Decision-framing to Incorporate Stakeholder Perspectives in Implementation Toolkit

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It takes an average of 17 years for an evidence-based practice (EBP) to be adopted into clinical practice—and most EBPs are never widely adopted. The decision-framing approach described below makes it easy to identify the values that different stakeholders have about implementing a possible change, potentially speeding the adoption and improving the effectiveness of EBPs. Stakeholders include, for example, payers, clinic managers, clinic staff, and patients. Once the different groups’ values are known, the potential EBP and/or aspects of the clinic workflow and setting can be modified to raise the likelihood that the EBP will be adopted.

Implementing a new practice in an organization can be viewed as a process involving a group of healthcare stakeholders who all have to cooperate in a conscious way.

Implementation is a dynamic process that involves real people making decisions in the real world. At each level–from payers, to management, to staff, to patients–healthcare stakeholders are making decisions about whether to adopt the change you’re trying to implement. If the people at one level decide not to adopt a proposed new practice, the practice probably will not be adopted. For example, if managers promote a practice that staff find onerous, staff are likely not to adopt it. Abstaining from decision-making by not participating in implementation is tantamount to not adopting. All the relevant decision makers need to be participating and ultimately to agree or the process is over and the implementer can go home. This happens nearly all the time. Remember, 17 years?

Who should use this toolkit?

This approach is intended for healthcare researchers, facilitators, and others who want to introduce an improvement in primary care clinics.

What does the toolkit contain?

This toolkit contains information on how people make decisions, and how common decision-making biases can affect the success of implementation projects.

It also includes steps that can be taken to convene stakeholders, identify their values, and use the values to take actions that improve the likelihood of adoption.

Development of this toolkit

The Decision-framing to Incorporate Stakeholder Perspectives in Implementation Toolkit was developed by researchers and clinicians (Principal Investigator: Andrew Quanbeck) at the University of Wisconsin-Madison School of Medicine & Public Health – Department of Family Medicine and Community Health.

The National Institute on Drug Abuse (NIDA) is the primary funder of the study (K01-DA039336-01). The funder had no role in study design, the collection or interpretation of data, or the publication of results. Additional funding was provided by NIDA grants R34-DA036720-01 and R01-DA030431-01.

Please contact Dr. Quanbeck with any questions regarding this approach or suggestions for improving it:

Toolkit Citation

Andrew Quanbeck. Decision-framing to Incorporate Stakeholder Perspectives in Implementation toolkit. University of Wisconsin – Madison Department of Family Medicine & Community Health. Madison, WI; 2019. Available at:


About the Author

Andrew QuanbeckAndrew Quanbeck, PhD, is an Assistant Professor in the University of Wisconsin – Madison Department of Family Medicine and Community Health. Dr. Quanbeck is a systems engineer—someone trained to solve real-world problems using ideas and techniques from many different disciplines. He specializes in implementation science, a field dedicated to improving the use of evidence-based practices in clinical care. Dr. Quanbeck’s work focuses on primary care.