Assessing the implementation level of advance care planning– the first comprehensive fidelity scale

Assessing the implementation level of advance care planning– the first comprehensive fidelity scale | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing the implementation level of advance care planning– the first comprehensive fidelity scale Siri Faerden Westbye, Maria Romøren, Marc Ahmed, Karin Berg Hermansen, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3610212/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Many studies report that the implementation of advance care planning (ACP) is low, but we lack an instrument to actually measure this. Implementation fidelity can be such a tool and refers to the degree to which an intervention or program is delivered as intended. This method has rarely been used in trials where ACP is the intervention, and if so, only studying parts of fidelity. Methods We developed and employed the first comprehensive fidelity-scale to measure ACP practice in hospital units. The scale was used in a cluster randomized controlled trial to measure baseline implementation of ACP in the routine care for acutely admitted patients in 12 geriatric units. The scale consists of 22 items that are scored from 1 to 5, where 1 equals no implementation, and 5 equals full implementation. Data was analyzed using descriptive statistics and calculation of interrater reliability. Results The mean score was 1,16 for the total scale. The few items that had a higher score were the item on program philosophy, which was known to devoted professional individuals, but not owned by entire units. Furthermore, parts of what would constitute good quality of the intervention where in place in some units, but do not represent a systematic practice. As a measure of interrater reliability, the intra-class correlation coefficient was 0,99. Conclusions The level of implementation of ACP was generally low. Our novel fidelity scale shows promising preliminary psychometric properties and may prove to be a useful tool to guide the implementation strategy to accelerate the implementation of ACP in health care. advance care planning implementation science fidelity health care services autonomy older patients geriatrics Background The implementation problem of advance care planning (ACP) ACP is defined as a process that supports patients in understanding and sharing their personal values, life goals, and preferences regarding future medical care to help ensure that people receive medical care that is consistent with them (1). Although the effectiveness of ACP has been debated (2), particularly the potential to improve goal-concordant care (3-5), by large the recent summary of evidence supports the potential of ACP to support the involvement of older patients and their caregivers and improve communication. A 2021 systematic review found that 88 % of studies showed positive impact upon patient-surrogate/clinician congruence. They found that 100 % of studies had a positive impact on patients/surrogate/clinician satisfaction with communication, and 75 % had a positive impact on surrogate satisfaction with patients' care (4). The newest and largest review to date (5) also found consistent evidence that ACP interventions improve patient–physician communication (68 %), preference for comfort care (70%), decisional conflict (64%) and patient-caregiver congruence in preference (82%) (5). However, the implementation of ACP seems to be low. This has been raised as an important problem by many (3, 6-12). A further and fundamental problem is that we have not yet been able to reliably assess the level of implementation of ACP either. Implementation fidelity Measuring implementation fidelity is used to measure levels of implementation of evidence-based practices (13). Fidelity can be defined in different ways. The narrower definition relates individually and exclusively to the intervention. A broader definition includes adherence to an intervention; but also to capture a "comprehensive" or "more complete picture" of the implementation process (14). Most fidelity research focuses solely on adherence to the intervention (14). The few fidelity-studies that have been conducted for ACP also define and study fidelity only relating to the intervention (15, 16). In this study we decided to develop a fidelity scale based on the broad definition of fidelity which – to our knowledge - has not been done in any previous study. Thus, we aim to measure both fidelity to the intervention and to the implementation to give a more comprehensive measure. Complex interventions ACP is a complex intervention because it contains several interacting components at different levels (17). But implementation support for ACP is likely to be a complex intervention in itself, because it is also characterized by a number of interacting components, and a degree of flexibility or tailoring to local circumstances (17). The concept of complex intervention has been developed mainly to evaluate interventions (17). However, the concept is also relevant to develop implementation strategies. As such, there is a need for evaluation methods that embrace the complexity of the intervention to be studied, as well as implementation strategies corresponding to the same complexity. To improve the involvement of older patients in medical care, we needed a systematic and comprehensive assessment of the current level of implementation of ACP. The research question of this study is therefore: Can we develop an instrument that has the psychometric properties needed to assess the complexity of implementation of ACP? And if yes, what is the current implementation level of ACP? To our knowledge, this paper describes the first systematic, comprehensive, and broad investigation of ACP to date. The aim of this article is both to present this new fidelity scale and to report the results from the baseline assessment used to test the scale. We present the fidelity scale it in this article, including the methodology for developing the scale, the evidence-base for the scale, the validation process, the pilot and the testing at baseline. Material and methods Study design, setting and participating sites This is a cross-sectional sub-study part of a larger trial. The trial uses a cluster randomized controlled design (study protocol submitted). We tested the scale through doing measurements in the clusters in the intervention arm and control arm at baseline. A cluster was defined as an acute geriatric unit or internal medical unit with a geriatrician among staff. The reason for choosing geriatric units was that we met considerable motivation and interest for ACP in these units. Twelve out of fifteen eligible units in the South-Eastern Norway Regional Health Authority agreed to participate, covering a catchment area of over 2 million inhabitants. We considered this a good foundation for further spreading the implementation of ACP to larger parts of the services. ACP is still pioneering work in Norway, and there are multiple barriers to its implementation explored in a separate paper. The main reason given for non-participation among the remaining units was a lack of time and staff. Table 1 sums up the characteristics of all the clinical sites. The baseline measurements were conducted in all 12 units during May to July 2022 before randomization. (Please insert Table 1 here) Instrument: the fidelity scale for ACP The project group developed a comprehensive fidelity scale consisting of three subscales assessing 1) the quality of the intervention, 2) an evaluation of the implementation, and 3) the penetration rate in participating units. Penetration rate is defined as the percentage of consumers who have access to an EBP as measured against the total number of consumers who could benefit from the EBP (18). The purpose of the scale is to operationalize the national and international recommendations for implementing ACP in the health- and care services. To develop the items for the subscale on quality, we selected recommendations from guidelines and clustered them into key items. The items in the implementation subscale and penetration rate subscale were based on previous fidelity scales developed and tested in a project for better family involvement (13, 18), and the conceptual framework used in implementation fidelity theory (14, 19, 20). To assess the implementation of ACP as a complex intervention, we have included both the clinical level and organizational level in the scale. We have also considered the context where we are implementing, by including barriers and facilitators in the scale. This, to make the unit aware about typical obstacles and facilitates good strategies to overcome them. For an overview of the items in the scale and how they correspond to the implementation, quality and penetration rate subscales, please see Additional file 1. (Please insert Additional file 1 here). In total the fidelity scale consists of 22 items. Each item is scored from 1 to 5, where 1 equals no implementation and 5 equals full implementation. The sites that did not offer ACP were scored 1 on all items, but a thorough report on what services were offered would be conducted on each site to inform the implementation process, e.g., what structures and practices could be built upon. After intervention, the scale will be used as a comprehensive monitoring of changes during an implementation process. This will be done after 6 months and after 12 months, when the implementation program ends. Within the different theoretical approaches in implementation science (20) this fidelity scale will mainly be categorized as a process model that provides the unit with the practical steps to translate ACP-evidence into practice. Thus, the scale is in principle a structured interview guide that takes you through the steps of the program needed to implement ACP. It begins with implementation measures in the initial phase and ends with implementation measures to maintain the practice continuously. Evidence-base for the scale Methodology for developing the scale To develop the items in the scale, we used Bond’s (2020) standardized methodology for developing and validating fidelity scales (19). The first step in the methodology is to clarify the purpose of the fidelity scale including its primary users, in this case health personnel and leaders in a hospital ward. Here Bond emphasizes the importance of balancing the need for short pragmatic items and rigorous, precise measurements. Therefore it has often been better to divide an item into several items that could be scored separately, instead of a long list of criteria that would be hard to sum up for a clinician in one go (19). This is also important because most of the items are prone to a discretionary assessment. Simplifying the items and making the interpretation of the item as clear as possible, was an important step. The second step is to identify the key principles. The principles should be grounded in research, ideally with each principle supported by direct evidence from the literature (see evidence-base for the intervention). In sum, we have selected recommendations from national and international guidelines and clustered these into the following key principles: 1. Implementation measures in the start-up phase 2. Continuous implementation measures 3. Mapping of eligible patients and invitation to ACP 4. Quality of ACP 5. Follow-up after ACP 6. Monitoring of the implementation process The third step has been to operationalize 3-5 items under each of these key principles. Here ordering the items chronologically, making sure they adequately and fully cover all steps in describing and guiding the process of translating evidence into practice has been important, corresponding to a process model. The fourth step has been to calibrate each of the items. Item calibration involves defining the criteria to rate items on a gradient consisting of 5 distinct scale points, intended to have equal intervals between scale points. Here we have looked to and taken inspiration from reliable previous fidelity scales (13, 18) (see also evidence-base for the implementation intervention). Evidence-base for the clinical intervention To develop the items to measure the quality of the clinical intervention we have mainly relied on three sources, recommended by Bond (19). The first source and also most rigorous method of identifying the key principles is to use expert panels (19) . Here we refer to the Delphi panel studies on recommendations for ACP widely sited and adopted as a consensus definition (1, 21). The second most useful source was Up to Date's summary of the practical steps recommended as part of an ACP-conversation (22). This guide sets out the steps in the practical execution for ACP, which was very useful in making the item on the quality of ACP and was complementary to the Delphi panel consensus definitions (1, 21). The third source recommended by Bond was to rely on systematic reviews in the literature to define core items recommended by Bond (19). A challenge was that ACP interventions vary considerably in the literature(3). There is also poor description of the interventions used, and often the interventions use licensed programs that are not openly accessible. So here we rather started out going through systematic reviews using ACP interventions in older patients (23-28) to carve out what would be recurrent steps and compare them with the steps already drafted from the Delphi panels and the guideline from UptoDate. For an overview of the literature search for the reviews and for the identified reviews from this search, please see Additional file 2. From these reviews, randomized controlled trials that provided a description of implementation of ACP programs in RCTs and particularly a description of intervention and/ or the curriculum and training program for health personnel were included. (Please insert Additional file 2 here). Studies that only included advance directives without patient involvement, specific diagnoses, and ethnic minorities as study subjects, and studies that did not provide a detailed description of how the intervention was done, were excluded. Furthermore, we included the overview of systematic reviews by Jimenez which did not come up in the search (3). Most of the ACP interventions were informative by nature, i.e., information was provided about ACP and how to complete an AD either verbally, in writing or through a video, sometimes combined with a discussion end-of-life care preferences, but also self-guided computer programs for patients. Other interventions were workshops or training programs for health professionals with trained facilitators (usually nurses), but also seminars with training for health professionals alone (doctors and nurses or social workers) and psychoeducation of the families. Recurrent steps would be to identify patients nearing end of life, assessing or exploring the patient’s needs and/or personal values, talking about different care options and choices and final decisions, and documenting ACP in a coordinated way (24-26). To adapt the scale to a Norwegian context, evidence from previous research on ACP in Norway was used as the evidence-base. The most useful source was an interview-guide for ACP which was tested in a randomized cluster study in nursing homes. The study were this guide was adopted used a whole ward approach (29) which is also the approach in this study. This means that the entire ward is involved in ACP, and as such facilitates informal conversations where the patient takes the initiative to talk about what is important to him or her with staff, for example during care or others daily activities. Finally we looked at a procedure guide for ACP developed at the Oslo University Hospital (30). The procedure is based on the Gold Standard Framework which is one of many ACP models (43). Evidence-base to evaluate the implementation intervention We based the subscale on implementation on previous fidelity scales developed and tested in a project for better family involvement (13) based on The Evidence Based Practices KIT (Knowledge Informing Transformation) that gives a template for fidelity scales (18) as well as practice guidelines for family involvement. This template is from mental health care since the use of fidelity originated here, but has since spread to a wider part of the health care system (31), although no such template exists for ACP specifically. We have also included a review article presenting the model for implementing the Gold Standard Framework (32). It is important to be aware of known barriers and facilitators to have an idea of what areas could be relevant to address in the implementation process. To summarize barriers and facilitators for ACP, we have based the scale on an advanced search on reviews on barriers and facilitators for ACP (3, 6, 8, 33-39). See Additional file 3 to see the search strategy and the selected results. (Please insert Additional file 3 here). Validity and reliability of the scale Validation process and discussions that led to the final version The reviewing of items has been assessed and revised within the research team who were all health professionals, in the form of internal validation. This validation process lasted from September 2020 when the face validity of the first draft of the scale was first assessed, to revising it during the planning of the project in fall 2021 and during the recruitment period in winter 2021-2022 considering responsive evaluation from stakeholders. Face validity is the appropriateness, sensibility or relevance of the test as it appears to the persons answering the test (40). In other words we assessed whether the test seemed valid and meaningful to the individuals taking the test, and if respondents would view the content of the test and its items relevant to their context (40). Responsive evaluation is a responsiveness to key issues or problems, especially those recognized by people at the site. It is not particularly responsive to program theory or stated goals but more to stakeholder concerns (41). Therefore, the items were adapted to local circumstances as the research team became more acquainted with the units and their contexts. As such we tailored the scale to local circumstances by evaluating the adequacy of items with clinicians from the context where we are implementing. After this, the team carried out a pilot of the scale in two rounds with a nurse and a ward leader/geriatrician to represent the main sources that would be interviewed at baseline. Adequacy of the items and particularly recalibration and division into further items was then discussed after the piloting process, but also during baseline measurements to refine and strengthen the psychometric properties of the scale. Important discussions that led to the final version of the scale where that the items where acceptable and relevant to everyday practice, but at the same time valid and reliable enough to answer the research question of what the level of implementation is. Feasibility and realism were important aspects, and we often decided on dividing items, simplifying the elements, and lowering the threshold to achieve a full score. Furthermore, a discussion was how to fairly score when implementation of ACP was in fact not in place, without failing to credit their work, for example cooperation with next of kin. Here we decided to credit what was done, even if it was just one ACP-conversation with the palliative team or parts of an ACP-conversation during a hospital stay in the rules for scoring. We also generally scored the ACP-conversations that were done, relying on the main sources that would be involved in these conversations in the unit. We also provided rich reports of the practices, resources and competency which was already in place to accompany the scores and guide further implementation. Another discussion was about what would constitute well implemented documentation and communication routines within a Norwegian context. We asked for feedback from leaders and practitioners during planning and recruitment to set out what would be the most logical, feasible and correct way to document ACP. Examples from the literature are documenting ACP-related conversations in the medical record, written advance care plans, use of end-of-life care plans and numbers of DNAR (do not attempt resuscitation) orders (24, 25). After several rounds we landed on that this would have to be dissemination in the discharge note, and the summary care record summary care record that collates important information about the patient and makes it available both to healthcare professionals across levels. We therefore also included this as an element for the penetration rate, e.g., how many of the patients did not only receive ACP but where ACP was also correctly documented and disseminated soundly in order to be effective beyond that admission/hospital stay. Another important discussion within the research team was also to gauge the length and the feasibility of the scale for busy hospital staff and avoid overlapping elements. Here to carry out a pilot was efficient, and also looking to the methodology e.g. what would be the maximum number of items, which is no more than 25 (19). To standardize interviewing and rules for scoring, particularly in cases of possible diverse interpretations, we took note of good questions and how to score whenever in doubt, to get clear and unambiguous answers. The questions and rules for scoring were written down in a manual, which is also recommended by Bond (19). Each measurement took no longer than 30-40 minutes. Finally, we established benchmarks for good fidelity. By convention, an average score of 4,0 (on a 5-point scale) has typically been used as the benchmark for good fidelity (19). But we are keeping in mind that if items consistently score below 4 it may need recalibration (19). Overall, it is important that the development of the scale is transparent and adaptable to revisions both for scientific and practical reasons. The scientific reasons include emerging research evidence and feedback from practitioners and trainers (19). Reliability We used the intraclass correlation coefficient (ICC) to determine the interrater reliability which reflects the variation between two or more raters who measure the same group of subjects (42). The ICC at baseline is expected to be good, because ACP is not practiced in the units. Most fidelity scales achieve excellent interrater reliability (19) and this is also the case in this study (see results). Percentage agreement is calculated by dividing the number of observations agreed upon by the total number of observations. Testing of the scale at baseline Baseline measurements took place during May-June 2022 by two trained fidelity assessors at each site. The assessors were drawn from a pool of eight researchers, who were also health professionals, but none of them worked at the clinical sites. The measurements were performed as structured interviews with leaders, doctors, nurses and resource-persons such as palliation team as the main sources. The two fidelity assessors first scored all items independently and then reached a consensus score for each item, based on the answers from all the sources interviewed. Building upon the discussions that lead to the consensus scores, we decided to divide item 19 into five distinct points instead of four, because the first point initially measured both documenting who participated and the assessment of decision-making capacity. These are two distinct activities that is better measured separately. Another adjustment was that item 14 and 13 where switched, as it was in better accordance with recommendations to first assess what is important to the patient before eliciting preferences (1, 21, 22, 24, 30). Some of the measurements were conducted digitally to increase their feasibility. We considered this justifiable on the premises that none of the sites did ACP systematically at baseline. We also asked if the units had any written or online material on ACP, which just included a procedure for ACP described in an electronic procedures’ manual in one of the sites. The head of the unit (department-, or section-leader) was interviewed individually, whereas clinicians, and resource-persons (if applicable) were interviewed in separate or combined groups of 1–5 persons, with a total of 3–4 interviews of 30–40 min length at each site. We also collected organizational data (Table 1). The fidelity assessors prepared a detailed report for each site to accompany the scores. Scores and reports were then sent to the units in the intervention arm for them to correct any misunderstandings or misconceptions, and to adjust scores if necessary. Data analysis We examined item distributions for the scale, including the degree of implementation of the various items. Interrater reliability was investigated by calculating the Intra-class Correlation Coefficient (ICC) for total mean fidelity and for each item. We used a One-Way Random-Effects Model because in our material each subject is rated by a different set of raters who were randomly chosen from a larger population of possible raters. The type k was chosen due to multiple raters, as well as absolute agreement because different raters assigned the same score to the same subject. All data analyses were carried out using SPSS version 28. Results Item distributions and interrater reliability for the scale are listed in Table 2. (Please insert Table 2 here). The mean score in the 12 sites was 1,16 ranging from 1,05 to 1,68. None of the sites had a systematic implementation of ACP. None of the sites offered training or supervision of their health professionals in ACP. A higher score was reached on the item on program philosophy which was known to individual resource persons in some sites, but not owned by entire wards in a consistent way. Hence there is a need for teaching and practical training for all sites. Four of the sites had appointed a coordinator in relation to the starting up of the project, but their tasks were not concretized, and there had not yet been a meeting with key staff, as well as an establishment of implementation teams in the units. This will have to be put in place as a first step in the implementation process. Concerning the quality of the intervention, none of the units practiced ACP in adherence to guidelines (1, 21, 22). There was much communication going on with next of kin, but not ACP. Typically, this would be discussions about the patient’s function and the current issue for that hospital stay, but not preparing for future treatment and care. Assessing decision making capacity was also mostly done in relation to the patient’s capacity to take care of his/herself or the use of restraint, but not as an indication of the patient’s capacity to participate in ACP. The fragmentary practice of ACP was also reflected in the penetration rate, with a mean of 1,04. Regarding the psychometric properties of the scale the measures of interrater reliability indicate a high level of agreement between raters, with an ICC of 0.99. None of the units in the intervention arm gave any feedback that resulted in a score adjustment. Discussion This is the first study to present a comprehensive fidelity scale for ACP that was tested at baseline as part of a large trial. The results from this study demonstrate a general lack of structures and standard procedures in Norwegian geriatric units in hospitals when it comes to ACP. Fortunately, these results can be used as a base for targeted quality improvement in the large trial. Main targets for improvement will be improving knowledge, competence, and skills regarding ACP particularly regarding practical training, and agreeing and setting up standardized ways of documenting and communicating ACP. Regarding the penetration rate in the units, ACP was not offered to most patients, although many recognized the relevance of ACP and had several screening systems in place that could be used to identify eligible patients, such as for instance the Clinical Frailty Scale. Establishing routines for identifying eligible patients and using screening tools that are already in place are also useful strategies in the implementation process to increase the penetration rate. With regards to psychometric properties, this scale shows promising results indicating that the scale generates similar scores with different raters. Concerning face validity, the items in the scale are also well-founded in the summarization of guidelines and likely to correspond to clinical practices in real life. This is because we have made sure to balance the summarization of evidence with the adequacy of items and use simple formulations that makes it possible for raters to communicate fast and precisely about complex phenomena with clinicians. Furthermore, confirming the scores by different stakeholders at different levels within the same units also strengthens validity since this is a complex intervention. This fidelity scale is aimed at hospital units, preferably geriatric sections, but can be used as a starting point for developing fidelity scales throughout the health care service. Hence this fidelity scale can be used as part of a basic program for doing ACP in the services, in large scale. This is particularly relevant regarding the need for a system-wide or a unified approach for ACP (3, 8). We underscore that for a complex intervention such as ACP, the scale should be tailored to local circumstances, and that this scale is adapted to a European context where advance directives are rarely used. Concerning strengths and weaknesses, a weakness of this study is that it was probably easier to achieve good interrater reliability because little or no ACP was done, and therefore it was easier to score. Another weakness of this approach is that one does not investigate practices that are not addressed by the scale and one could also argument that the items as such set up a construction of positive evidence because the units would start low at baseline. However, in our fidelity reports we recorded if the units had any ACP practices that our instruments failed to credit. These were few and had more the nature of being discussions about treatment level at that hospital stay, which is not ACP. As such the results also illustrate the probable status quo: ACP probably does not happen in a systematic, structured and standardized way. Balancing the pitfall of positive evidence is therefore the great potential for quality improvement in the services. Another weakness is that we could have included additional data sources to enhance the validity and reliability of the results. A review of medical records or observations was not done at baseline due to limited resources, but also because ACP was not practiced in a systematic way in any of the sites. However, a review of patient records and health register data will be done in the intervention period. Alongside the intervention, we will also conduct separate qualitative interviews and collect questionnaires from staff, patients and next of kin to evaluate service and patient outcomes. Concerning the representability of the sample where we conducted our fidelity measurements, a critique could be that we only included units with a priori expertise in the care for older patients, including communication. This could pose as a problem of selection bias in the results. Thus, in terms of external validity, these findings do not necessarily reflect the situation in other wards where for instance a more holistic approach and broad assessment of the patient is not already an integrated part of the working method. Yet, our results support the assumption that ACP is not implemented even in wards specialized in the health care for older patients. When the implementation is this low even in units prone to be more adaptive to this practice, we have little reason to believe that ACP practices in other wards with other older patient groups will be more systematic or of higher quality. The main strength of the scale is that it is broad and assesses both the quality of ACP, the implementation of ACP and how widespread ACP is. This gives a comprehensive assessment of the implementation of ACP and can also give an assessment of all units in one sample (19). This is useful to guide implementation strategies in large projects, for instance in multicenter studies as this sub-study is part of, to improve the implementation of ACP. Conclusion ACP is an evidence-based intervention whose implementation is assumed to be low. This assumption was supported by the findings in this cross-sectional fidelity study. This is the first paper to present a comprehensive fidelity scale to assess the implementation level of ACP in hospital units. The scale shows promising preliminary psychometric properties that may prove a useful tool to accelerate the low implementation of ACP. There is a need to increase the implementation and penetration rate of ACP in the services to improve the involvement of older patients. Abbreviations ACP: Advance care planning, EBP: Evidence-based practice, GSF: Gold Standard Framework, ICC: Intra-class Correlation Coefficient. Declarations Acknowledgments We would like to thank Associate Professor Kristin Heiervang at the Department of Health, Social and Welfare Studies at the University of South-Eastern Norway for valuable help regarding fidelity scale development, and PhD fellow Lars Hestmark for valuable help regarding the calculations of ICC. We would also like to thank Senior Consultant Geriatrician Pål Friis and Professor and Senior Consultant Geriatrician Siri Rostoft for valuable comments during the validation process. Finally we would like to thank PhD fellows Shereen Cox and Tore Hofstad for valuable comments during the writing process. Disclosure The author reports no conflicts of interest in this work. Funding: The Research Council of Norway funded the study. The funding source had no role in the design if this study, and did not have any role during its execution, analyses, interpretation of the data, or decision to submit results. Availability of data and materials: The dataset used and/or analyzed during the current study is available from the corresponding author on reasonable request. Consent for publication: Not Applicable. Consent to participate declaration: Informed consent was obtained from all subjects. Ethics approval: This research complies with international and national standards and has been performed in accordance with the Declaration of Helsinki. It has been approved by the appropriate national ethics committee. NSD- Norwegian Centre for Research Data, the Data Protection Official for Research, approved the study May 20th 2022. Their reference number is 805491. Authors’ contributions: SFW, MR, MA, KBH, LB, AKW, TJLS, LT and RP have participated in developing the fidelity scale and participated in the validation process and discussions that led to the final version of the fidelity scale. SFW, MR, KBH, LB, AKW, TJLS, LT and RP did the baseline measurements. SFW and RP wrote the main manuscript text and SFW prepared tables and additional files. SFW, MR; MA; KBH, LB, AKW, TJLS, LT, RP reviewed the manuscript. Competing interests: The authors declare that they have no competing interests. References Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, et al. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. J Pain Symptom Manage. 2017;53(5):821-32.e1. Morrison RS, Meier DE, Arnold RM. What's Wrong With Advance Care Planning? Jama. 2021;326(16):1575-6. Jimenez G, Tan WS, Virk AK, Low CK, Car J, Ho AHY. 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Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655. Family Psychoeducation: Evaluating Your Program. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration: U.S. Department of Health and Human Services; 2009. Bond GR, Drake RE. Assessing the Fidelity of Evidence-Based Practices: History and Current Status of a Standardized Measurement Methodology. Adm Policy Ment Health. 2020;47(6):874-84. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10:53. Rietjens JAC, Sudore RL, Connolly M, van Delden JJ, Drickamer MA, Droger M, et al. Definition and recommendations for advance care planning: an international consensus supported by the European Association for Palliative Care. Lancet Oncol. 2017;18(9):e543-e51. Detering, Silveira. Facilitating advance care planning discussion (UpToDate) [cited 2020 1.2.2020]. Available from: https://www.uptodate.com/contents/advance-care-planning-and-advance-directives?search=advance%20care%20planning&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H2094995 Cardona-Morrell M, Benfatti-Olivato G, Jansen J, Turner RM, Fajardo-Pulido D, Hillman K. A systematic review of effectiveness of decision aids to assist older patients at the end of life. Patient Educ Couns. 2017;100(3):425-35. Gleeson A, Noble S, Mann M. Advance care planning for home health staff: a systematic review. BMJ Support Palliat Care. 2021;11(2):209-16. Hopkins SA, Bentley A, Phillips V, Barclay S. Advance care plans and hospitalized frail older adults: a systematic review. BMJ Support Palliat Care. 2020;10(2):164-74. Jain A, Corriveau S, Quinn K, Gardhouse A, Vegas DB, You JJ. Video decision aids to assist with advance care planning: a systematic review and meta-analysis. BMJ Open. 2015;5(6):e007491. Kelly AJ, Luckett T, Clayton JM, Gabb L, Kochovska S, Agar M. Advance care planning in different settings for people with dementia: A systematic review and narrative synthesis. Palliat Support Care. 2019;17(6):707-19. Weathers E, O'Caoimh R, Cornally N, Fitzgerald C, Kearns T, Coffey A, et al. Advance care planning: A systematic review of randomised controlled trials conducted with older adults. Maturitas. 2016;91:101-9. Sævareid TJLS. Advance care planning in nursing homes: a mixed method study of a complex intervention using a whole-ward approach University of Oslo; 2019. Ahmed M. Procedure for advance care planning. Oslo University Hospital; 2020. Mowbray CT, Holter MC, Teague GB, Bybee D. Fidelity Criteria: Development, Measurement, and Validation. American Journal of Evaluation. 2003;24(3):315-40. Reynolds J, Croft S. How to implement the Gold Standards Framework to ensure continuity of care. Nurs Times. 2010;106(32):10-3. Bernacki RE, Block SD. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994-2003. Fien S, Plunkett E, Fien C, Greenaway S, Heyland DK, Clark J, et al. Challenges and facilitators in delivering optimal care at the End of Life for older patients: a scoping review on the clinicians' perspective. Aging Clin Exp Res. 2021;33(10):2643-56. Frechman E, Dietrich MS, Walden RL, Maxwell CA. Exploring the Uptake of Advance Care Planning in Older Adults: An Integrative Review. J Pain Symptom Manage. 2020;60(6):1208-22.e59. Ke LS, Huang X, O'Connor M, Lee S. Nurses' views regarding implementing advance care planning for older people: a systematic review and synthesis of qualitative studies. J Clin Nurs. 2015;24(15-16):2057-73. Lum HD, Sudore RL, Bekelman DB. Advance care planning in the elderly. Med Clin North Am. 2015;99(2):391-403. Ryan T, Amen KM, McKeown J. The advance care planning experiences of people with dementia, family caregivers and professionals: a synthesis of the qualitative literature. Ann Palliat Med. 2017;6(4):380-9. Threapleton DE, Chung RY, Wong SYS, Wong ELY, Kiang N, Chau PYK, et al. Care Toward the End of Life in Older Populations and Its Implementation Facilitators and Barriers: A Scoping Review. J Am Med Dir Assoc. 2017;18(12):1000-9.e4. Holden RB. The Corsini Encyclopedia of Psychology (4th ed.). Irving B. Weiner IaWEC, editor2010. Stake R. Responsive Evaluation. In: Kellaghan T, Stufflebeam DL, editors. International Handbook of Educational Evaluation. Dordrecht: Springer Netherlands; 2003. p. 63-8. Koo TK, Li MY. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J Chiropr Med. 2016;15(2):155-63. Tables Table 1: Description of the 12 clinical sites included in the cluster randomized trial Site Type of unit 1 Catchment population Total number of patients Mean length of stay for acute geriatric patients (days) Full-time equivalent staff (FTE) Patients per FTE 1 Gjøvik IMU 30 267 10 3,48 17,7 1,77 2 Kongsberg AGU 50 000 6 4,55 23 3,83 3 Elverum AGU 60 000 5 3,3 30,7 1,33 4 Arendal AGU 120 000 9 4 40 4,44 5 DHS AGU 150 000 16 4,1 42,7 2,67 6 Kristiansand AGU 155 000 4 2,5 19,8 4,95 7 Drammen AGU 168 000 8 4 39,4 4,9 8 Bærum AGU 180 000 8 3,6 33,7 4,21 9 OUS AGU 200 000 20 4,9 36 1,8 10 SIV AGU 230 000 9 4 16,5 1,83 11 SØK AGU 323 453 18 4 47,2 2,6 12 Ahus AGU 594 000 23 6 53,5 2,32 1 AGU: Acute geriatric unit, IMU: Internal medical unit with geriatrician among staff. Table 2: Fidelity baseline results, distributions, interrater reliability and percentage agreement for the fidelity scale, after testing in the 12 hospital units. Item number Item description Mean (SD) Numbers of sites achieving score Agreement (%) ICC 1 2-3 4-5 Implementation subscale 1 Meeting 1 (0) 12 0 0 100 1,000 2 Action plan 1 (0) 12 0 0 100 1,000 3 Program philosophy 2,25 (0,65) 1 11 0 66,67 0,784 4 Coordinator 1,33 (0,48) 8 4 0 100 1,000 5 Training and supervision 1 (0) 12 0 0 100 1,000 6 Systematic identification of eligible patients 1 (0) 12 0 0 100 1,000 22 Continuous implementation measures 1 (0) 12 0 0 100 1,000 Subtotal for structural/ implementation measures 1,21 (0.083 ) 12 0 0 — 0,969 Quality subscale 7 Assessing decision-making capacity. 1 (0) 12 0 0 100 1,000 10 Verbal and written invitation. 1 (0) 12 0 0 100 1,000 11 Level of involvement 1,08 (0,28) 11 1 0 100 1,000 12 Provide information 1 (0) 12 0 0 100 1,000 13 What is important to the patient 1,08 (0,28) 11 1 0 100 1,000 14 Elicit preferences regarding future and current treatment and care 1,08 (0,28) 11 1 0 100 1,000 15 Previous documentation of patient’s values, goals and preferences. 1 (0) 12 0 0 100 1,000 16 Permission to pass on information to other health personnel 1,08 (0,280) 11 1 0 100 1,000 17 Summing up and evaluating the ACP-discussion 1,25 (0,84) 11 0 1 100 1,000 19 Quality of documentation 1,25 (0,84) 11 0 1 100 1,000 20 Dissemination of ACP in discharge summary 1,33 (1,12) 11 0 1 1 100 1,000 Subtotal for quality 1,11 (0,37) 11 1 0 — 1,000 Penetration rate subscale 8 Proportion invited 1 (0) 12 0 0 100 1,000 9 Proportion given ACP (penetration rate in the unit) 1 (0) 12 0 0 100 1,000 18 Checking in the patient’s record if ACP has been done previously 1,11 (0,67) 11 0 1 100 1,000 21 ACP in discharge summary 1 (0) 12 0 0 100 1,000 Subtotal for penetration rate 1,04 (0,144) 12 0 0 — 1,000 Scale total 1,16 12 0 0 — 0,990 1 In one of the units, the palliative team summed up, documented and disseminated ACP in the discharge summary, but the few patients that did receive ACP from them, did not receive a written and verbal invitation to ACP. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1ACP04.10.23.docx Additionalfile2Fidelity10.10.22.docx Additionalfile3FidelityACP10.10.22.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3610212","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":252425920,"identity":"161c6732-be4c-4105-a9aa-793387302e8f","order_by":0,"name":"Siri Faerden 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05:02:46","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15809,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2Fidelity10.10.22.docx","url":"https://assets-eu.researchsquare.com/files/rs-3610212/v1/c19a320264dcec9f15142ecc.docx"},{"id":47175038,"identity":"4ee766c8-cb42-414a-b2b1-9f2ddc2e67dc","added_by":"auto","created_at":"2023-11-28 05:02:46","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":16883,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3FidelityACP10.10.22.docx","url":"https://assets-eu.researchsquare.com/files/rs-3610212/v1/3dabd914a4bbbe228a3973fd.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing the implementation level of advance care planning– the first comprehensive fidelity scale","fulltext":[{"header":"Background","content":"\u003cp\u003e\u003cstrong\u003eThe implementation problem of advance care planning (ACP)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eACP is defined as a process that supports patients in understanding and sharing their personal values, life goals, and preferences regarding future medical care to help ensure that people receive medical care that is consistent with them (1). Although the effectiveness of ACP has been debated (2), particularly the potential to improve goal-concordant care\u0026nbsp;(3-5), by large the recent summary of evidence supports the potential of ACP to support the involvement of older patients and their caregivers and improve communication. A 2021 systematic review found that 88 % of studies showed positive impact upon patient-surrogate/clinician congruence. They found that 100 % of studies had a positive impact on patients/surrogate/clinician satisfaction with communication, and 75 % had a positive impact on surrogate satisfaction with patients\u0026apos; care\u0026nbsp;(4). The newest and largest review to date\u0026nbsp;(5)\u0026nbsp;also found consistent evidence that ACP interventions improve patient\u0026ndash;physician communication (68 %), preference for comfort care (70%), decisional conflict (64%) and patient-caregiver congruence in preference (82%)\u0026nbsp;(5). However,\u0026nbsp;the implementation of ACP seems to be low. This has been raised as an important problem by many\u0026nbsp;(3, 6-12). A further and fundamental problem is that we have not yet been able to reliably assess the level of implementation of ACP either.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation fidelity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMeasuring implementation fidelity is used to measure levels of implementation of evidence-based practices\u0026nbsp;(13). Fidelity can be defined in different ways. The narrower definition relates individually and exclusively to the intervention. A broader definition includes\u0026nbsp;adherence to an intervention; but also to\u0026nbsp;capture a \u0026quot;comprehensive\u0026quot; or \u0026quot;more complete picture\u0026quot; of the implementation process\u0026nbsp;(14).\u0026nbsp;Most\u0026nbsp;fidelity research focuses solely on adherence to the intervention\u0026nbsp;(14). The few fidelity-studies that have been conducted for ACP also define and study fidelity only relating to the intervention\u0026nbsp;(15, 16).\u003c/p\u003e\n\u003cp\u003eIn this study we decided to develop a fidelity scale based on the broad definition of fidelity which \u0026ndash; to our knowledge - has not been done in any previous study. Thus, we aim to measure both fidelity to the intervention and to the implementation to give a more comprehensive measure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplex interventions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eACP is a complex intervention because it contains several interacting components at different levels\u0026nbsp;(17). But implementation support for ACP is likely to be a complex intervention in itself, because it is also characterized by a number of interacting components, and a degree of flexibility or tailoring to local circumstances\u0026nbsp;(17).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe concept of complex intervention has been developed mainly to evaluate interventions\u0026nbsp;(17). However, the concept is also relevant to develop implementation strategies. As such, there is a need for evaluation methods that embrace the complexity of the intervention to be studied, as well as implementation strategies corresponding to the same complexity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo improve the involvement of older patients in medical care, we needed a systematic and comprehensive assessment of the current level of implementation of ACP. The research question\u0026nbsp;of this study is therefore: Can we develop an instrument that has the psychometric properties needed to assess the complexity of implementation of ACP? And if yes, what is the current implementation level of ACP? To our knowledge, this paper describes the first systematic, comprehensive, and broad investigation of ACP to date. The aim of this article is both to present this new fidelity scale and to report the results from the baseline assessment used to test the scale.\u003c/p\u003e\n\u003cp\u003eWe present the fidelity scale it in this article, including the methodology for developing the scale, the evidence-base for the scale, the validation process, the pilot and the testing at baseline. \u0026nbsp;\u003c/p\u003e"},{"header":"Material and methods","content":"\u003ch2\u003eStudy design, setting and participating sites\u003c/h2\u003e\n\u003cp\u003eThis is a cross-sectional sub-study part of a larger trial. The trial uses a cluster randomized controlled design (study protocol submitted).\u0026nbsp;We tested the scale through doing measurements in the clusters in the intervention arm and control arm at baseline. A cluster was defined as an acute geriatric unit or internal medical unit with a geriatrician among staff. The reason for choosing geriatric units was that we met considerable motivation and interest for ACP in these units. Twelve out of fifteen eligible units in the South-Eastern Norway Regional Health Authority agreed to participate, covering a catchment area of over 2 million inhabitants. We considered this a good foundation for further spreading the implementation of ACP to larger parts of the services. ACP is still pioneering work in Norway, and there are multiple barriers to its implementation explored in a separate paper. The main reason given for non-participation among the remaining units was a lack of time and staff. Table 1 sums up the characteristics of all the clinical sites. The baseline measurements were conducted in all 12 units during May to July 2022 before randomization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(Please insert Table 1 here)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInstrument: the fidelity scale for ACP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project group developed a comprehensive fidelity scale consisting of three subscales assessing 1) the quality of the intervention, 2) an evaluation of the implementation, and 3) the penetration rate in participating units. Penetration rate\u003cem\u003e\u0026nbsp;\u003c/em\u003eis defined as the percentage of consumers who have access to an EBP as measured against the total number of consumers who could benefit from the EBP\u0026nbsp;(18).\u0026nbsp;The purpose of the scale is to operationalize the national and international recommendations for implementing ACP in the health- and care services.\u003c/p\u003e\n\u003cp\u003eTo develop the items for the subscale on quality,\u0026nbsp;we\u0026nbsp;selected recommendations from guidelines and clustered them into key items. The items in the implementation subscale and penetration rate subscale were based on previous fidelity scales\u0026nbsp;developed and tested in a project for better family involvement\u0026nbsp;(13, 18), and the conceptual framework used in implementation fidelity theory\u0026nbsp;(14, 19, 20).\u003c/p\u003e\n\u003cp\u003eTo assess the implementation of ACP as a complex intervention, we have included both the clinical level and organizational level in the scale. We have also considered the context where we are implementing, by including barriers and facilitators in the scale. This, to make the unit aware about typical obstacles and facilitates good strategies to overcome them.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor an overview of the items in the scale and how they correspond to the implementation, quality and penetration rate subscales, please see Additional file 1.\u003c/p\u003e\n\u003cp\u003e(Please insert Additional file 1 here).\u003c/p\u003e\n\u003cp\u003eIn total the fidelity scale consists of 22 items. Each item is scored from 1 to 5, where 1 equals no implementation and 5 equals full implementation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe sites that did not offer ACP were scored 1 on all items, but a thorough report on what services were offered would be conducted on each site to inform the implementation process, e.g., what structures and practices could be built upon.\u0026nbsp;After intervention, the scale will be used as a comprehensive monitoring of changes during an implementation process. This will be done after 6 months and after 12 months, when the implementation program ends.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWithin the different theoretical approaches in implementation science\u0026nbsp;(20)\u0026nbsp;this fidelity scale will mainly be categorized as a process model that provides the unit with the practical steps to translate ACP-evidence into practice.\u0026nbsp;Thus, the scale is in principle a structured interview guide\u0026nbsp;that\u0026nbsp;takes you through the steps of the program needed to implement ACP. It begins with implementation measures in the initial phase and ends with implementation measures to maintain the practice continuously.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEvidence-base for the scale\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology for developing the scale\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo develop the items in the scale, we used Bond\u0026rsquo;s (2020) standardized methodology for developing and validating fidelity scales\u0026nbsp;(19).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe first step in the methodology is to clarify the purpose of the fidelity scale including its primary users, in this case health personnel and leaders in a hospital ward. Here Bond emphasizes the importance of balancing the need for short pragmatic items and rigorous, precise measurements. Therefore it has often been better to divide an item into several items that could be scored separately, instead of a long list of criteria that would be hard to sum up for a clinician in one go\u0026nbsp;(19). This is also important because most of the items are prone to a discretionary assessment. Simplifying the items and making the interpretation of the item as clear as possible, was an important step.\u003c/p\u003e\n\u003cp\u003eThe second step is to identify the key principles.\u0026nbsp;The principles should be grounded in research, ideally with each principle supported by direct evidence from the literature\u0026nbsp;(see evidence-base for the intervention).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn sum, we have selected recommendations from national and international guidelines and clustered these into the following key principles:\u003c/p\u003e\n\u003cp\u003e1. Implementation measures in the start-up phase\u003c/p\u003e\n\u003cp\u003e2. Continuous implementation measures\u003c/p\u003e\n\u003cp\u003e3. Mapping of eligible patients and invitation to ACP\u003c/p\u003e\n\u003cp\u003e4. Quality of ACP\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e5. Follow-up after ACP\u003c/p\u003e\n\u003cp\u003e6. Monitoring of the implementation process\u003c/p\u003e\n\u003cp\u003eThe third step has been to operationalize 3-5 items under each of these key principles. Here ordering the items chronologically, making sure they adequately and fully cover all steps in describing and guiding the process of translating evidence into practice has been important, corresponding to a process model.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe fourth step has been to calibrate each of the items.\u0026nbsp;Item calibration involves defining the criteria to rate items on a gradient consisting of 5 distinct scale points, intended to have equal intervals between scale points.\u0026nbsp;Here we have looked to and taken inspiration from reliable previous fidelity scales\u0026nbsp;(13, 18)\u0026nbsp;(see also evidence-base for the implementation intervention).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvidence-base for the clinical intervention\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo develop the items to measure the quality of the clinical intervention we have mainly relied on three sources, recommended by Bond\u0026nbsp;(19).\u003c/p\u003e\n\u003cp\u003eThe first source and also most rigorous method of identifying the key principles is to use expert panels\u0026nbsp;(19)\u0026nbsp;. Here we refer to the Delphi panel studies on recommendations for ACP widely sited and adopted as a consensus definition\u0026nbsp;(1, 21).\u003c/p\u003e\n\u003cp\u003eThe second most useful source was Up to Date\u0026apos;s summary of the practical steps recommended as part of an ACP-conversation\u0026nbsp;(22). This guide sets out the steps in the practical execution for ACP, which was very useful in making the item on the quality of ACP and was complementary to the Delphi panel consensus definitions\u0026nbsp;(1, 21).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe third source recommended by Bond was to rely on systematic reviews in the literature to define core items recommended by Bond\u0026nbsp;(19). A challenge was that ACP interventions vary considerably in the literature(3). There is also poor description of the interventions used, and often the interventions use licensed programs that are not openly accessible. So here we rather started out going through systematic reviews using ACP interventions in older patients\u0026nbsp;(23-28)\u0026nbsp;to carve out what would be recurrent steps and compare them with the steps already drafted from the Delphi panels and the guideline from UptoDate. For an overview of the literature search for the reviews and for the identified reviews from this search, please see Additional file 2. From these reviews, randomized controlled trials that provided a description of implementation of ACP programs in RCTs and particularly a description of intervention and/ or the curriculum and training program for health personnel were included.\u003c/p\u003e\n\u003cp\u003e(Please insert Additional file 2 here).\u003c/p\u003e\n\u003cp\u003eStudies that only included advance directives without patient involvement, specific diagnoses, and ethnic minorities as study subjects, and studies that did not provide a detailed description of how the intervention was done, were excluded. Furthermore, we included the overview of systematic reviews by Jimenez which did not come up in the search\u0026nbsp;(3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost of the ACP interventions were informative by nature, i.e., information was provided about ACP and how to complete an AD either verbally, in writing or through a video, sometimes combined with a discussion end-of-life care preferences, but also self-guided computer programs for patients. Other interventions were workshops or training programs for health professionals with trained facilitators (usually nurses), but also seminars with training for health professionals alone (doctors and nurses or social workers) and psychoeducation of the families. Recurrent steps would be to identify patients nearing end of life,\u0026nbsp;assessing or exploring the patient\u0026rsquo;s needs and/or personal values, talking about different care options and choices and final decisions, and documenting ACP in a coordinated way\u0026nbsp;(24-26).\u003c/p\u003e\n\u003cp\u003eTo adapt the scale to a Norwegian context, evidence from previous research on ACP in Norway was used as the evidence-base. The most useful source was an interview-guide for ACP which was tested in a randomized cluster study in nursing homes. The study were this guide was adopted used a whole ward approach\u0026nbsp;(29)\u0026nbsp;which is also the approach in this study. This means that the entire ward is involved in ACP, and as such facilitates informal conversations where the patient takes the initiative to talk about what is important to him or her with staff, for example during care or others daily activities. Finally we looked at a procedure guide for ACP developed at the Oslo University Hospital\u0026nbsp;(30). The procedure is based on the Gold Standard Framework which is one of many ACP models (43).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvidence-base to evaluate the implementation intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe based the subscale on implementation on previous fidelity scales developed and tested in a project for better family involvement\u0026nbsp;(13)\u0026nbsp;based on The Evidence Based Practices KIT (Knowledge Informing Transformation) that gives a template for fidelity scales\u0026nbsp;(18)\u0026nbsp;as well as practice guidelines for family involvement.\u0026nbsp;This template is from mental health care since the use of fidelity originated here, but has since spread to a wider part of the health care system (31), although no such template exists for ACP specifically.\u0026nbsp;We have also included a review article presenting the model for implementing the Gold Standard Framework\u0026nbsp;(32). It is important to be aware of known barriers and facilitators to have an idea of what areas could be relevant to address in the implementation process. To summarize barriers and facilitators for ACP, we have based the scale on an advanced search on reviews on barriers and facilitators for ACP\u0026nbsp;(3, 6, 8, 33-39). See Additional file 3 to see the search strategy and the selected results.\u003c/p\u003e\n\u003cp\u003e(Please insert Additional file 3 here).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eValidity and reliability of the scale\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eValidation process and discussions that led to the final version\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe reviewing of items has been assessed and revised within the research team who were all health professionals, in the form of internal validation. This validation process lasted from September 2020 when the face validity of the first draft of the scale was first assessed, to revising it during the planning of the project in fall 2021 and during the recruitment period in winter 2021-2022 considering responsive evaluation from stakeholders. Face validity is the appropriateness, sensibility or relevance of the test as it appears to the persons answering the test\u0026nbsp;(40). In other words we assessed whether the test seemed valid and meaningful to the individuals taking the test, and if respondents would view the content of the test and its items relevant to their context\u0026nbsp;(40).\u0026nbsp;Responsive evaluation is a responsiveness to key issues or problems, especially those recognized by people at the site. It is not particularly responsive to program theory or stated goals but more to stakeholder concerns (41). Therefore, the items were adapted to local circumstances as the research team became more acquainted with the units and their contexts. As such we tailored the scale to local circumstances by evaluating the adequacy of items with clinicians from the context where we are implementing.\u003c/p\u003e\n\u003cp\u003eAfter this, the team carried out a pilot of the scale in two rounds with a nurse and a ward leader/geriatrician to represent the main sources that would be interviewed at baseline.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdequacy of the items and particularly recalibration and division into further items was then discussed after the piloting process, but also during baseline measurements to refine and strengthen the psychometric properties of the scale.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eImportant discussions that led to the final version of the scale where that the items where acceptable and relevant to everyday practice, but at the same time valid and reliable enough to answer the research question of what the level of implementation is.\u0026nbsp;Feasibility and realism were important aspects, and\u0026nbsp;we often decided on dividing items, simplifying the elements,\u0026nbsp;and lowering the threshold to achieve a full score.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, a discussion was how to fairly score when implementation of ACP was in fact not in place, without failing to credit their work, for example cooperation with next of kin. Here we decided to credit what was done, even if it was just one ACP-conversation with the palliative team or parts of an ACP-conversation during a hospital stay in the rules for scoring. We also generally scored the ACP-conversations that were done, relying on the main sources that would be involved in these conversations in the unit. We also provided rich reports of the practices, resources and competency which was already in place to accompany the scores and guide further implementation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother discussion was about what would constitute well implemented documentation and communication routines within a Norwegian context. We asked for feedback from leaders and practitioners during planning and recruitment to set out what would be the most logical, feasible and correct way to document ACP. Examples from the literature are documenting ACP-related conversations in the medical record, written advance care plans, use of end-of-life care plans and numbers of DNAR (do not attempt resuscitation) orders\u0026nbsp;(24, 25). After several rounds we landed on that this would have to be dissemination in the discharge note, and the summary care record summary care record that collates important information about the patient and makes it available both to healthcare professionals across levels. We therefore also included this as an element for the penetration rate, e.g., how many of the patients did not only receive ACP but where ACP was also correctly documented and disseminated soundly in order to be effective beyond that admission/hospital stay.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother important discussion within the research team was also to gauge the length and the feasibility of the scale for busy hospital staff and avoid overlapping elements. Here to carry out a pilot was efficient, and also looking to the methodology e.g. what would be the maximum number of items, which is no more than 25\u0026nbsp;(19). To standardize interviewing and rules for scoring, particularly in cases of possible diverse interpretations, we took note of good questions and how to score whenever in doubt, to get clear and unambiguous answers. The questions and rules for scoring were written down in a manual, which is also recommended by Bond\u0026nbsp;(19). Each measurement took no longer than 30-40 minutes.\u003c/p\u003e\n\u003cp\u003eFinally, we established benchmarks for good fidelity.\u0026nbsp;By convention, an average score of 4,0 (on a 5-point scale) has typically been used as the benchmark for good fidelity\u0026nbsp;(19). But we are keeping in mind that if items consistently score below 4 it may need recalibration\u0026nbsp;(19). Overall, it is important that the development of the scale is transparent and adaptable to revisions both for scientific and practical reasons. The scientific reasons include emerging research evidence and feedback from practitioners and trainers\u0026nbsp;(19).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReliability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe used the intraclass correlation coefficient (ICC) to determine the interrater reliability which reflects the variation between two or more raters who measure the same group of subjects\u0026nbsp;(42). The ICC at baseline is expected to be good, because ACP is not practiced in the units. Most fidelity scales achieve excellent interrater reliability\u0026nbsp;(19)\u0026nbsp;and this is also the case in this study (see results). Percentage agreement is calculated by dividing the number of observations agreed upon by the total number of observations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTesting of the scale at baseline\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBaseline measurements took place during May-June 2022 by two trained fidelity assessors at each site. The assessors were drawn from a pool of eight researchers, who were also health professionals, but none of them worked at the clinical sites. The measurements were performed as structured interviews with leaders, doctors, nurses and resource-persons such as palliation team as the main sources. The two fidelity assessors first scored all items independently and then reached a consensus score for each item, based on the answers from all the sources interviewed. Building upon the discussions that lead to the consensus scores, we decided to divide item 19 into five distinct points instead of four, because the first point initially measured both documenting who participated and\u0026nbsp;the assessment of decision-making capacity. These are two distinct activities that is better measured separately.\u0026nbsp;Another adjustment was that item 14 and 13 where switched, as it was in better accordance with recommendations to first assess\u0026nbsp;what is important to the patient before eliciting preferences\u0026nbsp;(1, 21, 22, 24, 30).\u003c/p\u003e\n\u003cp\u003eSome of the measurements were conducted digitally to increase their feasibility. We considered this justifiable on the premises that none of the sites did ACP systematically at baseline. We also asked\u0026nbsp;if the units had any written or online material on ACP, which just included a procedure for ACP described in an electronic procedures\u0026rsquo; manual in one of the sites. The head of the unit (department-, or section-leader) was interviewed individually, whereas clinicians, and resource-persons (if applicable) were interviewed in separate or combined groups of 1\u0026ndash;5 persons, with a total of 3\u0026ndash;4 interviews of 30\u0026ndash;40 min length at each site. We also collected organizational data (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe fidelity assessors prepared a detailed report for each site to accompany the scores. Scores and reports were then sent to the units in the intervention arm for them to correct any misunderstandings or misconceptions, and to adjust scores if necessary.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe examined item distributions for the scale, including the degree of implementation of the various items. Interrater reliability was investigated by calculating the Intra-class Correlation Coefficient (ICC) for total mean fidelity and for each item. We used\u0026nbsp;a One-Way Random-Effects Model because in our material each subject is rated by a different set of raters who were randomly chosen from a larger population of possible raters.\u0026nbsp;The type \u003cem\u003ek\u0026nbsp;\u003c/em\u003ewas chosen due to multiple raters, as well as absolute agreement because different raters assigned the same score to the same subject. All data analyses were carried out using SPSS version 28.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eItem distributions and interrater reliability for the scale are listed in Table 2.\u003c/p\u003e\n\u003cp\u003e(Please insert Table 2 here).\u003c/p\u003e\n\u003cp\u003eThe mean score in the 12 sites was 1,16 ranging from 1,05 to 1,68. None of the sites had a systematic implementation of ACP. None of the sites offered training or supervision of their health professionals in ACP. A higher score was reached on the item on program philosophy which was known to individual resource persons in some sites, but not owned by entire wards in a consistent way. Hence there is a need for teaching and practical training for all sites. Four of the sites had appointed a coordinator in relation to the starting up of the project, but their tasks were not concretized, and there had not yet been a meeting with key staff, as well as an establishment of implementation teams in the units. This will have to be put in place as a first step in the implementation process.\u003c/p\u003e\n\u003cp\u003eConcerning the quality of the intervention, none of the units practiced ACP in adherence to guidelines (1, 21, 22). There was much communication going on with next of kin, but not ACP. Typically, this would be discussions about the patient\u0026rsquo;s function and the current issue for that hospital stay, but not preparing for future treatment and care. Assessing decision making capacity was also mostly done in relation to the patient\u0026rsquo;s capacity to take care of his/herself or the use of restraint, but not as an indication of the patient\u0026rsquo;s capacity to participate in ACP.\u003c/p\u003e\n\u003cp\u003eThe fragmentary practice of ACP was also reflected in the penetration rate, with a mean of 1,04.\u003c/p\u003e\n\u003cp\u003eRegarding the psychometric properties of the scale the measures of interrater reliability indicate a high level of agreement between raters, with an ICC of 0.99. None of the units in the intervention arm gave any feedback that resulted in a score adjustment.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first study to present a comprehensive fidelity scale for ACP that was tested at baseline as part of a large trial.\u0026nbsp;The results from this study demonstrate a general lack of structures and standard procedures in Norwegian geriatric units in hospitals when it comes to ACP.\u0026nbsp;Fortunately, these results can be used as a base for targeted quality improvement in the large trial. Main targets for improvement will be improving knowledge, competence, and skills regarding ACP particularly regarding practical training, and agreeing and setting up standardized ways of documenting and communicating ACP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the penetration rate in the units, ACP was not offered to most patients, although many recognized the relevance of ACP and had several screening systems in place that could be used to identify eligible patients, such as for instance the Clinical Frailty Scale. Establishing routines for identifying eligible patients and using screening tools that are already in place are also useful strategies in the implementation process to increase the penetration rate.\u003c/p\u003e\n\u003cp\u003eWith regards to psychometric properties, this scale shows promising results indicating that the\u0026nbsp;scale generates similar scores with different raters.\u0026nbsp;Concerning face validity, the items in the scale are also well-founded in the summarization of guidelines and likely to\u0026nbsp;correspond to clinical practices in real life. This is because we have made sure to balance the summarization of evidence with the adequacy of items and use simple formulations that makes it possible for raters to communicate fast and precisely about complex phenomena with clinicians. Furthermore, confirming the scores by different stakeholders at different levels within the same units also strengthens validity since this is a complex intervention.\u003c/p\u003e\n\u003cp\u003eThis fidelity scale is aimed at hospital units, preferably geriatric sections, but can be used as a starting point for developing fidelity scales throughout the health care service. Hence this fidelity scale can be used as part of a basic program for doing ACP in the services, in large scale. This is particularly relevant regarding the need for a system-wide or a unified approach for ACP\u0026nbsp;(3, 8). We underscore that for a complex intervention such as ACP, the scale should be tailored to local circumstances, and that this scale is adapted to a European context where advance directives are rarely used.\u003c/p\u003e\n\u003cp\u003eConcerning strengths and weaknesses, a weakness of this study is that it was probably easier to achieve good interrater reliability because little or no ACP was done, and therefore it was easier to score.\u003c/p\u003e\n\u003cp\u003eAnother weakness of this approach is that one does not investigate practices that are not addressed by the scale and one could also argument that the items as such set up a construction of positive evidence because the units would start low at baseline. However, in our fidelity reports we recorded if the units had any ACP practices that our instruments failed to credit. These were few and had more the nature of being discussions about treatment level at that hospital stay, which is not ACP. As such the results also illustrate the probable status quo: ACP probably does not happen in a systematic, structured and standardized way. Balancing the pitfall of positive evidence is therefore the great potential for quality improvement in the services.\u003c/p\u003e\n\u003cp\u003eAnother weakness is that we could have included additional data sources to enhance the validity and reliability of the results. A review of medical records or observations was not done at baseline due to limited resources, but also because ACP was not practiced in a systematic way in any of the sites. However, a review of patient records and health register data will be done in the intervention period. Alongside the intervention, we will also conduct separate qualitative interviews and collect questionnaires from staff, patients and next of kin to evaluate service and patient outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConcerning the representability of the sample where we conducted our fidelity measurements, a critique could be that we only included units with a priori expertise in the care for older patients, including communication. This could pose as a problem of selection bias in the results. Thus, in terms of external validity, these findings do not necessarily reflect the situation in other wards where for instance a more holistic approach and broad assessment of the patient is not already an integrated part of the working method. Yet, our results support the assumption that ACP is not implemented even in wards specialized in the health care for older patients. When the implementation is this low even in units prone to be more adaptive to this practice, we have little reason to believe that ACP practices in other wards with other older patient groups will be more systematic or of higher quality.\u003c/p\u003e\n\u003cp\u003eThe main strength of the scale is that it is broad and assesses both the quality of ACP, the implementation of ACP and how widespread ACP is. This gives a comprehensive assessment of the implementation of ACP and can also give an assessment of all units in one sample (19). This is useful to guide implementation strategies in large projects, for instance in multicenter studies as this sub-study is part of, to improve the implementation of ACP.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eACP is an evidence-based intervention whose implementation is assumed to be low. This assumption was supported by the findings in this cross-sectional fidelity study. This is the first paper to present a comprehensive fidelity scale to assess the implementation level of ACP in hospital units. The scale shows promising preliminary psychometric properties that may prove a useful tool to accelerate the low implementation of ACP. There is a need to increase the implementation and penetration rate of ACP in the services to improve the involvement of older patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACP: Advance care planning, EBP: Evidence-based practice, GSF: Gold Standard Framework, ICC: Intra-class Correlation Coefficient.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eWe would like to thank Associate Professor Kristin Heiervang at the Department of Health, Social and Welfare Studies at the University of South-Eastern Norway for valuable help regarding fidelity scale development, and PhD fellow Lars Hestmark for valuable help regarding the calculations of ICC. We would also like to thank Senior Consultant Geriatrician P\u0026aring;l Friis and Professor and Senior Consultant Geriatrician Siri Rostoft for valuable comments during the validation process. Finally we would like to thank PhD fellows Shereen Cox and Tore Hofstad for valuable comments during the writing process.\u003c/p\u003e\n\u003cp\u003eDisclosure\u003c/p\u003e\n\u003cp\u003eThe author reports no conflicts of interest in this work.\u003c/p\u003e\n\u003cp\u003eFunding:\u003c/p\u003e\n\u003cp\u003eThe Research Council of Norway funded the study. The funding source had no role in the design if this study, and did not have any role during its execution, analyses, interpretation of the data, or decision to submit results.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials:\u003c/p\u003e\n\u003cp\u003eThe dataset used and/or analyzed during the current study is available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eConsent for publication:\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003eConsent to participate declaration:\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all subjects.\u003c/p\u003e\n\u003cp\u003eEthics approval:\u003c/p\u003e\n\u003cp\u003eThis research complies with international and national standards and has been performed in accordance with the Declaration of Helsinki. It has been approved by the appropriate national ethics committee. NSD- Norwegian Centre for Research Data, the Data Protection Official for Research, approved the study May 20th 2022. Their reference number is 805491.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions:\u003c/p\u003e\n\u003cp\u003eSFW, MR, MA, KBH, LB, AKW, TJLS, LT and RP have participated in developing the fidelity scale and participated in the validation process and discussions that led to the final version of the fidelity scale. SFW, MR, KBH, LB, AKW, TJLS, LT and RP did the baseline measurements. SFW and RP wrote the main manuscript text and SFW prepared tables and additional files. SFW, MR; MA; KBH, LB, AKW, TJLS, LT, RP reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003eCompeting interests:\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, et al. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. J Pain Symptom Manage. 2017;53(5):821-32.e1.\u003c/li\u003e\n\u003cli\u003eMorrison RS, Meier DE, Arnold RM. What\u0026apos;s Wrong With Advance Care Planning? Jama. 2021;326(16):1575-6.\u003c/li\u003e\n\u003cli\u003eJimenez G, Tan WS, Virk AK, Low CK, Car J, Ho AHY. Overview of Systematic Reviews of Advance Care Planning: Summary of Evidence and Global Lessons. J Pain Symptom Manage. 2018;56(3):436-59.e25.\u003c/li\u003e\n\u003cli\u003eMcMahan RD, Tellez I, Sudore RL. Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review. J Am Geriatr Soc. 2021;69(1):234-44.\u003c/li\u003e\n\u003cli\u003eMalhotra C, Shafiq M, Batcagan-Abueg APM. What is the evidence for efficacy of advance care planning in improving patient outcomes? A systematic review of randomised controlled trials. BMJ Open. 2022;12(7):e060201.\u003c/li\u003e\n\u003cli\u003eSharp T, Moran E, Kuhn I, Barclay S. Do the elderly have a voice? Advance care planning discussions with frail and older individuals: a systematic literature review and narrative synthesis. Br J Gen Pract. 2013;63(615):e657-68.\u003c/li\u003e\n\u003cli\u003eLund S, Richardson A, May C. Barriers to advance care planning at the end of life: an explanatory systematic review of implementation studies. PLoS One. 2015;10(2):e0116629.\u003c/li\u003e\n\u003cli\u003eCombes S, Nicholson CJ, Gillett K, Norton C. Implementing advance care planning with community-dwelling frail elders requires a system-wide approach: An integrative review applying a behaviour change model. Palliat Med. 2019;33(7):743-56.\u003c/li\u003e\n\u003cli\u003eGjerberg E, Lillemoen L, Weaver K, Pedersen R, F\u0026oslash;rde R. Advance care planning in Norwegian nursing homes. Journal of the Norwegian Medical Association. 2017;137(6):447-50.\u003c/li\u003e\n\u003cli\u003eGlaudemans JJ, Moll van Charante EP, Willems DL. Advance care planning in primary care, only for severely ill patients? A structured review. Fam Pract. 2015;32(1):16-26.\u003c/li\u003e\n\u003cli\u003eKlomstad K, Pedersen R, F\u0026oslash;rde R, Rom\u0026oslash;ren M. Involvement in decisions about intravenous treatment for nursing home patients: nursing homes versus hospital wards. BMC Med Ethics. 2018;19(1):34.\u003c/li\u003e\n\u003cli\u003eHofacker S. Akutte innleggelser fra sykehjem til sykehus i livets sluttfase. [Emergency admissions from nursing homes to hospital at the end of life] Tidsskrift for den Norske laegeforening, 2010; 130: 1721-4.\u003c/li\u003e\n\u003cli\u003eHestmark L, Heiervang KS, Pedersen R, Hansson KM, Ruud T, Rom\u0026oslash;ren M. Family involvement practices for persons with psychotic disorders in community mental health centres - a cross-sectional fidelity-based study. BMC Psychiatry. 2021;21(1):285.\u003c/li\u003e\n\u003cli\u003eCarroll C, Patterson M, Wood S, Booth A, Rick J, Balain S. A conceptual framework for implementation fidelity. Implementation Science. 2007;2(1):40.\u003c/li\u003e\n\u003cli\u003eVaccaro L, Butow PN, Lee D, Johnson SB, Bell M, Clayton J, et al. Fidelity is fundamental: intervention predictors in advance care plans in terminal cancer. BMJ Support Palliat Care. 2019;9(4):397-403.\u003c/li\u003e\n\u003cli\u003eVolandes AE, Zupanc SN, Paasche-Orlow MK, Lakin JR, Chang Y, Burns EA, et al. Association of an Advance Care Planning Video and Communication Intervention With Documentation of Advance Care Planning Among Older Adults: A Nonrandomized Controlled Trial. JAMA Netw Open. 2022;5(2):e220354.\u003c/li\u003e\n\u003cli\u003eCraig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655.\u003c/li\u003e\n\u003cli\u003eFamily Psychoeducation: Evaluating Your Program. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration: U.S. Department of Health and Human Services; 2009.\u003c/li\u003e\n\u003cli\u003eBond GR, Drake RE. Assessing the Fidelity of Evidence-Based Practices: History and Current Status of a Standardized Measurement Methodology. Adm Policy Ment Health. 2020;47(6):874-84.\u003c/li\u003e\n\u003cli\u003eNilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10:53.\u003c/li\u003e\n\u003cli\u003eRietjens JAC, Sudore RL, Connolly M, van Delden JJ, Drickamer MA, Droger M, et al. Definition and recommendations for advance care planning: an international consensus supported by the European Association for Palliative Care. Lancet Oncol. 2017;18(9):e543-e51.\u003c/li\u003e\n\u003cli\u003eDetering, Silveira. Facilitating advance care planning discussion (UpToDate) [cited 2020 1.2.2020]. Available from: https://www.uptodate.com/contents/advance-care-planning-and-advance-directives?search=advance%20care%20planning\u0026amp;source=search_result\u0026amp;selectedTitle=1~150\u0026amp;usage_type=default\u0026amp;display_rank=1#H2094995\u003c/li\u003e\n\u003cli\u003eCardona-Morrell M, Benfatti-Olivato G, Jansen J, Turner RM, Fajardo-Pulido D, Hillman K. A systematic review of effectiveness of decision aids to assist older patients at the end of life. Patient Educ Couns. 2017;100(3):425-35.\u003c/li\u003e\n\u003cli\u003eGleeson A, Noble S, Mann M. Advance care planning for home health staff: a systematic review. BMJ Support Palliat Care. 2021;11(2):209-16.\u003c/li\u003e\n\u003cli\u003eHopkins SA, Bentley A, Phillips V, Barclay S. Advance care plans and hospitalized frail older adults: a systematic review. BMJ Support Palliat Care. 2020;10(2):164-74.\u003c/li\u003e\n\u003cli\u003eJain A, Corriveau S, Quinn K, Gardhouse A, Vegas DB, You JJ. Video decision aids to assist with advance care planning: a systematic review and meta-analysis. BMJ Open. 2015;5(6):e007491.\u003c/li\u003e\n\u003cli\u003eKelly AJ, Luckett T, Clayton JM, Gabb L, Kochovska S, Agar M. Advance care planning in different settings for people with dementia: A systematic review and narrative synthesis. Palliat Support Care. 2019;17(6):707-19.\u003c/li\u003e\n\u003cli\u003eWeathers E, O\u0026apos;Caoimh R, Cornally N, Fitzgerald C, Kearns T, Coffey A, et al. Advance care planning: A systematic review of randomised controlled trials conducted with older adults. Maturitas. 2016;91:101-9.\u003c/li\u003e\n\u003cli\u003eS\u0026aelig;vareid TJLS. Advance care planning in nursing homes: a mixed method study of a complex intervention using a whole-ward approach University of Oslo; 2019.\u003c/li\u003e\n\u003cli\u003eAhmed M. Procedure for advance care planning. Oslo University Hospital; 2020.\u003c/li\u003e\n\u003cli\u003eMowbray CT, Holter MC, Teague GB, Bybee D. Fidelity Criteria: Development, Measurement, and Validation. American Journal of Evaluation. 2003;24(3):315-40.\u003c/li\u003e\n\u003cli\u003eReynolds J, Croft S. How to implement the Gold Standards Framework to ensure continuity of care. Nurs Times. 2010;106(32):10-3.\u003c/li\u003e\n\u003cli\u003eBernacki RE, Block SD. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994-2003.\u003c/li\u003e\n\u003cli\u003eFien S, Plunkett E, Fien C, Greenaway S, Heyland DK, Clark J, et al. Challenges and facilitators in delivering optimal care at the End of Life for older patients: a scoping review on the clinicians\u0026apos; perspective. Aging Clin Exp Res. 2021;33(10):2643-56.\u003c/li\u003e\n\u003cli\u003eFrechman E, Dietrich MS, Walden RL, Maxwell CA. Exploring the Uptake of Advance Care Planning in Older Adults: An Integrative Review. J Pain Symptom Manage. 2020;60(6):1208-22.e59.\u003c/li\u003e\n\u003cli\u003eKe LS, Huang X, O\u0026apos;Connor M, Lee S. Nurses\u0026apos; views regarding implementing advance care planning for older people: a systematic review and synthesis of qualitative studies. J Clin Nurs. 2015;24(15-16):2057-73.\u003c/li\u003e\n\u003cli\u003eLum HD, Sudore RL, Bekelman DB. Advance care planning in the elderly. Med Clin North Am. 2015;99(2):391-403.\u003c/li\u003e\n\u003cli\u003eRyan T, Amen KM, McKeown J. The advance care planning experiences of people with dementia, family caregivers and professionals: a synthesis of the qualitative literature. Ann Palliat Med. 2017;6(4):380-9.\u003c/li\u003e\n\u003cli\u003eThreapleton DE, Chung RY, Wong SYS, Wong ELY, Kiang N, Chau PYK, et al. Care Toward the End of Life in Older Populations and Its Implementation Facilitators and Barriers: A Scoping Review. J Am Med Dir Assoc. 2017;18(12):1000-9.e4.\u003c/li\u003e\n\u003cli\u003eHolden RB. The Corsini Encyclopedia of Psychology (4th ed.). Irving B. Weiner IaWEC, editor2010.\u003c/li\u003e\n\u003cli\u003eStake R. Responsive Evaluation. In: Kellaghan T, Stufflebeam DL, editors. International Handbook of Educational Evaluation. Dordrecht: Springer Netherlands; 2003. p. 63-8.\u003c/li\u003e\n\u003cli\u003eKoo TK, Li MY. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J Chiropr Med. 2016;15(2):155-63.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Description of the 12 clinical sites included in the cluster randomized trial\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSite\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of unit\u003ca href=\"#_ftn1\" name=\"_ftnref1\" title=\"\"\u003e\u003c/a\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCatchment population\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal number of patients\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean length of stay for acute geriatric patients (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFull-time equivalent staff (FTE)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients per FTE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e1 Gj\u0026oslash;vik\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eIMU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e30 267\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e3,48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e17,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e1,77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e2 Kongsberg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eAGU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e50 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e4,55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e3,83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e3 Elverum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eAGU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e60 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e3,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e30,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e1,33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e4 Arendal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eAGU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e120 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e4,44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e5 DHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eAGU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e150 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e16\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e4,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e42,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e2,67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e6 Kristiansand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eAGU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e155 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e2,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e19,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e4,95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e7 Drammen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eAGU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e168 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e39,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e4,9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e8 B\u0026aelig;rum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eAGU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e180 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e3,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e33,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e4,21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e9 OUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eAGU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e200 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e4,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e1,8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e10 SIV\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eAGU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e230 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e16,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e1,83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e11 S\u0026Oslash;K\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eAGU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e323 453\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e47,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e2,6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e12 Ahus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003eAGU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e594 000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e53,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" valign=\"top\"\u003e\n \u003cp\u003e2,32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cdiv id=\"ftn1\"\u003e\n \u003cp\u003e\u003csup\u003e1\u003c/sup\u003e AGU: Acute geriatric unit, IMU: Internal medical unit with geriatrician among staff.\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2: Fidelity baseline results, distributions, interrater reliability and percentage agreement for the fidelity scale, after testing in the 12 hospital units.\u003c/strong\u003e\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem number\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem description\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumbers of sites achieving score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAgreement\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eICC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.434782608695652%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.78260869565217%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2-3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.78260869565217%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e4-5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eImplementation subscale\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eMeeting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eAction plan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eProgram philosophy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e2,25 (0,65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e66,67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e0,784\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eCoordinator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1,33 (0,48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eTraining and supervision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eSystematic identification of eligible patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eContinuous implementation measures \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eSubtotal for structural/ implementation measures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1,21 (0.083 )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e0,969\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eQuality subscale\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eAssessing decision-making capacity.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eVerbal and written invitation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eLevel of involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1,08 (0,28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eProvide information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eWhat is important to the patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1,08 (0,28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eElicit preferences regarding future and current treatment and care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1,08 (0,28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious documentation of patient\u0026rsquo;s values, goals and preferences.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003ePermission to pass on information to other health personnel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1,08 (0,280)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eSumming up and evaluating the ACP-discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1,25 (0,84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eQuality of documentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1,25 (0,84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e20 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eDissemination of ACP in discharge summary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1,33 (1,12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003csup\u003e1\u003c/sup\u003e\u003ca href=\"#_ftn1\" name=\"_ftnref1\" title=\"\"\u003e\u003c/a\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eSubtotal for quality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1,11 (0,37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePenetration rate subscale\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eProportion invited\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eProportion given ACP (penetration rate in the unit)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eChecking in the patient\u0026rsquo;s record if ACP has been done previously\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1,11 (0,67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eACP in discharge summary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003eSubtotal for penetration rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e1,04 (0,144)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.2680412371134%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eScale total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1,16\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.216494845360825%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.154639175257732%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,990\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003csup\u003e1\u003c/sup\u003e\u003ca href=\"#_ftnref1\" name=\"_ftn1\" title=\"\"\u003e\u003c/a\u003e In one of the units, the palliative team summed up, documented and disseminated ACP in the discharge summary, but the few patients that did receive ACP from them, did not receive a written and verbal invitation to ACP.\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"advance care planning, implementation science, fidelity, health care services, autonomy, older patients, geriatrics","lastPublishedDoi":"10.21203/rs.3.rs-3610212/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3610212/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMany studies report that the implementation of advance care planning (ACP) is low, but we lack an instrument to actually measure this. Implementation fidelity can be such a tool and refers to the degree to which an intervention or program is delivered as intended. This method has rarely been used in trials where ACP is the intervention, and if so, only studying parts of fidelity.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe developed and employed the first comprehensive fidelity-scale to measure ACP practice in hospital units. The scale was used in a cluster randomized controlled trial to measure baseline implementation of ACP in the routine care for acutely admitted patients in 12 geriatric units. The scale consists of 22 items that are scored from 1 to 5, where 1 equals no implementation, and 5 equals full implementation. Data was analyzed using descriptive statistics and calculation of interrater reliability.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe mean score was 1,16 for the total scale. The few items that had a higher score were the item on program philosophy, which was known to devoted professional individuals, but not owned by entire units. Furthermore, parts of what would constitute good quality of the intervention where in place in some units, but do not represent a systematic practice. As a measure of interrater reliability, the intra-class correlation coefficient was 0,99.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe level of implementation of ACP was generally low. Our novel fidelity scale shows promising preliminary psychometric properties and may prove to be a useful tool to guide the implementation strategy to accelerate the implementation of ACP in health care.\u003c/p\u003e","manuscriptTitle":"Assessing the implementation level of advance care planning– the first comprehensive fidelity scale","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-11-28 05:02:41","doi":"10.21203/rs.3.rs-3610212/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a5ad2c9b-a96d-4862-be2d-916974b6895a","owner":[],"postedDate":"November 28th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-11T13:59:47+00:00","versionOfRecord":[],"versionCreatedAt":"2023-11-28 05:02:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3610212","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3610212","identity":"rs-3610212","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}