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Background <p>Implementation strategies often fail to achieve their intended outcomes, yet limited methodological guidance exists for systematically understanding why strategies fail or how to adapt them for new contexts. Causal pathway diagrams (CPDs) are tools that map the mechanisms through which implementation strategies work. This study proposes a methodologic approach to use CPDs both retrospectively to understand implementation failure in one context and prospectively to inform adaptation for a new context.</p> Methods <p>We illustrate the proposed methodology using a case study of a failed implementation strategy bundle—including an electronic best practice alert and clinical decision support, provider education, and clinical champion—designed to improve metabolic-associated steatotic liver disease (MASLD) screening in a weight management clinic. Using mixed methods data and realist evaluation principles, we constructed CPDs guided by three theoretical frameworks (i-PARIHS, Theory of Planned Behavior, and Technology Acceptance Model) and post-intervention qualitative interviews to understand failure mechanisms. We then applied insights from these CPDs alongside qualitative interviews with primary care providers to develop predictive CPDs for implementing adapted strategies in the primary care setting.</p> Results <p>The retrospective CPDs revealed specific failure points not apparent during initial planning. The clinical decision support strategy failed because fundamental preconditions were unmet: only 54.2% of patients had recent laboratory results needed for automated calculations, and the alert placement misaligned with provider workflows. Provider education and clinical champion strategies were undermined by moderators including lack of confidence in the FIB-4 screening tool and competing clinical priorities. The prospective primary care CPDs identified necessary adaptations including replacing best practice alerts with integrated health maintenance reminders, adding content about MASLD complications and treatments to provider education, and selecting multiple champions to ensure adequate coverage.</p> Conclusions <p>CPDs provide a systematic framework for transforming implementation failures into actionable insights for future intervention design. The integration of realist evaluation principles with multi-theoretical CPD development offers a replicable methodology for retrospective mechanistic failure analysis and context-adapted prospective implementation. This approach advances implementation science by moving beyond descriptive accounts toward rigorous understanding of how and why implementation strategies work across diverse settings.</p>

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Failing to succeed: advancing mechanistic understanding of implementation strategies through retrospective and prospective use of causal pathway diagrams

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2025年12月29日

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  • Kirsten Austad,
  • Kathryn L. Fantasia,
  • Arpan Mohanty,
  • Kayla C. Jones,
  • Nicholas A. Bosch,
  • Mari-Lynn Drainoni

摘要

Background

Implementation strategies often fail to achieve their intended outcomes, yet limited methodological guidance exists for systematically understanding why strategies fail or how to adapt them for new contexts. Causal pathway diagrams (CPDs) are tools that map the mechanisms through which implementation strategies work. This study proposes a methodologic approach to use CPDs both retrospectively to understand implementation failure in one context and prospectively to inform adaptation for a new context.

Methods

We illustrate the proposed methodology using a case study of a failed implementation strategy bundle—including an electronic best practice alert and clinical decision support, provider education, and clinical champion—designed to improve metabolic-associated steatotic liver disease (MASLD) screening in a weight management clinic. Using mixed methods data and realist evaluation principles, we constructed CPDs guided by three theoretical frameworks (i-PARIHS, Theory of Planned Behavior, and Technology Acceptance Model) and post-intervention qualitative interviews to understand failure mechanisms. We then applied insights from these CPDs alongside qualitative interviews with primary care providers to develop predictive CPDs for implementing adapted strategies in the primary care setting.

Results

The retrospective CPDs revealed specific failure points not apparent during initial planning. The clinical decision support strategy failed because fundamental preconditions were unmet: only 54.2% of patients had recent laboratory results needed for automated calculations, and the alert placement misaligned with provider workflows. Provider education and clinical champion strategies were undermined by moderators including lack of confidence in the FIB-4 screening tool and competing clinical priorities. The prospective primary care CPDs identified necessary adaptations including replacing best practice alerts with integrated health maintenance reminders, adding content about MASLD complications and treatments to provider education, and selecting multiple champions to ensure adequate coverage.

Conclusions

CPDs provide a systematic framework for transforming implementation failures into actionable insights for future intervention design. The integration of realist evaluation principles with multi-theoretical CPD development offers a replicable methodology for retrospective mechanistic failure analysis and context-adapted prospective implementation. This approach advances implementation science by moving beyond descriptive accounts toward rigorous understanding of how and why implementation strategies work across diverse settings.