Epidemiology Department and the health economists involved in the project.

Tjia 2015: An interdisciplinary team of geriatric physicians, pharmacists, and a nurse used the needs assessment results, CERSG data, and an environmental scan of existing NH quality improvement toolkits to develop the NH antipsychotic prescribing toolkit.

Köpke et al. 2012: Multidisciplinary guideline development group of nationwide experts from all relevant fields, including a residents’ representative, was convened. Group members received a 1-day introduction to evidence-based medicine and guideline development. The guideline development group met 5 times between October 2007 and May 2008.

Tailored interventions: “Interventions to change practice that are selected based on an assessment of barriers to change, for example through interviews or surveys.”

ERIC Taxonomy [42]:

Develop academic partnerships: Partner with a university or academic unit for the purposes of shared training and bringing research skills to an implementation project

The collaborative research approaches described in the literature involve knowledge users throughout the research process (i.e., research question generation, data collection, analysis, interpretation of findings). The approaches described in the included studies of this review highlight multidisciplinary teams involved in the research process to support guideline implementation. This differs from the “Tailored Interventions” strategy in the EPOC taxonomy, as it focuses on the who and how knowledge users were involved in the research process, beyond an assessment of barriers and selection of strategies.

Facilitation

Facilitation “represents the active ingredient of implementation, with individuals defined as facilitators taking on a change agency role to identify elements of evidence and context that might influence implementation and then utilizing appropriate facilitation methods and processes to enable the implementation process.” [45]

Snelgrove-Clarke 2015: Supported by the principal investigator facilitator, groups of four to six nurses participated in monthly, 2-h Action Learning meetings by sharing their experiences of adhering to the IA component of the guideline for low-risk laboring women. The facilitator conducted 1:1 coaching at least once on the birthing unit between monthly meetings.

Vallerand 2004: The principal investigator, an expert consultant, was

available by pager to provide a way for the nurses to have their questions answered while in the field. The consultant also was available to provide guidance while nurses in the clinical setting developed care plans and to direct role-playing to prepare for situations requiring advocacy for more effective pain management (e.g., telephone calls to physicians requesting changes in analgesic orders)

Feldman 2004:

The interactive practitioner training utilized experienced facilitators, as well as role-playing and audiotaping, to help nurses increase their skills in communicating with and motivating their patients to adhere to treatment instructions.

Local opinion leaders: “The identification and use of identifiable local opinion leaders to promote good clinical practice.”

ERIC taxonomy:

Facilitation: A process of interactive problem solving and support that occurs in a context of a recognized need for improvement and a supportive interpersonal relationship

Facilitation has been tested in several trials as a distinct and effective implementation strategy to optimize the implementation of evidence into practice [46,47,48,49]. It differs from the “Local Opinion Leaders” category, as it focuses on distinct facilitation processes to enable change.

Guideline adaptation

Guideline adaptation includes reviewing the available evidence, contextualizing the evidence to the local context, and customizing recommendations to adapt guideline to the local context [50]. 

Fairall 2005, 2010: The guideline was adapted from WHO’s PAL guideline after consultation with South African primary care physicians, nurses and managers, and harmonized with local guidelines such as the national essential drug list, HIV and tuberculosis programmes.

Feldman 2004: The HOME Plan adapted the heart failure guideline developed by the Agency for Healthcare Research and Quality (AHRQ), to the home care setting.

Harrison 2000: These guidelines include a wall chart and a

manual on the syndromic management of STD, adapted from the World Health Organization recommendations on STD treatment, and evaluated locally to determine treatment effectiveness.

Naylor 2004: Evidence-based protocol, guided

by national heart failure guidelines and designed specifically for this patient group and their caregivers with a unique focus on comprehensive management of needs and therapies associated with an acute episode of heart failure complicated by multiple comorbid conditions.

Tailored interventions: “Interventions to change practice that are selected based on an assessment of barriers to change, for example through interviews or surveys.”

Local consensus process: “Formal or informal local consensus processes, for example agreeing a clinical protocol to manage a patient group, adapting a guideline for a local health system or promoting the implementation of guidelines.”

ERIC Taxonomy: Promote adaptability: Identify the ways a clinical innovation can be tailored to meet local needs and clarify which elements of the innovation must be maintained to preserve fidelity

Guideline adaptation differs from “Tailored Interventions”, as it focuses on tailoring and making changes to the guideline itself to meet local needs and local context, which aligns with the ERIC taxonomy “Promoting Adaptability” category.

In contrast, the EPOC taxonomy category of “Tailored Interventions” focuses on tailoring the implementation strategy to the local context.

Guideline adaptation also differs from “Local Consensus Process”, as it involves a more robust process to adaptation beyond what is implied in the EPOC definition of local consensus process. Guideline adaptation includes reviewing the available evidence, contextualizing the evidence to the local context, and customizing recommendations to adapt guideline to the local context [50]. Similarly, this aligns with the ERIC taxonomy “promoting adaptability” category.