Table 3.

Strategies for Routine PtDA Implementation, Derived from Our Program Theory of Successful PtDA Implementation in Routine Health Care Settings

What Does It Involve?	How Does It Help?	Examples of Studies
1. Coproduction of PtDA content and processes or adapting existing PtDAs to a local level—designing tools and processes that fit everyone
Early and meaningful involvement of the intended knowledge users in PtDA design and implementation planning, via a coproductive approach. It moves beyond seeking the input of HCPs/patients on PtDA design/content (without consulting other core team members, e.g., administrative staff) or views on feasibility of intended PtDA use after several versions of the PtDA have already been developed. Meaningful involvement from the beginning of the design process: What is the problem our patients face in making decisions that are right for them? How can a PtDA help to address that problem (or is there a better way to promote SDM with these patients)? How can the PtDA be used and integrated into the care pathway, and what changes would we need to make? How can appropriate PtDA tasks be delegated to appropriate staff across the entire team? Views all end-users as equitable—recognizes the skills, abilities, time, and other qualities that they can bring to the PtDA design and implementation planning process61 and would involve everyone from patients and carers, HCPs, administrative staff, to health care managers.	•Increases ownership, trust, and buy-in to the PtDA •Leads to equitable division of tasks to appropriate team members •Allows teams to develop a tool that best fit within their setting, which addresses the needs of all end-users	Dahl Steffensen 2018; Hsu 2016; Hsu 2013; Johnson 2010; Joseph-Williams 2017; Lin 2013; Lloyd 2013; Munro 2019; Savelberg 2019; Scalia 2017; Scalia 2018; Sepucha 2017; THF 2013
2. Training the entire team—explaining purpose, increasing understanding, developing skills
Training sessions delivered before PtDA implementation are essential. SDM/PtDA training has typically focused on upskilling and improving knowledge for HCPs. Our findings highlight the importance of training for the entire team. Administrative staff are not just passive distributors of the tool; they play critical roles in preidentifying eligible patients, successfully integrating PtDAs into workflows, and championing PtDA use. Quite often, they will be the first person to introduce the concept of “choice” to patients, preparing them for PtDA use at the very start of their health care journey. However, they can only achieve this if training is delivered to the entire team and there is whole-team coherence regarding PtDA purpose and intended use.	•Understanding of how PtDA is intended to be used and how it fits in the patient pathway •All staff championing PtDA use •Improved integration of PtDA into workflows •Coherence on expected PtDA benefits •Reflection on existing practice and greater clarity of how SDM differs and where PtDAs fit in that process •Improved confidence in SDM/PtDA delivery	Berry 2019; Bonfils 2018; Brinkman 2017; Dahl Steffensen 2018; Feibelman 2017; Giguere 2014; Joseph-Williams 2017; Lin 2013; Lloyd 2013; Mangla 2018; Munro 2019; Savelberg 2019; Scalia 2017; Stacey 2015; THF 2013
3. Preparing and prompting the patient to engage with the PtDA—a key 2-step approach
A 2-step process of preparing patients to engage with the PtDA followed by a prompt to engage with the PtDA is important in ensuring PtDAs are used in the way intended (i.e., to inform patients and support them to share their preferences with the HCP). First step (preparing) involves sending an invitation to the patient before the consultation (with an accompanying PtDA, if feasible), informing them of the PtDA purpose and encouraging use. When patients are not prepared, they are less likely to understand the purpose of the PtDA and less likely to engage with it when presented to them during a consultation. Second step (prompting) involves an explicit reminder from the HCP during the consultation to engage with the PtDA (ideally accompanied by a duplicate copy if PtDA was distributed beforehand). When patients are not prompted, they are less likely to share their preferences, even if they had used the PtDA as intended prior to the consultation. Systematizing or automating invitation and PtDA delivery can help, but it is not always feasible (e.g., general practice) or desirable (e.g., sensitive and significant diagnosis) to preidentify patients ahead of their consultations. However, it is still possible to create a culture of preparedness and “permission” for involvement by distilling messages that patient involvement is valued and actively sought, e.g., through the use of general patient activation campaigns.9,59,62–64	Preparing •Increases patients’ understanding of the PtDA’s purpose, relevance, and their own role in the decision-making process •Reinforces that patient input is valued and desired •Reminder for patient to use (if sent before consultation) or engage with the PtDA (if delivered during consultation). •Prompting •“Permission” (as perceived by patients) for patients to share their preference •Further validates input in decision-making process •Encourages open and honest discussion of patient preferences	Berry 2019; Dahl Steffensen 2018; Dharod 2019; Feibelman 2017; Giguere 2014; Johnson 2010; Joseph-Williams 2017; Krist 2017; Munro 2019; Savelberg 2019; THF 2013
4. Senior-level buy-in: “it’s what we do around here”
Demonstrable leadership from senior clinicians and managers is important for successful PtDA implementation and also sustainability of implementation. Although whole-team engagement is important (see points 1 and 2 above), it is important to identify a core leadership team early on, or at least a “clinical champion,” who will take on the responsibility for driving the work forward and maintaining the impetus garnered during the earlier phases of implementation. It is not intended as a top-down authoritative strategy, in which clinical teams are being told what to do by senior team members. It is intended as a facilitative and motivational strategy that supports the team, demonstrating that they are “in it together,” all contributing to a common goal, and have the necessary support to do so.	•Provision of adequate training so team has necessary skill set to use PtDAs •Ensuring PtDAs are prioritized and remain a priority in the team •Ensuring linkage between organizational priorities and PtDA outcomes •Facilitating feedback on PtDA outcomes and associated improvements for the team and their patients (see also point 5 below). •Conveys seriousness of intent; creates a sense that SDM / PtDAs is “what we do around here”	Berry 2019; Bonfils 2018; Dahl Steffensen 2018; Feibelman 2017; Giguere 2014; Joseph-Williams 2017; Lin 2013; Lloyd 2013; MacDonald-Wilson 2017; Scalia 2017; Stacey 2018; THF 2013
5. Measuring to improve—linking PtDAs with routinely collected data to demonstrate improvement
Linking PtDA outcomes with measures that the organization values is important for successful and sustained implementation. When an organization can see the improvements that result from using PtDAs, they are more likely to become integrated into routine clinical care. Ideally, a “learning health care system” will be in place, which will support this. Implementation planners should work to understand the key priorities (at the patient, team, organizational, or national guideline/policy level) and link these with key reported PtDA benefits. Further, they should identify the data that are already being routinely collected and use this where possible, e.g., Patient Reported Experience Measures (PREMS) or Patient Reported Outcome Measures (PROMS). Specifically, designed measures can also be helpful in early stages of implementation; see Coulter (2018, pp. 24–27)9 for examples of both routine and special measures used in various countries.	•When PtDA outcomes are linked with measures that are valued by the organization, it shows clinical teams that PtDAs are an important driver for change and improvement, making them more likely to be valued and embedded.	Feibelman 2017; Joseph-Williams 2017; Lloyd 2013; MacDonald-Wilson 2017; Munro 2019; Savelberg 2019; THF 2013

PtDA, patient decision aid; HCP, health care professional.