Table 1 Five Active Implementation Frameworks (5 AIFs) as applied to enhanced recovery protocol (ERP) implementation

Effective practices

Usable innovations

Well-operationalized innovations that are teachable, learnable, doable, and readily assessed in practice

Operationalization: essential functions of ERPs and pathways

Fidelity: statements on fidelity to ERPs; may include measurement of implementation or recommendations and suggestions about measurement

Function: evidence in other areas that have used ERPs or strategies for using ERPs; adaptation of ERPs in current practice

Philosophy: attitudes and beliefs about ERPs; rationale for implementing ERP

• Evidence-based ERPs with validation by expert panels

• Implementation tools

Effective implementation

Stages

Integrated, non-linear process starting with exploration and ending with full implementation of an innovation into practice

Exploration: descriptions of whether ERP implementation was feasible; readiness for implementation; activities related to preparing to implement ERPs, including engaging colleagues and experts

Installation: discussions of steps needed prior to being able to implement ERPs at site, including capacity building; partnering with experts to build competencies to implement ERPs at site (i.e., seminars, trainings); consulting expert partners and consultants to implement ERPs at the site

Initial implementation: experiences that hospitals have with the initial implementation of the innovation; early improvements or changes needed to the early ERP implementation; initial or preliminary results/outcomes or policies related to initial ERP implementation

Full implementation: discussions about ERP implementation becoming standard practice at the site including standardization of protocols

• Local team infrastructure and defined roles: surgical champion, anesthesia champion, child life specialist, patient advocate liaison, quality improvement leader (QI), and ERP coordinator

• Learning collaboratives for pediatric surgical hospitals

Implementation drivers

Drivers of success including development of competencies, obtaining organizational supports, and engaging leadership.

Organization drivers: infrastructure components necessary to ERP implementation, including decision support data systems, and facilitative administration

Competency drivers for clinicians: coaching and professional development designed to help the team use ERPs as intended; training that is skills-based and informed by adult learning processes; onboarding staff specifically to support ERP implementation

Leadership drivers: support by hospital leaders for ERPs

• Monthly training curriculum through learning collaboratives

• Coaching by topic experts

• Facilitative leadership

• Support engaging team members and hospital administrators

Enabling context

Teams

Supportive teams to define infrastructures and support methods and improve outcomes

Receptiveness and buy-in: receptiveness of ERPs among team members

Collaboration: communication across and within departments, meetings about ERPs

Team engagement: team members that have or should be involved in the implementation of ERPs, including a champion, health care clinician, data collector, patient and family liaison, and hospital administration liaison

• Toolkit and troubleshooting support to help hospitals move through the stages; with exploration completed, the learning collaborative will help hospitals move from installation and initial implementation phases to full implementation

• ERP implementation sustainability assessment

Improvement cycles

Based on Plan, Do, Study, Act (PDSA) process with rapid cycle feedback for continuous QI and learning

Not applicable in this preliminary examination of ERP implementation in the study centers; all centers were in the pre-implementation phase that precedes improvement cycles

• Quarterly data-driven feedback sessions for hospitals during learning collaborative meetings

• QI expert on implementation teams