About this toolkit (An English print version is available here.) (A Rioplatense Spanish version of the toolkit is available here.)

The implementation of evidence-based clinical guidelines, policies or health system interventions are impacted by a variety of Barriers & Facilitators, which are factors that can either hinder or support implementation efforts. Barriers & Facilitators can affect implementation efforts at three different levels:

1. The Patient/Community level;
2. The Provider Level and;
3. The Health System Level.

Identifying Barriers & Facilitators, and developing strategies to address them, is key to successful implementation.

The aim of this toolkit is:

1. To assist users in identifying Barriers (i.e. challenges) & Facilitators (i.e. opportunities) that can impact the implementation of evidence-based guidelines, practices and/or policies; and
2. To assist users in selecting strategies to address these Barriers & Facilitators in order to increase users' success in the implementation of their evidence-based guidelines, practices and/or policies.

How to use the toolkit?

The Toolkit may be used online, downloaded to a computer or printed for use. This toolkit can be used by a wide variety of users—including health workers (i.e. physicians, nurses, midwives etc.), policy makers (i.e. government officials), hospital administrators, researchers, and community members (i.e. patients and/or patients' families etc.).

In assessing Barriers & Facilitators and developing strategies to address them in implementation planning, it is important to involve a wide range of participants, who bring diverse perspectives and experiences to the discussion (such as, front line clinicians, program administrators, policymakers, patients/family members/patient representatives, community leaders (religious leaders, elders, etc.). This variety of perspectives will increase understanding of Barriers & Facilitators, and improve planning for options to address them that are feasible and acceptable to those involved in and impacted by implementation.

With this in mind, we encourage users to use this toolkit in a group setting whether in person or online. The process of working through the toolkit together helps to ensure that all perspectives are included and allows for perspectives that may be unique and/or variably impact different participants to be understood and incorporated into implementation planning. In working through the toolkit as a group, it is important to create a space where all perspectives are welcome and all participants feel comfortable sharing their personal opinions and experiences, and allow enough time for all perspectives to be heard and discussed. In order to ensure that everyone has an adequate understanding of the topic, we suggest that meeting participants be provided with a brief outline of the topic to be discussed including the local data on current practices and outcomes, and the anticipated benefits of implementing the evidence based guideline/practice/policy. In addition, we recommend posting the topic visibly for reference during discussions and using facilitators to help keep the small/large group(s) focused on the specific implementation topic being discussed.

Definitions

Below are some key definitions/terms to keep in mind when using the toolkit:

Barriers are factors that limit or block the evidence-based practices. For example, a lack of resources (like drugs or equipment) would be a barrier to the use of a guideline, practice or policy that required these items.

Facilitators are factors that have been shown to or are believed to have potential to promote the use of evidence-based practices. For example, a local community leader supporting the use of a specific guideline or practice would be a facilitator.

Health Systems Level: Barriers & Facilitators at this level involve factors related to how a health systems works (or does not work). A lack of resources necessary for implementation (e.g., equipment or drugs) is an example of a system level Barrier. An example of a system level Facilitator would be an organization's commitment to fund the implementation of a particular health guideline.

Provider Level: Barriers & Facilitators at this level include the beliefs, knowledge or skills of health care providers. An example of a Provider Level Barrier would be a provider's lack of knowledge and/or skill to perform a required task and an example of a Facilitator at this level would be a provider's belief in the importance of or value of implementing a guideline, practice or policy.

Patient/Community Level: Barriers & Facilitators at this level affect patients and/or communities. An example of a patient level barrier is need for travel to access care or cost of care, and a Patient level Facilitator would be patient awareness of benefits of care.

To use this toolkit, please follow these steps:

1. To start a new assessment, click "START A NEW ASSESSMENT" button. Assessments are saved by date and are available online and offline.
2. Begin your assessment by selecting the START button beside the "PATIENT/COMMUNITY" level option. This will take users to a list of Barriers & Facilitators. The Barriers & Facilitators are listed separately and are grouped by topic/theme (i.e. financial resources). It is helpful to read through each section before beginning to select barriers/facilitators that apply to the specific topic, in your context.
3. Select the Barriers & Facilitators that apply to your group's specific context or situation and specific evidence-based guideline, practice or policy. What factors either positively or negatively affect the implementation of your evidence-based guideline, practice, and/or policy and why? Note, not all barriers/facilitators apply to all situations, and only those relevant to the specific topic should be selected.
   • The total number of Barriers & Facilitators you select will be tracked and you can keep track of them on the first page of the assessment.
   • At the end of each section, users will have the option to add any additional Barriers & Facilitators that may not have been included on the lists.
4. Once users have completed the assessment at the PATIENT/COMMUNITY level, they can continue on to the "PROVIDER" and "HEALTH SYSTEMS" levels and complete steps 2 and 3 again. Users are free to move back and forth between levels at all times and are not required to complete all levels. However, users are encouraged to consider all levels so that important factors that may impact implementation efforts are not overlooked. We recommend beginning with the PATIENT/COMMUNITY level and then complete the "PROVIDER" and "HEALTH SYSTEMS" levels, to ensure that enough time and attention is given to all levels of relevance to the implementation project.
5. After users complete the initial selection of barriers/facilitators relevant to the specific topics, they can organize their selections by considering what factors will have the biggest impact on implementation efforts.
   • The Barriers with the biggest potential impact (i.e. ones that are of high importance) should have 3 Xs and the Barriers with the smallest potential impact (i.e. ones that are of low importance) should have 1 X.
   • The Facilitators with the biggest potential impact (i.e. ones that are of high importance) should have 3 stars and the Facilitators with the smallest potential impact (i.e. ones that are of low importance) should have 1 star.

   For example, Barriers that must be addressed before implementation efforts can begin (e.g. Barriers related to policy or law) should receive 3 Xs to highlight its importance.

6. Once step 5 is complete, the list of potential strategies to address identified Barriers & Facilitators should be reviewed and discussed as a group to select the strategies best suited to address the barriers/facilitators identified. Users should keep in mind the importance of identified barriers, as well as, feasibility, sustainability, and acceptability of the potential strategies. At the end of this toolkit, a table of potential strategies has been included to aid in this discussion. This table lists the Barriers & Facilitators used in this toolkit and provides examples of possible interventions that can be used to address them. In considering strategies it is important to consider the evidence for effectiveness of potential strategies, as well as, appropriateness, feasibility and sustainability, in their context.

   For example, if providers forgetting to use a new clinical guideline were identified as an important barrier, you would find this category on the table in the habits, memory and decision processes row under the provider column, and could then discuss the suitability of different reminder processes, such as posters, pocket cards or computer decision aids, in your context.

   NOTE: first time users may find it helpful to review the attached worked example, available here as a pdf and accompanying audio file.

   Resources: Below are links to a couple of resources that you may find helpful in selecting implementation strategies to address the barriers and facilitators identified in steps 1-5.

   1. The CFIR-ERIC implementation strategy mapping tool (and associated articles) provides a list and short description of implementation strategies and is available at https://cfirguide.org/choosing-strategies/
   2. The SELECT tool provides an approach to categorizing barriers and facilitators, identifying and prioritizing intervention functions and includes a list and definitions of potential implementation strategies to address identified barriers and facilitators in section 3, available at https://knowledgetranslation.net/the-select-tool/