Mechanisms of practice facilitation identified using system dynamics diagramming in a tailored implementation study of unhealthy alcohol screening and treatment in primary care

Abstract Background Practice facilitation is a valuable strategy for enhancing the adoption, implementation, and sustainability of evidence-based practices in primary care. It is important to understand how practice facilitation works to develop implementation strategies that are tailored to the needs of the practice. Research is needed to understand the mechanisms by which practice facilitation strategies impact clinic dynamics. Methods We used a diagramming approach from qualitative system dynamics to model the mechanisms by which practice facilitators supported implementation in a pragmatic study of unhealthy alcohol use screening and treatment in primary care settings. The model was developed based on secondary analysis of qualitative data and participatory modeling sessions with study team members. We then analyzed the model to identify individual mechanisms underlying strategies used by practice facilitators by connecting strategies to feedback loops. Results We produced two systems diagrams, one describing the dynamics of screening and treatment for unhealthy alcohol use in the usual care scenario and one illustrating how the practice facilitator strategies acted on those dynamics in the intervention. Facilitator strategies included health information technology support, workflow mapping, toolkit sharing, academic detailing, support finding community resources, goal setting, relationship building, needs assessment, and monthly facilitation sessions. We identified twenty-seven unique mechanisms connected with the facilitator strategies, which we illustrate using diagrams and narrative descriptions. Conclusions Our analysis demonstrates that practice facilitation is a highly adaptive, context-sensitive meta-strategy. System dynamics diagramming is well suited for identifying and describing mechanisms of practice facilitation in implementation research because it illustrates how strategies act on existing dynamics to affect outcomes. This approach could provide a way to specify mechanisms of change in future implementation of screening and treatment of unhealthy alcohol use, as well as other evidence-based interventions. Trial registration Not applicable.