Engaging

Engaging members of teams tasked with implementing an intervention (or to be ‘first users’) is an often overlooked part of implementation [1]. It is vital that early members are carefully and thoughtfully selected or allowed to rise naturally [1][2], especially ‘implementation leaders’ and ‘champions.’ If early users and leaders are homophilous (similar socioeconomic, professional, educational, and cultural backgrounds) with intended users, individuals will be more likely to adopt the intervention [3]. The influence of these leaders can be evaluated by assessing their presence or absence (e.g., does the implementation effort have a clear champion or not?), how they are brought on board (e.g., appointed, volunteered), their role in the organization (formal and/or informal roles), and their role in implementation. One means by which influence is transmitted is role modeling [4].

The positive influence of having the “right people in the right seats” [5] is strong. Likewise, having the wrong people or missing key opportunities to “engage” important individuals can have tremendous negative influence on implementation success. An approach used in some implementations, is simply to select people by virtue of their role in the organization or to select somewhat randomly. This approach may be effective in some situations but in others it squanders a valuable opportunity to build a cohesive team consisting of effective champions and stakeholders who are most likely to make the implementation a success. If supporters of the intervention outnumber and are better strategically positioned than opponents are, the implementation is more likely to be successful [3]. Involving all stakeholders (e.g., leadership, agents, users) early in implementation enhances success [3]. Engaging staff in meaningful problem-solving is one of five interactive elements critical to transform patient care [6]. Implementation will be more effective when key individuals are dedicated (in terms of time and energy), empowered, and supported in their efforts [7][8][9]. Key individuals are those who rise up in any capacity to help shepherd the implementation process to completion. Implementation leaders may be opinion leaders, formally appointed internal implementation leaders, champions, and/or external change agents. The quality of support provided by these implementation leaders is positively associated with implementation [10]. Effectively identifying and engaging these key individuals early in the process is important [1]. These leadership roles are used inconsistently and sometimes synonymously in the literature [3]. It is important to provide clarity in defining these roles. Implementation leaders may emerge somewhat organically through the course of implementation. For example, a leader may emerge out of a grass-roots (bottom-up) initiative to improve compliance with an infection control practice. Alternatively, implementation leaders may be identified through top-down appointment for example, by appointing local champions or a project coordinator. The PARiHS model asserts that “the role of the appropriately prepared facilitator, along with the team(s) they are working with, is to construct a programme of change that meets individual and team learning needs” [11, pg. 22]. The CFIR takes a broader view, recognizing the role of many different types of leaders and influencers. Specific roles and expectations will vary depending on the study and setting and even over time within a single implementation effort. However, any one role cannot function in isolation; personal characteristics certainly matter but relationships between these individuals can be more important than individual roles or characteristics [12].