MICHEL WENSING, Full Professor of Health Services Research and Implementation Science, University of Heidelberg, Heidelberg; Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany; Department IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.

RICHARD GROL, Emeritus Professor, Radboud University, Nijmegen; and Maastricht University, Maastricht, The Netherlands.

JEREMY GRIMSHAW, Senior Scientist, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario; Full Professor, Department of Medicine, University of Ottawa, Ottawa, Ontario; Canada Research Chair in Health Knowledge Transfer and Uptake, Ottawa, Ontario, Canada.

List of Contributors xv Introduction xix Part I Principles of the Implementation of Change 1 1 Implementation of Change in Healthcare: A Complex Problem 3Richard Grol and Michel Wensing 1.1 Introduction 3 1.2 The Implementation Problem 5 1.2.1 Effective Care 6 1.2.2 Safe Care 6 1.2.3 Efficient Care 7 1.2.4 Access to Care 8 1.2.5 Patient-Centered Care 8 1.2.6 Variation in the Provision of Care 8 1.3 Various Approaches to the Implementation of Change in Patient Care 9 1.4 What is Implementation? 12 1.5 Which Recommended Practices Should Be Adopted? 15 1.5.1 New Insights and Technologies 15 1.5.2 Problems in Healthcare Practice 16 1.6 A Systematic Approach to "Sustainable Change" 16 References 17 2 Theories on Implementation of Change in Healthcare 21Michel Wensing and Richard Grol 2.1 Introduction 21 2.2 Theories on Factors Related to Individual Professionals 23 2.2.1 Cognitive Theories 23 2.2.2 Educational Theories 25 2.2.3 Motivational Theories 26 2.3 Theories on Social Processes 27 2.3.1 Social Learning Theory 27 2.3.2 Theories on Communication 27 2.3.3 Social Network Theories 28 2.3.4 Theories on Teamwork 29 2.3.5 Theories on Professionalization 29 2.3.6 Theories on Leadership 30 2.4 Theories on Organizational Systems 31 2.4.1 Theories of Effective Organizations 31 2.4.2 Theory of Quality and Safety Management 31 2.4.3 Theory of Operations Management 33 2.4.4 Theory of Complex Systems 33 2.4.5 Theory of Organizational Learning 34 2.4.6 Theories of Organizational Culture 35 2.5 Theories on Economic and Societal Structures 36 2.5.1 Economic Theories 36 2.5.2 Theories on Contracting 37 2.6 Conclusions 37 References 39 3 Effective Implementation of Change in Healthcare: A Systematic Approach 45Richard Grol and Michel Wensing 3.1 Elements of Effective Implementation 45 3.2 The Implementation of Change Model 52 3.3 Developing a Proposal and Targets for Change 53 3.4 Assessment of Performance 55 3.5 Analysis of the Target Group and Setting 56 3.5.1 Aims and Settings of the Implementation 57 3.5.2 Segments within the Target Group and Stages of Change 57 3.5.3 Phases in a Process of Change: A Summary of the Literature 58 3.5.4 Orientation 59 3.5.5 Insight 59 3.5.6 Acceptance 59 3.5.7 Change 60 3.5.8 Maintenance 60 3.5.9 Barriers and Facilitators to Changing Practice 60 3.6 Selection and Development of Improvement Strategies 61 3.7 Development, Testing, and Execution of an Implementation Plan 61 3.8 Sustainable Change: Integration of Change into Practice Routines 63 3.9 Evaluation and (Possible) Adaptations to the Plan 63 3.10 Planning of the Implementation Process 66 3.11 Conclusions 68 References 68 4 Planning and Organizing the Change Process 73Richard Grol and Michel Wensing 4.1 Introduction 73 4.2 A Motivated Team Comprising All Relevant Expertise 75 4.3 Creating a Context for Change 76 4.3.1 The Central Role of Physicians 76 4.3.2 Collaboration in Teams for Patient Care 78 4.4 Involving the Target Group and Stakeholders in the Plan 81 4.5 Leaders and Key Figures 81 4.5.1 Medical Leadership 82 4.6 Project Management: Time Schedule and Responsibilities 82 4.7 Resources and Support 83 4.8 Conclusions 84 References 84 Part II Guidelines and Innovations 87 5 Characteristics of Successful Innovations 89Richard Grol and Michel Wensing 5.1 Introduction 89 5.2 Various Types of Improvements Require Various Types of Change Proposals 91 5.2.1 Scientific Literature, Guidelines, Decision Support, and Decision Aids 91 5.2.2 Clinical Pathways 92 5.2.3 Improved Care Processes 93 5.2.4 Other Innovations 93 5.3 Characteristics of Innovations That Promote Implementation 94 5.4 Format and Presentation 97 5.5 Involvement of the Target Group and Local Adaptation 99 5.6 Conclusions 100 References 100 6 Clinical Practice Guidelines as a Tool for Improving Patient Care 103Jako Burgers, Trudy van der Weijden, and Richard Grol 6.1 Introduction 103 6.2 Aims of Guidelines 104 6.3 Potential Benefits and Limitations of Guidelines 105 6.3.1 Potential Benefits 106 6.3.2 Possible Limitations 106 6.4 Development of Effective Guidelines 107 6.4.1 Topic Selection 107 6.4.2 Composition of the Guideline Development Group 110 6.4.3 Patient and Public Involvement 111 6.4.4 Drafting the Scope 113 6.4.5 Development of Draft Guideline 114 6.4.6 Identifying and Reviewing Available Guidelines and Reviews 114 6.4.7 Collection and Evaluation of Scientific Evidence 115 6.4.8 Contribution of All Relevant Expertise and Experience 116 6.4.9 Formulation of Recommendations 116 6.4.10 Consultation and Authorization 118 6.4.11 Consultation 118 6.4.12 Pilot Testing 119 6.4.13 Authorization 119 6.4.14 Design of the Guideline and Related Products 119 6.4.15 Evaluation 120 6.4.16 Updating Guidelines 121 6.5 Quality of Guidelines and Guideline Development Programs 121 6.6 International Collaboration in Guideline Development 123 6.7 Conclusion 124 References 125 Part III Assessment of Performance 131 7 Indicators for Quality and Safety of Care 133Jozé Braspenning, Rosella Hermens, Hilly Calsbeek, Stephen Campbell, Philip van der Wees, and Richard Grol 7.1 Introduction 133 7.1.1 Aim of the Assessment 135 7.2 Indicators for Quality and Safety of Care 137 7.2.1 Aims of Measurement 137 7.2.2 Domains and Perspectives 138 7.2.3 Categories of Indicators 138 7.3 Methods to Develop a Set of Indicators 140 7.4 Selecting or Developing a Preliminary Set of Indicators 140 7.4.1 Indicator Attributes 141 7.4.2 Number of Indicators 141 7.5 Finding Consensus among Target Users 141 7.5.1 Delphi Technique 142 7.5.2 RAND/UCLA Appropriateness Method 142 7.6 Testing the Indicators Empirically 144 7.6.1 Validity and Reliability 144 7.7 Create a Feedback Report 147 7.7.1 Calculating Indicators and Benchmarks 147 7.7.2 Formulating Aims of Improvement 147 7.8 Use and Effect of Quality Indicators 148 7.8.1 Unintended Effects 148 7.9 Conclusion 149 References 150 Part IV Problem Analysis 155 8 Determinants of Implementation 157Michel Wensing and Richard Grol 8.1 Introduction 157 8.2 Analysis of Stakeholders 159 8.3 Determinants of Change 161 8.3.1 Individual Health Professional Factors 161 8.3.1.1 Cognitive Factors 161 8.3.1.2 Motivational Factors 162 8.3.1.3 Behavioral Factors (Routines) 163 8.3.2 Patient Factors 163 8.3.3 Professional Interactions 163 8.3.3.1 Team Processes 163 8.3.4 Professional Networks 164 8.3.5 Organizational Factors 165 8.3.5.1 Capacity for Organizational Change 165 8.3.6 Organizational Structure 165 8.3.7 Organizational Culture 166 8.3.8 Availability of Necessary Resources 166 8.3.9 Societal Factors 166 8.3.9.1 Health Professions 166 8.3.9.2 Financial Incentives and Disincentives 167 8.3.9.3 Legislation 167 8.4 Subgroups in the Target Population 167 8.5 Conclusions 168 References 168 9 Methods to Identify and Analyze Determinants of Implementation 173Michel Wensing and Richard Grol 9.1 Introduction 173 9.2 Interviews 175 9.2.1 Individual Interviews 175 9.2.2 Group Interviews 175 9.3 Surveys 177 9.3.1 Questionnaires about Clinical Guidelines 178 9.3.2 Questionnaires on Theory-Based Determinants of Implementation 178 9.4 Observation 180 9.4.1 Routinely Collected Data 180 9.4.2 Direct Observation 180 9.5 Data Analysis 181 9.5.1 Scientific Methods of Data Analysis 182 9.5.2 Quality Improvement Methods 183 9.5.3 Paretogram 183 9.5.4 Fishbone Diagram 184 9.5.5 Flow Chart 185 9.6 Prioritization and Goal Setting 186 9.7 Conclusions 186 References 187 Part V Strategies for Change 189 10 Selection of Strategies for Improving Patient Care 191Richard Grol and Michel Wensing 10.1 Introduction 191 10.2 Methods to Select and Develop Implementation Strategies 192 10.2.1 Explorative Methods 194 10.2.2 Theory-Based Methods 196 10.3 Classification of Implementation Strategies 196 10.4 Implementation Strategies in the Different Phases of Change 199 10.4.1 Orientation 200 10.4.2 Insight and Understanding 200 10.4.3 Acceptance 201 10.4.4 Change 201 10.4.5 Maintenance 202 10.5 Subgroups within the Target Group 202 10.6 The Effectiveness of Different Strategies and Interventions 203 10.7 Conclusions 204 References 205 11 Dissemination of Innovations 207Richard Grol and Michel Wensing 11.1 Introduction 207 11.2 Mass Media Approach 210 11.2.1 Written Materials 210 11.2.2 Internet-Based Approaches 210 11.2.3 Factors Associated with the Impact of Mass Media Strategies 212 11.3 Personalized Approaches 213 11.3.1 CME Courses and Conferences 214 11.3.2 Social Networks 214 11.3.3 Influential Individuals 215 11.3.4 Personal Introduction in Practice 216 11.4 Conclusion 217 References 218 12 Educational Implementation Strategies 221Michel Wensing, Cornelia Fluit, Jeremy Grimshaw, and Richard Grol 12.1 Introduction 221 12.2 Types of Educational Strategies 223 12.3 Effectiveness of Education 224 12.3.1 Educational Materials 225 12.3.2 Educational Meetings 225 12.3.3 Outreach Visits 226 12.3.4 E-learning 226 12.4 Determinants of the Effectiveness of Education 227 12.4.1 Targets for Education 228 12.4.2 Active Participation 229 12.4.3 Duration of Education 229 12.4.4 Opinion Leaders 229 12.4.5 Assessment and Feedback 230 12.5 Discussion and Conclusions 230 References 231 13 Clinical Performance Feedback and Decision Support 235Noah Ivers, Benjamin Brown, and Jeremy Grimshaw 13.1 Introduction 235 13.2 Definitions, Characteristics, and Components 238 13.2.1 Feedback 238 13.2.2 Decision Support 238 13.3 Effectiveness of Feedback and Decision Support 239 13.4 Factors Associated with Effects 241 13.4.1 Underlying Assumptions, Relevant Theories, and Mechanisms 241 13.4.2 Factors Associated with Effects 242 13.5 Discussion and Conclusions 246 References 248 14 Engaging Patients in Healthcare Improvement and Innovation 253Glyn Elwyn and Amy Price 14.1 Introduction 253 14.2 Impact of Patient Engagement on Direct Care 254 14.2.1 Well-Established Conceptual Frameworks 254 14.2.2 Persistent Theory-Practice Gap 255 14.2.3 Broader Impacts 256 14.3 Impact of Patient Engagement on Organizational Design and Governance 257 14.4...