Organizational- and system-level characteristics that...

SYSTEMATIC REVIEW Open Access

Organizational- and system-levelcharacteristics that influenceimplementation of shared decision-makingand strategies to address them — a scopingreviewIsabelle Scholl1,2* , Allison LaRussa1, Pola Hahlweg2, Sarah Kobrin3 and Glyn Elwyn1

Abstract

Background: Shared decision-making (SDM) is poorly implemented in routine care, despite being promoted byhealth policies. No reviews have solely focused on an in-depth synthesis of the literature around organizational-and system-level characteristics (i.e., characteristics of healthcare organizations and of healthcare systems) that mayaffect SDM implementation. A synthesis would allow exploration of interventions to address these characteristics.The study aim was to compile a comprehensive overview of organizational- and system-level characteristics that arelikely to influence the implementation of SDM, and to describe strategies to address those characteristics describedin the literature.

Methods: We conducted a scoping review using the Arksey and O’Malley framework. The search strategy includedan electronic search and a secondary search including gray literature. We included publications reporting onprojects that promoted implementation of SDM or other decision support interventions in routine healthcare. Wescreened titles and abstracts, and assessed full texts for eligibility. We used qualitative thematic analysis to identifyorganizational- and system-level characteristics.

Results: After screening 7745 records and assessing 354 full texts for eligibility, 48 publications on 32 distinctimplementation projects were included. Most projects (N = 22) were conducted in the USA. Several organizational-levelcharacteristics were described as influencing the implementation of SDM, including organizational leadership, culture,resources, and priorities, as well as teams and workflows. Described system-level characteristics included policies,clinical guidelines, incentives, culture, education, and licensing. We identified potential strategies to influence thedescribed characteristics, e.g., examples how to facilitate distribution of decision aids in a healthcare institution.(Continued on next page)

* Correspondence: [email protected]; [email protected] Dartmouth Institute for Health Policy and Clinical Practice, DartmouthCollege, Level 5, Williamson Translational Research Building, One MedicalCenter Drive, Lebanon, NH 03756, USA2Department of Medical Psychology, University Medical CenterHamburg-Eppendorf, Martinistr. 52, W26, 20246 Hamburg, GermanyFull list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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Conclusions: Although infrequently studied, organizational- and system-level characteristics appear to play a role inthe failure to implement SDM in routine care. A wide range of characteristics described as supporting and inhibitingimplementation were identified. Future studies should assess the impact of these characteristics on SDMimplementation more thoroughly, quantify likely interactions, and assess how characteristics might operate acrosstypes of systems and areas of healthcare. Organizations that wish to support the adoption of SDM should carefullyconsider the role of organizational- and system-level characteristics. Implementation and organizational theory couldprovide useful guidance for how to address facilitators and barriers to change.

Keywords: Shared decision-making, Decision aids, Implementation, Routine care, Organizational -level characteristics,Health system -level characteristics, Implementation science, Leadership, Incentives, Health policy,

BackgroundAlthough recognized as ethically important and fre-quently included in healthcare policies [1], the practiceof engaging patients in their healthcare decisions is in-frequently implemented in routine care [2–6]. Researchon shared decision-making (SDM) has identified thisfailure of implementation, but has focused primarily onthe associated patient- and provider-level characteristics[7–10]. Studies of other practice-changing interventionshave similarly identified implementation challenges, butin other areas, the search for solutions has extended tocharacteristics of healthcare delivery beyond the patientand clinician to the organizational characteristics andthe system-level policies. How these findings from theimplementation literature, and research onorganizational- and system-level characteristics specif-ically, might affect efforts to implement SDM is notwell known.SDM is a widely recognized approach to cultivate

patient-centered care [11, 12]. It is an approach whereclinicians and patients share the best available evidencewhen faced with the task of making decisions, and wherepatients are supported to consider options and toachieve informed preferences [13]. SDM is a communi-cative process that can be supported by the use of deci-sion aids, also called decision support interventions. Inthe last several years, there has been growing interest inadvancing SDM in routine healthcare. In many coun-tries, health policies include implementation of SDM. Ina series of articles recently published on the develop-ment of activities to promote SDM in 22 different coun-tries, it was shown that 19 countries have health policiesthat foster or even demand SDM implementation [1].Despite this health policy commitment to SDM and itsinclusion in a range of clinical practice guidelines, studyresults from other countries point towards poor imple-mentation in routine clinical practice [2–6].These results have led to work that attempts to explain

the difficulty of implementing SDM in routine care. Re-search on barriers to and facilitators of SDM mostlyidentifies contributing factors at the individual level of

care, i.e., characteristics of individual patients, clinicians,or the direct patient-clinician interaction [8–10]. Twosystematic reviews on perceived barriers and facilitatorsof SDM implementation not only reported individualfactors (i.e., knowledge, attitudes, and behavior), but alsoincluded a few environmental factors (e.g., time, re-sources) [10, 14]. A similarly narrow focus on attitudes,skills, and behavior of individual clinicians and patientsmanifest in most interventions developed for SDM [15].Recent work has acknowledged the importance of takingorganizational-level characteristics into account. Theseare the characteristics of specific healthcare organiza-tions (i.e., entities that deliver healthcare, e.g., hospitals,practices) that affect the implementation of SDM. Forexample, Müller and colleagues [16] highlighted the im-portance of organizational culture, leadership support,and changes in workflow structures to better implementSDM in cancer care. Additionally, little is known aboutthe role of system-level characteristics in the implemen-tation of SDM. These are the characteristics of thehealthcare system that guide the work of healthcare or-ganizations (i.e., the political, economic, and social con-text in which healthcare organizations are embedded,e.g., policies and legislation) [17].Research on the implementation of health innovations

has shown that it is crucial to take into account charac-teristics of healthcare institutions and of the healthcaresystem at large in order to change practice [18–20].Those characteristics may otherwise function as power-ful barriers to implementing SDM at the individual en-counter level. Nevertheless, implementation strategiesare often targeted to change knowledge, attitudes, andbehavior of individual providers [21], hindered perhaps,by the lack of measures available to assess system-levelcharacteristics [18]. Similarly, in research on SDM, nostudies have focused solely on an in-depth synthesis ofthe literature around organizational- and system-levelcharacteristics that may influence the implementation ofSDM in routine care. A greater understanding of theorganizational- and system-level characteristics thatcould impede or support implementation of SDM in

Scholl et al. Implementation Science (2018) 13:40 of 22

routine care may be helpful in finding ways to addressthese characteristics in implementation strategies. Thus,the aim of this scoping review is to compile a compre-hensive overview of experiences with organizational-and system-level characteristics in implementing SDMin routine care. The following research questions guidedthis scoping review:

1. What experiences with organizational- and system-level characteristics are reported in SDM implemen-tation projects?

2. What strategies to address these characteristics arediscussed in the literature?

MethodsDesignWe performed a scoping review rather than a systematicreview due to the broad nature of our research ques-tions, the young field of SDM research, and our anticipa-tion of high variation in study designs andmethodologies [22]. We used the definition of scopingreview given by Colquhoun and colleagues: “a form ofknowledge synthesis that addresses an exploratory re-search question aimed at mapping key concepts, types ofevidence, and gaps in research related to a defined areaor field by systematically searching, selecting, and syn-thesizing existing knowledge” [23].

ProtocolWe developed our protocol based on the Arksey andO’Malley framework [22], as well as on subsequentlypublished guidance on how to conduct scoping reviews[24–26]. The final version of the protocol can be foundin Additional file 1.

Eligibility criteriaWe included publications that reported on the results ofprojects, quality improvement programs, or studies thataimed to implement SDM, decision aids (i.e., tools foruse inside or outside the clinical encounter [27]) orother decision support interventions (i.e., mediated bymore interactive or social technologies [27]) in routinehealthcare through a certain implementation strategy oreffort. To be included, these full texts also needed to re-port on organizational-level and/or system-level charac-teristics described to influence the implementation, and/or describe strategies that might address organizational-level and/or system-level characteristics. Opinion pieces,reviews, and study protocols were excluded, but reviewswere used in the secondary search process, as describedbelow. The full list of inclusion and exclusion criteria,specifying concepts and contexts of this scoping review,is displayed in Table 1.

Search strategyWe performed an electronic literature search in Med-line, CINAHL, and Web of Science Core Collection. Weincluded articles published between January 1997, theyear in which Charles and colleagues described the con-cept of SDM in their seminal article [28], and October10, 2016. The search was limited to articles published inEnglish or German, as these were the only languagesspoken by a minimum of two members of the reviewteam. Details of the search strategies in the different da-tabases can be found in Additional file 2.Our primary electronic search was complemented by a

comprehensive secondary search strategy. All recordsexcluded through criterion E2 (systematic, scoping, andstructured literature reviews) [10, 14, 15, 29–42] werechecked to see whether they reported on studies thatcould potentially be relevant for this scoping review.Subsequently, the reference lists of six of these reviews

Table 1 Inclusion and exclusion criteria

Inclusion criteria Excluded full texts(N = 306)

I1 The full text is accessible. 2

I2 Context: the language of the fulltext is English or German.

0

I3 Concept: the main subjectof the full text is shareddecision-making (SDM) ordecision aids or otherdecision support interventions.

33

I4 Concept: the full text reportson the results of a project,quality improvement program,or study that aims to implementSDM or decision aids orother decision supportinterventions in routinehealthcare through a certainimplementation strategy or effort.

157

I5 Concept: the full textreports on the role of experiencedorganizational- and/orsystem-level characteristicsthat influenced theimplementation of SDM,decision aids, or otherdecision support interventions.

10

Exclusion criteria

E1 Context: the full text is anopinion piece, commentary,editorial, analysis article, orletter, i.e., does not reporton a primary data collection.

61

E2 Context: the full text is asystematic review, a scopingreview or a structuredliterature review.

22

E3 Context: the full textis a study protocol.

21


[10, 15, 29, 36, 39] were assessed for eligibility. Further-more, two books were searched for chapters meeting theinclusion criteria [43, 44], and a gray literature searchwas conducted on a range of websites listed inAdditional file 3.

Study selection processWe imported all identified records into reference man-agement software (Endnote) and removed duplicates.First, IS and a second reviewer (PH, AL, or RPM) per-formed an independent title and abstract screening tocheck for potential inclusion of records. A record wasincluded into the next step of full text assessment if atleast one reviewer deemed it appropriate. Second, fulltext assessment was conducted. To ensure quality andconsistency of full text assessments, the first 20% of ran-domly selected full texts were assessed by two teammembers (IS and PH or IS and AL). In 83% of the cases,the team members agreed on inclusion or exclusion.Discrepant assessments were subsequently discussed bythe team members. This process led to minor revisionsin the exact wording of the inclusion and exclusion cri-teria and an instruction of how to use the criteria. Then,another round of double assessment using another set of10% of randomly selected full texts was conducted, lead-ing to agreement in 93% of the cases. The subsequentassessment of the remaining 70% of full texts was con-ducted by one reviewer (IS) using a conservative ap-proach. Whenever the single assessor (IS) was in slightdoubt about whether to include or exclude a full text, asecond reviewer was assigned to assess that full text, andfinal decision regarding inclusion was made by discus-sion. This procedure was done for a total of 14 full texts.

Data extractionWe extracted general information on each study andspecific information related to the research questions.We extracted any information on experiences related toorganizational- and system-level characteristics and po-tential strategies to address them. As we wanted to givea broad overview, we extracted all information on expe-riences reported in the publications, including experi-ences derived from results (empirical) and from theinterpretation of results (opinion-based). The number offull texts identified and selected is described using thePRISMA flowchart. The initial data extraction sheet wasdeveloped by one team member (IS), based on experi-ence from other reviews [12, 15, 45, 46]. It was pilottested by IS and AL, using two included full texts [47,48]. We compared the extracted data and found onlyvery minor differences in the level of detail of the re-spective extractions. As a result, the extraction sheet wasslightly revised (e.g., by adding definitions of what to ex-tract). Further data extraction was conducted by one

person (either AL or IS). Whenever one data extractorwas in doubt regarding what to extract for a certain cat-egory, the second person checked the full text and bothmet to discuss agreement on what to extract.

Methodological quality appraisalWe did not appraise the methodological quality or riskof bias of the included studies, which is consistent withguidance on the conduct of scoping reviews [22].

SynthesisWe conducted a descriptive analysis of characteristics ofthe included studies (e.g., types of study design, years ofpublication) as well as a qualitative thematic analysis ofthe organizational- and system-level characteristics iden-tified in the studies. We decided to report what otherstudies reported as influential characteristics, rather thanclassify them as barriers or facilitators. This analysisdrew on principles of qualitative content analysis de-scribed by Hsieh and Shannon [49] and consisted of thefollowing steps: first, two researchers (AL and IS) readthe entire set of extracted data to gain an overview. Sec-ond, one researcher (AL) coded the material (initial in-ductive coding). Third, comments by a secondresearcher (IS) led to adaptation of the coding system.Fourth, the revised codes were organized into a codingsystem using clusters and subcategories, agreed in dis-cussion with two other team members (GE and SK).Fifth, the material was re-coded by one researcher (AL)using the established coding system. Sixth, the re-codedmaterial was cross-checked by a second researcher (IS)and minimal changes were made in discussion (IS andAL). Potential strategies mentioned in the publicationsto address organizational- and system- level characteris-tics were synthesized and mapped onto identified char-acteristics in a team discussion (IS, AL, GE). Noqualitative data analysis software was used. Analyseswere conducted on the level of distinct implementationprojects, i.e., publications reporting on the same imple-mentation project were grouped under one single pro-ject ID.

ResultsIncluded studiesAfter screening 7745 titles and abstracts for eligibility,and checking 354 full texts against the inclusion and ex-clusion criteria, we included 48 full texts (see Fig. 1).Reasons for exclusion of full texts are displayed inTable 1. The included full texts report on a total of 32distinct implementation projects. While most projectswere only reported in a single publication, several pro-jects were described in two or more publications.Twenty-two projects were conducted in the USA, and26 projects focused on the implementation of decision


aids or other forms of decision support. Projects focusedon various settings and a broad range of decisional con-texts. Table 2 gives an overview on the included projectsand publications.

Characteristics influencing SDM implementationFigure 2 gives an overview of the identified characteristics.

Organizational-level characteristicsTable 3 displays the organizational-level characteristicsreported in the included full texts as influencing the im-plementation of SDM, decision aids, or other decisionsupport interventions. The table includes descriptions ofall identified characteristics. Six main categories oforganizational characteristics were described in the in-cluded studies: organizational leadership, culture, team-work, resources, priorities, and workflows. Five of thesix main categories also included several subcategoriesof organizational-level characteristics; for example, thecategory “organizational resources” included the subcat-egories time (that healthcare providers have per patient),financial resources (that are available for certain activ-ities within a healthcare organization), workforce (i.e.,employees available for and assigned to certain activitieswithin a healthcare organization), and space (i.e., roomavailable for certain activities within a healthcareorganization). Both the availability of resources withinan organization and organizational workflows (e.g., pa-tient information dissemination strategies, scheduling

routines, use of the electronic health record) were de-scribed to have influenced SDM implementation effortsin over three quarters of the projects, and facets of theorganizational culture and teamwork within anorganization were reported in only a third of the projects(see column “Project IDs” in Table 3).

System-level characteristicsWhile many organizational characteristics were identi-fied in the included full texts, only four main categoriesof characteristics of the healthcare system were de-scribed: incentives (i.e., the role of payment models andaccreditation/certification criteria), policies and guide-lines (i.e. the role of healthcare legislation and clinicalpractice guidelines), culture of healthcare delivery, andhealthcare provider education and licensing. Table 4gives an overview of the characteristics of the healthcaresystem that were reported as influencing implementa-tion. The table includes descriptions of all identifiedcharacteristics. While only four projects reported thatthe culture of healthcare delivery influenced SDM im-plementation, about one third of the projects reportedthat incentives, policies and guidelines, and healthcareprofessional education and licensing influenced SDMimplementation (see column “Project IDs” in Table 4).

Strategies to address organizational- and system-levelcharacteristicsA range of possible strategies to address organizational-and system-level characteristics and thereby potentiallyfoster SDM implementation were discussed in the publi-cations and mapped onto the identified characteristics.They are displayed in Table 5. Similar to the results on ex-perienced characteristics, most proposed strategies fo-cused on the organizational level. Most studies identifiedworkflow as an organizational-level characteristic influen-cing SDM implementation and also generated potentialstrategies to tackle that characteristic. Few strategies weresuggested to change organizational culture [50–52], whichwas also described in fewer studies. A large range of po-tential strategies were also described to promote leader-ship activities that might facilitate SDM implementation(see full list in Table 5). At the system-level, fewer strat-egies were described. Suggestions included changes inpayment models [53–55], legislation [51, 56, 57], andhealth professional education [51, 58–60].

DiscussionSummary of the review findingsWe described a broad range of organizational- andsystem-level characteristics that were experienced as influ-encing the implementation of SDM in routine care, as wellas strategies to potentially address those characteristics.Included studies reported more often on characteristics

Fig. 1 Flow chart of study selection. *Reasons for exclusion: I1: 2 intotal (1 full text from primary search, 1 full text from secondarysearch). I2: none. I3: 33 in total (29 full texts from primary search, 4full texts from secondary search). I4: 157 in total (113 full texts fromprimary search, 44 full texts from secondary search). I5: 10 in total (8full texts from primary search, 2 full texts from secondary search). E1:61 in total (58 full texts from primary search, 3 full texts fromsecondary search). E2: 22 in total (17 full texts from primary search, 5full texts from secondary search). E3: 21 in total (20 full texts fromprimary search, 1 full texts from secondary search)


Table

2Includ

edim

plem

entatio

nprojects

ProjectID

Autho

r(year)

Cou

ntry

Stud

yde

sign

*Setting

Con

text

Implem

entedinterven

tion

Implem

entatio

nstrategy

P1Abrines-Jaumeet

al.(2016)[47]

UK

Qualityim

provem

entstud

yOutpatient,inp

atient,

commun

ity,and

outreach

Child

andadolescent

men

talh

ealth

SDM

inge

neral

Team

swereen

couraged

totry

arang

eof

toolsto

supp

ort

SDM

andreceived

cross-site

learning

even

tsevery3

mon

thsinclud

inginform

ation

andmaterials,g

roup

discussion

s,andactio

nlearning

setsas

partof

theClosing

theGap

prog

ram.The

yalso

received

regu

lar

site

meetin

gsandph

one

andem

ailg

uidance.

P2And

rewset

al.(2016)[68]

Berg

etal.(2011)[69]

Friedb

erget

al.(2013)[70]

USA

n/r(descriptive

implem

entatio

nstud

y)Specialty

andprim

ary

care

inan

academ

icmed

icalcenter

Ortho

pedics,b

reast

cancer,h

ipandknee

osteoarthritis,prostate

cancer,cancerscreen

ing,

spinecond

ition

s,he

art/chronic/othe

r

Decisionaids

andothe

rform

ofde

cision

supp

ort

Whe

nindicated,

individu

al’s

treatm

entpreferen

ces,qu

estio

ns,

andothe

rde

cision

-makingdata

wereshared

with

theirclinician

andrecorded

intheirelectron

icmed

icalrecord

(EMR).Shared

decision

-makingsummaries

(dashb

oards)wererepo

rted

tode

partmen

tsat

regu

larintervals

inan

effortto

system

atically

mon

itorandevaluate

theuse

ofde

cision

supp

ortprog

rams

inclinicalcare.

P3Arterbu

rnet

al.(2016)[71]

Con

radet

al.(2011)[55]

Hsu

etal.(2013)[52]

Hsu

etal.(2013)[72]

King

andMou

lton(2013)

[51]

USA

Mixed

-metho

dscase

stud

ySpecialty

care

inan

integrated

health

system

Focuson

decision

sregardingsurgical

treatm

ents:b

reast

cancer

andDCIS,hip

andknee

osteoarthritis,

chroniclow

back

pain,

livingbe

tter

with

chronic

pain,colon

cancer

screen

ing,

depression

,diabetes,PSA

testing

Decisionaids

Senior

projectmanagem

ent

consultantsworkedwith

service

lineleadersto

develop

implem

entatio

nagreem

ents

andprocessflow

diagramsfor

each

serviceline.Onceadraft

distrib

utionprocesswas

gene

rated,

theproject

managersmet

with

frontline

providersandstaffto

introd

ucetheDAs,the

distrib

utionprocessand

answ

erqu

estio

ns.Process

revision

swerebasedon

provider

reactio

nsand

sugg

estio

ns.O

ncean

implem

entatio

nprocess

was

agreed

upon

,a“go-live”

date

was

set,afterwhich

theprojectmanagersvisited

each

clinicsite

atleaston

ceto

mon

itorim

plem

entatio

nprocessesandprog

ress.Sites

expe

riencingchalleng

esreceived

additio

nalvisits

and

calls

asne

cessary.DAswere

distrib

uted

usingan

existin

gservicethat

supp

lies

educationalm

aterialsto

patientsviaUSmail.The

DVD

versions

oftheDAs

couldbe

orde

redforpatients


Table

2Includ

edim

plem

entatio

nprojects(Con

tinued)

ProjectID

Autho

r(year)

Cou

ntry

Stud

yde

sign

*Setting

Con

text

Implem

entedinterven

tion

Implem

entatio

nstrategy

byclinicalstaffusingthe

electron

iche

alth

record.

Patientscouldalso

view

theDAon

lineviathe

patient

portal,and

providers

couldem

bedalinkto

the

vide

oDAin

thepatient’s

after-visitsummary.In

treatm

entde

cision

for

which

thetim

ebe

tween

apatient’sinitialappo

intm

ent

andtheproced

urewas

very

short,theDAscouldalso

bedistrib

uted

intheoffice.

Processwas

mon

itored

usingtw

ice-mon

thly

distrib

utionrepo

rtsgiven

toclinicalleaders.In

the

second

year,the

serepo

rts

includ

edmorespecific

numbe

rsforindividu

alclinicians.

P4Belkora(2011)

[73]

Belkoraet

al.(2008)[74]

Belkoraet

al.(2011)[75]

Belkoraet

al.(2012)[48]

Belkoraet

al.(2015)[76]

USA

Qualityim

provem

entstud

yBreastcare

center

(inan

NCId

esignated

compreh

ensive

care

center)

Breastcancer

Decisionaids

and

othe

rform

ofde

cision

supp

ort

Long

-term

projectwith

multip

leiteratio

ns.

Implem

entatio

nsconsisted

ofconsultatio

nplanning

,recording,

summarizing

services

inwhich

supp

ort

staffassisted

patientsin

commun

icatingwith

their

providersbe

fore

avisit

(questionbrainstorm

ing)

anddu

ringavisit(aud

iorecording).Improvem

ents

onthisserviceconsisted

ofadjustingthesche

duling

system

andworkflow

ofde

cision

supp

ort,mailing

DAsto

patientsat

home,

andmakingfollow-upcalls

P5Belkoraet

al.2008[77]

USA

Post-im

plem

entatio

nqu

alitativestud

yCom

mun

ityclinics

andcommun

ityresource

centers

Breastcancer

Other

form

ofde

cision

supp

ort

One

-tim

eCon

sultatio

nPlanning

training

worksho

psinclud

edlectures,structured

roleplaying,

andgrou

pdiscussion

sessions.

P6Brackettet

al.(2010)[78]

USA

n/r(descriptive

implem

entatio

nstud

y)Prim

arycare

inon

eacadem

icmed

ical

center

andon

eVeteran’s

Affairs

Med

icalCen

ter

Prostate

cancer

andcolorectal

cancer

screen

ing

Decisionaids

Four

metho

dswerecompared:

(1)

automaticpre-visitmailing

toallp

oten

tially

eligible

patients,(2)letter

mailed

toallp

oten

tially

eligible

patientsofferin

gpre-visit

DA(3)e

ligiblepatients

offeredDAat

checkout

from

prim

arycare

visit

(4)clinicianprescribes

DA


Table

2Includ

edim

plem

entatio

nprojects(Con

tinued)

ProjectID

Autho

r(year)

Cou

ntry

Stud

yde

sign

*Setting

Con

text

Implem

entedinterven

tion

Implem

entatio

nstrategy

toeligiblepatients

durin

gprim

arycare

visit

P7Clayet

al.(2013)[79]

Friedb

erget

al.(2013)[70]

USA

n/r(descriptive

implem

entatio

nstud

y)Acade

micmed

icalcenter

departmen

tof

orthop

edics

Ortho

pedics

Decisionaids

Embe

ddingde

cision

aidinto

new

EMRto

system

aticallyandautomatically

deliver

DAto

therig

htpatient

attherig

httim

e.

P8Elwyn

andThom

son

(2013)

[80]

King

etal.(2013)[58]

Lloydet

al.(2013)[81]

LloydandJoseph

-Williams(2016)

[82]

UK

Servicede

velopm

ent/qu

ality

improvem

entprog

ram

NHSho

spitalsand

prim

aryandsecond

ary

care

team

s

Headandne

ckcancer,

breastcancer,p

ediatric

tonsillectomy,ob

stetrics,

urolog

icalprob

lems,ear,

nose

andthroat,kne

eosteoarthritis,statins,

managingmoo

ddisorders,

sexualhe

alth

and

contraception,

uppe

rrespiratory

tractinfection,

managingcarpaltunn

elsynd

rome,sm

oking

cessation,

men

orrhagia,

long

-term

care,b

enign

prostatic

hype

rplasia

SDM

inge

neral

Makinggo

odde

cision

sin

collabo

ratio

n(M

AGIC)

improvem

entprog

ram:an

approach

that

integrates

shared

decision

-making

into

routinecare

throug

htraining

inshared

decision

-making

andtheuseof

decision

supp

orttools,pe

ersupp

ort

forclinicians,and

supp

ort

forpatientsto

become

moreen

gage

din

theircare.

Thisprog

ram

hasbe

enim

plem

entedat

several

sitesandisadaptedfor

bestusein

thecontext

ofeach

site.

P9Elwyn

etal.(2012)[83]

UK

Post-im

plem

entatio

nmixed

-metho

dsstud

yNHShe

althcare

profession

als

Knee

osteoarthritis,

amniocen

tesis,

breastcancer,b

enign

prostatic

hype

rplasia,

localized

prostate

cancer

Decisionaids

Toolsweremadeavailable

onNHSDirect’sweb

platform

andpatientswere

directed

totoolsby

staff.

P10

Feibelmannet

al.

(2011)

[84]

USA

n/r(descriptive

implem

entatio

nstud

y)Cancercenters,ho

spitals,

privatepractices,

andresource

centers

Breastcancer

Decisionaids

Lettersweremailedto

providers

atsites.Sitescouldfaxor

mailb

ackarequ

estfora

sampleprog

ram

andthen

sign

aparticipantagreem

ent

toreceivecopies

ofde

cision

aids

tousewith

patients.

Vario

usim

plem

entatio

ntechniqu

eswereused

atindividu

alsites.

P11

Fortnu

met

al.(2015)[85]

Australia

n/r(descriptive

implem

entatio

nstud

y)Renalu

nits

End-stagekidn

eydisease

Decisionaids

DecisionaidPD

Fsweremadeavailable

natio

nally

(dow

nloadable

from

Kidn

eyHealth

Australia

andKidn

eyHealth

New

Zealandweb

sites).Edu

catio

nwas

provided

toover

2000

ANZ

health

profession

alsthroug

hteleconferen

ces,web

inar,

web

site

distrib

ution,

state

worksho

ps,u

nitvisits,

conferen

cepresen

tatio

ns,

andem

ail.

P12

Frosch

etal.(2011)[50]

Uyet

al.(2014)[86]

USA

n/r(descriptive

implem

entatio

nstud

y)Prim

arycare

offices

and

commun

ityhe

alth

centers

Firstprostate

andcolon

cancer

screen

ingthen

Decisionaids

Theinitialim

plem

entatio

npractices

received

eviden

ce-based


Table

2Includ

edim

plem

entatio

nprojects(Con

tinued)

ProjectID

Autho

r(year)

Cou

ntry

Stud

yde

sign

*Setting

Con

text

Implem

entedinterven

tion

Implem

entatio

nstrategy

expand

edto

vario

uscontextswith

24different

decision

aids

available

brochu

rede

cision

supp

ort

interven

tions

(DESIs).Thego

alwas

toprovidetheDESIsto

patientsat

thetim

eof

anofficevisitandto

review

before

theconsultatio

nwith

theph

ysician.

Inan

expansionof

this

implem

entatio

nindividu

alpractices

selected

DESIs

toprovideto

patients.

Phase1:du

ringapatient

visit,ph

ysicianor

staff

wou

ldassess

approp

riatene

ssof

DAprescriptio

nthen

eligiblepatientsreceived

packagewith

DAto

take

homeandreview

before

follow

up-app

ointmen

t.Theexactlogisticsof

DA

distrib

utionwereestablishe

dby

practices

individu

ally.

Weekly“acade

micde

tailing

”visitswerecond

uctedwith

amem

berof

theresearch

team

toiden

tifybarriers

andde

veloppo

tential

solutio

ns.Phase

2:introd

uctio

nof

afinancial

incentiveto

compe

nsate

fortim

espen

tprescribing

DAsandinclusion/exclusion

criteria

(toen

sure

that

only

eligiblepatientsreceive

theDA)andph

one

survey

insteadof

questio

nnaire.

P13

Friedb

erget

al.(2013)[70]

Frosch

(2011)

[73]

Linet

al.(2013)[87]

May

etal.(2013)[88]

Tietbo

hlet

al.(2015)[89]

USA

Casestud

y(descriptive

implem

entatio

nstud

y)Prim

arycare

clinics

inan

integrated

health

system

Vario

uscontexts:16

different

decision

aids

available

Decisionaids

Theprojectteam

collabo

rated

with

clinicsto

tailorde

cision

aiddistrib

utionmetho

dsto

individu

alclinicworkflows.

Each

clinichadaph

ysician

andstaffcham

pion

respon

sible

forprom

otingtheprog

ram.

Theleadership

team

ateach

clinic,w

hich

includ

edbo

thph

ysicians

andleadersof

clinicalsupp

ortstaff,

selected

decision

aid

topics

fordistrib

utionfro

mthelistof

availabletools.

Projectteam

mem

bers

engage

din

academ

icde

tailing

visitsandsocial

marketin

geffortsto

prom

ote

distrib

utionof

thede

cision

aids.


Table

2Includ

edim

plem

entatio

nprojects(Con

tinued)

ProjectID

Autho

r(year)

Cou

ntry

Stud

yde

sign

*Setting

Con

text

Implem

entedinterven

tion

Implem

entatio

nstrategy

P14

Garde

n(2008)

[59]

Wirrman

andAskham

(2006)

[90]

UK

n/r(descriptive

implem

entatio

nstud

y)Urology

departmen

tsEarly

localized

prostate

cancer

orbe

nign

prostatic

hype

rplasia

Decisionaids

Nurse

specialistswere

traine

dto

implem

ent

DecisionSupp

ortAids

andDecisionQuality

Assessm

entForm

sto

patients(im

plem

ented

atdifferent

pointsin

thecare

pathway

atdifferent

sites).

P15

Holmes-Rovne

ret

al.

(2000)

[91]

USA

Mixed

-metho

dsfeasibility

stud

yHospitalcom

mun

ityhe

alth

educationcenters,

cardiology

education

andresearch

departmen

ts,

andhe

alth

educationlibraries

Breastcancer

and

ischem

iche

artdisease

Decisionaids

Toen

sure

localaccep

tance

oftheprog

ramsandto

fittheprog

ram

into

existin

groutines,h

ospitalswere

askedto

iden

tifystud

ycoordinatorswho

wou

ldworkwith

localp

hysicians

andnu

rses

toim

plem

ent

theprog

rams.Participating

clinicians

wereaskedto

review

decision

aidand

completesurvey

priorto

distrib

utingto

patients.

Clinicians

received

reminde

rsandstud

ycoordinatorsrepe

ated

lydiscussedtheDAswith

them

.

P16

Holmes-Rovne

ret

al.

(2011)

[92]

USA

Retrospe

ctive

post-the

n-prede

sign

Internalmed

icine

andfamily

med

icineclinics

Stablecoronary

artery

disease

SDM

inge

neral

Thecomplex

decision

supp

ort

system

calledShared

DecisionMakingGuidance

Reminde

rsin

Practice

(SDM-GRIP)

consistedof:(1)

provider

training

(2)patient

education.

Tofacilitatediscussion

intheclinicalen

coun

ter,a

dedicatedSD

Mprovider

visitwas

establishe

d,andan

encoun

terde

cision

guide(EDG)was

givento

patients.TheED

Gprovided

aneviden

cesummaryand

decision

page

sto

record

choicesarrived

atin

theclinicalen

coun

ter.

P17

Julianet

al.(2011)[93]

USA

n/r(descriptive

implem

entatio

nstud

y)Com

preh

ensive

breastcare

center

Breastcancer,D

CIS

Decisionaids

and

othe

rform

ofde

cision

supp

ort

Anu

rsenavigator

coordinatedpatient

care

andprovided

decision

aids

towom

en.

P18

Korsen

etal.(2011)[73]

USA

n/r(descriptive

implem

entatio

nstud

y)Prim

arycare

inan

integrated

health

system

PSAtesting,

colorectal

cancer

screen

ing,

diabetes,acute

low

back

pain,chron

iclow

back

pain,d

epression,

men

opause,

advancedirectives

Decisionaids

Implem

entatio

ninclud

ed(1)pre-visit,visit-based,

andpo

st-visitdistrib

ution

mod

els,(2)useof

EHRforDA

referral,(3)

vario

ustraining

s,worksho

ps,and

presen

tatio

nsat

different

sites


Table

2Includ

edim

plem

entatio

nprojects(Con

tinued)

ProjectID

Autho

r(year)

Cou

ntry

Stud

yde

sign

*Setting

Con

text

Implem

entedinterven

tion

Implem

entatio

nstrategy

P19

Friedb

erget

al.(2013)[70]

Lewiset

al.(2011)[73]

Lewiset

al.(2013)[57]

Miller

etal.(2012)[94]

USA

n/r(descriptive

implem

entatio

nstud

y)Prim

arycare

clinic

PSAtestingand

weigh

tloss

surgery

Decisionaids

Thefocuswas

onautomated

DVD

DAde

liverythroug

hEH

Randsocialmarketin

gcampaign.

Five

delivery

mod

elswereused

:(1)

mailingDAs

priorto

visit(2)u

sing

Patient

Health

Survey

toiden

tifyeligiblepatients

andallow

them

torequ

est

aDA,(3)

requ

estin

gDAs

byph

ysician(4)distrib

uting

DAswith

inchronicdisease

managem

entprog

ram

(5)pre-visiton

line

screen

ingforDAeligibility

P20

McG

railet

al.(2016)[95]

USA

n/r(descriptive

implem

entatio

nstud

y)One

prim

arycare

clinic,

onege

neralh

ospital

Statins,anticoagu

latio

nin

patientswith

atrial

fibrillatio

n,osteop

orosis

andknee

osteoarthritis,

urinaryincontinen

ce

SDM

inge

neral

TheSH

ARE

approach

“train-the

-trainer”

worksho

pwas

followed

bytraining

sessions

forreside

ntsand

med

icalgrou

pstaff.

P21

Mollicon

eet

al.(2013)[96]

USA

n/r(descriptive

implem

entatio

nstud

y)Specialty

care

center

Chron

ickidn

eydisease

SDM

inge

neral

Treatm

entOptions

Prog

ram

(TOPs)consistsof

free

classesofferedlocally,

natio

nwide,by

traine

dFM

CNApe

rson

neltoed

ucate

patientsandfamily

mem

bers

abou

ttheop

tions

fortreatm

ent.

Follow

upcalls

encourage

patientsto

discussop

tions

with

theirdo

ctorsand

participatein

theircare.

P22

Friedb

erget

al.(2013)[70]

MorrisseyandElwyn

(2013)

[97]

MorrisseyandMiche

ls(2011)

[98]

USA

n/r(descriptive

implem

entatio

nstud

y)Prim

arycare

Benign

prostatic

hype

rplasia,

prostate

cancer,b

reast

cancer,d

epression,

uterinefib

roids,chronic

low

back

pain,chron

icpain,m

enop

ause

Decisionaids

and

othe

rform

ofde

cision

supp

ort

Threemod

elsfor

implem

entatio

nwereused

:(1)

patient

referred

from

prim

arycare

orspecialistforcare

coordinatio

n/na

vigatio

nwhich

includ

edface

toface

visitwith

DA(2)

provider

teed

upSD

Mconversatio

nin

exam

room

andhand

edpatient

offto

nursewho

provided

inform

ationandDA(3)

patient

requ

estedDAand

care

coordinatorfollows

upwith

acallfordiscussion

P23

New

someet

al.(2012)[60]

USA

Post-im

plem

entatio

nqu

alitativestud

yFamily

med

icineclinics

Cancerscreen

ing,

chronicillne

sscare

Decisionaids

Physicians

used

theDAs

inclinicalpracticeand

med

icalassistantswere

involved

indistrib

ution

ofDAs(detailsno

tspecified

,repo

rted

inaseparate

publication).


Table

2Includ

edim

plem

entatio

nprojects(Con

tinued)

ProjectID

Autho

r(year)

Cou

ntry

Stud

yde

sign

*Setting

Con

text

Implem

entedinterven

tion

Implem

entatio

nstrategy

P24

Pasternack

etal.(2011)[99]

Finland

n/r(descriptive

implem

entatio

nstud

y)Breastcancer

screen

ingproviders

Breastcancer

screen

ing

Decisionaids

Letter

templates

with

invitatio

nto

screen

ingandshort

decision

aidon

theback

whe

remadeavailableto

allb

reastcancer

screen

ing

facilitiesandmun

icipalities

inthecoun

try.Theshort

DAwas

puton

theback

oftheletter

toavoid

extracostsfortheproviders,

who

usually

justsend

out

theinvitatio

n.Aweb

site

containe

damorein

depth

decision

aid.

Theservice

providersreceived

inform

ation

onlegislation,

thene

wletter

templates,and

postersfor

thewaitin

groom

s.

P25

Sepu

chaandSimmon

s(2011)

[73]

Sepu

chaet

al.(2016)[100]

Simmon

set

al.(2016)[101]

USA

n/r(descriptive

implem

entatio

nstud

y)Prim

arycare

clinics

Vario

uscontexts:40

different

decision

aids

available

Decisionaids

Clinicians

wereableto

orde

rDAsthroug

htheelectron

icmed

icalrecord

(EMR).

TheEM

Rapplicationthen

gene

ratedano

tein

the

patient’schartdo

cumen

ting

that

thematerialh

asbe

ensent.The

distrib

utionand

inventoryof

DAwere

managed

centrally.The

DAswereavailablein

several

form

ats(e-m

ailm

essage

with

alinkto

access

theDAon

line;

DVD

andbo

okletin

themail).

Early

onDAprescriptio

nwas

done

inavisitby

theclinician,

buttheSD

Mim

plem

entatio

nteam

workedwith

clinicians

andadministratorsto

automatize

prescriptio

ns.Som

eyearsinto

theim

plem

entatio

nprog

ram,

ashort1htraining

mod

ule

was

delivered

toclinicians

toincrease

familiarity

with

theDAs,show

them

orde

ring

inEM

Randdiscussim

plem

entatio

nchalleng

es.The

yreceived

CMEpo

intsfortraining

.Further

into

theim

plem

entatio

nprog

ram,

patientsreceived

theop

portun

ityto

orde

rDAsthem

selves

(patient-directed

orde

ring).

Therewereno

mandatesor

long

-term

financialincentives

orpe

nalties

associated

with

usingor

notusingDAs


Table

2Includ

edim

plem

entatio

nprojects(Con

tinued)

ProjectID

Autho

r(year)

Cou

ntry

Stud

yde

sign

*Setting

Con

text

Implem

entedinterven

tion

Implem

entatio

nstrategy

P26

Silviaet

al.(2008)[102]

SilviaandSepu

cha(2006)

[103]

USA

Post-im

plem

entatio

nqu

alitativestud

yCom

mun

ityresource

centers,commun

ityho

spitals,acade

mic

centers,commun

ityon

cology

center

Breastcancer

Decisionaids

Providersandresource

centersacross

thecoun

try

wereinform

edabou

tthe

availabilityof

theprog

rams

throug

hlettersande-mail.

Interested

sitesreceived

free

copies

andwereleftto

decide

them

selves

how

tousethem

.

P27

Stacey

etal.(2006)[104]

Canada

n/r(descriptive

implem

entatio

nstud

y)Callcen

ter

Vario

ushe

alth

issues;b

irth

controlm

etho

ds,b

reast

versus

bottlefeed

ing,

malene

wbo

rncircum

cision

,wisdo

mteethremoval,

andtreatm

entof

miscarriage

mostcommon

Decisionaids

and

othe

rform

ofde

cision

supp

ort

Interven

tions

includ

edan

onlineauto

tutorial,

skill-buildingworksho

p,de

cision

supp

ortprotocol,

andfeed

back

onqu

ality

ofde

cision

supp

ort

provided

tosimulated

callers

P28

Stacey

etal.(2008)[105]

Australia

Pre-po

stteststud

yCancercallcenter

Cancer

Other

form

ofde

cision

supp

ort

Interven

tions

includ

eda

decision

supp

orttutorial,

skill-buildingworksho

p,andde

cision

coaching

protocol.Sup

ervisors

weretraine

din

decision

supp

ort,atraine

rworksho

pwas

held

forsupe

rvisory

staffmem

bers,and

the

director

ofthecancer

helplineaddressedworksho

pparticipantsto

validatethat

decision

supp

ortisan

impo

rtantpartof

their

callcenter

role.

P29

Stacey

etal.(2015)[106]

Canada

Prospe

ctivepragmatic

observationaltrial

Cystic

fibrosisclinics

Adu

ltswith

cysticfib

rosis

consideringreferral

forlung

transplant

Decisionaids

and

othe

rform

ofde

cision

supp

ort

Implem

entatio

nstrategy

was

basedon

results

ofpriorbarrierssurvey.It

consistedof

training

(worksho

pandon

line

tutorial),easy

access

tode

cision

aids,and

conferen

cecalls

for

ongo

ingsupp

ort.

Patientscompleted

DA

ontheirow

nanddiscussed

results

with

provider

atasubseq

uent

encoun

ter,

andasummarywas

includ

edin

theclinicrecord.

P30

Stapletonet

al.(2002)[107]

UK

Post-im

plem

entatio

nqu

alitativestud

yWom

en’sho

mes,

maternity

clinics

Anten

atalcare

and

maternity

services

Decisionaids

Leafletswereprovided

aspartof

aclusterrand

omized

controlledtrial.Health

profession

alsreceived

atraining

sessionin

how

tousethem

.


Table

2Includ

edim

plem

entatio

nprojects(Con

tinued)

ProjectID

Autho

r(year)

Cou

ntry

Stud

yde

sign

*Setting

Con

text

Implem

entedinterven

tion

Implem

entatio

nstrategy

P31

Swieskow

ski(2011)[73]

USA

n/r(descriptive

implem

entatio

nstud

y)Prim

arycare

clinics

Acute

andchroniclow

back

pain,d

iabe

tes,

wom

en’she

alth

issues,

knee

andhiposteoarthritis,

cardiaccond

ition

s,spinal

care,end

oflife

care,PSA

testing

Decisionaids

Potentialp

atientswereiden

tified

bypre-visitchartreview

and

DAswereprescribed

byproviders

orhe

alth

coache

sdu

ring

thevisit.Follow-upde

cision

supp

ortwas

provided

bythe

physicianor

thehe

alth

coachat

afollow-upvisit.

P32

Tapp

etal.(2014)[53]

USA

Process

improvem

entstud

yPrim

arycare

practices

Asthm

aSD

Min

gene

ral

Acommun

itybasedparticipatory

research

approach

was

used

toform

anadvisory

board

(includ

ingpatients,ph

ysician

cham

pion

s,othe

rhe

althcare

profession

als,administrative

staff)that

met

mon

thlyto

tailorinterven

tionto

need

sof

each

practice(e.g.,adaptin

ginterven

tionto

deliveryby

different

type

sof

staffmem

bers,

adaptin

gmaterialfor

useby

Spanish-speaking

,low

literacy

andpe

diatric

popu

latio

n,de

cide

onrollou

tsche

dule).

Allpractices

startedwith

kick-

offmeetin

g,then

discussion

roun

dsarou

ndlogistics,

training

sessions

(includ

ing

useof

decision

supp

ort

materials),regu

larfollow-up

meetin

gs.

UKUnitedKing

dom,U

SAUnitedStates

ofAmerica,SD

Mshared

decision

-making,

DCISdu

ctal

carcinom

ain

situ,P

SAprostate-spe

cific

antig

en,N

CINationa

lCan

cerInstitu

te,N

HSNationa

lHealth

Service,

*Study

design

:asrepo

rted

inpu

blication;

ifno

trepo

rted

(n/r),au

thorscatego

rized

basedon

stud

yde

scrip

tionin

brackets


influencing the organizational level than the health systemlevel. The reported organizational characteristics arestrongly influenced by health system characteristics; forexample, the amount of time that a HCP has for a pa-tient’s visit is linked to payment models, the organizationalculture is influenced by the general culture of healthcaredelivery, and the leadership decisions within anorganization are affected by policies, payment models, andaccreditation criteria. As the identified characteristics canbe barriers, facilitators or both barriers and facilitators toSDM implementation, we described them in a value-neutral way.

Strengths and limitationsWe extracted reports from implementation studies de-scribed in any part of the included publications. Ouranalyses therefore cannot differentiate between experi-ences based on results and those reflecting interpret-ation of results. However, for a young research field, webelieve this broad scoping review is an important firststep to gaining an overview of the topic.A second limitation is that the primary search was

limited to three electronic databases, so we might havemissed relevant publications. However, we prioritizedsensitivity in our electronic search, which is reflected bythe high number of screened abstracts, to identify mostrelevant work. Furthermore, we conducted an extensivesecondary search, including gray literature to find morework not indexed in the electronic databases searched.Another limitation is that we did not conduct a fulldouble assessment and double data extraction. However,

we did our best to minimize error by consulting with asecond reviewer whenever there was the slightest doubt.A main strength of this review is that it is the first of itskind to focus solely on the impact of organizational andsystem characteristics on the implementation of SDM.In previous work, the focus had mainly been on the indi-vidual clinician-patient level, and organizational- andsystem-level characteristics had not been examined indepth [10, 14]. Furthermore, it was conducted in aninter-professional and international team.

Comparison to previous workFirst, these findings need to be compared to previouswork on SDM. Our results reinforce prior calls for bettercoordination of care, engagement of non-physicianpersonnel, and the use of the electronic health record(EHR) to implement SDM in previous work [61]. Thesuggestions to use clinical practice guidelines, post-graduate training, and accreditation as means to betterimplement SDM [5] are also reflected in the data col-lected in this scoping review. Many of the characteristicsidentified in this review have been discussed in trials ofSDM interventions or decision aids, in studies of clini-cians’ perceptions, or in opinion pieces, but this is thefirst piece of work looking at characteristics experiencedin actual implementation studies.Second, the results need to be compared to more gen-

eral work in healthcare implementation science, beyondthe case of SDM as a particular innovation to imple-ment. Implementation frameworks and conceptualmodels like the one postulated by Greenhalgh and

Leadership• Encouragement• Feedback• Mission / vision

Culture• Autonomy (staff)• Shared views / goals

Teamwork• Communication• Coordination of care

Resources• Time• Money• Space• Workforce

Organizational priorities

Workflows• Information dissemination

strategies• Electronic health record• Scheduling & timeframes

Health care provider education & licensing

Culture of health care delivery

Incentives• Payment model• Accreditation /

certification

Policies and guidelines• Legislation• Practice guidelines• Quality indicators

Organizational Characteristics

Health System Characteristics

Fig. 2 Overview of identified characteristics. Main categories are displayed in bold; subcategories are listed as bullet points. The dashed linearound the organizational characteristics indicates that these characteristics are influenced by health system characteristics


Table

3Iden

tifiedorganizatio

nal-levelcharacteristics

Characteristics

Descriptio

ns#

ProjectIDs*

Organizationalleade

rship

2003

corporatemission

andvision

statem

ent

Deg

reeto

which

thede

scrip

tionof

theorganizatio

n’score

purposeandvision

forthefuture

supp

ortsSD

MP3,P8,P13,P25,P27,P28

Encouragem

ent

Deg

reeto

which

leadersin

organizatio

nproactivelysupp

ortSD

MP1,P2,P3,P4,P5,P8,P12,P13,P14,P25,P26,P27,P31

Perfo

rmance

measuremen

tand

feed

back

Use

ofresults

ofpe

rform

ance

measuremen

tor

quality

indicatormetricsto

indicate

room

forim

provem

ent

P2,P3,P7,P8,P13,P16,P18,P25,P27,P28,P32

Organizationalculture

Deg

reeto

which

anorganizatio

n’scultu

resupp

ortsSD

MP2,P3,P8,P12,P13,S14

Auton

omyof

staff

Deg

reeof

flexibilitythat

healthcare

providers(HCPs)have

toachieveorganizatio

nalg

oals

P1,P3,P8,P26

Shared

view

sandgo

als

Deg

reeto

which

team

mem

berssharethesameview

sandgo

als

P4,P8,P9,P13,P21,P31

Organizationalteamwork

Com

mun

ication

How

inform

ationisshared

with

inandbe

tweenteam

sP7,P8,P12,P13,P22,P32

Coo

rdinationof

care

Deliberateorganizatio

nof

care

byHCPs

from

different

specialties

P3,P7,P12,P13,P14,P16,P26,P32

Organizationalresou

rces

Availabilityof

resources

P12,P22,P26

Time

Amou

ntof

timeHCPs

have

perpatient/patient

visit

P1,P3,P5,P8,P9,P10,P12,P13,P14,P15,P19,P26,P27,P28,P29,

P30,P31,P32

Financialresou

rces

Amou

ntof

mon

eyavailableforcertainactivities

with

inorganizatio

nP2,P3,P4,P5,P11,P14,P19,P31

Space

Amou

ntof

room

availableforcertainactivities

with

inorganizatio

nP4,P5,P8,P26

Workforce

Availabilityandassign

men

tof

employeesforcertainactivities

with

inorganizatio

nP3,P4,P5,P8,P10,P12,P14,P18,P19,P22,P23,P27,P31,P32

Organizationalp

riorities

Deg

reeto

which

othe

raspe

ctsof

care

deliveryconflictor

alignwith

SDM

P2,P3,P4,P5,P8,P9,P10,P12,P13,P14,P18,P19,P26,P27,P31

Organizationalw

orkflows

Patient

inform

ationdissem

ination

strategies

Availabilityof

metho

dsto

dissem

inateinform

ationto

patientsandcompatib

ility

ofworkflowswith

decision

aid

distrib

utionprocesses

P2,P3,P4,P5,P6,P8,P12,P13,P14,P17,P22,P24,P25,P26,P27,

P28,P29,P31

Sche

dulingroutines

andtim

eframes

Deg

reeto

which

sche

duling(e.g.,of

appo

intm

entsor

forproced

ures)andtim

eframeavailableun

tilde

cision

isne

eded

impactsSD

MP3,P4,P6,P8,P10,P12,P13,P14,P15,P21,P22,P26,P29

Electron

iche

alth

record

(EHR)

Availabilityof

anEH

Rto

beused

inSD

M(e.g.,do

cumen

tatio

nof

process)

P2,P3,P6,P7,P8,P13,P14,P17,P18,P19,P20,P23,P27,P31

HCP

sHealth

care

prov

iders,EH

Relectron

iche

alth

record,SDM

shared

decision

-making

# The

descrip

tions

aretheresultof

thethem

atican

alysis

* For

projects

describ

edin

morethan

onepu

blication,

atleaston

epu

blicationha

dto

repo

rton

aspecificcharacteristic

tobe

listedin

thistable


colleagues [20] or the Consolidated Framework for Im-plementation Research (CFIR) [19] have described ele-ments in the inner and outer settings to influenceimplementation. Our results found a range of very simi-lar characteristics on the organizational level to the onesdescribed in the inner setting, e.g., communication andculture within an organization, leadership engagement,resources, and priorities. However, some of the charac-teristics we found (e.g., workflows) were not described inthe CFIR [19]. One could hypothesize that these aspectsare more focused around decision aid implementationand therefore not included in a more general implemen-tation framework. Similarly, several of our system-levelcharacteristics map well onto the CFIR’s outer setting(i.e., aspects around policies, guidelines, and incentives),but the culture of the healthcare system and educationand licensing of healthcare professionals cannot befound in the framework [19]. Furthermore, a systematicreview on determinants of implementation of preventiveinterventions on patient handling identified a total of 45environmental barriers and facilitators [62] that overlapwith experienced organizational characteristics identifiedin our scoping review, particularly the availability of re-sources, leadership support, and the organization ofworkflows. Overall, our results in the field of SDM dis-play many similarities with the characteristics describedin implementation science frameworks and in otherfields of health innovation. However, as we also identifycharacteristics less described in implementation scienceliterature, we believe it is important to not to be re-stricted by such frameworks, but enrich them with de-rived empirical evidence.Third, some of the strategies recommended by the in-

cluded projects to intervene on characteristics influen-cing SDM implementation (Table 5) are vague andrequire further specification and tailoring to a specific

context [63]. For example, some of the strategies that fallinto the leadership category could benefit from distin-guishing which level of leadership should take action forwhich strategy. While the people in a governing board ofan organization might be the ones to revise missionstatements, executive leadership, and departmental man-agement might be the ones who create a culture thatsupports SDM [64]. Furthermore, all other categoriesidentified as organizational-level characteristics, despitenot specifying who should be in charge of making spe-cific changes, imply that organizational leadership is theactor here. Although it is not specified, for example,who should implement multidisciplinary teams or createan SDM coordinator position, there is an implicit as-sumption that these are leadership tasks. Beyond lookingat implementation literature, it might therefore beworthwhile for stakeholders working on SDM imple-mentation to look into organizational theories in health-care [65], e.g., on the effective organization of healthcareteams or on strategies to restructure healthcareorganizations.

Implications and suggestions for further workAs healthcare systems are complex and composed ofcomponents that act nonlinearly [66], a certain identifiedcharacteristic can be a facilitator to one stakeholder anda barrier to another. Therefore, more work is needed tomove beyond the descriptive stage of this review, espe-cially as differences in the numbers of studies reportingon certain characteristics do not necessarily mean thatthose characteristics are the most important. Similarly toKoppelaar et al. [62], we believe there is a need to quan-tify the influence of the identified characteristics, espe-cially as this scoping review’s broad nature is notdistinguishing between experiences based on results ofimplementation studies and interpretation of those

Table 4 Identified system-level characteristics

Characteristics Descriptions# Project IDs*

Incentives

Payment model Impact of payment models on the use of SDM P2, P3, P8, P13, P15, P16, P21, P26, P31, P32

Accreditation/certificationcriteria

Degree to which SDM is included as a criterion inaccreditation/certification standards for healthcare institutions

P3

Policies and guidelines

Legislation Degree to which state or national legislation requires the useof SDM/decision support

P3, P14, P19, P21, P29

Practice guidelines Degree to which relevant practice guidelines support the use of SDM P2, P3, P9, P26, P27, P28

Quality indicators Degree to which quality indicators support the use of SDM P3, P8, P13, P15

Culture of healthcare delivery Degree to which the culture of healthcare delivery supports SDM P13, P14, P16, P22

HCP education and licensing Degree to which HCP initial and continuing education and licensing includesSDM training

P3, P8, P10, P13, P14, P16, P23, P25, P26,P31

HCPs healthcare providers, SDM shared decision-making#The descriptions are the result of the thematic analysis*For projects described in more than one publication, at least one publication had to report on a specific characteristic to be listed in this table


Table 5 Described strategies to address identified characteristics

Characteristics Strategies described

Organizational-level strategies

Organizational leadership

Corporate mission and vision statement Develop and promote a strong consistent message about importance of SDM [72]Make the value of SDM clear to physicians [83]Revise policy and procedure documents to include SDM in those directives [104, 105]

Encouragement Appoint an internal champion/have clinical champions [7, 54, 58, 59, 68, 87, 100, 103, 108]Provide personal testimonials from leaders [51]Support healthcare professionals (HCPs) in learning SDM skills, e.g., by protecting time to gettrained [7, 47, 51, 58]Support SDM implementation at all levels of the organization’s leadership [51, 59, 100, 102]Show interest by doing site visits to clinics/teams implementing SDM [7]Share success stories in grand rounds [58]

Performance measurement and feedback Provide continuous performance monitoring and feedback on SDM performance, decision aid distributionrate, decision quality, and patient satisfaction rates [7, 52, 53, 58, 69, 72, 81, 92, 104, 105, 108, 109]

Organizational culture Foster a well-organized and amicable work environment [50]Align SDM implementation with organization’s existing patient-centered philosophy and qualityimprovement spirit [51, 52]

Autonomy of staff Allow flexible use of decision aids and freedom on how to achieve SDM implementation goals [7, 47, 51]

Shared views and goals Address relational dynamics of healthcare teams before SDM implementation [89]Hold regular meeting to share goals and successes [54]

Organizational teamwork

Communication Foster frequent, timely, accurate, and problem solving communication about SDM implementationwithin and between teams [7, 89, 97]

Coordination of care Implement multidisciplinary teams [79, 102]Have a patient navigator [102]Have a clear definition of team members’ roles [50, 53]

Organizational resources

Time Decrease pressure for short patient interactions [105]/expand time to spend with patient [58, 103]Tailor interaction length guidelines for type of interaction [104]

Financial resources Obtain funding for SDM activities [90]Have access to high quality decision aids at low or no cost [52]

Space Use offices instead of clinical exam rooms for delivering decision support [74]

Workforce Engage non-physician personnel (e.g., nurses, office staff) [60, 70, 73, 90]Use unpaid or paid student interns or volunteers to deliver decision support [76, 77]Reorganize workforce responsibilities from over utilized to underutilized staff [74]Fund/hire a decision support/ care coordinator [77, 98]Salaried physicians for which SDM is part of employment obligations [51]

Organizational priorities Integrate SDM into other interventions or changes (e.g., health coaching, chronic disease managementprogram) [7, 94, 110]Align SDM with wider objectives of the organization (e.g., quality and safety) [7, 58]

Organizational workflows

Patient information dissemination strategies Automate decision aid distribution, e.g., pre-visit [78], based on triggers [70], send by mail [58, 75, 90]Keep decision aids/tools accessible in exam rooms and workspaces [7, 86, 87] and make them easilyavailable electronically [7, 58, 105]Offer in-office viewing of decision aids as well as other options (e.g., lending them to patients) [52]Align delivery of decision aids with other aspects of care (e.g., obtaining informed consent) [91]Partner with resource centers to deliver decision support [77]Clarify the place that decision aids have in the clinical pathway [103]Make decision aids available via a state-run website [51]Create protocols to prompted staff members to prescribe decision aid corresponding to the reasonfor referral [70]

Scheduling routines and time frames Get decision aids to patients prior to consultations [50, 52]Install scheduling system for SDM/decision aids/decision support [74, 103, 108]Require slowing down the flow of decision-making/reduce time pressure on patient path to treatmentdecision [58, 91]Allow for flexible patient pathways and scheduling [7, 75]


results. By evaluating the influencing characteristics inimplementation studies, we could analyze interactionsbetween characteristics and find out which of them pre-dict implementation outcomes [18].As the included studies were predominantly from the

USA, future work needs to assess the importance of theidentified characteristics in different healthcare systemswith variation in financing, coverage, spending, utilization,capacity, and performance [67], as well as different fieldsof healthcare (e.g., cancer care, mental healthcare). Thiswould help to gain a more specific insight that could fos-ter prioritization of the most important characteristics in aparticular setting and strategies to address them.

ConclusionAlthough infrequently studied, organizational- andsystem-level characteristics appear to play a role in thefailure to implement SDM in routine care. A widerange of characteristics described as supporting andinhibiting implementation were identified. Futurestudies should quantify these characteristics’ differen-tial impact on SDM implementation, their likely inter-actions, and how different characteristics mightoperate across types of healthcare systems and areasof healthcare. Healthcare organizations that wish tosupport the adoption of SDM should carefully con-sider the role of organizational- and system-level

characteristics. Implementation and organizationaltheory could provide useful guidance for how to ad-dress facilitators and barriers to change.

Additional files

Additional file 1: Protocol. (PDF 129 kb)

Additional file 2: Electronic searches. (PDF 24 kb)

Additional file 3: Gray literature search. (XLSX 15 kb)

AbbreviationsCFIR: Consolidated Framework for Implementation Research; EHR: Electronichealth record; RCTs: Randomized controlled trials; SDM: Shared decision-making

AcknowledgementsWe thank Pamela Bagley for her support in developing the final electronicsearch strategy and for running the electronic database searches.Furthermore, we thank Robin Paradis Montibello for her work in the processof screening titles and abstracts.

FundingSupport for this research was provided by The Commonwealth Fund andthe B. Braun Foundation. The views presented here are those of the authorsand should not be attributed to The Commonwealth Fund or its directors,officers, or staff. The funding bodies were not involved in the design of thestudy and collection, analysis, and interpretation of data and in writing themanuscript.

Availability of data and materialsAll data generated or analyzed during this study are included in thispublished article and its supplementary information files.

Table 5 Described strategies to address identified characteristics (Continued)

Characteristics Strategies described

Electronic health record (EHR) Use EHR to prompt and document SDM process [7, 54, 70, 73]Use EHR (and merge it with computerized scheduling data) to identify patients eligible fordecision aids [69, 73, 78, 87, 90]Have decision aids available on EHR for easy access and have them available of patient portal onEHR [52, 58, 95, 104, 108]

System-level strategies

Incentives

Payment model Use a payment model that motivates providers to engage in SDM (e.g., patient-centered medicalhome) [51, 52, 92]Reimburse the use of a decision aid and time spent engaging in SDM conversation [91, 96, 103]Move away from fee-for-service to alternative model (e.g., pay-for-performance) [53–55]

Accreditation/certification criteria Revise accreditation/certification criteria by adding the implementation of SDM as criterion/qualityindicator [51]

Policies and guidelines

Legislation Create state legislation that fosters SDM (e.g., comparable to Washington state: enhanced legalprotection when doing SDM) [51, 56, 57]Create legislation that encourages healthcare organization structures that support SDM [51]

Practice guidelines Incorporate the use of SDM in clinical practice guidelines [103, 105]

Quality indicators Make the use of decision aids a quality of care indicator/list SDM as performance metric [55, 87, 91]Health plans could collect and distribute SDM performance data [51]Use a national set of measures [58]

Culture of healthcare delivery Promote culture of patient engagement in medical school [59]

Education and licensing Incorporate SDM communication skills (as compulsory) into medical school and residency curricula,as well as into state medical licensing criteria [51, 58–60]Offer CME/CEU credits for watching decision aids/for SDM training [54, 84, 109]

HCPs healthcare providers, EHR electronic health record, SDM shared decision-making, CME continuing medical examination, CEU continuing education units


https://doi.org/10.1186/s13012-018-0731-z

https://doi.org/10.1186/s13012-018-0731-z

https://doi.org/10.1186/s13012-018-0731-z

Authors’ contributionsIS, SK, and GE contributed to the conceptualization. IS, PH, SK, and GEcontributed to the design. IS, AL, and PH carried out the data selection andextraction. IS, AL, SK, and GE contributed to the data analysis. IS and ALconducted the data synthesis. IS, SK, and GE were involved in theinterpretation. SK and GE supervised the project. IS, GE and AL contributedto the visualization. IS and AL wrote the first manuscript draft. All authorswere engage in reviewing and editing the manuscript. All authors read andapproved the final manuscript.

Ethics approval and consent to participateNot applicable

Consent for publicationNot applicable

Competing interestsIS conducted one physician training in shared decision-making for which shereceived travel compensation from Mundipharma GmBH in 2015. AL and PHhave no competing interests to declare. SK has no competing interests todeclare and is an employee of the US government. GE reports personal feesfrom EMMI Solutions LLC, National Quality Forum, Washington State HealthDepartment, PatientWisdom LLC, SciMentum LLC, Access Community HealthNetwork, and Radcliffe Press outside the submitted work. GE has initiatedand led the Option Grid TM patient decisions aids collaborative, which pro-duces and publishes patient knowledge tools.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Author details1The Dartmouth Institute for Health Policy and Clinical Practice, DartmouthCollege, Level 5, Williamson Translational Research Building, One MedicalCenter Drive, Lebanon, NH 03756, USA. 2Department of Medical Psychology,University Medical Center Hamburg-Eppendorf, Martinistr. 52, W26, 20246Hamburg, Germany. 3Healthcare Delivery Research Program, National CancerInstitute, 9609 Medical Center Drive, Rockville, MD 20852, USA.

Received: 3 August 2017 Accepted: 27 February 2018

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