Implementation

The Cochrane Collaboration’s Review Group on Effective Practice and Organisation of Care has identified four broad categories of implementation strategy interventions targeted at either: healthcare organisations, healthcare recipients, healthcare workers, or specific types of practice, conditions or settings. Many of these are widely used in practice, and a large number of systematic reviews have examined their effectiveness.

There is no strategy suitable for all circumstances, and what works best will depend on the intervention, the setting, the people involved and what resources the project has. Improving the reporting of implementations tudies wil help us build our understanding of what works in what contexts. [2] The Standards for reporting Implementation Studies (StaRI) statement will lead to comparable studies that will help in this regard. Nevertheless, Wensing recommends working creatively to plan a cost-effective mix of approaches tailored to the local setting, relying where possible on methods that have worked elsewhere in similar situations. [5]

It is worth noting that there have only been a few KT and Implementation theories, models and frameworks used in end of life studies. [7] Palliative care specific models such as the Evidence-based Model for the Transfer and Exchange of Research Knowledge (EMTReK) are now emerging. [8]

Plan the implementation! Possibly the most important element of implementing change is to actually plan the implementation, rather than assume it will automatically happen on the strength of the identified need or the evidence alone.

Wensing [6] emphasises the importance of planning. First, there should be a good basis for change. This could be new scientific knowledge, or perhaps a particular problem or best practice is identified. Second, the implementation should be planned (when, where, how, and by whom the implementation will occur). Clearly outlining the advantages of change, and solutions for any possible disadvantages also helps. [5] A diagnostic analysis can reveal the target group and behaviours, and identify barriers and facilitators to change. In common with dissemination, program logic models and theories of change are useful tools in planning implementation programs.

Principles

The general principles of planning are similar across different projects and circumstances but include: [9]

• Plan development
• Testing
• Adapting and scheduling
• Evaluation and organisation of the implementation.

Barriers and facilitators

Implementation effectiveness with different KT strategies varies. How well the barriers to implementation can be overcome has been identified as a key factor in success. [2]

Characteristics of successful innovations include: [6]

• Compatibility with existing norms and values
• Opportunity to try them out
• A clear and easily accessible format
• Co-design and opportunity to adapt to local situation

Identifying factors or determinants that might facilitate or block change is important because targeting these can result in a more effective implementation strategy. [6]

Tools such as Identifying Barriers to Evidence Uptake (NICS) and How To: Implement Change Successfully (113kb pdf) (University Hospitals Bristol, UK) may be useful in your clinical implementation project. Planning for change can benefit from input from theories on implementation of change. Visit the pages on theories of change for an overview of how these can help facilitate stakeholder involvement and uptake of change.

1. Eccles MP, Mittman BS. Welcome to Implementation Science [editorial]. Implement Sci. 2006 Feb;1:1. https://doi.org/10.1186/1748-5908-1-1
2. Barwick M, Dubrowski R, Petricca K. Knowledge translation: The rise of implementation (1.32MB pdf). Washington, DC: American Institutes for Research. 2020 Nov.
3. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011 Mar;38(2):65-76. doi: 10.1007/s10488-010-0319-7.
4. Mallidou AA, Atherton P, Chan L, Frisch N, Glegg S, Scarrow G. Core knowledge translation competencies: a scoping review. BMC Health Serv Res. 2018 Jun 27;18(1):502. doi: 10.1186/s12913-018-3314-4.
5. Curran GM. Implementation science made too simple: a teaching tool. Implement Sci Commun. 2020 Feb 25;1:27. doi: 10.1186/s43058-020-00001-z.
6. Wensing M, Grol R, Grimshaw J, edtiors. Improving Patient Care: The Implementation of Change in Health Care [Internet]. 3rd ed. Wiley–Blackwell; 2020. [cited 2022 May 19].
7. Strifler L, Cardoso R, McGowan J, Cogo E, Nincic V, Khan PA et al. Scoping review identifies significant number of knowledge translation theories, models, and frameworkswith limited use. J Clin Epidemiol. 2018 Aug;100:92-102. doi: 10.1016/j.jclinepi.2018.04.008. Epub 2018 Apr 13.
8. Payne C, Brown MJ, Guerin S, Kernohan WG. EMTReK: An Evidence-based Model for the Transfer & Exchange of Research Knowledge-Five Case Studies in Palliative Care. SAGE Open Nurs. 2019 Jul 26;5:2377960819861854. doi: 10.1177/2377960819861854.
9. Grol R, Wensing M, Eccles M, editors. Improving patient care: the implementation of change in clinical practice. Oxford: Elsevier; 2005.