Underlying the concept of sufficient dose is the mechanism of action: until there is a clear understanding of the mechanism of action by which an intervention is likely to succeed, it is difficult to grapple with issues of dose or intensity. Implicit in his discussion are theoretical perspectives, such as those underlying the use of opinion leaders to influence key stakeholders within the target organizations in the study, or the concept of intensity or dose of intervention.
In his accompanying editorial, Peterson 8 points to additional features that could have been incorporated into this trial that may have enhanced the probability of success. While several limitations were acknowledged by the authors, the authors did not address the “why” of the unsuccessful trial beyond pointing to elements that could have been improved.
No explicit theories of individual or organizational behavior change were applied in planning the design and conducting the study. 7 The principles guiding the design of the study were empirical, applying insights and findings from prior studies. This has been described as the Nike™ school of implementation: Just do it.Ī prominent recent example is the administrative data feedback for effective cardiac treatment (AFFECT) study report of a negative trial of administrative data feedback in attempting to improve hospital performance on key indicators of cardiac care.
In quality improvement, there may be a reluctance to examine theoretical bases for planning implementation activities and efforts, possibly in part because of a perceived need to differentiate between the nature of quality improvement activities and the nature of research, and in part because a focus on theory may not appear relevant, when the imperative is to act quickly. We also believe that the information presented in this paper is relevant and important both for researchers and for people involved in quality improvement activities in health care organizations. We believe that explicitly outlining and understanding some form of theory that explains the reason for why an intervention may work to induce planned change is a critical step in planning interventions to change provider or patient behavior, particularly in order to promote evidence-based care.
We focus on theories appropriate to change processes in clinical settings, typically complex organizations with multiple functioning parts. 1 – 6 Our objective in this paper is to describe ways to use theory to provide a foundation for designing and planning strategies for intervention and selecting tools with a better than random probability of success in implementing evidence-based findings into practice. Most attempts to implement evidence-based practices in clinical settings are either only partially successful, or unsuccessful, in the attempt.