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BMC Health Serv Res. 2019 Oct 22;19(1):730. doi: 10.1186/s12913-019-4591-2.

Implementation of a national policy for improving health and social care: a comparative case study using the Consolidated Framework for Implementation Research.

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Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.
Department of Public Health Analysis and Data Management, Public Health Agency of Sweden, SE 171 82, Solna, Sweden.
Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.
Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, SE 901 87, Umeå, Sweden.
Center for Epidemiology and Community Medicine, Stockholm County Council, SE 171 29, Stockholm, Sweden.



Comprehensive policies are becoming common for addressing wicked problems in health and social care. Success of these policies often varies between target organizations. This variation can often be attributed to contextual factors. However, there is a lack of knowledge about the conditions for successful policy implementation and how context influences this process. The aim of this study was to investigate county-level actors' perspectives on the implementation of a comprehensive national policy in three Swedish counties. The policy focused on developing quality of care for elderly based on the use of national quality registries (NQRs) and to improve coordination of care.


A comparative case study approach was used. Data was collected longitudinally through documents and interviews. The Consolidated Framework for Implementation Research (CFIR) guided the analysis.


All three counties shared the view that the policy addressed important issues. Still, there was variation regarding how it was perceived and managed. Adaptable features-i.e., NQRs and improvement coaches-were perceived as relevant and useful. However, the counties differed in their perceptions of another policy component-i.e., senior management program-as an opportunity or a disturbance. This program, while tackling complex issues of collaboration, fell short in recognizing the counties' pre-existing conditions and needs and also offered few opportunities for adaptations. Performance bonuses and peer pressure were strong incentives for all counties to implement the policy, despite the poor fit of policy content and local context.


Comprehensive health policies aiming to address wicked problems have better chances of succeeding if the implementation includes assessments of the target organizations' implementation capacity as well as the implicit quid pro quos involved in policy development. Special attention is warranted regarding the use of financial incentives when dealing with wicked problems since the complexity makes it difficult to align incentives with the goals and to assess potential consequences. Other important aspects in the implementation of such policies are the use of collaborative approaches to engage stakeholders with differing perspectives, and the tailoring of policy communication to facilitate shared understanding and commitment.


CFIR; Consolidated framework for implementation research; Elderly care; Implementation; Large-scale change; National quality registry; Policy; Wicked problems

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