The Expert Recommendations for Implementation Change (ERIC) project,1; 2 EvidenceNOW,3 and the National Association of Community Health Center’s Transforming Primary Care for LGBT People Toolkit4 document various implementation strategies for teams to consider when moving toward new policies or practices. Table 1 reviews the most common strategies and their associated activities. Your clinic likely has a strong track record of using such strategies to get things done. The strategies are organized under the following domains: Action Plan; Adaptation; Provide Educational Material; Financial Considerations; Implementation Team; Meetings and Training; Multilevel Engagement, Leadership and Policy; Organizational Assessment; Organizational Infrastructure and Processes; Partnerships; Physical Environment; Quality Assurance and Data Systems; Role Modeling; and Roll Out.
The list of implementation strategies in Table 7.1 is not exhaustive. The Implementation Team should not shy away from creating new strategies to achieve their goals, nor should members feel compelled to use every strategy listed. Implementation strategies are being identified all the time or tweaked to better navigate the specific facilitators and barriers present in local healthcare settings!
Common Implementation Strategies
Implementation Action Plan
Develop an implementation blueprint that includes all goals and strategies for implementing recommendations for SGM care. Use and update this plan to guide the implementation of recommendations over time.
Tailor implementation strategies to address barriers and leverage facilitators identified through earlier data collection (e.g., organizational assessment).
Identify ways that recommendations can be tailored (or adapted) to meet local needs and clarify which elements of the recommendations must be maintained to preserve fidelity.
Provide Educational Materials
Adapt and/or develop educational materials to make it easier for stakeholders to learn about the recommendations and for providers and staff to deliver and/or support the implementation of these recommendations.
Develop and/or distribute a list of terms describing recommendations, their implementation, and involved stakeholders.
Distribute educational materials in person, by mail, and/or electronically.
Fund/Incentivize the Implementation
Access new or existing money to facilitate the implementation of recommendations.
Work to incentivize the adoption and implementation of the recommendations.
Place adherence to SGM competent primary care recommendations on lists of actions for which providers can be reimbursed (e.g., drug is placed on a formulary, a procedure is now reimbursable).
Develop a team of individuals to guide the implementation process.
Collaborate with one or more facilitators, consultants, coaches, advisors, and/or other experts in implementation.
Identify and prepare change champions (e.g., providers and staff) who dedicate themselves to supporting, marketing, and driving the implementation of recommendations and overcoming indifference or resistance at the clinic.
Organize protected time for providers and staff to participate in team meetings so members can reflect on the implementation effort, share lessons learned, and support one another’s planning and implementation efforts.
Develop and use a centralized system for providing technical assistance to support the implementation of recommendations.
Recruit, designate, and train leaders for the implementation and facilitate multilevel representation on the team.
Meetings and Training
Conduct ongoing and dynamic educational meetings and/or outreach visits to educate multiple clinic stakeholder groups.
Vary the information delivery methods to cater to different learning styles and work contexts.
Capture and share local knowledge from others regarding successful implementation of SGM competent primary care.
Use train-the-trainer strategies such that clinic personnel are trained or designated to train others in using the recommendations.
Make training accessible to all levels of providers and staff at the clinic.
Multilevel Engagement, Leadership and Policy
Create and engage a formal group of multiple kinds of stakeholders at varying organizational levels to provide input and advice on implementation efforts and elicit recommendations for improvements.
Involve governing structures (e.g., Boards of Directors, medical staff boards) in the implementation of recommendations—including the review of data on implementation processes (as defined in the Action Plan).
Mandate change such that adherence to the recommendations for SGM health care is required by leadership and monitor adherence.
Obtain written, formal commitments from partners that state what they will do to implement the recommendations.
Include patients and family members in the implementation effort.
Develop strategies with patients to encourage and problem-solve around adherence to recommendations. For example, patient surveys can assess awareness of and satisfaction with the receipt of SGM competent primary care, or a telephone line can be developed for SGM and other patients to call to report problems related to service delivery.
Prepare patients to be active in their care, to ask questions, and specifically inquire about the recommendations for SGM competent primary care, the evidence supporting clinical decisions, or the availability of evidence-supported treatments. Patient education materials can be developed or adapted to address patient-centered care for SGM patients, including a small paragraph explaining why the clinic collects information about sexual orientation and gender identity on registration and intake forms.
Use social and/or mass media to reach larger numbers of people to spread the word about implementing the recommendations.
Assess for organizational readiness, barriers, and facilitators for implementation of the recommendations.
Assess current work processes and workflow, and plan for desired work processes, identifying changes necessary to accommodate, encourage, or incentivize the use of the recommendations.
Audit and provide feedback on clinical performance data over time.
Conduct a local needs assessment regarding the need for implementing the recommendations.
Organizational Infrastructure and Processes
Use existing communication channels (all-staff meetings, advisory boards, workgroups) or create new ones to communicate organizational priorities around the recommendations and inform leadership and others about their implementation.
Shift or revise professional roles for provision of care and/or redesign job characteristics.
Connect providers, staff, and patients to community resources outside the clinic.
Develop partnerships and resource-sharing agreements with organizations with the resources needed to implement the guidelines.
Develop partnerships with a university or academic/research unit for shared training. Bringing research expertise to this endeavor may facilitate a focus on quality improvement and assurance.
Evaluate current configurations and adapt, as needed, the physical structure or equipment (e.g., changing signage and the layout of a room, adding equipment) to best accommodate the implementation of the recommendations.
Quality Assurance and Data Systems
Develop, test, and introduce language, protocols, algorithms, standards, and measures (of process, patient outcomes, and implementation outcomes) specific to the recommendations into the quality assurance system.
Change records systems to allow better assessment of implementation or outcomes.
Develop reminder systems to help clinicians recall information and/or prompt them to do so.
Provide clinicians with ongoing supervision focusing on the recommendations. Provide training for supervisors of clinicians and staff involved in implementing the recommendations to enhance quality.
Involve, hire, or consult experts to inform clinic management about using data generated by implementation efforts. Develop and distribute data reports to monitor quality.
Develop and organize systems and procedures to monitor clinical processes/outcomes for quality assurance and improvement. Monitor progress and adjust practices and implementation strategies to continuously improve the quality of care.
Model or simulate the change before implementation of the recommendations.
Identify early adopters at the clinic (or in other clinics) to learn from their experiences with implementation.
Identify opinion leaders or “educationally influential” providers about the need for implementing the recommendations, hoping that they will adopt them and influence their colleagues to adopt them.
Offer ways for providers and staff to directly observe experienced people using the recommendations in their care delivery.
Use train-the-trainer strategies.
Visit sites where a similar implementation effort has been successful.
Phase implementation efforts by starting with small pilots or demonstration projects and gradually expand roll-out. Phasing should occur in conjunction with cyclical quality assurance efforts; a clinic may elect to begin implementing select recommendations, gradually expanding to the full list.