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Instructions: Use the pencil icon in the top right to edit the form below. ↗️ Remember to push PUBLISH UPDATE when you are done to save your work. |
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Important Health Center Context Fill out this section during your planning process | |
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Internal Characteristics | |
What are the characteristics of your health center? (rural/urban; other demographic variables, use of expanded care team, culture)? |
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How do interventions and/or workflows need to be adapted to ensure health equity? |
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How complex are the patient interventions to implement (e.g., perceived difficulty of implementation, reflected by duration, scope, radicalness, disruptiveness, and number of steps required)? |
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What are key characteristics of the participating setting(s)? |
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External Characteristics | |
What external or environmental supports or threats are there? |
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Plan | Actual |
Describe Intervention Chosen intervention: Plan for intervention: | Chosen Intervention: Date when implemented: Updates: |
Reach (#/% patients – or providers, for provider-facing interventions – who participated in intervention) | |
Reach of implementers/providers? Planned: | Reach of implementers/providers? Actual: |
Reach of patients? Planned: | Reach of patients? Actual: |
Efficacy (Impact of intervention on important outcomes) | |
How will you measure that your intervention is working? | Were you able to accurately measure how your intervention was working? |
What outcomes do you expect? | What outcomes have you seen? |
How will you ensure your intervention will be effective for your target population? | Did your intervention reach the target population? |
What unintended consequences or outcomes might there be? | What unintended outcomes did you experience? |
Adoption (#/% and representativeness of staff and sites who implemented the intervention) How did clinicians respond to interventions to intensify medication more rapidly/address therapeutic inertia? | |
Who will deliver the intervention (actually do the work)? Include staff and sites, if applicable. | Who delivered the intervention? Did they have the skills and time needed to complete the intervention? |
How will you know if clinicians/care teams/sites used the intervention? | What proportion of the planned staff/sites implemented the intervention? Were there any differences between care teams/sites who adopted the intervention best vs. others who did not (e.g., differences in staff types, capacity, etc.)? |
Implementation Fidelity (How closely the staff/sites followed the intervention design, delivered it as intended – also called fidelity to the intervention) | |
How will you know what adaptations or modifications were made during the intervention? | How did you track modifications during the intervention? |
What might be some of the possible obstacles to consistent implementation? | What were the barriers to consistent intervention implementation? |
What costs and resources (including time and burden, not just money) need to be considered? | What costs and resources (including time and burden, not just money) need to be considered? |
How closely did the staff/sites follow the intervention design and deliver as intended? Check all that apply:
Modifications made and other notes: | |
Maintenance (Extent to which intervention is part of routine practices and protocols) | |
What reinforcements will you put in place to sustain the intervention, if effective?
Explain: | What reinforcements did you put into place to sustain the intervention?
Explain: |
How will you spread your intervention and lessons learned? | How will you spread your intervention and lessons learned? |
What are likely modifications or adaptations that will need to be made to sustain the intervention over time (e.g., lower cost, different staff, reduced intensity, different settings)? | |
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