- There can be no one-size-fits-all approach to successful implementation due to the relationships between the technical, human, and organisational factors in complex care settings such as aged care.
- Various human factors, such as how people think and feel about technology, can affect how they interact with a new product and whether they accept and use it. Characteristics of the organisation and features of the product to be implemented can also influence its use.
- Effective implementation requires careful planning to ensure any potential barriers to success are anticipated, and either avoided or reduced.
- A technology implementation project within an aged care setting may benefit from having an implementation plan in place to guide considerations and processes. This plan may be simple or elaborate, depending on the type of product and the number of people and processes affected by its introduction.
- Conducting a needs assessment, developing a business plan, creating a communication strategy, and considering potential barriers and enablers to success ahead of implementation may improve the likelihood of product uptake and acceptance.
During the implementation phase of a technology project, a product is formally introduced and begins to be used under real-world conditions and circumstances by its intended users.  Depending on the complexity of the technology, this phase might require a range of structured activities aimed at increasing acceptance by end-users and integrating it into routine use where it may deliver on its promised benefits. 
Effective implementation requires careful planning to ensure any potential barriers to success are anticipated, and either avoided or reduced.  Ideally, planning for implementation begins in parallel with, or is firmly based on, the needs assessment and design phases. [1, 4] This ensures the focus of implementation remains on users and their needs, as well as the organisation's strategic goals. [3, 5] Ongoing monitoring activities throughout the implementation project are also critical for identifying problems as they arise and adapting the product or adopting processes to counter them. 
A technology implementation project aims to introduce a new product in a way that increases its chances of being used as intended and delivering on its expected benefits.  All activities up to this point—the needs assessment, the business case, and the design and testing process—have been laying the groundwork for successful implementation.
In a well-planned implementation project, end-users will have a clear understanding of the purpose of a technology and how it relates to their needs, values, and goals. At a very early stage, the project team will have identified potential barriers to success, such as staff or care recipient resistance, and put strategies in place to counter them. Therefore, at the end of the implementation phase, the product is more likely to be:
- Fit for its intended purpose in the local context
- Accepted by its intended users
- Perceived by end-users to be easy to access and use
- Consistently used in a way that optimises outcomes of importance
- Supported by the organisation’s leadership team
- Considered a good return on investment with benefits exceeding costs. 
Potential barriers to successful implementation exist across all phases of a technology acquisition (or development) project.  Some of the common individual, organisational, and technology-related barriers are outlined below, followed by suggestions for reducing their risk for successful implementation of the product.
Individual (or ‘human’) factors
Various human factors, such as how people think and feel about technology, can affect how they interact with a new product and whether they accept and use it. 
Negative attitudes towards technology
People can have negative attitudes about technology, either generally or about a specific product. This may be for a range of reasons. Some may expect a technology to be difficult to use without having tried it, or based on negative past experiences.  Others might not believe in its promised benefits, feel it is not suitable for them, or expect it to be burdensome to engage with.  Staff may also have negative attitudes towards technology if they view it as a threat to their job security. 
People receiving care may worry about increased dependence on technology or fear a particular type of technology, such as a monitoring device with a built-in camera, might violate their privacy.  Some may view visible alarms or monitors worn on the body as stigmatising evidence of decline.  Informal carers may resist working with a technology for reasons related to ethnicity or culture, or if they perceive it to represent an additional workload , (e.g., constantly monitoring reminder systems).  People with dementia may not see a product as appropriate for their needs or expect more from it than what it can realistically offer. 
Lack of knowledge, skills, or confidence
People with limited previous exposure to technology are also less likely to want to engage with it.  They may expect it to be challenging or fear the consequences of making mistakes. Lack of digital literacy (or ‘tech savviness’) can be a major barrier to technology adoption that should be assessed and planned for within the aged care setting. 
People may reject or be reluctant to engage with a technology for ethical reasons. Clinical staff might, for example, view the introduction of telehealth consultations as a threat to their professional autonomy or a risk to patient safety due to the inability to conduct an accurate physical examination. Care recipients or their informal carers might view constant monitoring or tracking technologies as restricting their freedom or privacy.  Technologies may also raise personal or data security concerns.  Older people may see some overt devices designed to keep them safe as drawing attention to their limitations and dependency, thereby stigmatising, or infantilising them.  For many older people in aged care, decisions around the use of technologies may be made for them, rather than involving them, thereby reducing their autonomy and freedom to choose. 
In the aged care context, technologies to be used by the care recipient may be rejected due to physical and/or cognitive decline, frailty, or vision or hearing impairment.  It is therefore important to introduce technologies that have been specifically designed for older people and in collaboration with them. This includes people with a range of impairments that may limit their ability to operate a device or engage with a digital program.
An organisation’s structure, culture, procedures, or policy environment can also impede implementation success, often through inadequate planning for this phase.
Strong leadership commitment to a project is shown to be a key factor in implementation success. [15, 16] This support is demonstrated by effective communication regarding the purpose and value of the technology,  as well as visible leadership involvement in implementation processes.  Leaders can show support by:
- Providing staff with clarity around their roles and responsibilities
- Introducing policies and procedures that help people understand and accept new workflows and processes
- Endorsing the time and resources needed for end-user training and ongoing monitoring for quality improvement. 
Engagement with stakeholders
Preparing an organisation for change is an important part of planning for the implementation of a new product.  This means engaging with those likely to be affected by the introduction of a new technology and communicating about the potential benefits, trade-offs, how the change might affect them, and what the anticipated timeline is. Without this information, people may be less incentivised to adopt the product.  Part of the implementation plan should focus on ensuring end-users from each stakeholder group are involved at each stage of the process to improve acceptance and promote a sense of ownership. [15, 19]
If implementation projects are inadequately funded, this may compromise the technical quality of the product or the infrastructure to support it. For example, there may not be enough physical workstations for staff to input data into a new clinical data management system, or newly introduced mobile devices or telehealth might be rendered unreliable by low bandwidth or Wi-Fi blackspots.  Funding requests, which form part of the business case, should also allow for more than the capital outlay on the technology. They should factor in ongoing technical support from the vendor (or design support from a developer), [19, 20] the potential time and resources needed to optimise the technology and train end-users,  and the capacity for continued monitoring of the product’s use, benefits, and costs. 
Insufficient provision of training and support
Implementation efforts need to be underpinned by adequate resources for staff or care recipient training. People also need time to gain confidence and proficiency in using new products.  This includes preparing for increased technology engagement by gauging the digital readiness of the workforce or care recipients ahead of implementation. It also includes the provision of responsive mentors, support groups, or champions that people may turn to at the point of need. Without adequate planning for the human factors that hamper uptake, people are unlikely to use a product, or not use it to its full potential.
Implementation projects need to include mechanisms for tracking how well the product has been implemented into the organisation or a care recipient’s routine. This feedback is needed on an ongoing basis to maintain or improve, the fit between the technology and its intended purpose.  It is also needed as evidence that the technology provides value for money and should therefore continue to be maintained by the organisation. However, monitoring requires a reasonable period of time  as potential benefits may not be immediately apparent. 
The project team can obtain valuable information about the use and acceptance of a technology through verbal or written feedback from stakeholders. Meanwhile, objective, clearly defined and measurable indicators may provide evidence of effectiveness.  These indicators may be especially illuminating when benchmarked against an old process. For example, an organisation might choose to record:
- The number of times a technology is used to provide care (e.g., resident telehealth consultations with a general practitioner versus practitioner visits to the facility).
- The quality of electronic data compared to the utility and quality of a paper-based system
- The number of times a technology has impacted resident safety
- The time it takes to complete a new digital process compared to the former analogue one
- Important outcomes for care recipients such as increased levels of engagement when using a virtual reality program.
It is also important to monitor the quality of the implementation process to know if the technology has been implemented successfully, or if more work is required. This might be done by asking end-users and other stakeholders about their perceptions of training and the introduction of new processes.  Another evidence theme in this series (Monitoring use over time) provides more information on this topic.
For effective implementation, people must be able to work with the product. Ideally, any flaws in hardware, software, functionality, or content would be detected before the implementation phase if enough attention has been paid to multi-step user testing with real end-users representing all stakeholder groups. [19, 20, 23] However, if the testing phase has been overlooked, the product may not work optimally or be too complex. Design problems that may appear during the implementation phase include:
- Lack of user-friendliness or technology that is cumbersome or time-consuming to use 
- Complex access requirements, including passwords and authentication procedures 
- Poor use of language or navigation features on a web product 
- Inflexible products that cannot be personalised and adapted to end-user needs 
- Highly complex technologies (e.g., electronic health record systems) requiring onerous training and retraining sessions 
- Lack of interoperability between systems that need to work together for optimal workflow.  Ideally, there should be seamless interconnection between devices and data across the aged care organisation. 
- Products that do not meet regulations, national or international standards, or policies to address privacy and security concerns. 
The implementation phase should not focus solely on the new technology and its functionality. This is also an opportunity to assess any issues end-users are experiencing with it and work with them to resolve them.  By anticipating some of the common barriers to implementation success, the project team can devise and document strategies for preventing them or mitigating their impact at the outset.
Having a communication plan
People may be less resistant to the introduction of a new technology if they understand the reasons why it is needed, how it may benefit them personally, and if it will affect their work or routines.  This highlights the importance of using a communication strategy to keep people informed and engaged with a project of this kind, rather than assuming they will automatically understand its goals. This strategy should, ideally, originate with the leadership group and run across the duration of the project.  The communication strategy can help to ensure messages are clear, consistent, and appropriately tailored to each stakeholder group. Each message might give the ‘big picture’, reiterate the problem being improved by the technology, and explain how its features and functionality align with the values and needs of individuals and the organisation.  Benefits, potential trade-offs, and anticipated timelines should also be described using realistic terms to keep expectations in check. [15, 19] Managing expectations from the start is important as any discrepancies between people’s expectations and actual functionality can lead to a lack of acceptance. 
Communication should work in two directions. People are more likely to engage with an implementation project if they believe their input is valued.  The perspectives of those closest to the product are also likely to reveal initial issues with processes or something potentially missing in care delivery.  For these reasons, the implementation team should consider building feedback mechanisms across all stages of the project that people are aware of and encouraged to use.
Appointing local champions—individuals who volunteer or are appointed to ‘enthusiastically’ promote and facilitate the implementation of an innovation —may also work to overcome resistance in an organisational context.  These local leaders might be respected colleagues and end-users rather than management.  Ideally, a champion will work between the different levels of an organisation including management, clinical, and information technology (IT) staff groups. [15, 19]
Offering incentives and rewards
Some staff may be more motivated to adopt a change brought by technology if offered incentives or rewards. [3, 31] These could be in the form of money, prizes (e.g., vouchers), or simple public acknowledgement of their efforts.
Assessing digital readiness
An organisation might assess staff ability and readiness for working with digital technologies ahead of an implementation project using a tool such as Be Connected Network’s Digital Skills Checker. Tools of this type can highlight gaps in knowledge that might be targeted for pre-implementation training (e.g., the ability to use an app on an iPad to input resident data).
The digital readiness of the organisation and its overall capacity to support new technologies are also important factors in implementation success. This may require adopting cloud capabilities or introducing or extending broadband and Wi-Fi access across residential facilities. 
Providing time to familiarise
Another strategy to support people to engage with a product is to give them ample and unpressured time to familiarise themselves with it before the formal implementation stage begins. [10, 19] Lack of time to learn to use a technology effectively has been highlighted as a major barrier to staff, care recipients, and informal carer uptake of new technologies in Australian aged care settings.  Allowing people time to practice, play around with the product, ask questions, and make mistakes without consequences, can gradually increase confidence. For example, evidence suggests that people with dementia and their informal carers are more likely to accept and use telehealth technologies if they receive help setting up the equipment at home and are given training and time to familiarise themselves before any scheduled appointment. 
Ongoing training and support
Other strategies that are important to helping people engage with a new technology include:
- Engaging, hands-on training tailored to the individual roles of users, offered continually to keep skills fresh 
- Instruction manuals, guidelines, or workflow processes that have been tested by people with a range of skills levels and kept up to date
- Staff or care recipients who are willing to serve as mentors to less confident users, being available to demonstrate, solve problems, and answer questions as they arise [6, 7, 34]
- User support groups during and after implementation 
- Implementing a technology associated with complex workplace changes in phases rather than all at once. 
According to Cresswell , training during implementation should consume about 40% of the implementation budget but rarely reaches this proportion. This highlights the need to adequately resource the training phase within the business case and planning stage of implementation.
Rather than a single, one-off event, implementation is something that occurs over time in stages. These stages may overlap, and their timing and order will depend on organisational needs and context, as well as the complexity of the project. Some flexibility is needed because unforeseen setbacks, such as product failure, can also send a project back to an earlier stage.  One guideline for implementation  divides the process into four simple stages:
- Engage and explore
This involves communicating with stakeholders, setting up a team, assessing readiness, and considering barriers and enablers.
- Plan and prepare
This includes developing the implementation plan, deciding how to monitor progress, and starting to prepare people for the implementation through communication, training, or practice opportunities.
- Initiate and refine
Here the technology is introduced and continuously monitor and improved.
- Sustain and scale
Here the technology is fully embedded into ‘business as usual’ with the option to extend its range further (scale-up), if appropriate.
A documented plan for implementation can keep the project on track and help to anticipate and counter barriers at an early stage. Naturally, more complex technology projects will require more elaborate and detailed plans. The list below provides suggestions for what might be considered in the implementation plan.
Establishing a governance structure for an implementation project that documents lines of responsibility can prevent any confusion over roles, tasks, and resources required during the implementation phase. The governance structure might cover:
- Those responsible for developing and managing the implementation process. Ideally, the project manager will be trained, skilled, or experienced in project management involving multiple stakeholder groups. 
- Members of the project team
- Methods for managing project documentation
- The anticipated start date
- The anticipated outcomes of the implementation process
- The roles needed to support the implementation process and the responsibilities to be assigned to each role
- The resources needed to fully support the project during its duration. 
For each process during the implementation phase, it may be helpful to document:
- What the process entails (e.g., providing staff training, updating manuals, monitoring outcomes) and who should be involved
- The goals of the process (e.g., to ensure staff supporting a telehealth service know how to adjust the audio-visual quality to account for sensory impairments)
- The financial, physical, human, and/or IT resources needed
- The person(s) responsible for the process
- Anticipated timelines.
The communication strategy
In developing a communication strategy within the implementation plan, the project team might consider asking:
- Who are the stakeholders in this project and what are their needs and values? (If not already determined by an earlier needs assessment.)
- What are the key messages that should be communicated to each stakeholder group?
- Who will communicate the project to stakeholders using the language of their needs and values? (e.g., a manager or the leadership team, an elected ‘champion’). Early messages might include:
- What is the rationale for introducing the technology?
- What benefits can be realistically expected?
- What might the trade-offs be?
- What is the expected timeline of the project?
- How and when will messages be scheduled to keep stakeholders informed and engaged with the process?
- What mechanisms should be used to engage with stakeholders? (e.g., meetings, emails, newsletters)
- How will stakeholders provide feedback and how will the feedback be acknowledged and used?
Other implementation plan considerations
In addition to governance and communication plans, the following considerations (many covered in the business case) might be documented in the implementation plan:
- What are the key milestones for reporting on deliverables and expenditures?
- How and when will the outcomes of the implementation be measured to demonstrate progress and impact?
- What are the anticipated barriers to success? What strategies will be used to increase technology acceptance and appropriate use?
- What are the risks to the project (e.g., change fatigue, staff turnover)?
- Will the team assess staff or care recipient/carer digital readiness? How will this be done?
- Will pre-implementation training be conducted to help familiarise end-users with the product?
- What will formal implementation training entail?
- Will incentives or rewards of any kind be offered to end-users?
- Are mentors or a user support group required for ongoing support?
- Is a manual or guideline for appropriate use required? How will they be made available? Who will develop and maintain these supporting resources and who will test them for clarity and accuracy?
- How will new processes and workflows be documented and tested with different end-users?
If the product is central to operations, it may be important to have a backup plan organised (or pre-planned workarounds) in case the product does not work at all at the implementation stage. 
A technology implementation project within an aged care setting may benefit from having an implementation plan in place to guide considerations and processes. This plan may be simple or elaborate, depending on the type of product and the number of people and processes affected by its introduction. There can be no one-size-fits-all approach to successful implementation due to the relationships between the technical, human, and organisational factors in complex care settings such as aged care.  However, conducting a needs assessment, developing a business plan, and considering potential barriers and enablers ahead of implementation may improve the likelihood of product uptake and acceptance. 
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