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221 Assessing fidelity of shared decision making in clinical encounters: development of an implementation fidelity approach using an electronic conversation aid for cardiovascular risk prevention
  1. Jennifer L Ridgeway1,2,
  2. Maggie M Paul2,
  3. Victor M Montori1,3
  1. 1Knowledge and Evaluation Research Unit, Mayo Clinic, Minnesota, USA
  2. 2Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Minnesota, USA
  3. 3Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Minnesota, USA


Introduction Several instruments have been developed for observer assessment of shared decision making (SDM) in clinical encounters. However, most do not address implementation of SDM conversation aids in clinical workflows or the potentially moderating effect of implementation on SDM. The objective of this work was to develop an approach for assessing SDM implementation fidelity in a hybrid implementation-effectiveness study of SDM for cardiovascular risk prevention in three U.S. healthcare systems.1

Methods Literature was reviewed to identify conceptual models of implementation fidelity to map onto items from existing SDM observation checklists; new items were written as needed, guided by the SHARE approach.2 The study team reviewed 10 encounter videos to identify additional aspects of fidelity.

Results The literature review identified one conceptual model explicitly addressing implementation fidelity.3 The model and video review were used to further develop items in three domains (tool implementation, quality of delivery, and participant responsiveness). Other potential data sources related to implementation fidelity were also mapped to the model, including patient and clinician survey reports. The instrument (Observed SDM Implementation Measure, OSIM) was reviewed by six social scientists and clinician investigators with expertise in SDM.

Discussion Inclusion of implementation factors in observation of SDM fidelity can provide insights into how and why SDM conversations occur and inform strategies to bolster adoption and routine use of SDM tools. A reliable and valid measure of fidelity of use at the point of care is essential for theory- based analyses of fidelity in implementation studies of SDM encounter tools.

Conclusion Videorecorded encounters identified aspects of SDM tool implementation that may impact SDM and contributed to a new instrument (OSIM) to assess observed fidelity of use. The adapted conceptual model and resulting instrument also serve as guides to identifying other implementation moderators not observable in encounters.


  1. Ridgeway JL, Branda ME, Gravholt D, Brito JP, Hargraves IG, Hartasanchez SA, Leppin, AL, Gomez, YL, Mann, DM, Nautiyal, V, Thomas, RJ, Behnken, EM, Torres Roldan, VD, Shah, ND, Khurana, CS, Montori, VM, Increasing risk-concordant cardiovascular care in diverse health systems: a mixed methods pragmatic stepped wedge cluster randomized implementation trial of shared decision making (SDM4IP). Implement Sci Commun. 2021;2(1):43.

  2. Carroll, C, Patterson, M, Wood, S Booth, A, Rick, J, Balain, S, A conceptual framework for implementation fidelity. Implementation Sci. 2007;2(1):1–9.

  3. Hargraves, IG, Fournier, AK, Montori, VM, Bierman, AS, Generalized shared decision making approaches and patient problems. Adapting AHRQ’s SHARE Approach for Purposeful SDM. Patient Educ Couns. 2020;103(10):2192–9.

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