Background: The successful implementation of evidence-based practices (EBPs) in real-world settings requires an adaptive approach and ongoing process evaluation and tailoring. Although conducting a needs assessment during the preparation phase of implementation is beneficial, it is challenging to predict all barriers to EBP implementation that may arise over the course of implementation and sustainment. This article describes a process evaluation that identified emergent and persistent barriers that impacted the implementation of an EBP across multiple behavioral health organizations and clinics. Methods: This study was conducted during the first cohort of a cluster randomized controlled trial testing the effectiveness of the Leadership and Organizational Change for Implementation (LOCI) strategy to implement motivational interviewing (MI) in substance use disorder treatment agencies and clinics. We used a modified nominal group technique (NGT) in which clinic leaders identified barriers faced during the implementation process. Barriers were categorized, then ranked and rated according to leaders’ perceptions of each barrier’s influence on implementation. The barriers were then contextualized through individual qualitative interviews. Results: Fifteen barriers were identified, grouped into staff-level barriers, management-level barriers, and implementation program barriers. Time and resistance to MI were rated as the most influential staff-level barriers. Among management-level barriers, time was also rated highest, followed by turnover and external contractual constraints. The most influential implementation barrier was client apprehension of recording for fidelity assessment and feedback. Individual interviews supported these findings and provided suggested adaptations for future implementation efforts. Conclusion: EBP implementation is an ongoing process whereby implementation strategies must be proactively and strategically tailored to address emergent barriers. This research described a process evaluation that was used to identify 15 emergent and/or persistent barriers related to staff, management, and the implementation program. Using implementation strategies that can be tailored and/or adapted to such emergent barriers is critical to implementation effectiveness. Plain Language Summary Unforeseen barriers often arise during the course of implementation. Conducting evaluations during implementation allows for tailoring the implementation strategy. As part of a larger study using the Leadership and Organizational Change for Implementation (LOCI) strategy to implement motivational interviewing (MI), we collected data from the first cohort of LOCI clinic leaders to identify barriers to MI implementation that persisted despite advanced planning and to understand unanticipated barriers that arose during implementation. Leaders identified 15 barriers faced during the implementation process that fell into three categories: staff-level barriers, management-level barriers, and implementation program barriers. The leaders ranked time as the most influential barrier at both the staff and management levels. Staff apprehension, resistance to MI implementation, and staff turnover were also of significant concern to leaders. Future implementation efforts may benefit from conducting a similar process evaluation during the implementation phase.
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