Table 1

Implementation strategies used in the current evaluation per the (ERIC)32 discrete implementation strategies and Proctor’s framework33

Proctor domain	Explanation	ERIC strategy
Actor	Who delivers the strategy? SALHN FLS clinical staff including those within the MDT FLS, the associated SALHN BDT team and the consulting endocrinologist	Build a coalition
Action	Steps to be taken to carry out the strategy? Organisational structure supports the implementation of routine VFA for every patient accessing the osteoporosis care pathway including discussions with Directors and Heads of Departments. It should be noted that the SALHN BDT already had the necessary imaging equipment to perform VFAs, so no new equipment was needed to implement the quality improvement. The FLS staff led the implementation in line with best practice guidelines.36 The BDT and consulting endocrinologist were consulted regarding the concept of the new pathway. This was achieved through departmental meetings and other channels which are in place to support the communication of change of practice directives. The positives and negatives of implementing VFA were discussed including logistics (e.g., ensuring we had the right equipment and prolonging scan time slots for room booking and staff/patient time (e.g., positioning the patient for the VFA can take some time). The FLS team committed to aiding the BDT throughout the project, which including aiding with patient positioning within the scanner. Staff were orientated to the evidence (e.g., CTF framework) supporting the change, particularly BDT and higher management who were less familiar with the CTF bronze, silver and gold rating system. Specific training was provided to ensure collaboration between staff for effective case-finding and management of patients with osteoporotic vertebral fractures. For example, it was critical to standardise the reporting system (e.g., terminology) in the BDT to clearly diagnose vertebral fractures for the FLS staff. On the service referral and results form, a tick box reminder system was available for the completion of a VFA	Involve executive boards Assess for readiness and identify barriers and facilitators Conduct educational meetings Develop and implement tools for quality monitoring Facilitation Remind clinicians Organise clinician implementation team meetings
Target of the action	Who/what the actors are attempting to impact, based on conceptual models of implementation? Change risk assessment for osteoporosis for all patients by introducing the VFA. Treatment initiation is to be recommended for patients who exhibit vertebral fractures, regardless of BMD score
Temporality	When does the strategy take place; what is the order of the strategies? One-time rollout in March 2020 with ongoing monitoring. Clinical evaluation in October 2022	Audit and provide feedback
Dose	Frequency and intensity Ongoing practice
Outcomes affected	What will the strategy change? The overall goal is to improve osteoporosis care quality and reduce the number of secondary fractures. The strategy will ensure every eligible FLS patient is offered a VFA as part of their routine care. The strategy also aims to increase the number of patients with normal BMD offered osteoporosis treatment initiation based on previous vertebral fractures. Furthermore, we have also made changes to the reporting system for vertebral fractures, ensuring results are clear and unambiguous for the FLS who are initiating treatment and talking to patients. We hope these changes will increase staff confidence for initiating treatment and increase patient confidence for accepting treatment	Promote adaptability
Justification	Basis for the strategy in research or practice? National and international clinical guidelines and standards advocate for the implementation of VFA

BDT, bone densitometry team; BMD, bone mineral density; CTF, Capture the Fracture; FLS, Fracture Liaison Service; MDT, multidisciplinary team; SALHN, Southern Adelaide Local Health Network; VFA, vertebral fracture assessment.