Implementation Research Research Articles

The Alive & Thrive multilevel, multicomponent intervention to engage fathers in complementary feeding in Kaduna State, Nigeria previously showed significant increases in complementary feeding practices for children. This analysis explores the perceptions of intervention deliverers and recipients to inform future spread. The intervention components included counseling cards, home visits, feeding bowls, texts/prerecorded messages, posters, leaflets, sermon guides, talking points, radio and television spots. In-depth interviews (24) were conducted with intervention deliverers (community health extension workers, community and religious leaders) and focus group discussions (16) with recipients (parents of children 6–23 months) from 6 rural and urban wards. Participants were purposively sampled; parents were not selected as couples. Eligibility for CHEWs and CRLs included being ≥ 18 years and having participated in intervention implementation. Eligibility for parents included being ≥18 years (or married mothers 15–17 years), having a biological child 6–23 months, and receiving the intervention. Transcripts were coded descriptively in Atlas.ti and the results were mapped to the domains and constructs of the Consolidated Framework for Implementation Research 2.0. For the innovation domain, intervention deliverers and recipients reported high acceptability and appropriateness of the intervention components. For the outer domain, the intervention was perceived to be influenced by values and beliefs (fathers’ roles as providers), systemic conditions (economic hardships), and critical incidents (COVID-19). The intervention was also influenced by relational connections, compatibility, intervention deliverers and recipients, teaming, tailoring strategies and engaging for the domains of inner setting, individuals, and implementation process, respectively. For implementation strategies, intervention deliverers liked the training and monthly meetings where they shared experiences and problem solved. The Alive & Thrive intervention in Kaduna State, Nigeria was acceptable, appropriate, and feasible for intervention deliverers and recipients.

Leveraging implementation research to end HIV as a public health threat in our lifetimes.

Registered dietitian nutritionists (RDNs) use clinical practice guidelines (CPGs) to inform evidence-based practice. Despite the availability of CPGs, guidelines are not always translated into practice. This challenge is central to implementation science (IS), which seeks to understand how evidence can be adopted and sustained. The Gestational Diabetes Mellitus (GDM) Registry Study was a multiphase, multisite hybrid implementation study that explored guideline implementation using quality improvement (QI) methods grounded in the Model of Improvement and guided by Plan-Do-Study-Act (PDSA) cycles. Following a baseline period, RDNs completed training, conducted a gap analysis, and identified 2 CPG implementation aims. Sites completed iterative PDSA cycles. Deidentified nutrition care data were entered into the GDM Study Registry and manually audited to evaluate process outcomes. RDNs participated in a closing interview. Qualitative data were analyzed using a constructivist approach and reflexive thematic analysis, supported by artificial intelligence (AI)-assisted qualitative software. Six themes were identified, highlighting the value of assessing current practices and the flexibility of PDSA as an implementation strategy. Themes were mapped against the Normalization Process Theory and Consolidated Framework for Implementation Research and showed alignment between PDSA and implementation principles. The registry audit demonstrated improved process measures. The median normalization score across RDNs (9.00) and sites (9.42) was high, suggesting normalization. PDSA facilitated the work of normalization and enabled practice changes. This study contributes to IS by demonstrating how QI strategies, such as PDSA can help RDNs translate evidence into everyday nutrition care.

To explore how, why and under what circumstances transitional care can be normalised as a routine care practice for adult patients with enterostomy after discharge from hospitals. Realist review. This review was conducted in three iterative phases: (1) constructing an initial programme theory to identify the scope of the study; (2) retrieving and evaluating the evidence, extracting data and integrating the evidence; and (3) analysing and integrating the evidence to refine the programme theory. Five bibliographic databases and the grey literature were searched from 1947 to 2024 to identify the studies of two core concepts: enterostomy and transitional care. A total of 36 papers were included, identifying nine context-mechanism-outcome configurations that explain how, why and under what circumstances transitional care can be normalised as routine care for adult patients with enterostomy after discharge: (1) Responsibilities of individual roles; (2) Interdisciplinary team collaboration; (3) Support from upper management; (4) Communication and interaction; (5) Multiple linkage; (6) Professional training; (7) External support and policy formulation; (8) Personalised measures; and (9) Evaluation and feedback. The normalised implementation of transitional care is essential to help enterostomal patients better adapt to stoma life and improve their quality of life. An effective transitional care model not only relies on the support of professional caregivers, but requires the close cooperation of patients, family members, communities and healthcare organisations. Reporting was adhered to the RAMESES publication standards: realist syntheses. Patients and members of the public were involved in study design. Their contributions were participating in advisory groups, ensuring the research was addressed. This study provides theoretical guidance for clinical stoma transitional care, translating the research findings into routine healthcare practices, constantly optimising and improving the stoma care system, and offering patients higher-quality and more efficient services. This research, through the realist review approach in combination with the Normalisation Process Theory (NPT) and the Consolidated Framework for Implementation Research (CFIR), systematically elucidates for the first time how, why and under what circumstances transitional care can be regularised as a routine post-discharge care measure for adult enterostomy patients. The research findings will: Improve the quality of life of patients: Through personalised care plans and multidisciplinary team cooperation, help patients better adapt to life with an ostomy, reduce complications and improve self-management ability. Optimise clinical practice: Provide theoretical guidance for medical staff, promote the regular implementation of transitional care and improve the quality and efficiency of care. Promote education and training: Emphasise the importance of professional training and communication skills, and provide new ideas for nursing education. Support policy formulation: Call on the government and medical institutions to improve relevant policies, provide more resources and support and promote the rational allocation of medical resources.

Developing a medication safety self-assessment tool for high-alert medications in community pharmacies

Abstract Background Integrated care initiatives for socioeconomically vulnerable groups can deliver personalised care, improve health outcomes, and foster greater equity within the healthcare system. However, incorporating these initiatives into standard care remains rare. Insight into implementation determinants and selecting strategies for further implementation and upscaling is therefore needed. Methods We conducted a case study on an integrated care initiative for citizens with prediabetes in the form of group consultations. We used a qualitative design guided by the Consolidated Framework for Implementation Research (CFIR) and the Rainbow Model of Integrated Care. Semi-structured interviews and a focus group were conducted with participants, including professionals, policy makers, and experts by experience. We used Framework analysis to identify implementation determinants and matched implementation strategies to a selection of barriers using CFIR's Expert Recommendations of Implementation Research matching tool. Results We conducted 28 interviews and one focus group (n = 16). Key barriers included insufficient involvement of citizens, which could be overcome by involving patients/consumers and family members. We also identified a lack of embedding in formal structures and fragmentated funding as barriers. These could be addressed through formal commitments, alternative payment schemes, and resource-sharing agreements. Key facilitators were the widespread enthusiasm for the concept of group consultations, a sense of urgency for change, and the adaptability of the initiative to the local context. Conclusions Citizen involvement in designing an integrated care initiative is a key determinant of implementation when targeting socioeconomically vulnerable groups. Despite broad support for integrated care, its implementation is hindered by organisational and system-level barriers related to fragmentation of healthcare and social support. Key messages • Citizen involvement is key to improve implementation of integrated care initiatives for socioeconomically vulnerable groups. • Solutions are needed to overcome implementation barriers caused by fragmentation of healthcare and social support systems.

Abstract There are several training models to support the implementation of scientific evidence to improve quality or effectiveness of care. Meanwhile, participatory approaches for workplace-oriented development and design of new practices, processes and services have been increasingly used in health and social care. Implementation research has long discussed the possibility to transfer models to new contexts. Because contexts differ, transferring may require making adaptations to the model, for example, regarding the forms of support or the target group. However, sometimes the model or intervention drifts because of misapplications or abandonment of core components. This session aims at discussing the adaptations of The Breakthrough Series (BTS) in Finland. BTS is the most well-known model for the quality improvement collaboratives (QIC), and it was developed in the institute for Health Improvement (IHI) in 1995. The model is freely available and is widely spread around the world. According to IHI, a BTS process typically lasts 6-18 months. The key elements of BTS are 1) selecting a topic where existing scientific knowledge is sound, but not widely used, 2) group of experts designs the aims, measurement strategies and list of evidence-based changes and 3) provides coaching to 4) multidisciplinary teams from multiple sites. The teams then participate in 5) learning sessions and 6) in active working periods in-between the sessions, the teams test changes in their local settings and collect data to measure these changes while 7) they learn carrying out the Model for Improvement including Plan-Do-Study-Act cycles (PDSA). In 2022-2025, the BTS model was integrated into two national development programs in Finland. The Ministry of Social Affairs and Health mandated that all wellbeing services counties receiving EU Recovery and Resilience Facility funding (2022-2025) participate in BTS, facilitated by the Finnish Institute for Health and Welfare, and develop multiprofessional service chains for vulnerable groups. Secondly, projects funded by the Good Work Programme (2022-2027), initiated by Prime Minister Orpo's Government, were guided by the Ministry to participate in BTS facilitated by the Finnish Institute of Occupational Health, aiming to improve personnel attraction and retention models. The BTS model was chosen as a pedagogical model because it had been used in several projects in Finland to improve the waiting times of health services (2010-2023). However, applying the model for two entirely new purposes required several changes and adaptations. Therefore, the three presentations in the session discuss the history of transferring the model between countries, how its theoretical and epistemological backgrounds have evolved, and what kinds of results and impact the training model's elaborated versions have produced in Finland. Key messages • Training and coaching models tend to adopt culturally convenient and popular theoretical resources while they transfer between countries. • Eclectic combinations of theoretical approaches in training and coaching models both enrich and create incompatible dynamics from the participants’ perspective for learning.

Exercise Training in Multiple Sclerosis: Preparing for Dissemination and Implementation Based on Integrating the NIH Stage Model of Intervention Development.

IntroductionThe use of digitally enabled technology is considered a promising platform to prevent morbidity and enhance youth mental health as youth are growing up in the digital world and accessing the Internet at increasingly younger age. This scoping review will identify, describe and categorise the models, frameworks and strategies that have been used to study the implementation of digital mental health interventions targeted at youth aged 15–34 years.Methods and analysisWe will conduct a scoping review following the Arksey-O’Malley five-stage scoping review method and the Scoping Review Methods Manual by the Joanna Briggs Institute. Implementation methods will be operationalised according to pre-established aims: (1) process models that describe or guide the implementation process; (2) evaluation frameworks evaluating or measuring the success of implementation; and (3) implementation strategies used in isolation or combination in implementation research and practice. Primary research studies in all languages will be identified in CINAHL, Cochrane Central Register of Controlled Trials, Embase, ERIC, Education Research Complete, MEDLINE and APA PsycINFO on 6 January 2025. Two reviewers will calibrate screening criteria and the data charting form and will independently screen records and abstract data. We will use the Evidence Standards Framework for Digital Health Technologies by the National Institute for Health and Care Excellence to classify digital interventions based on functions, and a pre-established working taxonomy to synthesise conceptually distinct implementation outcomes. Convergent integrated data synthesis will be performed.Ethics and disseminationEthical approval is not applicable as this scoping review will be conducted only on data presented in the published literature. Findings will be published and directly infused into our multidisciplinary team of academic researchers, youth partners, health professionals and knowledge users (healthcare and non-governmental organisation decision makers) to co-design and pilot test a digital psychoeducational health intervention to engage, educate and empower youth to be informed stewards of their mental health.

Transcranial magnetic stimulation (TMS) has emerged as the pivotal non-invasive neuromodulation technique for the diagnosis and treatment of various neuropsychiatric disorders worldwide. In India, the adoption and evolution of TMS services have been marked by significant research contributions and clinical advancements over the past three decades. This review synthesizes the historical development, current applications, and prospects of TMS services in psychiatry in India, drawing on a comprehensive analysis of all relevant Indian publications. The growth of TMS research, institutional contributions, clinical protocols, and challenges in implementation is explored, while highlighting the potential for personalized and scalable TMS interventions in the Indian healthcare landscape.

Implementation and evaluation of service learning at higher education institutions.

Interdisciplinary healthcare providers (IHPs) can support effective delivery of optimal rheumatology care. To inform widespread implementation efforts, we assessed rheumatology workforce characteristics and determinants of integrating of IHPs within rheumatology practices in Ontario, Canada. A convergent mixed methods design included an environmental scan to identify clinically active rheumatologists and a workforce survey guided by the Consolidated Framework for Implementation Research 2.0. Quantitative data were analyzed descriptively and stratified by subgroups. Qualitative responses were analyzed using conventional content analysis. Integration of findings enabled a comprehensive understanding of implementation determinants. Of the 293 Ontario rheumatologists identified by the environmental scan (as of 2025), 26 were nearing retirement, leaving approximately 267 eligible for the survey. 197 rheumatologists participated in the survey, yielding a response rate of 74%, and coverage of >90% of practice sites. Pediatric rheumatologists and those in hospital-based settings had more structural and collaborative supports than community-based rheumatologists. Overall, 177 (91%) indicated they were interested in adding IHPs, with 126 (65%) preferring an Extended Role/Scope Provider. While inadequate funding was the key deterrent to adoption, motivational readiness was high: 92% perceived an IHP team-based model as an improvement, 85% saw it as a good fit, and 83% considered it a priority to better meet patient needs. Many noted a lack of supportive climate, including lack of support, processes, and resources to enable this practice change. Rheumatologists report high motivation for practice change to integrate IHPs. System-level and practice-level implementation strategies are needed to support workforce transformation.

BackgroundThe second most common cause of death in Germany is cancer, and new cases are expected to increase by over 20% by 2045. About 35% of patients are of working age at diagnosis. Returning to work (RTW) is crucial for individuals, promoting social participation and security. Amidst demographic changes and labor shortages, also the society benefits from cancer patients’ RTW. However, only up to 74% of cancer patients return, indicating problems in the process. Outpatient cancer counseling centers (OCCs) provide free psychosocial and social law support for patients. An intensified counseling intervention was developed to assist cancer patients in RTW, and this study aims to examine the factors that facilitate or hinder its implementation.MethodsThe CARES feasibility study used a sequential, quasi-experimental pre-post design. The counseling intervention was piloted in 18 OCCs. The formative evaluation included semi-structured interviews with 16 clients in the intervention group and 11 counselors. The interview guides and the data analysis were based on the Consolidated Framework for Implementation Research (CFIR). In the content analysis, deductive codes according to the CFIR were supplemented inductively. This study presents results for the implementation process domain.ResultsThe counseling professionals were intrinsically motivated to participate and willing to help clients. Also, they were motivated by the financial support through the study. However, additional required efforts and labor shortages hindered implementation. Overall, the clients’ willingness to participate facilitated the implementation, but difficulties during enrolment and usage of some intervention parts occurred.ConclusionsCounseling professionals and clients’ motivation facilitated implementation. The changeable barriers can be adapted in future implementation processes of the counseling intervention, e.g. during the follow-up project QV-CARES.Key messages• The present results of the formative evaluation provide first evidence of the feasibility and acceptability of the intervention.• Changeable barriers for implementation can be adapted in future implementation processes of the counseling intervention.

BackgroundAn organized breast cancer screening program has been introduced by the local government in Ordos City since 2010. Women between 35 and 64 years are eligible to be screened freely at local maternal and child healthcare hospitals. The screening coverage rate in Ordos City is relatively higher than the national average level. However, the overall breast cancer detection rate remains low. This study aims to identify contextual influencing factors of this program from local maternal and child healthcare hospitals’ perspectives and provide suggestions for screening service improvement in Ordos City.MethodsWe conducted a qualitative study to evaluate the implementation of the organized breast cancer screening program from maternal and child healthcare hospitals’ perspectives in Ordos City. Four domains (outer setting, inner setting, individuals, and process) and nine constructs were selected for evaluation under the instruction of the Consolidated Framework for Implementation Research (CFIR). CIFR constructs were rated in both valence and strength factors. The interview scripts were coded and themes were generated by using content analysis. Data obtained were interpreted and described by tables and charts.ResultsA total of 28 individuals participated in our study. We found that the implementation of the organized breast cancer screening in Ordos City went well. Policies & laws, partnerships & connections, performance-measurement pressure, implementation leads, teaming, and engaging constructs holistically facilitated the implementation performance. Available resources varied and this construct chiefly displayed a neutral impact. Access to knowledge & information and doing constructs were considered to negatively influence the implementation performance. Political commitment to cervical cancer elimination, multisectoral collaboration, specialized leadership, and structured screening teams were the main factors promoting the screening progress. Inconsistent referrals, underqualified professional competence of primary health workers, and non-interoperable electronic systems were the main barriers to screening performance.ConclusionsWe recommend that Ordos City further facilitates the prompt referral for imaging and biopsy, promotes the capacity building of primary health workers, and strengthens the construction of electronic systems. Future quantitative studies are necessary to comprehend the knowledge and attitudes of caregivers and target population toward breast cancer screening. Interviews with other stakeholders, such as policymakers and target population, are also needed.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12913-025-13289-1.

Organizational barriers and recommendations for colorectal cancer survivorship care in Thailand: A qualitative study using the consolidated framework for implementation research.

Abstract Objectives This umbrella review aimed to synthesize evidence on various interventions targeting these issues to inform strategies for optimizing medication use in the elderly population. Methods A search was conducted on PubMed, Embase, Scopus, Web of Science, and Cochrane CENTRAL until 2024 to find relevant systematic reviews of interventions to improve medication management among elderly aged ≥60 years. Eligible reviews focused on pharmacist-led reviews, deprescribing protocols, educational programs, clinical decision support systems (CDSS), and community-based initiatives. Data were extracted, and the methodological quality was evaluated. The outcomes were: medication-related process, physical and functional, health care utilization and cost, and acceptability of the intervention among physicians and patients. Descriptive statistics was used. The credibility of the evidence was determined. Results Seventy-one systematic reviews with >1.5 million participants were included. Pharmacist-led reviews and deprescribing interventions indicated significant improvement in medication appropriateness. Multidisciplinary approaches and CDSS could improve adherence and prescribing practices. Improvements in clinical outcomes, such as quality of life, cognitive function, and mortality, were inconsistent. Economic evaluations showed mixed results. Implementation challenges were scalability and resource allocation. Evidence was convincing in reducing the number of medications, inappropriate prescribing, and falls. Conclusions Although interventions, such as deprescribing and pharmacist-led reviews can be effective in improving medication outcomes, their impact on broader clinical and economic metrics is variable. There is a need for targeted, context-specific strategies, and rigorous implementation research. Future studies should concentrate on scalable, patient-centered interventions with measurable improvements in clinical and system-level outcomes. Key messages • This umbrella review demonstrated that pharmacist-led reviews and deprescribing interventions could lead to a significant improvement in medication appropriateness in the elderly population. • Multidisciplinary approaches and clinical decision support systems could improve adherence and prescribing practices.

Schools' readiness appears an important factor influencing their implementation of violence prevention programs. This review was undertaken to identify, describe, and compare existing theoretical readiness models and their strengths and limitations, and to select an appropriate theoretical model to underpin the study of schools' readiness for child sexual abuse (CSA) prevention education. This, in turn, would guide development of a new instrument to assess schools' readiness for CSA prevention. Searches were conducted from September to December 2022 in ERIC, PsychINFO, PubMed, Science Direct, Sociological Abstracts, Web of Science, and Google Scholar, and handsearches were made in academic journals. We included peer-reviewed papers published in English that reported the development, testing, or use of a theoretical readiness model at an organizational level. We identified three candidate groups of theoretical models from 85 papers: the community readiness model, the multidimensional child maltreatment prevention readiness model, and organizational readiness for change theories. These models were appraised using four criteria for selecting implementation science theories and frameworks (Birken et al. 2017). We propose Weiner's (2009) organizational readiness for change as the most plausible theoretical model with both descriptive and analytical potential for assessing schools' readiness for child sexual abuse prevention education, and discuss the conceptual and empirical strengths and weaknesses of the identified models. The review has demonstrated the utility of applying criteria (Birken et al. 2017) to appraise and select theoretical readiness models in CSA prevention education and other implementation research areas.

ABSTRACT Objective The inclusion of family in mental health practice has been understood as a beneficial step in an individual's mental health recovery. Yet, the implementation of a family-inclusive approach has been met with challenges within mental health services. This study used the Consolidated Framework for Implementation Research to investigate the clinical factors that facilitate and/or hinder the implementation of a family-inclusive practice. Method This study used a qualitative approach to thematically analyse survey data from 24 staff members at Concord Centre for Mental Health, New South Wales, Australia. Using the domains of the Consolidated Framework, participant responses were categorised as either a facilitator or barrier to the implementation of family-inclusive practices. Results Thematic analysis of 24 participant responses revealed 5 main themes and 7 sub-themes relating to the facilitating and/or hindering factors within the following Framework domains: Innovation Characteristics, Outer Settings, Inner Settings and Individuals. Discussion Findings from the present study indicated that a family-inclusive approach to mental health practice requires diverse responses and adjustments from clinicians employed in both inpatients and community settings. Facilitating and hindering factors were shown to interact and shape the current state of family inclusion in mental health practice.

335 Background: Cancer-related financial hardship and other supportive care needs remain under-detected in routine oncology practice. We developed a modular electronic patient-reported outcome (ePRO) framework integrated within the electronic health record to systematically assess supportive care needs among head and neck cancer (HNC) patients. This report describes the development and initial implementation of financial toxicity screening embedded within a comprehensive supportive care infrastructure. Methods: Through a user-informed developmental approach guided by the Consolidated Framework for Implementation Research (CFIR v2.0), we conducted 46 formative qualitative interviews with healthcare professionals (n = 20) and HNC patients (n = 26) to inform intervention design. Through these interviews, financial toxicity was identified as a critical yet under-addressed need with strong consensus for integration in supportive care screening. The resultant modular ePRO framework assessed multiple domains: financial toxicity, symptom burden, psychological distress, malnutrition, and treatment complications. Financial toxicity was screened using a validated single screening item from the FACIT-COST measure ("My illness has been a financial hardship to my family and me") with responses ranging from "not at all," “a little bit,” “somewhat,” “quite a bit,” to "a lot." Patient responses of "quite a bit" or "a lot" were considered a positive screening, and triggered dynamic clinical decision support for financial counseling referrals. Results: During phased implementation from January 2024 to May 2025, 2,762 automated screenings were delivered via MyChart to patients with HNC, with 60% (n = 1,647) patient completion. Among respondents completing the financial assessment (n = 1,599), 50% (n = 800) reported no financial burden, 39% (n = 620) reported mild to moderate burden, and 11% (n = 179) screened positive for severe financial hardship. Positive financial toxicity screening was significantly associated with younger age, male gender, and worse symptom burden including pain, depression, anxiety, fatigue, and overall wellbeing. Conclusions: Integration of financial toxicity screening within comprehensive supportive care assessment is feasible and identifies a meaningful subset of patients with unmet financial needs. The strong association between financial hardship and symptom burden underscores the interconnected nature of social determinants and clinical outcomes in cancer care, highlighting the need for multidisciplinary approaches to address complex needs in financially vulnerable cancer patients.

472 Background: Learning collaboratives are a widely used to support the spread of complex innovations, but little is known about how learning collaboratives develop. The OncoPRO initiative, a PCORI-funded national learning collaborative hosted by ASCO focused on implementing remote symptom monitoring (RSM) using electronic patient-reported outcomes (ePROs) in oncology, provides a unique opportunity to explore this process. This study offers critical insights into both the development of learning collaboratives and their ability to support the long-term success of complex healthcare initiatives. Methods: This study employed a multi-methods implementation science approach to examine the development and first year of the OncoPRO initiative. In its initial year (January-December 2024), OncoPRO provided support to 12 independent health systems. We identified cross-organizational barriers encountered during collaborative development, as well as the implementation strategies employed to address them, using field notes generated during all OncoPRO-related meetings, site-level communications, and presentations. We systematically identified and categorized barriers and implementation strategies using the Consolidated Framework for Implementation Research (CFIR) 2.0 and the Expert Recommendations for Implementing Change (ERIC) frameworks. Results: We identified 27 overarching barriers (e.g., lack of best practices; lack of buy-in) that were addressed through 23 foundational implementation strategies relevant to developing and facilitating the learning collaborative. These implementation strategies were organized temporally into six phases: building a multi-level foundation, engaging and onboarding implementation sites, building shared learning structures, supporting technical rollout, embedding feedback loops and quality monitoring, and stimulating demand for RSM and collaborative participation. Most barriers were addressed using multiple strategies, and individual strategies often targeted several barriers simultaneously. Broad strategies addressing multiple barriers (e.g. build a coalition; identify early adopters) were deployed early to develop a base for the collaborative. As the initiative matured, strategies targeting specific barriers (e.g. develop and implement quality monitoring systems) were added to support site-level operationalization and continuous improvement. Conclusions: This approach to building a national learning collaborative offers a roadmap for constructing and sustaining complex collaboratives. It lays the groundwork for future analyses of implementation variation and strategy effectiveness across sites, and highlights how learning collaboratives can be pivotal in supporting the successful implementation of complex quality initiatives like RSM in oncology.