This study provides a description of a systematic and iterative process used to develop an implementation strategy to support a co-located exercise clinic in a private oncology setting. Employing the Implementation Mapping process to overcome challenges to utilization of an exercise oncology clinic within a private cancer center raised three important issues. First, context specific implementation strategies can strengthen exercise oncology programs. Second, the IM process provides a clear and attainable roadmap to guide the development of an implementation strategy. Finally, partnership development and stakeholder selection to the planning committee are pivotal to a project’s success.
Overcoming the challenge of program implementation is a critical step towards exercise becoming integrated into standard oncology care. Despite the exponential increase of evidence demonstrating the value of exercise in oncology, the gap between research and practice severely limits its potential impact . Programs that do not have an integrated, well-considered contextually appropriate plan are unlikely to achieve on their potential success . This poses an important risk to the advancement of the field, as underutilization is often a precursor to poor program outcomes . Low utilization dilutes outcomes critical to demonstrating the value of exercise oncology to providers, administrators, and payers , suggesting the program itself is not effective. Buy-in from these sectors is vital in creating the infrastructure necessary to bring exercise oncology into standard healthcare pathways  and this cannot be accomplished without robust data to demonstrate impact. The Co-LEC is an example of an effective program hamstrung by implementation issues that severely impacted its utilization ; but it is not unique. Beidas et al documented their process of implementing an exercise oncology research program into a community setting . They also encountered barriers negatively impacting utilization, including lack of oncologist engagement. Despite this, few examples exist of exercise oncology programs engaging in robust implementation planning.
The IM process provided an appropriate roadmap to guide the development of an implementation strategy to support the Co-LEC. While it has been established that evidence-based implementation plans are an integral component of successful translational research , there remains limited guidance about how to select and tailor implementation strategies appropriately . The development of an implementation strategy for the Co-LEC required a process that was evidence-based yet could be operationalized to keep all stakeholders engaged. The IM’s systematic approach allowed stakeholders to see the logical progression of the process from the outset. The inclusion of an implementation expert was critical, as it provided familiarity with the core principles of implementation science that served to focus the direction of the team. As calls are being made to include implementation as part of effectiveness trials in the future , the IM process is well suited to meet this need. Its step-by-step guidance allows a group with diverse expertise to create a contextually appropriate implementation strategy, and its iterative process encourages continual improvement . Furthermore, it was designed specifically to be developed in conjunction with program development .
Finally, implementation research is dependent on strong partnerships to be successful. For research to be translated into clinical settings, organizations must be willing to allow systemic changes that will impact their delivery of service, and potentially key business outcomes . For example, when considering methods to change physician behaviors, Grol emphasizes that individual doctors cannot be expected to change without corresponding changes in healthcare teams and the overall organization . This was true for the Co-LEC, with oncologists suggesting referrals needed to be built into usual workflows to be effective. Updating workflows required organizational-level system changes and had implications for service outcomes beyond the Co-LEC. Strong partnerships must be developed to elicit this level of trust between organizations and healthcare researchers. Developing partnerships is an important component of implementation success as functional partnerships can take several years to develop . The partnership between EMRI-ECU and GenesisCare had been fostered over nearly a decade. The organizations collaborated on several research studies over the years that were integral to the initial development of the Co-LEC. The belief in exercise among the oncologists and the trust in the research team by the leadership played a central role in the successful engagement of GenesisCare. This enabled an openness to re-implementing, rather than eliminating, a program that was underperforming.
Furthermore, the strong partnership facilitated participation of key senior-level stakeholders in the project. The IM protocol requires a deep understanding of the organizational structure of the adopting agency and access to key stakeholders throughout the development process . Organizational change is inherent in IM. Lewin’s three-stage model of change theory describes this step as “unfreezing” whereby organizations need to both determine what needs to change and create a need for change to happen; communication between program end-users and program planners is critical during this phase . Recognizing this when choosing SAG members is important to facilitate the “unfreezing” process. For the Co-LEC implementation planning, members of the SAG included a senior oncologist and the regional head of marketing at GenesisCare. They served as a linkage system to ensure the needs of the program end users were appropriately considered during the planning process . Moreover, their demonstrated ability to be influential within the organization allowed for generation of support for the project in anticipation of the implementation . Additionally, the regional GM of GenesisCare served on the SAG. As buy-in and support of senior management is nearly always required for implementation projects to be successful , and his involvement was critical. Because he was an active participant in the process, he was engaged in the program and had direct authority to enact changes immediately, bypassing the proverbial “red tape” often involved in organizational change. This saved the committee time and resources and set the project up for success as it moved to the next “change” phase of organizational change, where leadership engagement and motivation are critical components of success .