Engaging stakeholders to retrospectively discern implementation strategies to support program evaluation: Proposed method and case study.

Background: Availability of evidence-based practices (EBPs) is critical for improving health care outcomes, but diffusion can be challenging. Implementation activities increase the adoption of EBPs and support sustainability. However, when implementation activities are a part of quality improvement processes, evaluation of the time and cost associated with these activities is challenged by the need for a correct classification of these activities to a known taxonomy of implementation strategies by implementation actors.

Design: Observational study of a four-stage, stakeholder-engaged process for identifying implementation activities and estimating the associated costs.

Results: A national initiative in the Veterans Health Administration (VHA) to improve Advance Care Planning (ACP) via Group Visits (ACP-GV) for rural veterans identified 49 potential implementation activities. Evaluators translated and reduced these to 14 strategies used across three groups with the aid of implementation actors. Data were collected to determine the total implementation effort and applied cost estimates to estimate the budget impact of implementation for VHA.

Limitations: Recall bias may influence the identification of potential implementation activities.

Conclusions: This process improved understanding of the implementation effort and allowed estimation of ACP-GV 's budget impact.

Implications: A four-stage, stakeholder-engaged methodology can be applied to other initiatives when a pragmatic evaluation of implementation efforts is needed.