Implementation approaches

We all need to care about implementation in care settings. Research and practice evidence continues to accumulate at a great cost to governments, yet the potential improvements in health and social care lag far behind. We are all affected by this gap between knowledge of what works from research and what happens in real-world practice. The very quality of our care can be affected by it.

Knowing some general principles about implementation at the start of a project can help prepare you for some of the challenges you might face.
 

• Implementation is a team effort, not a one-person activity. Success usually depends on everyone involved in a change owning it and contributing to the implementation activities. Implementation processes are social processes, requiring good communication and collaborative relationships between people. 
• Implementation processes are dependent on the context in which they take place. This means considering the immediate organisation and where necessary the wider community or an entire sector. The context of the organisation includes everything from its culture, current staffing levels, leadership styles, and what the organisation considered its priorities (e.g., COVID-19 management!). Context beyond this includes emerging political and economic issues of the day and their implications for the sector.  
• Implementation is therefore complex. Change takes time and even the simplest of changes may require both thoughtful planning and genuine commitment. This is particularly so when it involves altering people’s behaviours, individually and collectively. 

At its simplest, an implementation project involves these phases. 

1. Recognising a problem that needs addressing 
   Not all practices may need changing and not all evidence needs to be implemented. Organisations invest in fixing prioritised problems that are having a significant (not trivial) impact on care in some way. Start by defining the problem clearly so that everyone understands the focus and scope of the implementation project.
    
2. Seeking an evidence-based solution
   Find out if research has identified any practices that show effectiveness in fixing this problem. It is important to consider the setting and context of any research study. Knowledge from a study of middle-aged people in an inpatient hospital setting may not be very relevant to a problem involving people with dementia living in residential aged care. Consider the type of evidence available too. Systematic reviews of multiple intervention trials and randomised controlled trials are considered the most trustworthy study designs for answering questions about what works. 
   
   If the evidence you find is not a perfect fit for your context, you might decide to modify it. You might also choose to implement only part of a complex multi-component intervention if that is a more realistic option for your organisation.
   
   Often you may find there is no evidence available or what is available is deemed inconclusive. This should not prevent you from trying a different approach. The knowledge you gain will have value, providing the new approach is person-centred, has no associated harms, and has the support of the person involved and their family. This is also where you could draw on the knowledge and expertise of staff with years of practice experience.
      
3. Identifying factors that hinder or champion implementation
   Before implementing a change, seek out the factors specific to your context that could help or hinder your project. Invest in the enabling factors and do what you can to minimise those that could be a barrier to success. Enablers include:  
   
   Supportive leaders who champion the change
   Motivation and buy-in from those implementing the change
   Having the necessary resources, including staff, time, space, training opportunities, and technology.
   Having a clear goal, a plan, and good channels of communication in place. 
   
   There are tools available such as the Alberta Context Tool to help gauge the readiness of an organisation for change. [2]
    
4. Continuing to assess and monitor to sustain change
   Implementation is an ongoing process, not a one-off destination. Once you have implemented a change, you need to evaluate if it has had a positive impact. You should also continue to monitor the change over time. People may start to drift back to an old practice or start making adaptations to the new approach. Sustaining the change over a longer period involves more than this. As contexts shift and change, the changed practice may no longer be as relevant as it was. The innovation may need tweaking, or the way it was implemented might have to be revisited and started all over again.
   
   Finally, it is important to report on the success of any implementation project and acknowledge and reward those who contributed to that success. This creates a sense of accomplishment and goodwill toward the next project. 

There are many frameworks and models of implementation that can serve as useful guides in the practice of implementation. These three may be a good place to start if you are new to implementation.  

1. Knowledge to Action cycle 
   This practical and user-friendly model starts with the evidence that needs to be implemented into a practice change, for example, an evidence-based guideline recommendation, and provides a phased, cyclical process for achieving this. [3]  
    
2. The i-PARiHS (integrated-Promoting Action on Research Implementation in Health Services) framework 
   In supporting practice change, the Promoting Action on Research Implementation in Health Services (PARiHS) framework emphasises the importance of the context or setting into which new evidence is being introduced and how the evidence is implemented. [4,5]
    
3. Conceptual model of implementation research 
   A simple, easy-to-understand model from the mental health services that explains the relationship between implementation and evidence-based practice. Covers implementation strategies and how to measure their effectiveness.  [6]

For a wider range of options, read the articles Making sense of implementation theories, models and frameworks by Nilsen [7] and "There is nothing so practical as a good theory": A pragmatic guide for selecting theoretical approaches for implementation projects by Lynch. [8]

You might also like to try our one-click PubMed searches on implementation and knowledge translation. Choose from free full text, systematic reviews only, or articles specific to aged care.

1. Centre for Effective Services. An introductory guide to implementation [Internet]. Dublin, Ireland: CES; 2022 [cited 2022 Jul 31]. Available from: https://implementation.effectiveservices.org/overview/what-is-implementation.
2. Estabrooks CA, Squires JE, Cummings GG, Birdsell JM, Norton PG. Development and assessment of the Alberta Context Tool. BMC Health Serv Res. 2009;9:234.
3. Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, Robinson N. Lost in knowledge translation: Time for a map? J Contin Educ Health Prof. 2006 Winter;26(1):13-24.
4. Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: A conceptual framework. Qual Health Care. 1998;7(3):149–158. 
5. Harvey G, Kitson A. PARIHS revisited: From heuristic to integrated framework for the successful implementation of knowledge into practice. Implement Sci. 2016 Mar 10;11:33. 
6. Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman B. Implementation research in mental health services: An emerging science with conceptual, methodological, and training challenges. Adm Policy Ment Health. 2009 Jan;36(1):24-34. 
7. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015 Apr 21;10:53. 
8. Lynch EA, Mudge A, Knowles S, Kitson AL, Hunter SC, Harvey G. "There is nothing so practical as a good theory": A pragmatic guide for selecting theoretical approaches for implementation projects. BMC Health Serv Res. 2018 Nov 14;18(1):857.