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The influence of formal and informal policies and practices on health care innovation implementation

A mixed-methods analysis

DiMartino, Lisa D.; Birken, Sarah A.; Hanson, Laura C.; Trogdon, Justin G.; Clary, Alecia S.; Weinberger, Morris; Reeder-Hayes, Katherine; Weiner, Bryan J.

doi: 10.1097/HMR.0000000000000193
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Background: The implementation science literature has contributed important insights regarding the influence of formal policies and practices on health care innovation implementation, whereas informal implementation policies and practices have garnered little attention. The broader literature suggests that informal implementation policies and practices could also influence innovation use.

Purpose: We used the Organizational Theory of Innovation Implementation to further understand the role of formal and informal implementation policies and practices as determinants of implementation effectiveness. We examined their role within the context of initiatives to increase palliative care consultation in inpatient oncology.

Methods: We used a case study design in two organizational settings within one academic medical center: medical and gynecologic oncology. We completed semistructured interviews with medical (n = 12) and gynecologic (n = 10) oncology clinicians using questions based on organizational theory. Quantitative data assessed implementation effectiveness, defined as aggregated palliative care consult rates within oncology services from 2010 to 2016. Four palliative care clinicians were interviewed to gain additional implementation context insights.

Results: Medical oncology employed multiple formal policies and practices including training and clinician prompting to support palliative care consultation and a top-down approach, yet most clinicians were unaware of the policies and practices, contributing to a weak implementation climate. In contrast, gynecologic oncology employed one formal policy (written guideline of criteria for initiating a consult) but also relied on informal policies and practices, such as spontaneous feedback and communication; they adopted a bottom-up approach, contributing to broader clinician awareness and strong implementation climate. Both services exhibited variable, increasing consult rates over time.

Practice Implications: Informal policies and practices may compensate or substitute for formal policies and practices under certain conditions (e.g., smaller health care organizations). Further research is needed to investigate the role of formal and informal policies and practices in shaping a strong and sustainable implementation climate and subsequent effective innovation implementation.

Lisa D. DiMartino, PhD, MPH, is Implementation Scientist, RTI International. E-mail: ldimartino@rti.org.

Sarah A. Birken, PhD, is Assistant Professor, Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill.

Laura C. Hanson, MD, MPH, is Professor, Division of Geriatric Medicine, Center for Aging and Health, UNC Palliative Care Program, Chapel Hill, North Carolina.

Justin G. Trogdon, PhD, is Associate Professor, Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill.

Alecia S. Clary, MSW, is Doctoral Candidate, Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill.

Morris Weinberger, PhD, is Professor and Chair, Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill.

Katherine Reeder-Hayes, MD, MBA, MSc, is Assistant Professor, Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill.

Bryan J. Weiner, PhD, is Professor, Department of Health Services, School of Public Health, University of Washington; Department of Global Health, School of Public Health, University of Washington.

Dr. DiMartino’s work on this research was supported by funding from the National Cancer Institute Cancer Control Education Program (R25 CA057726). Ms. Clary’s work on this research was supported by the National Cancer Institute at the National Institute of Health (R25CA116339). The project described was also supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant Award TL1TR001110. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

The research was approved by the University of North Carolina at Chapel Hill Institutional Review Board (IRB 16-0087). All participants provided verbal informed consent prior to participation in the study.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

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