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 xvIntroduction xixPart I Principles of the Implementation of Change 11 Implementation of Change in Healthcare: A Complex Problem 3Richard Grol and Michel Wensing1.1 Introduction 31.2 The Implementation Problem 51.2.1 Effective Care 61.2.2 Safe Care 61.2.3 Efficient Care 71.2.4 Access to Care 81.2.5 Patient-Centered Care 81.2.6 Variation in the Provision of Care 81.3 Various Approaches to the Implementation of Change in Patient Care 91.4 What is Implementation? 121.5 Which Recommended Practices Should Be Adopted? 151.5.1 New Insights and Technologies 151.5.2 Problems in Healthcare Practice 161.6 A Systematic Approach to “Sustainable Change” 16References 172 Theories on Implementation of Change in Healthcare 21Michel Wensing and Richard Grol2.1 Introduction 212.2 Theories on Factors Related to Individual Professionals 232.2.1 Cognitive Theories 232.2.2 Educational Theories 252.2.3 Motivational Theories 262.3 Theories on Social Processes 272.3.1 Social Learning Theory 272.3.2 Theories on Communication 272.3.3 Social Network Theories 282.3.4 Theories on Teamwork 292.3.5 Theories on Professionalization 292.3.6 Theories on Leadership 302.4 Theories on Organizational Systems 312.4.1 Theories of Effective Organizations 312.4.2 Theory of Quality and Safety Management 312.4.3 Theory of Operations Management 332.4.4 Theory of Complex Systems 332.4.5 Theory of Organizational Learning 342.4.6 Theories of Organizational Culture 352.5 Theories on Economic and Societal Structures 362.5.1 Economic Theories 362.5.2 Theories on Contracting 372.6 Conclusions 37References 393 Effective Implementation of Change in Healthcare: A Systematic Approach 45Richard Grol and Michel Wensing3.1 Elements of Effective Implementation 453.2 The Implementation of Change Model 523.3 Developing a Proposal and Targets for Change 533.4 Assessment of Performance 553.5 Analysis of the Target Group and Setting 563.5.1 Aims and Settings of the Implementation 573.5.2 Segments within the Target Group and Stages of Change 573.5.3 Phases in a Process of Change: A Summary of the Literature 583.5.4 Orientation 593.5.5 Insight 593.5.6 Acceptance 593.5.7 Change 603.5.8 Maintenance 603.5.9 Barriers and Facilitators to Changing Practice 603.6 Selection and Development of Improvement Strategies 613.7 Development, Testing, and Execution of an Implementation Plan 613.8 Sustainable Change: Integration of Change into Practice Routines 633.9 Evaluation and (Possible) Adaptations to the Plan 633.10 Planning of the Implementation Process 663.11 Conclusions 68References 684 Planning and Organizing the Change Process 73Richard Grol and Michel Wensing4.1 Introduction 734.2 A Motivated Team Comprising All Relevant Expertise 754.3 Creating a Context for Change 764.3.1 The Central Role of Physicians 764.3.2 Collaboration in Teams for Patient Care 784.4 Involving the Target Group and Stakeholders in the Plan 814.5 Leaders and Key Figures 814.5.1 Medical Leadership 824.6 Project Management: Time Schedule and Responsibilities 824.7 Resources and Support 834.8 Conclusions 84References 84Part II Guidelines and Innovations 875 Characteristics of Successful Innovations 89Richard Grol and Michel Wensing5.1 Introduction 895.2 Various Types of Improvements Require Various Types of Change Proposals 915.2.1 Scientific Literature, Guidelines, Decision Support, and Decision Aids 915.2.2 Clinical Pathways 925.2.3 Improved Care Processes 935.2.4 Other Innovations 935.3 Characteristics of Innovations That Promote Implementation 945.4 Format and Presentation 975.5 Involvement of the Target Group and Local Adaptation 995.6 Conclusions 100References 1006 Clinical Practice Guidelines as a Tool for Improving Patient Care 103Jako Burgers, Trudy van der Weijden, and Richard Grol6.1 Introduction 1036.2 Aims of Guidelines 1046.3 Potential Benefits and Limitations of Guidelines 1056.3.1 Potential Benefits 1066.3.2 Possible Limitations 1066.4 Development of Effective Guidelines 1076.4.1 Topic Selection 1076.4.2 Composition of the Guideline Development Group 1106.4.3 Patient and Public Involvement 1116.4.4 Drafting the Scope 1136.4.5 Development of Draft Guideline 1146.4.6 Identifying and Reviewing Available Guidelines and Reviews 1146.4.7 Collection and Evaluation of Scientific Evidence 1156.4.8 Contribution of All Relevant Expertise and Experience 1166.4.9 Formulation of Recommendations 1166.4.10 Consultation and Authorization 1186.4.11 Consultation 1186.4.12 Pilot Testing 1196.4.13 Authorization 1196.4.14 Design of the Guideline and Related Products 1196.4.15 Evaluation 1206.4.16 Updating Guidelines 1216.5 Quality of Guidelines and Guideline Development Programs 1216.6 International Collaboration in Guideline Development 1236.7 Conclusion 124References 125Part III Assessment of Performance 1317 Indicators for Quality and Safety of Care 133Jozé Braspenning, Rosella Hermens, Hilly Calsbeek, Stephen Campbell, Philip van der Wees, and Richard Grol7.1 Introduction 1337.1.1 Aim of the Assessment 1357.2 Indicators for Quality and Safety of Care 1377.2.1 Aims of Measurement 1377.2.2 Domains and Perspectives 1387.2.3 Categories of Indicators 1387.3 Methods to Develop a Set of Indicators 1407.4 Selecting or Developing a Preliminary Set of Indicators 1407.4.1 Indicator Attributes 1417.4.2 Number of Indicators 1417.5 Finding Consensus among Target Users 1417.5.1 Delphi Technique 1427.5.2 RAND/UCLA Appropriateness Method 1427.6 Testing the Indicators Empirically 1447.6.1 Validity and Reliability 1447.7 Create a Feedback Report 1477.7.1 Calculating Indicators and Benchmarks 1477.7.2 Formulating Aims of Improvement 1477.8 Use and Effect of Quality Indicators 1487.8.1 Unintended Effects 1487.9 Conclusion 149References 150Part IV Problem Analysis 1558 Determinants of Implementation 157Michel Wensing and Richard Grol8.1 Introduction 1578.2 Analysis of Stakeholders 1598.3 Determinants of Change 1618.3.1 Individual Health Professional Factors 1618.3.1.1 Cognitive Factors 1618.3.1.2 Motivational Factors 1628.3.1.3 Behavioral Factors (Routines) 1638.3.2 Patient Factors 1638.3.3 Professional Interactions 1638.3.3.1 Team Processes 1638.3.4 Professional Networks 1648.3.5 Organizational Factors 1658.3.5.1 Capacity for Organizational Change 1658.3.6 Organizational Structure 1658.3.7 Organizational Culture 1668.3.8 Availability of Necessary Resources 1668.3.9 Societal Factors 1668.3.9.1 Health Professions 1668.3.9.2 Financial Incentives and Disincentives 1678.3.9.3 Legislation 1678.4 Subgroups in the Target Population 1678.5 Conclusions 168References 1689 Methods to Identify and Analyze Determinants of Implementation 173Michel Wensing and Richard Grol9.1 Introduction 1739.2 Interviews 1759.2.1 Individual Interviews 1759.2.2 Group Interviews 1759.3 Surveys 1779.3.1 Questionnaires about Clinical Guidelines 1789.3.2 Questionnaires on Theory-Based Determinants of Implementation 1789.4 Observation 1809.4.1 Routinely Collected Data 1809.4.2 Direct Observation 1809.5 Data Analysis 1819.5.1 Scientific Methods of Data Analysis 1829.5.2 Quality Improvement Methods 1839.5.3 Paretogram 1839.5.4 Fishbone Diagram 1849.5.5 Flow Chart 1859.6 Prioritization and Goal Setting 1869.7 Conclusions 186References 187Part V Strategies for Change 18910 Selection of Strategies for Improving Patient Care 191Richard Grol and Michel Wensing10.1 Introduction 19110.2 Methods to Select and Develop Implementation Strategies 19210.2.1 Explorative Methods 19410.2.2 Theory-Based Methods 19610.3 Classification of Implementation Strategies 19610.4 Implementation Strategies in the Different Phases of Change 19910.4.1 Orientation 20010.4.2 Insight and Understanding 20010.4.3 Acceptance 20110.4.4 Change 20110.4.5 Maintenance 20210.5 Subgroups within the Target Group 20210.6 The Effectiveness of Different Strategies and Interventions 20310.7 Conclusions 204References 20511 Dissemination of Innovations 207Richard Grol and Michel Wensing11.1 Introduction 20711.2 Mass Media Approach 21011.2.1 Written Materials 21011.2.2 Internet-Based Approaches 21011.2.3 Factors Associated with the Impact of Mass Media Strategies 21211.3 Personalized Approaches 21311.3.1 CME Courses and Conferences 21411.3.2 Social Networks 21411.3.3 Influential Individuals 21511.3.4 Personal Introduction in Practice 21611.4 Conclusion 217References 21812 Educational Implementation Strategies 221Michel Wensing, Cornelia Fluit, Jeremy Grimshaw, and Richard Grol12.1 Introduction 22112.2 Types of Educational Strategies 22312.3 Effectiveness of Education 22412.3.1 Educational Materials 22512.3.2 Educational Meetings 22512.3.3 Outreach Visits 22612.3.4 E-learning 22612.4 Determinants of the Effectiveness of Education 22712.4.1 Targets for Education 22812.4.2 Active Participation 22912.4.3 Duration of Education 22912.4.4 Opinion Leaders 22912.4.5 Assessment and Feedback 23012.5 Discussion and Conclusions 230References 23113 Clinical Performance Feedback and Decision Support 235Noah Ivers, Benjamin Brown, and Jeremy Grimshaw13.1 Introduction 23513.2 Definitions, Characteristics, and Components 23813.2.1 Feedback 23813.2.2 Decision Support 23813.3 Effectiveness of Feedback and Decision Support 23913.4 Factors Associated with Effects 24113.4.1 Underlying Assumptions, Relevant Theories, and Mechanisms 24113.4.2 Factors Associated with Effects 24213.5 Discussion and Conclusions 246References 24814 Engaging Patients in Healthcare Improvement and Innovation 253Glyn Elwyn and Amy Price14.1 Introduction 25314.2 Impact of Patient Engagement on Direct Care 25414.2.1 Well-Established Conceptual Frameworks 25414.2.2 Persistent Theory–Practice Gap 25514.2.3 Broader Impacts 25614.3 Impact of Patient Engagement on Organizational Design and Governance 25714.4 Impact of Patient Engagement in Policy Making 25914.5 Conclusion 260References 26015 Organizational Implementation Strategies 263Michel Wensing, Miranda Laurant, and Richard Grol15.1 Introduction 26315.2 Revision of Professional Roles 26415.3 Enhanced Patient Care Teams 26615.4 Knowledge Management (Use of IT) 26715.5 Integrated Care Systems 26915.6 Quality and Safety Management 27115.7 Conclusions 272References 27216 Patient Safety Strategies 275Marieke Zegers, Mirelle Hanskamp-Sebregts, Hub Wollersheim, and Charles Vincent16.1 Introduction 27516.2 Definition of Patient Safety Concepts 27616.3 Strategies to Measure Patient Safety 27716.4 Patient Safety Improvement Strategies 28016.4.1 Teamwork Training 28016.4.2 Improved Handovers 28016.4.3 Rapid Response Team 28516.4.4 Infection Prevention 28516.4.5 Delirium Prevention 28616.4.6 Fall Prevention 28716.4.7 Pressure Ulcers 28716.4.8 Pain Management 28716.4.9 Interventions to Prevent Adverse Drug Events 28816.5 Strategies to Assure Patient Safety 28916.5.1 Leadership 28916.5.2 Safety Culture 29016.5.3 Governance 29016.6 Conclusions 292References 29217 Health System Strategies for Implementation 299Michel Wensing, Holger Pfaff, and Richard Grol17.1 Introduction 29917.2 Strategies to Enhance Evidence-Based Policy Making 30017.3 Scaling Up Interventions and Practices 30317.4 Changes in the Financial Reimbursement of Healthcare Providers 30417.5 Changes in the Financial Risk for Patients 30617.6 Changes in the Healthcare System 30717.7 Conclusions 309References 30918 Multifaceted Implementation Strategies 313Marlies Hulscher and Michel Wensing18.1 Introduction 31318.2 Strategies in Multifaceted Implementation Strategies 31418.3 Effectiveness of Multifaceted Implementation Strategies 32018.4 Tailoring in Multifaceted Strategies 32018.5 Volume and Classification of Strategies 32118.6 Combinations of Specific Strategies 32218.7 Conclusions 324References 325Part VI Organization and Evaluation 32919 Planning of Implementation 331Richard Grol19.1 Introduction 33119.1.1 Planning of the Implementation Process 33419.2 Development of the Plan According to Phases in the Change Process 33419.3 Planning of Activities for Different Levels of Care 33619.4 Planning of Activities over Time 33719.5 Incorporating the Implementation Plan into Existing Activities 33719.6 Testing of the Implementation Strategies 33819.7 Setting Goals for Evaluation 33919.8 Integration and Embedding of New Practice into Routines and Organization 34019.9 Conclusions 342References 34320 Experimental Designs for Evaluation of Implementation Strategies 345Michel Wensing and Jeremy Grimshaw20.1 Introduction 34520.2 Experimental Study Designs 34720.2.1 Pragmatic versus Explanatory Trials 34820.2.2 Cluster Randomization 34820.2.3 Options for Choice of Study Groups 34920.2.4 Block Designs 34920.2.5 Allocation of Participants to Study Arms 35020.3 Outcome Measures and Data-Collection Methods 35120.4 Statistical Power and Data Analysis 35320.5 Regulatory and Ethical Considerations 35420.6 Conclusion 354References 35521 Observational Evaluation of Implementation Strategies 357Michel Wensing and Jeremy Grimshaw21.1 Introduction 35721.2 Designs for Observational Evaluations 35821.3 Cross-Sectional Studies 35921.4 Before–After Comparisons 35921.5 Controlled Before–After Comparisons 36121.6 Multiple Case Studies 36321.7 Developmental Research 36421.8 Data Analysis in Observational Evaluation Designs 36521.9 Conclusions 366References 36622 Process Evaluation of Implementation Strategies 369Marlies Hulscher and Michel Wensing22.1 Introduction 36922.2 Frameworks for Process Evaluation 37022.3 Process Evaluation and Implementation Strategies 37222.3.1 Evaluation of Pilots and Small Improvement Projects 37322.3.2 Evaluation of Strategies in Experimental Designs 37322.3.3 Evaluation of Improvement Programs in Observational Designs 37422.4 Assessing the Fidelity of Implementation Strategies 37422.5 Framing Process Evaluations 37822.6 A Practical, Step-wise Approach to Process Evaluation 38122.6.1 Step 1: Analysis of Implementation Strategy as Planned 38122.6.2 Step 2: Assessment of Intervention Fidelity 38222.6.3 Step 3: Assessment of Participant Experiences 38322.6.4 Step 4: Exploration of Working Mechanisms 38422.7 Conclusions 385References 38623 Economic Evaluation of Implementation Strategies 389Johan L. Severens, Ties Hoomans, Eddy Adang, and Michel Wensing23.1 Introduction 38923.2 The Basics of Economic Evaluation 39023.2.1 Definition of Cost-Effectiveness 39123.3 Types of Economic Evaluation 39223.4 Policy Cost-Effectiveness 39523.5 Framing Economic Evaluations 39623.5.1 Choice of Comparator 39623.5.2 Time Horizon of a Study 39623.5.3 Study Perspective 39623.6 Cost Analysis 39823.6.1 Directly Attributable, Indirectly Attributable, Fixed, and Variable Costs 39823.6.2 Categories of Costs 39923.6.3 Volumes and Cost Prices 40023.7 Sensitivity Analysis, Quantitative Modeling, and Budget Impact 40223.7.1 Sensitivity Analysis 40223.7.2 Quantitative Modeling 40323.7.3 Budget Impact Analysis 40423.8 Ex Post Evaluation of the Efficiency of Implementation 40523.9 Conclusions 405References 406Index 409

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 xvIntroduction xixPart I Principles of the Implementation of Change 11 Implementation of Change in Healthcare: A Complex Problem 3Richard Grol and Michel Wensing1.1 Introduction 31.2 The Implementation Problem 51.2.1 Effective Care 61.2.2 Safe Care 61.2.3 Efficient Care 71.2.4 Access to Care 81.2.5 Patient-Centered Care 81.2.6 Variation in the Provision of Care 81.3 Various Approaches to the Implementation of Change in Patient Care 91.4 What is Implementation? 121.5 Which Recommended Practices Should Be Adopted? 151.5.1 New Insights and Technologies 151.5.2 Problems in Healthcare Practice 161.6 A Systematic Approach to “Sustainable Change” 16References 172 Theories on Implementation of Change in Healthcare 21Michel Wensing and Richard Grol2.1 Introduction 212.2 Theories on Factors Related to Individual Professionals 232.2.1 Cognitive Theories 232.2.2 Educational Theories 252.2.3 Motivational Theories 262.3 Theories on Social Processes 272.3.1 Social Learning Theory 272.3.2 Theories on Communication 272.3.3 Social Network Theories 282.3.4 Theories on Teamwork 292.3.5 Theories on Professionalization 292.3.6 Theories on Leadership 302.4 Theories on Organizational Systems 312.4.1 Theories of Effective Organizations 312.4.2 Theory of Quality and Safety Management 312.4.3 Theory of Operations Management 332.4.4 Theory of Complex Systems 332.4.5 Theory of Organizational Learning 342.4.6 Theories of Organizational Culture 352.5 Theories on Economic and Societal Structures 362.5.1 Economic Theories 362.5.2 Theories on Contracting 372.6 Conclusions 37References 393 Effective Implementation of Change in Healthcare: A Systematic Approach 45Richard Grol and Michel Wensing3.1 Elements of Effective Implementation 453.2 The Implementation of Change Model 523.3 Developing a Proposal and Targets for Change 533.4 Assessment of Performance 553.5 Analysis of the Target Group and Setting 563.5.1 Aims and Settings of the Implementation 573.5.2 Segments within the Target Group and Stages of Change 573.5.3 Phases in a Process of Change: A Summary of the Literature 583.5.4 Orientation 593.5.5 Insight 593.5.6 Acceptance 593.5.7 Change 603.5.8 Maintenance 603.5.9 Barriers and Facilitators to Changing Practice 603.6 Selection and Development of Improvement Strategies 613.7 Development, Testing, and Execution of an Implementation Plan 613.8 Sustainable Change: Integration of Change into Practice Routines 633.9 Evaluation and (Possible) Adaptations to the Plan 633.10 Planning of the Implementation Process 663.11 Conclusions 68References 684 Planning and Organizing the Change Process 73Richard Grol and Michel Wensing4.1 Introduction 734.2 A Motivated Team Comprising All Relevant Expertise 754.3 Creating a Context for Change 764.3.1 The Central Role of Physicians 764.3.2 Collaboration in Teams for Patient Care 784.4 Involving the Target Group and Stakeholders in the Plan 814.5 Leaders and Key Figures 814.5.1 Medical Leadership 824.6 Project Management: Time Schedule and Responsibilities 824.7 Resources and Support 834.8 Conclusions 84References 84Part II Guidelines and Innovations 875 Characteristics of Successful Innovations 89Richard Grol and Michel Wensing5.1 Introduction 895.2 Various Types of Improvements Require Various Types of Change Proposals 915.2.1 Scientific Literature, Guidelines, Decision Support, and Decision Aids 915.2.2 Clinical Pathways 925.2.3 Improved Care Processes 935.2.4 Other Innovations 935.3 Characteristics of Innovations That Promote Implementation 945.4 Format and Presentation 975.5 Involvement of the Target Group and Local Adaptation 995.6 Conclusions 100References 1006 Clinical Practice Guidelines as a Tool for Improving Patient Care 103Jako Burgers, Trudy van der Weijden, and Richard Grol6.1 Introduction 1036.2 Aims of Guidelines 1046.3 Potential Benefits and Limitations of Guidelines 1056.3.1 Potential Benefits 1066.3.2 Possible Limitations 1066.4 Development of Effective Guidelines 1076.4.1 Topic Selection 1076.4.2 Composition of the Guideline Development Group 1106.4.3 Patient and Public Involvement 1116.4.4 Drafting the Scope 1136.4.5 Development of Draft Guideline 1146.4.6 Identifying and Reviewing Available Guidelines and Reviews 1146.4.7 Collection and Evaluation of Scientific Evidence 1156.4.8 Contribution of All Relevant Expertise and Experience 1166.4.9 Formulation of Recommendations 1166.4.10 Consultation and Authorization 1186.4.11 Consultation 1186.4.12 Pilot Testing 1196.4.13 Authorization 1196.4.14 Design of the Guideline and Related Products 1196.4.15 Evaluation 1206.4.16 Updating Guidelines 1216.5 Quality of Guidelines and Guideline Development Programs 1216.6 International Collaboration in Guideline Development 1236.7 Conclusion 124References 125Part III Assessment of Performance 1317 Indicators for Quality and Safety of Care 133Jozé Braspenning, Rosella Hermens, Hilly Calsbeek, Stephen Campbell, Philip van der Wees, and Richard Grol7.1 Introduction 1337.1.1 Aim of the Assessment 1357.2 Indicators for Quality and Safety of Care 1377.2.1 Aims of Measurement 1377.2.2 Domains and Perspectives 1387.2.3 Categories of Indicators 1387.3 Methods to Develop a Set of Indicators 1407.4 Selecting or Developing a Preliminary Set of Indicators 1407.4.1 Indicator Attributes 1417.4.2 Number of Indicators 1417.5 Finding Consensus among Target Users 1417.5.1 Delphi Technique 1427.5.2 RAND/UCLA Appropriateness Method 1427.6 Testing the Indicators Empirically 1447.6.1 Validity and Reliability 1447.7 Create a Feedback Report 1477.7.1 Calculating Indicators and Benchmarks 1477.7.2 Formulating Aims of Improvement 1477.8 Use and Effect of Quality Indicators 1487.8.1 Unintended Effects 1487.9 Conclusion 149References 150Part IV Problem Analysis 1558 Determinants of Implementation 157Michel Wensing and Richard Grol8.1 Introduction 1578.2 Analysis of Stakeholders 1598.3 Determinants of Change 1618.3.1 Individual Health Professional Factors 1618.3.1.1 Cognitive Factors 1618.3.1.2 Motivational Factors 1628.3.1.3 Behavioral Factors (Routines) 1638.3.2 Patient Factors 1638.3.3 Professional Interactions 1638.3.3.1 Team Processes 1638.3.4 Professional Networks 1648.3.5 Organizational Factors 1658.3.5.1 Capacity for Organizational Change 1658.3.6 Organizational Structure 1658.3.7 Organizational Culture 1668.3.8 Availability of Necessary Resources 1668.3.9 Societal Factors 1668.3.9.1 Health Professions 1668.3.9.2 Financial Incentives and Disincentives 1678.3.9.3 Legislation 1678.4 Subgroups in the Target Population 1678.5 Conclusions 168References 1689 Methods to Identify and Analyze Determinants of Implementation 173Michel Wensing and Richard Grol9.1 Introduction 1739.2 Interviews 1759.2.1 Individual Interviews 1759.2.2 Group Interviews 1759.3 Surveys 1779.3.1 Questionnaires about Clinical Guidelines 1789.3.2 Questionnaires on Theory-Based Determinants of Implementation 1789.4 Observation 1809.4.1 Routinely Collected Data 1809.4.2 Direct Observation 1809.5 Data Analysis 1819.5.1 Scientific Methods of Data Analysis 1829.5.2 Quality Improvement Methods 1839.5.3 Paretogram 1839.5.4 Fishbone Diagram 1849.5.5 Flow Chart 1859.6 Prioritization and Goal Setting 1869.7 Conclusions 186References 187Part V Strategies for Change 18910 Selection of Strategies for Improving Patient Care 191Richard Grol and Michel Wensing10.1 Introduction 19110.2 Methods to Select and Develop Implementation Strategies 19210.2.1 Explorative Methods 19410.2.2 Theory-Based Methods 19610.3 Classification of Implementation Strategies 19610.4 Implementation Strategies in the Different Phases of Change 19910.4.1 Orientation 20010.4.2 Insight and Understanding 20010.4.3 Acceptance 20110.4.4 Change 20110.4.5 Maintenance 20210.5 Subgroups within the Target Group 20210.6 The Effectiveness of Different Strategies and Interventions 20310.7 Conclusions 204References 20511 Dissemination of Innovations 207Richard Grol and Michel Wensing11.1 Introduction 20711.2 Mass Media Approach 21011.2.1 Written Materials 21011.2.2 Internet-Based Approaches 21011.2.3 Factors Associated with the Impact of Mass Media Strategies 21211.3 Personalized Approaches 21311.3.1 CME Courses and Conferences 21411.3.2 Social Networks 21411.3.3 Influential Individuals 21511.3.4 Personal Introduction in Practice 21611.4 Conclusion 217References 21812 Educational Implementation Strategies 221Michel Wensing, Cornelia Fluit, Jeremy Grimshaw, and Richard Grol12.1 Introduction 22112.2 Types of Educational Strategies 22312.3 Effectiveness of Education 22412.3.1 Educational Materials 22512.3.2 Educational Meetings 22512.3.3 Outreach Visits 22612.3.4 E-learning 22612.4 Determinants of the Effectiveness of Education 22712.4.1 Targets for Education 22812.4.2 Active Participation 22912.4.3 Duration of Education 22912.4.4 Opinion Leaders 22912.4.5 Assessment and Feedback 23012.5 Discussion and Conclusions 230References 23113 Clinical Performance Feedback and Decision Support 235Noah Ivers, Benjamin Brown, and Jeremy Grimshaw13.1 Introduction 23513.2 Definitions, Characteristics, and Components 23813.2.1 Feedback 23813.2.2 Decision Support 23813.3 Effectiveness of Feedback and Decision Support 23913.4 Factors Associated with Effects 24113.4.1 Underlying Assumptions, Relevant Theories, and Mechanisms 24113.4.2 Factors Associated with Effects 24213.5 Discussion and Conclusions 246References 24814 Engaging Patients in Healthcare Improvement and Innovation 253Glyn Elwyn and Amy Price14.1 Introduction 25314.2 Impact of Patient Engagement on Direct Care 25414.2.1 Well-Established Conceptual Frameworks 25414.2.2 Persistent Theory–Practice Gap 25514.2.3 Broader Impacts 25614.3 Impact of Patient Engagement on Organizational Design and Governance 25714.4 Impact of Patient Engagement in Policy Making 25914.5 Conclusion 260References 26015 Organizational Implementation Strategies 263Michel Wensing, Miranda Laurant, and Richard Grol15.1 Introduction 26315.2 Revision of Professional Roles 26415.3 Enhanced Patient Care Teams 26615.4 Knowledge Management (Use of IT) 26715.5 Integrated Care Systems 26915.6 Quality and Safety Management 27115.7 Conclusions 272References 27216 Patient Safety Strategies 275Marieke Zegers, Mirelle Hanskamp-Sebregts, Hub Wollersheim, and Charles Vincent16.1 Introduction 27516.2 Definition of Patient Safety Concepts 27616.3 Strategies to Measure Patient Safety 27716.4 Patient Safety Improvement Strategies 28016.4.1 Teamwork Training 28016.4.2 Improved Handovers 28016.4.3 Rapid Response Team 28516.4.4 Infection Prevention 28516.4.5 Delirium Prevention 28616.4.6 Fall Prevention 28716.4.7 Pressure Ulcers 28716.4.8 Pain Management 28716.4.9 Interventions to Prevent Adverse Drug Events 28816.5 Strategies to Assure Patient Safety 28916.5.1 Leadership 28916.5.2 Safety Culture 29016.5.3 Governance 29016.6 Conclusions 292References 29217 Health System Strategies for Implementation 299Michel Wensing, Holger Pfaff, and Richard Grol17.1 Introduction 29917.2 Strategies to Enhance Evidence-Based Policy Making 30017.3 Scaling Up Interventions and Practices 30317.4 Changes in the Financial Reimbursement of Healthcare Providers 30417.5 Changes in the Financial Risk for Patients 30617.6 Changes in the Healthcare System 30717.7 Conclusions 309References 30918 Multifaceted Implementation Strategies 313Marlies Hulscher and Michel Wensing18.1 Introduction 31318.2 Strategies in Multifaceted Implementation Strategies 31418.3 Effectiveness of Multifaceted Implementation Strategies 32018.4 Tailoring in Multifaceted Strategies 32018.5 Volume and Classification of Strategies 32118.6 Combinations of Specific Strategies 32218.7 Conclusions 324References 325Part VI Organization and Evaluation 32919 Planning of Implementation 331Richard Grol19.1 Introduction 33119.1.1 Planning of the Implementation Process 33419.2 Development of the Plan According to Phases in the Change Process 33419.3 Planning of Activities for Different Levels of Care 33619.4 Planning of Activities over Time 33719.5 Incorporating the Implementation Plan into Existing Activities 33719.6 Testing of the Implementation Strategies 33819.7 Setting Goals for Evaluation 33919.8 Integration and Embedding of New Practice into Routines and Organization 34019.9 Conclusions 342References 34320 Experimental Designs for Evaluation of Implementation Strategies 345Michel Wensing and Jeremy Grimshaw20.1 Introduction 34520.2 Experimental Study Designs 34720.2.1 Pragmatic versus Explanatory Trials 34820.2.2 Cluster Randomization 34820.2.3 Options for Choice of Study Groups 34920.2.4 Block Designs 34920.2.5 Allocation of Participants to Study Arms 35020.3 Outcome Measures and Data-Collection Methods 35120.4 Statistical Power and Data Analysis 35320.5 Regulatory and Ethical Considerations 35420.6 Conclusion 354References 35521 Observational Evaluation of Implementation Strategies 357Michel Wensing and Jeremy Grimshaw21.1 Introduction 35721.2 Designs for Observational Evaluations 35821.3 Cross-Sectional Studies 35921.4 Before–After Comparisons 35921.5 Controlled Before–After Comparisons 36121.6 Multiple Case Studies 36321.7 Developmental Research 36421.8 Data Analysis in Observational Evaluation Designs 36521.9 Conclusions 366References 36622 Process Evaluation of Implementation Strategies 369Marlies Hulscher and Michel Wensing22.1 Introduction 36922.2 Frameworks for Process Evaluation 37022.3 Process Evaluation and Implementation Strategies 37222.3.1 Evaluation of Pilots and Small Improvement Projects 37322.3.2 Evaluation of Strategies in Experimental Designs 37322.3.3 Evaluation of Improvement Programs in Observational Designs 37422.4 Assessing the Fidelity of Implementation Strategies 37422.5 Framing Process Evaluations 37822.6 A Practical, Step-wise Approach to Process Evaluation 38122.6.1 Step 1: Analysis of Implementation Strategy as Planned 38122.6.2 Step 2: Assessment of Intervention Fidelity 38222.6.3 Step 3: Assessment of Participant Experiences 38322.6.4 Step 4: Exploration of Working Mechanisms 38422.7 Conclusions 385References 38623 Economic Evaluation of Implementation Strategies 389Johan L. Severens, Ties Hoomans, Eddy Adang, and Michel Wensing23.1 Introduction 38923.2 The Basics of Economic Evaluation 39023.2.1 Definition of Cost-Effectiveness 39123.3 Types of Economic Evaluation 39223.4 Policy Cost-Effectiveness 39523.5 Framing Economic Evaluations 39623.5.1 Choice of Comparator 39623.5.2 Time Horizon of a Study 39623.5.3 Study Perspective 39623.6 Cost Analysis 39823.6.1 Directly Attributable, Indirectly Attributable, Fixed, and Variable Costs 39823.6.2 Categories of Costs 39923.6.3 Volumes and Cost Prices 40023.7 Sensitivity Analysis, Quantitative Modeling, and Budget Impact 40223.7.1 Sensitivity Analysis 40223.7.2 Quantitative Modeling 40323.7.3 Budget Impact Analysis 40423.8 Ex Post Evaluation of the Efficiency of Implementation 40523.9 Conclusions 405References 406Index 409

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 xvIntroduction xixPart I Principles of the Implementation of Change 11 Implementation of Change in Healthcare: A Complex Problem 3Richard Grol and Michel Wensing1.1 Introduction 31.2 The Implementation Problem 51.2.1 Effective Care 61.2.2 Safe Care 61.2.3 Efficient Care 71.2.4 Access to Care 81.2.5 Patient-Centered Care 81.2.6 Variation in the Provision of Care 81.3 Various Approaches to the Implementation of Change in Patient Care 91.4 What is Implementation? 121.5 Which Recommended Practices Should Be Adopted? 151.5.1 New Insights and Technologies 151.5.2 Problems in Healthcare Practice 161.6 A Systematic Approach to “Sustainable Change” 16References 172 Theories on Implementation of Change in Healthcare 21Michel Wensing and Richard Grol2.1 Introduction 212.2 Theories on Factors Related to Individual Professionals 232.2.1 Cognitive Theories 232.2.2 Educational Theories 252.2.3 Motivational Theories 262.3 Theories on Social Processes 272.3.1 Social Learning Theory 272.3.2 Theories on Communication 272.3.3 Social Network Theories 282.3.4 Theories on Teamwork 292.3.5 Theories on Professionalization 292.3.6 Theories on Leadership 302.4 Theories on Organizational Systems 312.4.1 Theories of Effective Organizations 312.4.2 Theory of Quality and Safety Management 312.4.3 Theory of Operations Management 332.4.4 Theory of Complex Systems 332.4.5 Theory of Organizational Learning 342.4.6 Theories of Organizational Culture 352.5 Theories on Economic and Societal Structures 362.5.1 Economic Theories 362.5.2 Theories on Contracting 372.6 Conclusions 37References 393 Effective Implementation of Change in Healthcare: A Systematic Approach 45Richard Grol and Michel Wensing3.1 Elements of Effective Implementation 453.2 The Implementation of Change Model 523.3 Developing a Proposal and Targets for Change 533.4 Assessment of Performance 553.5 Analysis of the Target Group and Setting 563.5.1 Aims and Settings of the Implementation 573.5.2 Segments within the Target Group and Stages of Change 573.5.3 Phases in a Process of Change: A Summary of the Literature 583.5.4 Orientation 593.5.5 Insight 593.5.6 Acceptance 593.5.7 Change 603.5.8 Maintenance 603.5.9 Barriers and Facilitators to Changing Practice 603.6 Selection and Development of Improvement Strategies 613.7 Development, Testing, and Execution of an Implementation Plan 613.8 Sustainable Change: Integration of Change into Practice Routines 633.9 Evaluation and (Possible) Adaptations to the Plan 633.10 Planning of the Implementation Process 663.11 Conclusions 68References 684 Planning and Organizing the Change Process 73Richard Grol and Michel Wensing4.1 Introduction 734.2 A Motivated Team Comprising All Relevant Expertise 754.3 Creating a Context for Change 764.3.1 The Central Role of Physicians 764.3.2 Collaboration in Teams for Patient Care 784.4 Involving the Target Group and Stakeholders in the Plan 814.5 Leaders and Key Figures 814.5.1 Medical Leadership 824.6 Project Management: Time Schedule and Responsibilities 824.7 Resources and Support 834.8 Conclusions 84References 84Part II Guidelines and Innovations 875 Characteristics of Successful Innovations 89Richard Grol and Michel Wensing5.1 Introduction 895.2 Various Types of Improvements Require Various Types of Change Proposals 915.2.1 Scientific Literature, Guidelines, Decision Support, and Decision Aids 915.2.2 Clinical Pathways 925.2.3 Improved Care Processes 935.2.4 Other Innovations 935.3 Characteristics of Innovations That Promote Implementation 945.4 Format and Presentation 975.5 Involvement of the Target Group and Local Adaptation 995.6 Conclusions 100References 1006 Clinical Practice Guidelines as a Tool for Improving Patient Care 103Jako Burgers, Trudy van der Weijden, and Richard Grol6.1 Introduction 1036.2 Aims of Guidelines 1046.3 Potential Benefits and Limitations of Guidelines 1056.3.1 Potential Benefits 1066.3.2 Possible Limitations 1066.4 Development of Effective Guidelines 1076.4.1 Topic Selection 1076.4.2 Composition of the Guideline Development Group 1106.4.3 Patient and Public Involvement 1116.4.4 Drafting the Scope 1136.4.5 Development of Draft Guideline 1146.4.6 Identifying and Reviewing Available Guidelines and Reviews 1146.4.7 Collection and Evaluation of Scientific Evidence 1156.4.8 Contribution of All Relevant Expertise and Experience 1166.4.9 Formulation of Recommendations 1166.4.10 Consultation and Authorization 1186.4.11 Consultation 1186.4.12 Pilot Testing 1196.4.13 Authorization 1196.4.14 Design of the Guideline and Related Products 1196.4.15 Evaluation 1206.4.16 Updating Guidelines 1216.5 Quality of Guidelines and Guideline Development Programs 1216.6 International Collaboration in Guideline Development 1236.7 Conclusion 124References 125Part III Assessment of Performance 1317 Indicators for Quality and Safety of Care 133Jozé Braspenning, Rosella Hermens, Hilly Calsbeek, Stephen Campbell, Philip van der Wees, and Richard Grol7.1 Introduction 1337.1.1 Aim of the Assessment 1357.2 Indicators for Quality and Safety of Care 1377.2.1 Aims of Measurement 1377.2.2 Domains and Perspectives 1387.2.3 Categories of Indicators 1387.3 Methods to Develop a Set of Indicators 1407.4 Selecting or Developing a Preliminary Set of Indicators 1407.4.1 Indicator Attributes 1417.4.2 Number of Indicators 1417.5 Finding Consensus among Target Users 1417.5.1 Delphi Technique 1427.5.2 RAND/UCLA Appropriateness Method 1427.6 Testing the Indicators Empirically 1447.6.1 Validity and Reliability 1447.7 Create a Feedback Report 1477.7.1 Calculating Indicators and Benchmarks 1477.7.2 Formulating Aims of Improvement 1477.8 Use and Effect of Quality Indicators 1487.8.1 Unintended Effects 1487.9 Conclusion 149References 150Part IV Problem Analysis 1558 Determinants of Implementation 157Michel Wensing and Richard Grol8.1 Introduction 1578.2 Analysis of Stakeholders 1598.3 Determinants of Change 1618.3.1 Individual Health Professional Factors 1618.3.1.1 Cognitive Factors 1618.3.1.2 Motivational Factors 1628.3.1.3 Behavioral Factors (Routines) 1638.3.2 Patient Factors 1638.3.3 Professional Interactions 1638.3.3.1 Team Processes 1638.3.4 Professional Networks 1648.3.5 Organizational Factors 1658.3.5.1 Capacity for Organizational Change 1658.3.6 Organizational Structure 1658.3.7 Organizational Culture 1668.3.8 Availability of Necessary Resources 1668.3.9 Societal Factors 1668.3.9.1 Health Professions 1668.3.9.2 Financial Incentives and Disincentives 1678.3.9.3 Legislation 1678.4 Subgroups in the Target Population 1678.5 Conclusions 168References 1689 Methods to Identify and Analyze Determinants of Implementation 173Michel Wensing and Richard Grol9.1 Introduction 1739.2 Interviews 1759.2.1 Individual Interviews 1759.2.2 Group Interviews 1759.3 Surveys 1779.3.1 Questionnaires about Clinical Guidelines 1789.3.2 Questionnaires on Theory-Based Determinants of Implementation 1789.4 Observation 1809.4.1 Routinely Collected Data 1809.4.2 Direct Observation 1809.5 Data Analysis 1819.5.1 Scientific Methods of Data Analysis 1829.5.2 Quality Improvement Methods 1839.5.3 Paretogram 1839.5.4 Fishbone Diagram 1849.5.5 Flow Chart 1859.6 Prioritization and Goal Setting 1869.7 Conclusions 186References 187Part V Strategies for Change 18910 Selection of Strategies for Improving Patient Care 191Richard Grol and Michel Wensing10.1 Introduction 19110.2 Methods to Select and Develop Implementation Strategies 19210.2.1 Explorative Methods 19410.2.2 Theory-Based Methods 19610.3 Classification of Implementation Strategies 19610.4 Implementation Strategies in the Different Phases of Change 19910.4.1 Orientation 20010.4.2 Insight and Understanding 20010.4.3 Acceptance 20110.4.4 Change 20110.4.5 Maintenance 20210.5 Subgroups within the Target Group 20210.6 The Effectiveness of Different Strategies and Interventions 20310.7 Conclusions 204References 20511 Dissemination of Innovations 207Richard Grol and Michel Wensing11.1 Introduction 20711.2 Mass Media Approach 21011.2.1 Written Materials 21011.2.2 Internet-Based Approaches 21011.2.3 Factors Associated with the Impact of Mass Media Strategies 21211.3 Personalized Approaches 21311.3.1 CME Courses and Conferences 21411.3.2 Social Networks 21411.3.3 Influential Individuals 21511.3.4 Personal Introduction in Practice 21611.4 Conclusion 217References 21812 Educational Implementation Strategies 221Michel Wensing, Cornelia Fluit, Jeremy Grimshaw, and Richard Grol12.1 Introduction 22112.2 Types of Educational Strategies 22312.3 Effectiveness of Education 22412.3.1 Educational Materials 22512.3.2 Educational Meetings 22512.3.3 Outreach Visits 22612.3.4 E-learning 22612.4 Determinants of the Effectiveness of Education 22712.4.1 Targets for Education 22812.4.2 Active Participation 22912.4.3 Duration of Education 22912.4.4 Opinion Leaders 22912.4.5 Assessment and Feedback 23012.5 Discussion and Conclusions 230References 23113 Clinical Performance Feedback and Decision Support 235Noah Ivers, Benjamin Brown, and Jeremy Grimshaw13.1 Introduction 23513.2 Definitions, Characteristics, and Components 23813.2.1 Feedback 23813.2.2 Decision Support 23813.3 Effectiveness of Feedback and Decision Support 23913.4 Factors Associated with Effects 24113.4.1 Underlying Assumptions, Relevant Theories, and Mechanisms 24113.4.2 Factors Associated with Effects 24213.5 Discussion and Conclusions 246References 24814 Engaging Patients in Healthcare Improvement and Innovation 253Glyn Elwyn and Amy Price14.1 Introduction 25314.2 Impact of Patient Engagement on Direct Care 25414.2.1 Well-Established Conceptual Frameworks 25414.2.2 Persistent Theory–Practice Gap 25514.2.3 Broader Impacts 25614.3 Impact of Patient Engagement on Organizational Design and Governance 25714.4 Impact of Patient Engagement in Policy Making 25914.5 Conclusion 260References 26015 Organizational Implementation Strategies 263Michel Wensing, Miranda Laurant, and Richard Grol15.1 Introduction 26315.2 Revision of Professional Roles 26415.3 Enhanced Patient Care Teams 26615.4 Knowledge Management (Use of IT) 26715.5 Integrated Care Systems 26915.6 Quality and Safety Management 27115.7 Conclusions 272References 27216 Patient Safety Strategies 275Marieke Zegers, Mirelle Hanskamp-Sebregts, Hub Wollersheim, and Charles Vincent16.1 Introduction 27516.2 Definition of Patient Safety Concepts 27616.3 Strategies to Measure Patient Safety 27716.4 Patient Safety Improvement Strategies 28016.4.1 Teamwork Training 28016.4.2 Improved Handovers 28016.4.3 Rapid Response Team 28516.4.4 Infection Prevention 28516.4.5 Delirium Prevention 28616.4.6 Fall Prevention 28716.4.7 Pressure Ulcers 28716.4.8 Pain Management 28716.4.9 Interventions to Prevent Adverse Drug Events 28816.5 Strategies to Assure Patient Safety 28916.5.1 Leadership 28916.5.2 Safety Culture 29016.5.3 Governance 29016.6 Conclusions 292References 29217 Health System Strategies for Implementation 299Michel Wensing, Holger Pfaff, and Richard Grol17.1 Introduction 29917.2 Strategies to Enhance Evidence-Based Policy Making 30017.3 Scaling Up Interventions and Practices 30317.4 Changes in the Financial Reimbursement of Healthcare Providers 30417.5 Changes in the Financial Risk for Patients 30617.6 Changes in the Healthcare System 30717.7 Conclusions 309References 30918 Multifaceted Implementation Strategies 313Marlies Hulscher and Michel Wensing18.1 Introduction 31318.2 Strategies in Multifaceted Implementation Strategies 31418.3 Effectiveness of Multifaceted Implementation Strategies 32018.4 Tailoring in Multifaceted Strategies 32018.5 Volume and Classification of Strategies 32118.6 Combinations of Specific Strategies 32218.7 Conclusions 324References 325Part VI Organization and Evaluation 32919 Planning of Implementation 331Richard Grol19.1 Introduction 33119.1.1 Planning of the Implementation Process 33419.2 Development of the Plan According to Phases in the Change Process 33419.3 Planning of Activities for Different Levels of Care 33619.4 Planning of Activities over Time 33719.5 Incorporating the Implementation Plan into Existing Activities 33719.6 Testing of the Implementation Strategies 33819.7 Setting Goals for Evaluation 33919.8 Integration and Embedding of New Practice into Routines and Organization 34019.9 Conclusions 342References 34320 Experimental Designs for Evaluation of Implementation Strategies 345Michel Wensing and Jeremy Grimshaw20.1 Introduction 34520.2 Experimental Study Designs 34720.2.1 Pragmatic versus Explanatory Trials 34820.2.2 Cluster Randomization 34820.2.3 Options for Choice of Study Groups 34920.2.4 Block Designs 34920.2.5 Allocation of Participants to Study Arms 35020.3 Outcome Measures and Data-Collection Methods 35120.4 Statistical Power and Data Analysis 35320.5 Regulatory and Ethical Considerations 35420.6 Conclusion 354References 35521 Observational Evaluation of Implementation Strategies 357Michel Wensing and Jeremy Grimshaw21.1 Introduction 35721.2 Designs for Observational Evaluations 35821.3 Cross-Sectional Studies 35921.4 Before–After Comparisons 35921.5 Controlled Before–After Comparisons 36121.6 Multiple Case Studies 36321.7 Developmental Research 36421.8 Data Analysis in Observational Evaluation Designs 36521.9 Conclusions 366References 36622 Process Evaluation of Implementation Strategies 369Marlies Hulscher and Michel Wensing22.1 Introduction 36922.2 Frameworks for Process Evaluation 37022.3 Process Evaluation and Implementation Strategies 37222.3.1 Evaluation of Pilots and Small Improvement Projects 37322.3.2 Evaluation of Strategies in Experimental Designs 37322.3.3 Evaluation of Improvement Programs in Observational Designs 37422.4 Assessing the Fidelity of Implementation Strategies 37422.5 Framing Process Evaluations 37822.6 A Practical, Step-wise Approach to Process Evaluation 38122.6.1 Step 1: Analysis of Implementation Strategy as Planned 38122.6.2 Step 2: Assessment of Intervention Fidelity 38222.6.3 Step 3: Assessment of Participant Experiences 38322.6.4 Step 4: Exploration of Working Mechanisms 38422.7 Conclusions 385References 38623 Economic Evaluation of Implementation Strategies 389Johan L. Severens, Ties Hoomans, Eddy Adang, and Michel Wensing23.1 Introduction 38923.2 The Basics of Economic Evaluation 39023.2.1 Definition of Cost-Effectiveness 39123.3 Types of Economic Evaluation 39223.4 Policy Cost-Effectiveness 39523.5 Framing Economic Evaluations 39623.5.1 Choice of Comparator 39623.5.2 Time Horizon of a Study 39623.5.3 Study Perspective 39623.6 Cost Analysis 39823.6.1 Directly Attributable, Indirectly Attributable, Fixed, and Variable Costs 39823.6.2 Categories of Costs 39923.6.3 Volumes and Cost Prices 40023.7 Sensitivity Analysis, Quantitative Modeling, and Budget Impact 40223.7.1 Sensitivity Analysis 40223.7.2 Quantitative Modeling 40323.7.3 Budget Impact Analysis 40423.8 Ex Post Evaluation of the Efficiency of Implementation 40523.9 Conclusions 405References 406Index 409