Background:Implementation strategies are dynamic techniques used to apply evidence-based practices (EBPs) to diverse contexts. Despite their importance, context-specific selection and modification of implementation strategies remain underreported, limiting understanding of how to optimize strategy deployment across heterogeneous healthcare settings. We describe a systematic method to document and analyze modifications to implementation strategies using four diverse hospital sites from the Fluoroquinolone Restriction for the Prevention of Clostridioides difficile infection (FIRST) trial as case studies. Methods:FIRST was a multisite fluoroquinolone pre-prescription restriction intervention delivered via the electronic health record. We partnered with multidisciplinary stakeholders at each site to co-design and adapt the intervention using pre-planned implementation strategies. Multiple data sources (interviews, meeting notes, implementation diaries) collected iteratively over two years were analyzed to identify strategy modifications. Strategies were coded using Expert Recommendations for Implementing Change (ERIC) conceptual clusters, and modifications were documented using the Framework for Reporting Adaptations and Modifications to Evidence-Based Implementation Strategies (FRAME-IS). Modified strategies were categorized as planned or unplanned and contextualized via thematic content analysis. Results:Across 458 total modifications, the most modified strategies focused on facilitating stakeholder engagement, adapting to local contexts, and using evaluative approaches to improve EBP uptake/sustainment. Planned modifications (n=330, 72%) outnumbered unplanned modifications (n=157, 34%). Rural and community hospitals required more unplanned modifications (average 41 vs. 31 for academic centers), while sites with prior restrictive intervention experience had higher planned-to-unplanned ratios (3.1:1 vs. 1.6:1). Academic hospitals with trainee rotations required ongoing education and higher strategy modifications. All modifications maintained EBP core fidelity. Site-specific patterns organizational characteristics were linked to modification intensity and type, including absorptive capacity, prior experience, relational coordination, rurality, and educational requirements. Conclusions:Integrating ERIC and FRAME-IS enabled systematic documentation of implementation strategy modifications across diverse settings. Planned:unplanned modification ratios provided novel insights into organizational absorptive capacity and implementation preparedness. Standardized implementation approaches inadequately address critical organizational differences, requiring context-sensitive strategy selection and intensity calibration. This work advances implementation science methodology by demonstrating how systematic modification documentation can inform tailored implementation support.

Clostridioides difficile infection is the most common healthcare-associated infection, causing almost half a million infections in the United States annually. Inappropriate antibiotic usage is a known risk factor. Antibiotic stewardship efforts aim to optimize prescribing. Evidence supports pre-prescription authorization as a highly effective intervention. A pre-prescription intervention for fluoroquinolone antibiotics via a computerized clinical decision support tool called a “best practice alert” (BPA) embedded in the patient’s electronic health records has high potential for improving antibiotic stewardship. However, information is scant about the factors that might impact the uptake and effectiveness of this BPA and other similar evidence-based interventions when spread and adopted across multiple independent sites. Therefore, we utilized the Consolidated Framework for Implementation Research (CFIR) to understand the facilitators and barriers to the implementation process that influence clinical and implementation outcomes. In doing so, we conducted semi-structured interviews with 18 healthcare professionals across four hospitals. Our research team performed a qualitative analysis to understand the contextual factors influencing the implementation outcomes, such as acceptability and sustainability. Takeaways The following themes highlight the factors affecting the implementation of this healthcare innovation. Intervention characteristics domain Designing interventions that are customizable and low maintenance. Inner setting domain Maturity level of the Antibiotic Stewardship Program. Individuals domain Implementer’s experience/attitudes in implementing healthcare innovations. Outer setting domain The ability to prioritize initiatives as the organization responds to unintended circumstances (e.g., COVID). Process domain Adapting implementation approaches and strategies as technology spreads.

PURPOSE:The fluoroquinolone restriction for the prevention of Clostridioides difficile infection (FIRST) trial is a multisite clinical study in which sites carry out a preauthorization process via electronic health record-based best-practice alert (BPA) to optimize the use of fluoroquinolone antibiotics in acute care settings. Our research team worked closely with clinical implementation coordinators to facilitate the dissemination and implementation of this evidence-based intervention. Clinical implementation coordinators within the antibiotic stewardship team (AST) played a pivotal role in the implementation process; however, considerable research is needed to further understand their role. In this study, we aimed to (1) describe the roles and responsibilities of clinical implementation coordinators within ASTs and (2) identify facilitators and barriers coordinators experienced within the implementation process. METHODS:We conducted a directed content analysis of semistructured interviews, implementation diaries, and check-in meetings utilizing the conceptual framework of middle managers' roles in innovation implementation in healthcare from Urquhart et al. RESULTS:Clinical implementation coordinators performed a variety of roles vital to the implementation's success, including gathering and compiling information for BPA design, preparing staff, organizing meetings, connecting relevant stakeholders, evaluating clinical efficacy, and participating in the innovation as clinicians. Coordinators identified organizational staffing models and COVID-19 interruptions as the main barriers. Facilitators included AST empowerment, positive relationships with staff and oversight/governance committees, and using diverse implementation strategies. CONCLUSION:When implementing healthcare innovations, clinical implementation coordinators facilitated the implementation process through their roles and responsibilities and acted as strategic partners in improving the adoption and sustainability of a fluoroquinolone preauthorization protocol.

Rationale: Although aligning care with patient goals is fundamental to critical care, this process is often delayed and leads to conflict among patients, families, and intensive care unit (ICU) teams. Interprofessional collaboration within ICU teams is an opportunity to improve goal-aligned care, yet this collaboration is poorly understood. A better understanding of how ICU team members work together to provide goal-aligned care may identify new strategies for improvement. Objectives: Transactive memory systems is a theory of group mind that explains how high-performing teams use a shared memory and collective cognition. We applied this theory to characterize the process of interprofessional collaboration within ICU teams and its relationship with goal-aligned care. Methods: We conducted a secondary analysis of focus group (n = 10) and semistructured interview (n = 8) transcripts, gathered during a parent study at two academic medical centers on the process of ICU care delivery in acute respiratory failure. Participants (N = 70) included interprofessional ICU and palliative care team members, surrogates, and patient survivors. We used directed content analysis, applying transactive memory systems theory and its major components (specialization, coordination, credibility) to examine ICU team collaboration. Results: Participants described each ICU profession as having a specialized role in aligning care with patient goals. Different professions have different opportunities to gather knowledge about patient goals and priorities, which results in dispersion of this knowledge among different team members. To share and use this dispersed knowledge, ICU teams rely on an informal coordination process and "side conversations." This process is a workaround for formal channels (e.g., health records, interprofessional rounds) that do not adequately convey knowledge about patient goals. This informal process does not occur if team members are discouraged from asserting their knowledge because of hierarchy or lack of psychological safety. Conversely, coordination succeeds when team members recognize each other as credible sources of valued knowledge. Conclusions: We found that ICU team members work together to align care with patient goals and priorities, using transactive memory systems. The successful function of these systems can be disrupted or promoted by ICU organizational and cultural factors, which are potential targets for efforts to increase goal-aligned care.

Background: The FIRST Trial is a 5-year study funded by the Agency for Healthcare Research and Quality. Our investigation is situated within a more extensive study to restrict fluoroquinolone antibiotics by requiring providers to obtain authorization from an infectious disease physician before prescribing fluoroquinolones. Our research team is performing a systematic evaluation to identify organizational characteristics and influencers of the fluoroquinolone preprescription authorization implementation process to understand variables that may facilitate or hinder implementation success. Methods: To address this critical gap, we present a qualitative analysis from our ongoing, multisite research project aimed at systematically assessing the adoption of an antimicrobial stewardship intervention in the form of an EHR-integrated best-practice alert (BPA) at each site to identify work system factors that impact uptake and variability in the implementation of the BPA at each location. The evaluation provides a detailed explanation of activities through the implementation process (eg, before implementation, during implementation, and after implementation) to assess how an organization effectively negotiates the phases and transitions, ultimately influencing the impact of the intervention. We have used a contextual determinant framework (CFIR) that has enabled us to perform a systematic and comprehensive exploration and identification of potential explanatory themes or variables to shed light on the complex social phenomenon of implementation. Results: Participants who will be a part of our poster presentation will learn about implementing a BPA, the potential barriers to implementation, and strategies for overcoming these barriers. Stakeholders within our study include site coordinators, medical doctors, nurses, pharmacists, and clinical informaticists. Our analysis synthesizes their experiences implementing and sustaining this evidence-based antimicrobial stewardship intervention. It includes (1) a detailed description of the process of change, (2) work-system factors (eg, inner setting and outer setting) that they believe influenced the success of the intervention, (3) barriers and facilitators (eg, CFIR constructs) within the implementation process; and (4) description of how these could have influenced the outcomes of interest (eg, implementation and intervention effectiveness). Conclusions: Our research is expected to advance patient safety research and initiatives by providing a more robust approach to performing systematic intervention evaluations. By outlining stakeholders’ experiences within our study, implementation leaders within healthcare systems will utilize our findings to aid them in their design and implementation process when designing and implementing similar types of healthcare interventions. Disclosures: None

Root Cause Analysis and Action (RCA 2 ) guidelines offer fundamental improvements to traditional RCA. Yet, these guidelines lack robust methods to support a human factors analysis of patient harm events and the development of systems-level interventions. We previously described how human factors tools can be integrated into RCA 2 to create a robust process called HFACS-RCA 2 . Prior analyses of qualitative data associated with an 18-month implementation project at a large academic health center indicated that HFACS-RCA 2 fosters a more comprehensive human factors analysis of serious patient harm events and the identification of broader system interventions. The present study builds on this prior research by presenting the analysis of actual recommendations extracted from RCA reports. Results corroborate qualitative stakeholder findings that HFACS-RCA 2 produced recommendations that were stronger and included more substantive changes compared to former RCA methods.

Root Cause Analysis and Action (RCA2 ) guidelines offer fundamental improvements to traditional RCA. Yet, these guidelines lack robust methods to support a human factors analysis of patient harm events and development of systems-level interventions. We recently integrated a complement of human factors tools into the RCA2 process to address this gap. These tools include the Human Factors Analysis and Classification System (HFACS), the Human Factors Intervention Matrix (HFIX), and a multiple-criterion decision tool called FACES, for selecting effective HFIX solutions. We describe each of these tools and illustrate how they can be integrated into RCA2 to create a robust human factors RCA process called HFACS-RCA2 . We also present qualitative results from an 18-month implementation study within a large academic health center. Results demonstrate how HFACS-RCA2 can foster a more comprehensive, human factors analysis of serious patient harm events and the identification of broader system interventions. Following HFACS-RCA2 implementation, RCA team members (risk managers and quality improvement advisors) also experienced greater satisfaction in their work, leadership gained more trust in RCA findings and recommendations, and the transparency of the RCA process increased. Effective strategies for overcoming implementation barriers, including changes in roles, responsibilities and workload will also be presented.