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Does the ‘diffusion of innovations’ model enrich understanding of research
use? Case studies of the implementation of thrombolysis services for stroke
Annette Boaz*, Juan Baeza
1
and Alec Fraser
2
*Corresponding author – a.boaz@sgul.kingston.ac.uk, Faculty of Health, Social Care
and Education, St George's, University of London, Grosvenor Wing, Cranmer
Terrace
London SW17 0RE, UK
1
Lecturer in Health Policy, King’s College London
2
Research Fellow, London School of Hygiene and Tropical Medicine
Key words: implementation, diffusion of innovations, models
Reference: Boaz, A, Baeza, J and Fraser, A (2016) Does the ‘diffusion of
innovations’ model enrich understanding of research use? Case studies of the
implementation of thrombolysis services for stroke J Health Serv Res Policy
OnlineFirst, published on March 22, 2016 as doi:10.1177/1355819616639068
2
Abstract
Objectives: To test the applicability of the model of diffusion of innovations as an analytical
framework to explore the implementation of evidence based thrombolysis services for stroke
patients.
Methods: Four empirical case studies of the implementation of evidence into stroke services
in England and Sweden. Data were drawn from 95 semi structured interviews with a range of
clinical and managerial staff within four hospitals, working in stroke units, emergency
medicine, radiology, the ambulance service, community rehabilitation services and
community medicine.
Results: The implementation of thrombolysis in acute stroke management benefited from a
critical mass of factors featured within the model including, the support of national and local
opinion leaders, a strong evidence base and financial incentives. However, while the model
provided a starting point as an organizational framework for mapping the critical factors
influencing implementation, to properly understand the process of implementation and
explore the importance of the different factors identified requires a more fine grained
analyses of context and, in particular, of the human and social dimensions of change.
Conclusions: While recognising the importance of models in mapping the processes by which
the diffusion of innovations occurs, future studies would benefit from a greater use of
methods that lend themselves to in-depth analysis such as ethnography and the application of
relevant bodies of social theory.
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Do models enrich our understanding of research use? Applying the diffusion of
innovations model to implementation of thrombolysis services for stroke in England and
Sweden.
Background
The so called ‘implementation gap,’ into which promising practices have been seen to fall,
has attracted considerable attention within policy studies for decades [1]. Implementation
research has recently been gaining ground within health care research and practice, receiving
an additional impetus from debates about evidence based health care [2]. Understanding how
innovations, particularly those based on evidence, make their way into practice has been
identified as critical to clinical effectiveness in health services [3].
Under the auspices of evidence based medicine there have been numerous intervention
studies designed to improve the use of evidence, typically through the use of guidelines, audit
and feedback, and leadership [4]. These studies have concluded that single methods to
promote the take up of new evidence based interventions have limited impacts and that
multifaceted interventions are likely to be more effective [5]. Research contributions have
sought to shift the field of implementation research in health service organizations,
advocating greater attention to context, theory and process [6,7]. For example, Checkland et
al [8] argue that while organizations might identify similar sets of barriers, their underlying
processes of ‘sensemaking’ were rather different at each of the UK general practices studied.
While barriers can capture a rhetorical and rational account of practice, the importance of
context and social relations is often lost [9].
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There has also been a proliferation of models seeking to provide frameworks for the analysis
of dimensions of implementation [10, 11]. Notable is the extensive review of the diffusion of
innovations literature conducted by Greenhalgh and colleagues [12] for the then UK NHS
Service Delivery Organization (SDO). Building on the widely cited work on the
dissemination of innovations conducted by Rogers [13] the review draws together other
streams of thinking related to the dissemination and implementation of innovations from a
wide range of research traditions (including sociology, psychology and organizational
studies) to construct a comprehensive model of the implementation process. The dimensions
are grouped under the following headings drawn from the model: the nature of the
innovation, systems readiness for innovation, the adopter, the implementation process, the
outer context and communication and influence. The review advocates a move away from
linear models of implementation towards richer, more complex, accounts of the process of
change including greater consideration of the role of individuals within the change process
[14]. The diffusion of innovations model developed by Greenhalgh et al [14] was chosen for
this study as it is a widely recognised, cited and used [15, 16] model providing a framework
for analysing implementation processes. Although the model is not explicitly framed as a
‘how to’ approach, the domains provide a detailed and comprehensive map of the
implementation landscape [17].
This study focused on stroke, one of the leading causes of mortality and morbidity in the UK
and worldwide [18]. In terms of implementation and improvement, stroke has traditionally
been associated with limited treatment options for patients and few evidence based
interventions. However, stroke research has been animated by the development and
introduction of a number of new evidence based interventions designed to improve stroke
patient care and outcomes [19, 20]. In particular, the development of specialist stroke units
has led to greater coordination in the delivery of stroke care [21] and the introduction of
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thrombolysis as a treatment for stroke patients has received considerable attention
internationally [22, 23]. Thrombolysis is a time critical ‘clot busting’ intervention,
administered intravenously in the first four and a half hours post stroke in line with a strict
treatment protocol. Implementation involves coordination between ambulance services,
Accident and Emergency and stroke specialists and the recognition by patients and carers of
the need for emergency intervention. Few studies have investigated the implementation of
thrombolysis services, although one literature review [24] reported barriers to its
implementation, which included the limited recognition of stroke as a treatable condition,
poor triage of stroke patients and delays in critical neuro-imaging. This study uses the
domains within the diffusion of innovations conceptual model to explore the implementation
of thrombolysis in stroke care.
Methods
Four case studies were conducted in England (2 hospital sites) and Sweden (2 hospital sites).
The countries were selected, following discussions with European stroke specialists, to
represent different levels of development in the delivery of stroke services, which were
characterised, based on audit data, as highly developed (Sweden) and developing (England).
Focusing at the micro level, the sites were selected to include urban and rural hospitals. The
sample in each site included clinical and managerial staff within one hospital, working in
stroke units, emergency medicine, radiology, the ambulance service, community
rehabilitation services and community medicine. The roles of participants and their
organizations are listed in the table below.
[Insert table 1 here]
The interview schedule was informed by two literature reviews conducted by the authors –
the first based on social science approaches to implementation, and the other based on