There has been a growing impetus to bridge the gap between basic science discovery, development of evidence-based practices (EBPs) and their availability and delivery in order to improve public health impact of such practices. In seeking to capitalize on factors that support implementation and sustainment of EBPs, it is important to consider that healthcare is delivered within the outer context of public health systems, and the inner context of healthcare organizations and workgroups. Leaders have a key role in determining the nature of system and organizational context. This article will addresses the role of leadership across levels in developing strategic climate for EBP implementation within the outer (i.e., system) and inner (i.e., organization, work group) contexts of healthcare. Within the framework of Edgar Schein’s “climate embedding mechanisms,” we describe strategies that leaders at the system, organization, and work group levels can consider and apply to develop a strategic climates that support the implementation and sustainment of EBP in healthcare and allied healthcare settings.

BackgroundImplementing treatments and interventions with demonstrated effectiveness is critical for improving patient health outcomes at a reduced cost. When an evidence-based intervention (EBI) is implemented with fidelity in a setting that is very similar to the setting wherein it was previously found to be effective, it is reasonable to anticipate similar benefits of that EBI. However, one goal of implementation science is to expand the use of EBIs as broadly as is feasible and appropriate in order to foster the greatest public health impact. When implementing an EBI in a novel setting, or targeting novel populations, one must consider whether there is sufficient justification that the EBI would have similar benefits to those found in earlier trials.DiscussionIn this paper, we introduce a new concept for implementation called “scaling-out” when EBIs are adapted either to new populations or new delivery systems, or both. Using existing external validity theories and multilevel mediation modeling, we provide a logical framework for determining what new empirical evidence is required for an intervention to retain its evidence-based standard in this new context. The motivating questions are whether scale-out can reasonably be expected to produce population-level effectiveness as found in previous studies, and what additional empirical evaluations would be necessary to test for this short of an entirely new effectiveness trial. We present evaluation options for assessing whether scaling-out results in the ultimate health outcome of interest.ConclusionIn scaling to health or service delivery systems or population/community contexts that are different from the setting where the EBI was originally tested, there are situations where a shorter timeframe of translation is possible. We argue that implementation of an EBI in a moderately different setting or with a different population can sometimes “borrow strength” from evidence of impact in a prior effectiveness trial. The collection of additional empirical data is deemed necessary by the nature and degree of adaptations to the EBI and the context. Our argument in this paper is conceptual, and we propose formal empirical tests of mediational equivalence in a follow-up paper.

Integrated care increases the proportion of patients with HCV infection and psychiatric illness and/or substance abuse who begin antiviral therapy and achieve SVRs, without serious adverse events. ClinicalTrials.gov # NCT00722423.

No abstract