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Standardized care protocols, including clinical practice guidelines (CPGs), have been heralded by practitioners and researchers as a solution to issues involving inconsistency in care quality and outcomes (Grimshaw et al., 2004b; Grol & Grimshaw, 2003). Nevertheless, although numerous practice standards have been generated over the past two decades, their uptake and impact in real-world settings has been generally disappointing (Kastner et al., 2011; Scott, 2007; Shaw et al., 2006; Wright et al., 2003) and highly variable across sectors (Dijkstra et al., 2006; Grimshaw et al., 2004a). This includes the long-term care (LTC) sector (Gambassi et al., 1998; Gurwitz, Monette, Rochon, Eckler, & Avorn, 1997; Levine & Totolos, 1994; Orsted & Attrell, 1999; Xakellis, Frantz, Lewis, & Harvey, 1998), as well as other health care sectors. Research to date on standards and guideline implementation has clearly demonstrated "that guidelines alone are not the solution for inappropriate care and that they are certainly not self-implementing" (Solberg et al., 2000, p. 173). To succeed, organizations, and the individuals in them, need to be equipped with implementation-relevant knowledge, in addition to clinical care knowledge (Berta et al., 2010).
The primary aim of our study was to better understand how care protocols1are implemented in LTC homes operating in Ontario, and to learn what processes, structural mechanisms, and knowledge sources are relevant to their implementation. LTC institutional settings are generally under-studied in implementation science. We focused on the implementation of care protocols relating to six clinical issues in Ontario LTC homes, and addressed the following questions to directors of care within LTC homes: What motivates decisions to use care protocols? How are protocol selection decisions made? What information sources are regarded as important to protocol implementation? How is staff prepared to implement protocols? Finally, what structural-process factors contribute to successful protocol implementation? A secondary interest was to study the influence of context on approaches to implementation, and to examine relationships between implementation approaches and a modest set of organizational characteristics shown to influence knowledge uptake in health care (Dijkstra et al., 2006; Emmons, Weiner, Fernandez, & Tu, 2012; Grimshaw et al., 2004a) and in other settings (Argote, 1999; Damanpour, 1996; Damanpour & Schneider, 2006; Lewin, Massini, & Peeters, 2011).
Our study responds...