title: Improving Fidelity of Translation of the Stepping On Falls Prevention Program through Root Cause Analysis.
abstract: BACKGROUND
  Fidelity monitoring is essential with implementation of complex health interventions, but there is little description of how to use results of fidelity monitoring to improve the draft program package prior to widespread dissemination. Root cause analysis (RCA) provides a systematic approach to identifying underlying causes and devising solutions to prevent errors in complex processes. Its use has not been described in implementation science.
  
  
  METHODS
  Stepping On (SO) is a small group, community-based intervention that has been shown to reduce falls by 31%. To prepare SO for widespread U.S. dissemination, we conducted a pilot of the draft program package, monitoring the seven SO sessions for fidelity of program delivery and assessing participant receipt and enactment through participant interviews after the workshop. Lapses to fidelity in program delivery, receipt, and enactment were identified. We performed a RCA to identify underlying causes of, and solutions to, such lapses, with the goal of preventing fidelity lapses with widespread dissemination.
  
  
  RESULTS
  Lapses to fidelity in program delivery were in the domains of group leader's role, use of adult learning principles, and introducing and upgrading the exercises. Lapses in fidelity of participant receipt and enactment included lack of knowledge about balance exercises and reduced adherence to frequency of exercise practice and advancement of exercise. Root causes related to leader training and background, site characteristics and capacity, and participant frailty and expectations prior to starting the program. The RCA resulted in changes to the program manual, the training program, and training manual for new leaders, and to the methods for and criteria for participant and leader recruitment. A Site Implementation Guide was created to provide information to sites interested in the program.
  
  
  CONCLUSIONS
  Disseminating complex interventions can be done more smoothly by first using a systematic quality improvement technique, such as the RCA, to identify how lapses in fidelity occur during the earliest stages of implementation. This technique can also help bring about solutions to these lapses of fidelity prior to widespread dissemination across multiple domain lapses.
authors.affiliation: Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health , Madison, WI , USA.
authors.forename: Jane E
authors.initials: JE
authors.lastname: Mahoney
authors.affiliation: Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health , Madison, WI , USA.
authors.forename: Vicki L
authors.initials: VL
authors.lastname: Gobel
authors.affiliation: UW Health Department of Orthopedics and Rehabilitation , Madison, WI , USA.
authors.forename: Terry
authors.initials: T
authors.lastname: Shea
authors.affiliation: UW Health Department of Orthopedics and Rehabilitation , Madison, WI , USA.
authors.forename: Jodi
authors.initials: J
authors.lastname: Janczewski
authors.affiliation: The Greater Wisconsin Agency on Aging Resources, Inc. , Madison, WI , USA.
authors.forename: Sandy
authors.initials: S
authors.lastname: Cech
authors.affiliation: Ageing, Work and Health Research Unit, Faculty of Health Sciences, University of Sydney , Sydney, NSW , Australia.
authors.forename: Lindy
authors.initials: L
authors.lastname: Clemson
keywords: Stepping On; dissemination; falls prevention; implementation; root cause analysis