Why is the diffusion of innovations theory important for infection control?

Scientific discovery and innovation play major roles in both the prevention and control of infection. Yet, uptake of many key advances in everyday clinical settings is often suboptimal. Diffusion of innovations theory, based on a long tradition of research across several disciplines, provides an important framework for understanding and addressing the gap between optimal and actual use of evidence-based practices in clinical settings.

Mounting pressure for more effective, efficient and safer health care suggests even greater emphasis will be placed on rapidly translating infection prevention and control discoveries into appropriate clinical use. Hospital epidemiologists and infection preventionists play major roles in this translation or implementation process; thus, a basic understanding of the concepts and methods from diffusion of innovations theory and the emerging field of implementation science may help ensure future success in the continuing quest to reduce healthcare-associated infection.

Hospital epidemiologists and infection preventionists may also play a part in helping to advance knowledge within implementation science and thereby influence improvements in health care quality more broadly.

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What concepts of the diffusion of innovations theory are key for infection control?

Basic and clinical science focus on establishing the efficacy and effectiveness of interventions or technologies for preventing or controlling infection. Diffusion of innovations and implementation science focus on the social and behavioral aspects of moving these discoveries from an experimental environment into widespread everyday practice – often called quality improvement.

Diffusion has been a widely studied phenomenon for several decades and across many disciplines, including economics, sociology and psychology. A notable pioneer in diffusion of innovations work is Everett Rogers, who describes diffusion as “the process by which an innovation is communicated through certain channels over time among the members of a social system.”

Roger’s diffusion of innovations framework, as adapted for use in infection control and prevention by Krein and colleagues, describes a process in which characteristics of the innovation (i.e., infection prevention and/or control practice), characteristics of the organization, and the environment in which the organization operates influence innovation adoption and implementation. In turn, adoption and implementation of evidence-based infection prevention practices, along with organizational characteristics, ultimately affect healthcare-associated infection rates.

Adoption often begins when individuals in the organization identify a problem or performance gap, look for an innovation to deal with the problem and determine the fit between the problem and proposed innovation, leading to the adoption decision. Factors that play a role during the adoption process include characteristics of the innovation, characteristics of the organization and organizational decision-makers (organizational context), and the environment or social context in which the organization operates.

While adoption may be necessary, it does not necessarily lead to implementation and especially the effective implementation of a practice as required to produce the expected benefits. For example, deciding to adopt aseptic technique and use of sterile equipment during insertion of an indwelling urinary catheter by creating a new hospital policy does not ensure that the policy will be consistently or appropriately followed by all clinicians or clinical services to actually reduce the rate of catheter-associated urinary tract infections. As with adoption, characteristics of the innovation, certain organizational contextual factors and environmental factors all play a role during the implementation process.

At a minimum, hospital epidemiologists and infection preventionists should be familiar with these concepts, recognize the difference between adoption and implementation and be aware that many factors influence both the adoption and implementation of infection prevention and control practices. In particular, it is important to understand that it is often not the practice alone but the context, including organizational and environmental characteristics, that determines whether practices are effectively used and therefore whether desired outcomes are achieved.

Applying these concepts in real-world settings to influence effective and sustainable implementation of practices both within and across hospitals and other healthcare settings is a more advanced topic but is the key issue of interest and study within implementation science.

How can the diffusion of innovations theory be applied to infection control?

Diffusion of innovations theory, as well as other theories and models from implementation science and the social sciences, can be applied in infection prevention and control research and used to guide development of quality improvement interventions that promote the use of infection prevention and control practices in clinical settings.

In a 2009 review article, James Dearing describes how diffusion of innovations theory can be applied to accelerate the spread of evidence-based practice within the field of social work. Many of the examples in the article, including his top 10 list of dissemination mistakes, can just as readily be applied to the use of diffusion of innovations theory in hospital epidemiology and infection control.

Use of diffusion of innovations as it applies specifically to hospital epidemiology and infection control, includes work by Krein, Saint and colleagues who used the diffusion of innovations framework to study the implementation of infection prevention practices in acute care hospitals. This research is primarily descriptive but highlights how practice (innovation), organizational and environmental characteristics can influence the adoption and use of evidence-based practices to prevent central-line associated bloodstream infections, ventilator-associated pneumonia and catheter-associated urinary tract infections. Some of the findings focus on practices to prevent a particular type of infection, e.g., ventilator-associated pneumonia, while others emphasizes cross-cutting issues, such as the role of champions or leadership in the implementation of infection prevention practices.

Another example of the application of diffusion of innovations theory in hospital epidemiology and infection control is the work of Peter Pronovost and colleagues. In particular, diffusion of innovations was one of the frameworks underlying the “four Es” approach that was used by Pronovost and colleagues to translate evidence into practice and successfully reduce bloodstream infections in Michigan.

What are key challenges in the use of the diffusion of innovations theory for infection control?

Despite the importance of diffusion of innovations theory and implementation science to ensure the appropriate use of key infection prevention and control practices and reduce healthcare-associated infection risk, several challenges exist.

First, many clinicians and scientists are not familiar with the methods used to produce the evidence for addressing practice gaps and informing implementation efforts or may consider these methods “soft”. For example, a randomized controlled trial, the gold standard for testing efficacy in clinical science, is often not a preferred or even feasible design for studies that involve changing the practices or behaviors of individuals in an entire hospital or clinic. Rather, given the inherent complexity of health care and enacting clinical change, the use of non-traditional or novel methods, including qualitative and mixed-methods approaches, is often required. Understanding how to ensure rigor in the use of alternative designs and methods and how to interpret and use research findings that result from these methods is a current challenge in hospital epidemiology and infection control as well as many clinically based disciplines.

Second, implementation efforts often occur through site-specific quality improvement projects or infection prevention initiatives. These efforts have many merits. Yet, the approaches used often cannot be replicated across settings, do not contribute to broader knowledge and can be highly inefficient because there is much duplication of effort and re-invention. Consequently, we often end up, retrospectively, trying to figure out what went wrong or right. Theory-driven implementation enables replication of successful implementation approaches, produces more generalizable knowledge about how to implement and sustain interventions and can help those involved in implementation navigate complex situations based on the findings and experiences of others. Nonetheless, at present many quality improvement efforts and studies lack both theory and methodological rigor and so caution must be used in evaluating or applying findings from these studies. Specific guidance about how to appraise and use quality improvement articles can be found in a 2010 publication by Fan and colleagues.

Third, Rogers’ diffusion of innovations framework, while critically important in understanding the diffusion of infection prevention and control practices is generally not sufficient in providing the guidance required for putting this information into action to implement change. Implementation science is devoted to providing a systematic method for identifying, understanding, operationalizing and evaluating implementation. However, navigating the many theories, models and concepts that are found in the literature related to implementation science is nearly as complex as the topic it is designed to study. One helpful tool, developed by Laura Damschroder and colleagues, is the Consolidated Framework for Implementation Research (CFIR), which consolidates and unifies the wide-ranging set of constructs influencing implementation.

What are some key recommendations regarding the diffusion of innovations theory?

Guidelines or evidence-based recommendations generally focus on the technical aspects of infection prevention and control but provide little guidance about how to deal with the social or cultural considerations (i.e., context) that are likely to influence practice implementation. What can be done to help ensure our ability to effectively implement these technical components is as robust as the evidence we are trying to implement? Considering that current knowledge and experience in this area is still quite underdeveloped, below are several suggestions that have been adapted from a 2010 paper by Sanjay Saint and colleagues.

1. Efforts to define key practices to control or prevent infections must continue. However, additional research is also needed to ensure proper use. In particular, we need to understand and identify strategies to address the interaction between practice characteristics and the organizational and environmental context in which these practices are being implemented.

2. Infection prevention and control personnel need to collaborate with organizational behaviorists and other social scientists to develop approaches to address the dynamic and complex nature of practice implementation.

3. A robust investigative network of diverse hospitals and systems that uses systematic methods to understand not only what works but also how it works and in what settings should be established.

4. The training that infection prevention and control personnel — both hospital epidemiologists and infection preventionists — receive should include an overview of key concepts from diffusion of innovation theory and implementation science, as they relate to the social and behavioral aspects of changing clinical practice, as well as a basic introduction to the use of alternative study designs and methods, such as qualitative and mixed-methods research.

What is the evidence for the diffusion of innovations theory? What are the consequences of not employing the theory?

The literature provides ample evidence of the potential underuse of evidence-based practices across a wide-spectrum of health care services including many key infection prevention and control practices. The underuse of basic infection prevention and control practices, such as hand hygiene, has been identified in numerous articles including a 2010 review by Erasmus and colleagues. Similar examples related to use of other infection prevention practices, including those practices that are recommended as part of guidelines, can be found throughout the infection prevention and control literature.

Gaps in translation, which we often think of as underuse but could also be related to overuse of certain practices, can undoubtedly result in increased morbidity, mortality and higher healthcare costs. As pressure for more effective, efficient and safer health care continues to increase, it is likely that even greater emphasis will be placed on the rapid translation of infection prevention and control discoveries into appropriate clinical use. Consequently, the safety of patients depends on the ability of infection prevention and control personnel to not only understand the technical aspects of their job but through knowledge and tools from diffusion of innovations theory and implementation science, the social and behavioral components as well. Indeed, these components are likely to become increasingly important as cost constraints limit our ability to find technical fixes for the infection prevention problems that still plague our patients.

What practices, organizational and environmental, influence the adoption and implementation of infection prevention and control practices in hospitals?

As described in the Everett Rogers diffusion of innovations framework and adapted for use in infection prevention and control, there are three key components that influence adoption and implementation. These components, as broadly defined include characteristics of the innovation, characteristics of the organization and characteristics of the environment. Below we discuss these components in more detail. This includes providing some general descriptions of each component, drawing largely on descriptions provided by Rogers and expanded through the work of Greenhalgh and colleagues, as well as examples from the infection prevention and control literature.

Characteristics of the innovation. Each infection prevention practice has its own unique characteristics. However, these characteristics can be described using several general dimensions, such as relative advantage, complexity and compatibility with current practice.

Relative advantage refers to the benefits and costs related to innovation adoption and depend on such attributes as practice credibility, cost and potential cost-savings.

Credibility or plausibility is in part a function of the evidence used to demonstrate the efficacy of the practice as well as the perception of the evidence by key decision-makers. Practices based on rigorous scientific evidence and those for which the evidence is viewed favorably by decision-makers and opinion leaders may be more readily adopted and possibly more easily implemented. However, the extent to which strength of evidence influences implementation is not entirely clear since stakeholders can have different perceptions of the evidence or may be influenced more by other considerations such as clinical experience.

One example is the use of practices to prevent ventilator-associated pneumonia as described by Sarah Krein and colleagues. Evidence from several randomized controlled trials suggested that subglottic secretion drainage was effective in preventing ventilator-associated pneumonia vs. two trials of semi-recumbent positioning in which one showed benefit and the other did not. Despite this evidence, most hospitals were using semi-recumbent positioning and only a few subglottic secretion drainage. So, evidence in this situation was clearly not the primary factor in practice uptake.

Cost is another important element in the adoption decision and implementation process since if affects the organization’s budget and possibly the resources of a particular clinical service or unit. Infection prevention and control can involve both the purchase of new more costly products (e.g., antimicrobial urinary catheters) as well as practices that do not have a direct purchase price (e.g., elevating the head of bed for ventilated patients) but may involve other types of costs, such as nursing time, that can arise as implementation barriers.

Complexity is the ease or difficulty in using a particular innovation, which may be especially important in the implementation of a practice. For example, once the decision is made to purchase and stock an antimicrobial central venous catheter, catheter use does not substantially differ from that of a standard central venous catheter. On the other hand, implementing a policy requiring the use of maximum sterile barrier precautions during central venous catheter insertion has certain complexities (e.g., it requires more preparation time) that could prove to be a barrier to effective implementation.

Compatibility is the degree to which the innovation is viewed as consistent with organizational needs and the experiences, mission and practices of the organization. If a practice is regarded as a solution to a perceived problem it may facilitate both adoption and implementation of that practice. Similarly, practices that do not require substantial changes in work flow, specialized personnel or extensive re-training of current personnel are likely to be more easily assimilated. Compatibility from an administrative perspective as well as a staff perspective could be a deciding factor in either or both the adoption and implementation phases.

Organizational characteristics. Both general organizational characteristics, such as capacity, academic affiliation and specialization, and those specific to hospital infection prevention and control affect the adoption and implementation of infection prevention and control practices. General characteristics that have been shown to influence the innovation adoption decision include organizational size or capacity, functional and task differentiation, structural complexity, organizational culture, degree of specialization and external integration.

For example, being part of a healthcare system or having an academic affiliation could facilitate the adoption of practices due in part to the presence of a relatively formal communication channel that can enhance information dissemination and knowledge about a practice. Characteristics such as size, the degree of specialization and number or type of intensive care units could also influence practice adoption since they may be determinants of a specific problem or performance gap. Additionally, organizational characteristics such as task differentiation (e.g., the presence of a dedicated peripherally-inserted central catheter [PICC] team) and intra-organizational communication could play a significant role in implementation.

Included as part of organizational characteristics are those aspects that relate to the actual decision-maker or level where the adoption decision and implementation occurs (e.g., administrative level, physician level, nursing level) as well as involvement by organizational leaders. For example, hospital personnel play an important role in healthcare-associated infection prevention activities, both impeding and facilitating the implementation of evidence-based practices that prevent infection. Sanjay Saint and colleagues found that when trying to implement some infection practices, active resistance by certain hospital personnel to evidence-based practice change was common. Additionally, the presence of “organizational constipators” — mid- to high- level executives who acted as insidious barriers to change — increased the difficulty in implementing change. Recognizing that there may be these types of individuals in your own organization is an important step toward mitigating their potential effect on implementation. Effective leadership is also important in dealing with both active resistors and organizational constipators.

Fostering leadership support and engagement are key elements in some of the more prominent strategies for implementing infection prevention and control practices, including the approach used by Peter Pronovost and colleagues to reduce central-line associated bloodstream infections in hospitals throughout the state of Michigan. Likewise, in a 2010 publication Saint and colleagues describe the important role of leadership in healthcare-associated infection prevention as well as the characteristics of effective leaders.

More importantly, this study also suggests that hospital epidemiologists and infection preventionists can play an even more important leadership role in hospital patient safety activities than senior executives.

Another important person in the implementation of clinical innovation within infection prevention and control is the “champion”. Work by Damschroder and colleagues focusing specifically on implementation of infection prevention practices found that simply appointing someone as a champion for a certain practice or practice change was often not effective. Rather, successful champions were those individuals who were motivated and enthusiastic about the practices they promoted. In addition, while a single champion may be able to influence implementation of a new technology, more than one champion may be needed when practice implementation requires that people change their behaviors. The study includes examples of hospital epidemiologists and infection preventionists as champions or part of a champion team as well as serving in support roles by assisting champions in their quest for implementation success.

Environmental context. The environmental context plays an important part during the adoption decision as a source of information about an innovation and through social forces that can influence organizational behavior. Information about specific infection prevention practices can be disseminated through a variety of mechanisms including direct contact by a particular supplier, targeting by professional societies or advocacy organizations, mass media campaigns and quality or infection prevention focused collaboratives, which have become an increasingly popular approach for promoting practice change. In addition, adoption can be affected by institutional forces, whereby organizations model the activities of those around them and the adoption decision is influenced by social pressure and legitimation of the innovation by external forces.

Finally, market and regulatory pressure are also environmental factors that influence adoption and implementation. For example, the Centers for Medicare and Medicaid Services (CMS) policy to no longer pay for the additional cost of certain hospital-acquired infections as well as mandated reporting of hospital infection rates by individual states can have a strong influence on the adoption and to some extent implementation of infection prevention practices.

What other theories might be used to influence infection control practices?

There are a number of theories and models from management science, psychology and health behavior that can be used to identify or explain factors associated with implementation of infection prevention and control practices. Indeed, given the complex nature of most health care settings, the use of multiple theories may be required when studying as well as developing strategies for implementing change.

Two fundamental types of theories should be considered: 1) prescriptive theories (aka action or process theories) that prescribe how implementation should be planned, organized or scheduled; and 2) explanatory theories (aka descriptive or impact theories) that describe how change occurs and highlights potential influences (barriers and facilitators) on implementation. For example, the Ottawa Model of Research Use described by Graham and Logan is prescriptive and describes three types of activities: assess barriers and facilitators before starting implementation, monitor the implementation process and intervention use, and evaluate outcomes. Diffusion of innovations theory is an example of an explanatory theory. Some theories have elements of both. The Promoting Action on Research Implementation in Health Services (PARIHS) framework, as described by Kitson, Rycroft-Malone and colleagues, is a hybrid theory that integrates explanatory factors (the important influence of the evidence supporting a practice and organizational context) with prescriptive action; specifically, facilitation. Finally, specific change theories such as those that target individual behavior change or organizational change might also be useful in developing an implementation approach.

While knowledge of these different theories and frameworks is helpful, it is clear that it can be challenging to navigate among them, given differences in terminology and focus. As such, Damschroder and colleagues developed the Consolidated Framework for Implementation Research (CFIR), which helps to consolidate and unify the wide-ranging set of constructs influencing implementation. The CFIR provides a consistent set of terms with definitions and the evidence supporting its potential influence on implementation. The CFIR includes many of the terms from Roger’s diffusion of innovations theory (e.g., relative advantage, complexity), as well as potential organizational barriers and facilitators (e.g., leadership engagement, resource availability, tension for change), environmental factors (e.g., external policies such as the CMS payment rules), individual characteristics (e.g., knowledge and beliefs about a practice or change), and characteristics of the implementation process itself (e.g., planning, execution).

Guidance for measuring these constructs and examples of studies using the CFIR, along with core definitions and rationale for inclusion, can be accessed online at http://cfirguide.org/. The CFIR can be used as a foundational framework, providing consistent definitions and a comprehensive list of constructs to consider, as well as an organizing framework for reporting findings.

What guidelines exist related to the diffusion of innovations theory?

There are no specific guidelines for using diffusion of innovations theory in hospital epidemiology and infection control. There are, however, guidelines related to the publication of quality improvement studies in health care. The Standards for Quality Improvement Reporting Excellence (SQUIRE) or SQUIRE guidelines (http://www.squire-statement.org), as described by Davidoff and colleagues for the SQUIRE development group, were developed to facilitate publication of high-caliber quality improvement studies. Although targeted more at those seeking to publish they provide an instructive guide for consumers of this literature as well.

Another resource, which is described as a complement to the SQUIRE guidelines, is the article “How to Use an Article about Quality Improvement” that was published in 2010 by Fan and colleagues as part of JAMA’s users’ guides to the medical literature.

What's the Evidence?

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Damschroder, LJ, Lowery, JC. “Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR)”. Implement Sci. vol. 8. 2013. pp. 51[Development and Application of the Consolidated Framework for Implementation Research (CFIR)]

Damschroder, LJ, Banaszak-Holl, J, Kowalski, CP, Forman, J, Saint, S, Krein, SL. “The role of the champion in infection prevention: results from a multisite qualitative study”. Qual Saf Health Care. vol. 18. 2009. pp. 434-440. [Describes effective champions in the implementation of infection prevention practices]

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Dearing, JW. “Applying diffusion of innovation theory to intervention development”. Research on Social Work Practice. vol. 19. 2009. pp. 503-518. [Includes examples of how diffusion of innovations might be applied in the field of social work but could be similarly applied in infection control and prevention]

Eccles, MP, Mittman, MB. “Welcome to implementation science”. Implement Sci. vol. 1. 2006. pp. 1[Definition of implementation science and introduction to the journal Implementation Science, which publishes articles on a broad range of topics related to the field of implementation science]

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Fan, E, Laupacis, A, Pronovost, PJ, Guyatt, GH, Needham, DM. “How to use an article about quality improvement”. JAMA. vol. 304. 2010. pp. 2279-2287. [Useful tutorial on using quality improvement articles]

Forman, J, Creswell, JW, Damschroder, L, Kowalski, CP, Krein, SL. “Qualitative research methods: key features and insights gained by use in infection prevention research”. Am J Infect Control. vol. 29. 2008. pp. 333-341. [General overview of qualitative methods as applied in an infection prevention study]

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Greenhalgh, T, Robert, G, Macfarlane, F, Bate, P, Kyriakidou, O. “Diffusion of innovations in service organizations: systematic review and recommendations”. Milbank Quarterly. vol. 82. 2004. pp. 581-629. [Provides a thorough review of diffusion of innovation literature, expanding on Everett Rogers diffusion of innovations work]

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Harvey, G, Kitson, A. “Implementing Evidence-Based Practice in Healthcare: A Facilitation Guide”. 2015.

Harvey, G, Loftus-Hills, A, Rycroft-Malone, J, Titchen, A, Kitson, A, McCormack, B, Seers, K. “Getting evidence into practice: the role and function of facilitation”. J of Adv Nursing. vol. 37. 2002. pp. 577-588. [Description of facilitation as defined in the PARIHS framework]

Kitson, A, Harvey, G, McCormack, B. “Enabling the implementation of evidence based practice: a conceptual framework”. Quality in Health Care;. vol. 7. 1998. pp. 149-158. [Development and introduction of the PARIHS framework, an example of a theory that includes both prescriptive and explanatory elements]

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Krein, SL, Damschroder, LJ, Kowalski, CP, Forman, J, Saint, S. “The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study”. Social Science and Medicine. vol. 71. 2010. pp. 1692-1701. [Qualitative analysis of how certain organizational characteristics can influence implementation of practices to prevent CLABSI]

Krein, SL, Hofer, TP, Kowalski, CP, Olmsted, RN, Kauffman, CA, Forman, JH, Banaszak-Holl, J, Saint, S. “Use of central venous catheter-related bloodstream infection prevention practices by US hospitals”. Mayo Clinic Proceedings. vol. 82. 2007. pp. 672-678. [Quantitative analysis using diffusion of innovations framework to identify factors associated with use of practices to prevent CLABSI]

Krein, SL, Kowalski, CP, Damschroder, L, Forman, J, Kaufman, SR, Saint, S. “Preventing ventilator-associated pneumonia in the United States: a multicenter mixed-methods study”. Infect Control Hosp Epidemiol. vol. 29. 2008. pp. 933-940. [Quantitative and qualitative analysis using diffusion of innovations framework to identify factors associated with use of practices to prevent VAP]

Krein, SL, Olmsted, RN, Hofer, TP, Kowalski, C, Forman, J, Banaszak-Holl, J, Saint, S. “Translating infection prevention evidence into practice using quantitative and qualitative research”. Am J Infect Control. vol. 34. 2006. pp. 507-512. [Description of the application of diffusion of innovations theory to study the use of infection prevention practices by US hospitals]

Mauger Rothenberg, B, Marbella, A, Pines, E, Chopra, R, Black, ER, Aronson, N. “Prevention of Healthcare-Associated Infections. Closing the Quality Gap: Revisiting the State of the Science”.

[Review of strategies to improve adherence to evidence-based prevention interventions]

Portela, MC, Pronovost, PJ, Woodcock, T, Carter, P, Dixon-Woods, M. “How to study improvement interventions: a brief overview of possible study types”. BMJ Qual Saf. vol. 24. 2015 May. pp. 325-36. [Describes different methods for studying improvement interventions]

Pronovost, P. “Interventions to decrease catheter-related bloodstream infections in the ICU: the Keystone Intensive Care Unit project”. Am J Infect Control. vol. 36. 2008. pp. S171 e171-175. [Describes results from state-wide collaborative initiative that used the four Es action model]

Pronovost, PJ, Berenholtz, SM, Needham, DM. “Translating evidence into practice: a model for large scale knowledge translation”. BMJ. vol. 337. 2008. pp. a1714[Description of action model for implementation as applied in a statewide collaborative initiative]

Pronovost, PJ, Needham, D, Berenholtz, S, Sinopoli, D, Chu, H, Cosgrove, S. “2006. An intervention to decrease catheter-related bloodstream infections in the ICU”. NEJM. vol. 355-. 2006. pp. 2724-2732.

Rogers, EM. “Diffusion of Innovations”. 2003.

Rycroft-Malone, J. “The PARIHS framework — a framework for guiding the implementation of evidence-based practice”. J Nurs Care Qual. vol. 19. 2004. pp. 297-304. [Example of a theory with both prescriptive and explanatory elements]

Saint, S, Howell, JD, Krein, SL. “Implementation Science: how to jump-start infection prevention”. Infect Control Hosp Epidemiol. vol. 31. 2010. pp. S14-17. [Discussion of infection prevention as a paradigm for implementation science]

Saint, S, Kowalski, CP, Banaszak-Holl, J, Forman, J, Damschroder, L, Krein, SL. “How active resisters and organizational constipators affect health care-acquired infection prevention efforts”. Jt Comm J Qual Patient Saf. vol. 35. 2009. pp. 239-246. [Description of hospital personnel that can influence the implementation of infection prevention practices]

Saint, S, Kowalski, CP, Banaszak-Holl, J, Forman, J, Damschroder, L, Krein, SL. “The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study”. Infect Control Hosp Epidemiol. vol. 31. 2010. pp. 901-907. [Qualitative study defining leadership and some of the characteristics of effective leaders in the implementation of infection prevention practices]

Saint, S, Kowalski, CP, Forman, J, Damschroder, L, Hofer, TP, Kaufman, SR, Creswell, JW, Krein, SL. “A multicenter qualitative study on preventing hospital-acquired urinary tract infection in US hospitals”. Infect Control Hosp Epidemiol. vol. 29. 2008. pp. 333-341. [Qualitative study identifying practice, organizational and environmental factors influencing the use of practices to prevent CAUTI]

Saint, S, Kowalski, CP, Kaufman, SR, Hofer, TP, Kauffman, CA, Olmsted, RN, Banaszak-Holl, J, Forman, J, Damschroder, L, Krein, SL. “Preventing hospital-acquired urinary tract infection in the United States: a national study”. Clin Infect Dis. vol. 46. 2008. pp. 243-250. [Quantitative analysis using diffusion of innovations framework to identify factors associated with the use of practices to prevent CAUTI]

Saint, S, Krein, SL, Stock, B. “Preventing Hospital Infections: Real-World Problems, Realistic Solutions”. 2015. [Description of a quality improvement intervention in a model hospital that draws upon diffusion of innovations framework]

Shekelle, PG, Wachter, RM, Pronovost, PJ, Schoelles, K, McDonald, KM, Dy, SM, Shojania, K, Reston, J, Berger, Z, Johnsen, B, Larkin, JW, Lucas, S, Martinez, K, Motala, A, Newberry, SJ, Noble, M, Pfoh, E, Ranji, SR, Rennke, S, Schmidt, E, Shanman, R, Sullivan, N, Sun, F, Tipton, K, Treadwell, JR, Tsou, A, Vaiana, ME, Weaver, SJ, Wilson, R, Winters, BD. “Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices”. [Identifies key safety practices and implementation related considerations with one section focused specifically on infection prevention practices]