Khalil and Kynoch BMC Health Services Research (2021) 21:143

https://doi.org/10.1186/s12913-021-06115-x

RESEARCH ARTICLE Open Access

Implementation of sustainable complex

interventions in health care services: the
triple C model
Hanan Khalil1* and Kathryn Kynoch2,3

Abstract
Background: The changing and evolving healthcare environment means organisations are under increasing
pressure to deliver value-based, high quality care to patients through enabling access, reducing costs and
improving outcomes. These factors result in an increased pressure to deliver efficient and beneficial interventions to
improve patient care and support sustainability beyond the scope of the implementation of such interventions.
Additionally, the literature highlights the importance of coordination, cooperation and working together across
areas is critical to achieving implementation success. This paper discusses the development of a triple C model for
implementation that supports sustainability of complex interventions in health care services.
Methods: In order to develop the proposed implementation model, we adapted the formal tradition of theory
building that is described in sociology. Firstly, we conducted a review of the literature on complex interventions
and the available implementation models used to embed these interventions to identify the key aspects relating to
successful implementation. Secondly, we devised a framework that encompassed these findings into a simple and
workable model that can be easily embedded into everyday practice. This proposed model uses clear, systemic
explanation, adds to the current knowledge in this area and is fit for purpose, providing healthcare workers with a
simple easy-to-follow framework to embed practice change.
Results: A three-stage implementation model was devised based on the findings of the literature and named the
Triple C model (Consultation, Collaboration and Consolidation). The three stages are interconnected and overlap to
support sustainability is considered at all levels of the project ensuring its greater success. This model considers the
sustainability within any implementation project. Sustainability of interventions are a key consideration for
continuous and successful change in any health care organisation. A set of criteria were developed for each of the
three stages to support adaptability and sustainment of interventions are maintained throughout the life of the
intervention.
Conclusion: Ensuring sustainability of interventions requires continuing effort and embedding the need for
sustainability throughout all stages of an implementation project. The Triple C model offers a new approach for
healthcare clinicians to support sustainability of organizational change.
Keywords: Implementation, Health services, Sustainability, Translation

* Correspondence: [email protected]
1
School of Psychology and Public Health, La Trobe University, Level 3, 360
Collins Street, 3000 Melbourne, Vic, Australia
Full list of author information is available at the end of the article

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Khalil and Kynoch BMC Health Services Research (2021) 21:143 Page 2 of 10

Background used interchangeably in implementation science litera-

Given the changing landscape of healthcare in recent ture. However, they are distinct in their definitions. A
years, providing high-quality care through the imple- theory usually provides a clear explanation of how and
mentation of evidence-based innovations whilst also re- why a specific phenomenon exists [15]. A model typic-
ducing costs has become a priority for healthcare ally involves a deliberate simplification of a phenomenon
organisations [1]. While providing value for the patient or a specific aspect of a phenomenon. Models are also
is important, in order to achieve value-based healthcare, sometimes referred to as a narrow form of a theory and
sustainability of implemented interventions is crucial. In are descriptive, as opposed to theory which is explana-
areas identified for improvement, the implementation tory as well as descriptive. Frameworks on the other
process needs to be simple with sustainability a key hand do not provide explanations, they are a set of em-
focus throughout. The necessity of coordination, cooper- pirical phenomena that are translated into a set of cat-
ation and working together across areas is critical to egories. A framework usually denotes a structure,
achieving success [2]. It is important to consider how overview, outline, system or plan related to a specific
the complexities of healthcare influence the implementa- phenomenon. The current theories, models and frame-
tion process. works used in implementation science have been sum-
marised by Nilson (2015) in order to make sense of the
Complex interventions available methodologies. They all fall under three over-
The high prevalence of chronic conditions, aging popu- arching objectives; guiding the process of translation of
lations and new endemics have increased the pressure research into practice (process models), explaining what
on health services to incorporate interventions seen as influences implementation outcomes (determinant
“complex interventions” [3, 4]. These complex interven- frameworks, classic theories, implementation theories)
tions often contain a number of interacting components and evaluating implementation (evaluation frameworks)
as well as many different outcomes to improve the [15].
health care delivery and increase patient safety [5, 6]. Process models for evidence implementation origi-
Numerous papers report complex interventions that nated mainly in the nursing field [5, 11]. Some examples
have been integrated into health care practice to im- of known process models include ACE (Academic Cen-
prove the safety and quality of care provided to patients ter for Evidence Based Practice) Star Model of Know-
[7–12]. The types of interventions range from behav- ledge Transformation, the Knowledge to Action
ioural, technological, organisational and clinical and in- Framework, the Iowa Model, the Ottawa Model for Re-
clude a variety of consumers in health services. An early search Use and the Joanna Briggs Institute (JBI) model
study by Campbell and colleagues has highlighted the [18–21]. The focus of these models is on how to imple-
importance of determining the effectiveness of complex ment evidence into practice. Their main emphasis is on
interventions in health care and detailed a step-wise ap- careful planning using a stepwise linear approach to
proach for the design and evaluation of such interven- implementation as one step usually follows another.
tions [13]. They based their work on the Medical Explanatory frameworks for implementation usually
Research Council Framework for the development and include steps that identify barriers and facilitators to im-
evaluation of randomised controlled trials for complex plementation specifically considering the context in
interventions [14]. Moreover, the authors suggested that which the innovation is being implemented [24–28].
when planning for implementation of complex interven- Most of these frameworks rely on either individual or
tions, the steps needed to be clearly outlined and include organisational change, climate, culture and leadership.
a clear definition and understanding of the problem and Whereas others are based on specific theories such as
its context, describe the development of the intervention behavioural change and social cognition An example of
and finally optimise the evaluation of the intervention this based on theories is the Theoretical Domains
based on three possible scenarios. These scenarios in- Framework.
cluded: a consideration of the cost and resources in- Examples of other types of similar frameworks include:
volved, the evidence supporting the benefits of the Promoting Action on Research Implementation in
intervention and finally the cost benefit ratio of the Health Services (PARIHS), the conceptual model, Eco-
intervention [14]. logical framework and Consolidation for Implementation
Research (CFIR) [9, 27, 28].
Theoretical models The third type of implementation approach is evalu-
Many theoretical models have evolved to simplify the ation frameworks [32–35]. These frameworks provide a
implementation of such interventions and provide infor- structure for evaluating implementation or quality im-
mation about evaluation of these interventions [15–35]. provement projects. Examples of these include Re-AIM
The terms, theories, models and frameworks have been (Reach, Effectiveness, Adoption, Implementation,
Khalil and Kynoch BMC Health Services Research (2021) 21:143 Page 3 of 10

Maintenance) and PRECEDE-PROCEED (Predisposing, 2. It must have systematic explanation-this refers to

Reinforcing and enabling constructs in Educational the provision of enough explanation of the
Diagnosis and Evaluation-Policy, Regulatory) and Organ- phenomenon in form of causal or relational
isational constructs in Educational and Environmental mechanisms,
Development [32–35]. 3. It must support knowledge claims- this refers to the
In this paper firstly, we will focus on examining and use of theory in resulting knowledge claims in the
identifying the facilitators and barriers involved with forms of explanations, analytical propositions or
complex interventions and provide an alternate ap- experimental hypothesis and.
proach - The Triple C model - as a simple easy to use 4. It must be testable - this refers to that fact that
model for clinicians to use to implement interventions theory must be tested to support its concrete and
and support sustainability in clinical practice. Secondly, fit for purpose.
we will provide examples demonstrating the successful
use of the model across a range of health care settings The above framework was used to devise the compo-
and areas of practice including; wound care, medication nents of the model that explains the successful imple-
safety, palliative care, oncology and haematology. mentation of complex interventions in healthcare as
shown in Fig. 1.
Method
In order to develop the proposed implementation model,
we adapted the formal tradition of building a theory that Results
is described in sociology [36–38]. Within sociology, the- Barriers and facilitators of complex interventions in
ory is defined as multiple ideas that form the basis of health services
three types of conceptual work; describing, explaining A total of thirteen studies were identified from our search.
and predicting observed phenomena. We undertook a Several factors have been identified in the literature as
two-stage process. Firstly, a review of the literature on barriers and facilitators for implementing complex inter-
complex interventions and the available implementation ventions as shown in Table 1 [41–53]. Organisational bar-
models employed to embed these interventions. The lit- riers include organisational culture, support from
erature search included a search of three databases Med- leadership and the availability of resources. Other com-
line, Embase and Google Scholar using key terms such mon barriers across the studies included: education and
as, complex interventions, implementation methods/ training needs of staff, time constraints, complexity of
framework, sustainability and healthcare, barriers and fa- intervention, lack of staff engagement and poor manage-
cilitators. Full text of relevant articles were read and data ment and communication. Facilitators for implementing
were extracted and summarised in a table to identify the interventions included: sufficient resources, engagement
types of interventions, barriers and facilitators encoun- of stakeholders, staff involvement and support from
tered by the researchers. We used a scoping review meth- leaders and staff. Staffing issues were commonly cited bar-
odology where the subjects of the review were complex riers and facilitators than type of intervention [43–45, 48–
interventions, the concept was the barriers and facilitators 50, 53]. The complexity of intervention was only cited in a
of implementing them and the context was the health care few studies [41–53].
setting [39, 40]. A data extraction of these main character- Staffing issues are by far the most complex to address
istics was devised and presented in Table 1. when implementing interventions in health services as
opposed to organisational factors [57]. Several key fac-
Secondly, a framework was devised that encompassed tors were identified from the literature. Understanding
the findings from the scoping review into a simple and human behaviour, decision-making during critical situa-
workable model that can easily be embedded into every- tions and identifying sources of errors are key consider-
day practice and yet fit the criteria of a theory. We used ations and have the potential to influence the success or
a formal theory building used in sociology [54–56]. This failure of project implementation. Moreover, effective
framework was successfully used by other authors such teamwork requires cooperation, coordination and com-
as May et al., 2007 to build theories. It allows re- munication between the various team members [58]. Ef-
searchers to evaluate the generalisability of the frame- fective communication between and within teams
work to other settings and support congruence and enables cooperation and coordination. To support suc-
reliability in different situations [5, 6]. The criteria upon cess every member of the team requires an understand-
which the theory were built was as follows. ing of the purpose, team roles, responsibilities, task
requirements and the project plan. Trust in other team
1. It must have accurate description - this refers to members and sharing information are also essential to
the clarity of definitions used in the model, enable cooperation between teams [57–61].
Khalil and Kynoch BMC Health Services Research (2021) 21:143 Page 4 of 10

Table 1 Barriers and facilitators of project implementation

Study Country Interventions Barriers Facilitators
Bach- UK Evidence based interventions Organisational culture Engagement of central stakeholders,
Mortensen Lack of Support and expertise funders, clinicians
2018 [41]
Barnett 2011 UK Health care innovations Lack of quantitative evidence Interorganisational partnership
[42] The influence of human-based resources
the impact of organisational culture and
resources
Bird 2014 [43] UK Complex mental health Lack of staff skills to deliver the Ongoing support and supervision
interventions intervention Relevance to organisational culture and
Complexity of intervention values
Time constraints Cost benefit ratio
Lack of reimbursements and incentives
Bergs 2015 [44] Belgium Surgical safety checks Workflow adjustments as proposed by Good leadership
organisational structure Relevance of intervention and local
Staff perception context
Colvin 2013 South Task shifting interventions Lack of evidence about the intervention Teamwork
[45] Africa Lack of training, supervision and support
Ling 2012 [46] UK Integrating care Organisational structure Staff Involvement and support
Lack of Information technology Relationship between leaders
Financial arrangement
Governance
Humphries Canada In program management Organisational structure and process Successful individual interaction with
2014 [47] Organisational culture others in the organisation
Kormelinck Netherlands complex interventions for Communication and coordination Sufficient resources
2020 [48] residents with dementia between disciplines Openness to change (Organisational
Lack of Management support culture)
Unstable organisations Strong leadership and support of
High staff turnover champions
Perceived work and time pressure
McGinn 2011 Canada Electronic health care records Lack of time and workload proposed by Patient and health professional
[49] implementation the organisational structure interaction
The degree of difficulty of the
interventions
Pescheny 2018 UK Social prescribing services legal agreements Positive leadership and management
[50] staff turnover, staff engagement, Relationships and communication
Lack of infrastructure provided by the between partners and stakeholders
organisations
Verberne 2018 Netherlands Paediatric Palliative care Lack of clarity of tasks provided by The simplicity and clarity of the
[51] interventions leaders within the organisation intervention
The recognition of the need of the
intervention
Vlaeyen 2017 Belgium Fall prevention interventions Limited knowledge and skills Good communication
[52] Staffing issues Availability of resources
Poor management
Poor communication
Wood 2017 UK Collaborative care addressing Lack of role clarity improving inter-professional
[53] depression interventions communication

The synthesised model of implementation (the Triple the social relations and processes that will result in
C model) builds on these key staffing issues to enable outcomes.
successful implementation of complex interventions in It emphasises the processes by which complex inter-
health services as described in the next section [62]. ventions can be made practicable and embedded into
daily clinical care by underscoring the significance of
staffing issues. A three-stage implementation model was
Discussion devised based on the findings of the literature and
The development of the triple C model named the Triple C model (Consultation, Collaboration
The Triple C model proposes that to achieve successful and Consolidation) as shown in Fig. 2. The three stages
implementation in health services requires attention to of the model are in interconnected and overlap. As
Khalil and Kynoch BMC Health Services Research (2021) 21:143 Page 5 of 10

Fig. 1 Model development of the Triple C

opposed to other models, this model incorporates the culture. Examples of sustainability strategies include:
consideration of sustainability at all stages of the imple- long-term action plans, tracking of program adoption, fi-
mentation project. nancial planning and mapping of the community set-
Sustainability of interventions are a key factor for con- tings where interventions take place. Sustainability has
tinuous and successful change and can lead to reduction been defined in the literature as routinization, institutio-
in resistance to change and a shift in organisational nalisation, durability, maintenance and long-term

Fig. 2 The Triple C model (Consultation, Collaboration and Consolidation)

Khalil and Kynoch BMC Health Services Research (2021) 21:143 Page 6 of 10

follow-up of an implementation [10, 34, 57, 58]. Stirman been used extensively in health care [60]. A study by
and colleagues suggested that for an intervention to be Antonacci et al., 2018 highlighted the advantages of
sustainable certain core elements of the initial interven- using process mapping for planning projects in health
tion must be displayed and maintained after the initial care [11]. The authors highlighted five key factors for
implementation of the intervention [63]. Moreover, most successful process mapping including: appropriate and
researchers have conceptualised implementation to be easy visual representation of the project; information
the last step of any implementation process. The Triple collected from stakeholders; the ability of the facilitator
C model conceptualises sustainability as a set of pro- to gather ideas from those involved and capture them on
cesses that occur throughout the life cycle of any imple- the map; knowledge of software and equipment used if
mentation process. The continuous consultation, needed and the ability to follow-up any missing steps or
collaboration and consolidation supports that sustain- information throughout the process.
ability is not an end point but is a continuous process
whereby the three stages are interconnected and overlap
with each other to achieve sustainment [62]. The collaboration stage
Furthermore, health service research studies have in- The collaboration stage aims at identifying who should
creasingly recognised the value of adaptation in light of be involved in the project based on their skills, know-
the everchanging context of health care services. Adapt- ledge and contribution to the overall project. This stage
ability of an intervention to local context is necessary to requires a high level of communication and openness
support the usability and relevance of such interventions between team members. Nystrom et al., 2018 highlighted
[64]. The relationship between adaptability and sustain- the importance of collaboration on health projects from
ability has been discussed in depth by Shelton et al., an interdisciplinary perspective to support the success of
2018. Shelton and colleagues highlighted the importance the project [12]. Several collaborative approaches can be
of identifying barriers and facilitators to adaptability of used for successful implementation. These methods
an intervention to support its sustainability [10]. This is range from including higher degree students in the pro-
in addition to ensuring the core elements of the initial jects, clinicians having dual roles in the project as re-
intervention are still maintained. The Triple C model al- searchers and clinicians and involving staff from various
lows for adaptability and sustainability through the con- levels of healthcare [12]. The challenges of successful
tinuous engagement of project stakeholders. collaboration include lack of clarity around roles and re-
sponsibilities in the project plan, organisational changes
The consultation stage such as staff turnover, changing of policies or priorities
The consultation stage is typically the initial stage of any and cultural differences amongst the project team [43,
implementation model and this is where all stakeholders 51–53]. On the other hand, enablers of good collabor-
can prioritise their workflow and initiate ideas and sug- ation include established relationships, alignment of
gest areas for improvement. This stage should capture goals and priorities, skilled team members, clear com-
all the stakeholders’ priorities and map the pathway that munication, mutual trust and honesty between team
will be taken to support the successful implementation members as shown in Table 2 [41, 46, 52, 53].
of the project. A process map of the key steps involved
in the project supports a clear pathway of the project The consolidation stage
trajectory, areas for improvement and monitoring as This stage is the most crucial step in the model as it
shown in Table 2. To date, process mapping has not supports the sustainability of the project and its

Table 2 The components of the Triple C model

Stages of the Triple C model Enablers
Consultation • Prioritising of ideas
• Identification of areas of improvement
• Design of a process map
Collaboration • Clarity around roles and responsibilities
• Understanding of organisational change
• Culture of the organisation
Consolidation • Standardising policies and protocols
• Eliminating variances between policies and practice
• Right staff mix with appropriate skills
• Knowledge of patients’numbers
• Sufficient resources
• Business Intelligence tools
Khalil and Kynoch BMC Health Services Research (2021) 21:143 Page 7 of 10

incorporation into routine clinical care [3, 24]. This and a map of operations for the project delivery. Suffi-
stage may involve refinement of the initial ideas to sup- cient resources were made possible by engaging multiple
port their successful adaptability to the local context stakeholders early in the project through both in kind
while still leaving the core elements of the initial project and financial resources. The collaboration stage was cru-
unchanged. This stage is also done in each of the other cial as this project involved several organisations and
earlier stages with the refinement process, consultation training programs to support the successful delivery of
and collaboration are employed to support agreement the project across the multiple sites. A train-the-trainer
about the project steps and its success. Consolidating program was devised to support efficient implementa-
successful interventions in a dynamic health service is tion of the program. The consolidation stage involved
challenging as it requires the use of a number of strat- several steps such as standardising policies and proce-
egies, adapted to local context, that need to all work in dures across all sites on management of wounds across
sync. This process needs a few steps as follows; firstly, the rural region and the establishment of a regional
standardising policies and protocols across the health wound consultant role to oversee the project after its ex-
care setting to support minimal variability across depart- piry. These strategies were chosen by the project team
ments; secondly, eliminating variances between policies to support long-term sustainability of the program. This
and practices to support that processes are understood was in addition to continuous data collection across the
and orderly. Thirdly, having the right staff mix, with the sites to promote quality monitoring of wound healing
appropriate skills and experience at all times; fourthly, and costs and its consistency with the initial plan of the
having an idea about expected patient numbers that will project [66].
benefit from the proposed intervention and ensuring The second project where the Triple C model was
that resources are available to meet any possible increase used was in the implementation of a medication safety
in numbers [3, 24]. Finally, having access to business program in an Aboriginal health organisation in a large
intelligence tools such as deidentified patients data on regional area in Australia [67]. This project employed a
patients care, real time prescribing data and online clin- three-stage approach. The first stage was consultation
ical improvement tools to continue and refine outcomes where interviews were conducted with staff and Aborigi-
based on real time numbers is crucial for the success of nal health professionals to identify problems with medi-
this step as shown in Table 2. cation issues in the Aboriginal community. The results
All the elements discussed above on each of the three from these interviews have informed a process map
stages of the Triple C model have been mentioned by about the intervention to address the needs identified in
Proctor et al., 2015 to support sustainability of interven- the consultation stage [68]. The collaboration stage con-
tions [35]. The authors suggested that for sustainability sisted of identifying the staff mix to deliver the interven-
of evidence-based interventions to occur, various factors tion. In this case, it was a medication safety program
need to be included in implementation models and these which consisted of staff training and development of
are training and funding, context, definitions and policies addressing medication safety to be made avail-
conceptualization and measurement and analysis. These able for all staff through an online platform. Embedding
factors have been captured by the above three stages the program into staff training and policy were strategies
through having the right skills mix of staff and re- identified by the project team to support sustainability.
sources, clarity of responsibilities, process mapping and The consolidation stage of the project involved collation
having access to business intelligence tools respectively of data regarding satisfaction with the program and
as detailed in Table 2 for each of the above stages [35]. medications incidents [67, 68].
Another project where the Triple C model was
Examples of using the Triple C model in health services employed was the development of a skills matrix to
research identify areas of need to upskill palliative care nurses
The Triple C model has been used in several projects to [69]. Sustainability was considered from the outset of
verify its fit for purpose and to support its applicability the project as the overall objective was to design and de-
to implementation science. This is the final stage of liver educational programs that are relevant to the needs
building a theory as stated above. The Triple C model of palliative care staff across a large rural region involv-
was used in the successful implementation of an elec- ing several organisations. The project started with sev-
tronic wound care program across several organisations eral consultation sessions addressing the training needs
to track would healing and costs in rural Victoria in of staff involved in several organisations. Once the needs
Australia [65-70]. The authors were able to show a sig- were identified, a process map regarding the delivery
nificant improvement of wound healing times and de- and implementation of the intervention was designed
creasing dressing [66]. The researchers used the which included the development of a skills matrix to be
consultation stage to identify priority areas of research used by managers for individual staff appraisals and to
Khalil and Kynoch BMC Health Services Research (2021) 21:143 Page 8 of 10

identify their training needs and their levels of progress were mapped followed by a framework design incorpor-
throughout the year, as the training occurs. The consoli- ating the findings. The design of the framework was
dation stage involved the use of this matrix as a standard adapted from a sociology theory building concept based
form for staff appraisals and discussion about opportun- on description and explanation of the key concepts in-
ities for future improvements [69]. volved followed by aligning of the knowledge formed
A final example of a project using the Triple C model with evidence from the literature. Further elements to
in practice was the implementation of the validated Dis- the model was added to support its sustainability and
tress Thermometer to improve identification, assessment these were adaptability to local context and the intro-
and management of distress in the cancer care inpatient duction of business intelligence tools to support its con-
wards. This project was the result of a clinical incident tinuous improvement and becoming embedded into
and a root cause analysis recommendation. The setting practice.
for the project was the private and public inpatient on-
cology wards at a large tertiary referral hospital. Initially,
Abbreviations
the project involved consultation with all identified Triple C: Consultation, Collaboration and Consolidation
stakeholders to support BUY-in and to identify areas for
improvement across the public and private settings. Acknowledgements
The authors would like to thank the participants of all studies included in the
Next, a procedure for management of patient distress in implementation of the Triple C model.
the oncology inpatient setting was developed in collabor-
ation with multidisciplinary teams across oncology in- Authors’ contributions
HK designed the study, undertook the databases searches, drafted the
cluding; nurses, doctors and social workers. Staff were manuscript, HK and KK undertook the data analysis and data extraction. Both
involved in the development of strategies that would be authors read and approved the final manuscript.
used to change practice including initiatives such as
Funding
regular education sessions on identifying and managing None.
distress for patients admitted to the cancer care in-
patient wards and debrief sessions for staff where at-risk Availability of data and materials
Not applicable.
patients could be identified. The consolidation stage
which considered the sustainability of the implemented Ethics approval and consent to participate
interventions involved modifications to existing clinical Not applicable.

documentation as well as the availability of a patient in- Consent for publication

formation brochure for patients and families to support Not applicable.
sustainability of the changes [70, 71].
Competing interests
The authors declare that they have no competing interests.
Limitation of the model
While this model is adaptable to many contexts as Author details
1
School of Psychology and Public Health, La Trobe University, Level 3, 360
shown above by the variety of projects, its utilisation will Collins Street, 3000 Melbourne, Vic, Australia. 2Evidence in Practice Unit and
be limited by the resources available and time needed The Queensland Centre for Evidence Based Nursing and Midwifery, A JBI
for each project. In addition, capacity and capability of Centre of Excellence, Mater Health, Brisbane, Australia. 3The Queensland
Centre for Evidence Based Nursing and Midwifery, A JBI Centre of Excellence,
staff involved in the implementation will influence suc- Adelaide, Australia.
cessful use of the model. The availability of the business
intelligence tools is also a limitation if electronic medical Received: 28 September 2020 Accepted: 24 January 2021
records are not embedded in the hospital system or if
there is no method of collecting data automatically as References
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