Implementation Science: Implementation Stage

Original Editor - Stacy Schiurring based on the course by Lucio Naccarella

Top Contributors - Stacy Schiurring  

Introduction[edit | edit source]

Implementation is not an event.  Implementation is “a specified set of activities designed to put into practice an activity or program”. Implementation involves multiple decisions, actions, and corrections to change the structures and conditions necessary to implement and sustain new practices and programs successfully. [1]

Not everyone is excited by change. Changing practice or adopting a new intervention into practice is complex and takes time.  Changing practice can be challenging: just half of all new interventions are implemented as intended.  Therefore, a systematic set of strategies are needed to increase the probability of successful implementation change.

  • Implementation Strategies refers to HOW to enhance the adoption, implementation, and sustainability of evidence-based rehabilitation interventions, programs or practices into normal practice into clinical and community settings.
    • Implementation strategies have been described as the active ingredients of the implementation process and the ‘how to’ component of changing healthcare practice.[2]
    • Implementation strategies need to be linked to the mechanisms hypothesized to underlie its functioning. Mechanisms are the processes by which an implementation strategy operates to encourage the desired implementation outcome.[3]
  • Implementation Facilitation is also a key implementation strategy and refers to a multi-faceted strategy to help rehabilitation professionals to identify, focus on, and address the implementation challenges and leveraging the positive influences related to the evidence-based intervention/innovation, context for implementation and key stakeholders essential to the implementation process. Implementation facilitators need work with all involved in the provision of rehabilitation services, embracing the diverse experiences that drive and shape implementation efforts.


Implementation science takes evidence-based clinical innovations and testing strategies and helps to move them into wider practice. The protocols of implementation science do not ignore or control for context, but rather actively attempt to alter the intervention's context in order to improve their implementation. When possible, implementation scientists can work closely with healthcare leaders and staff to break down the research-practice divide increase the public health impact of evidence-based interventions.[4]

Implementation Strategy Classification[edit | edit source]

Implementation researchers have identified over 70 discrete implementation strategies for use in healthcare and health services.[5]  It can be overwhelming deciding what implementation strategy to select and for what purpose.  Ideally, implementation strategies will be in response to or aligned with the implementation challenges or barriers identified in the pre-implementation phases.  

Inability to appropriately implement interventions can limit the potential for patients and communities to benefit from advances in health promotion, medicine, and public health. A 2019 study by Fernandez et al discusses the use of Intervention Mapping as a systematic process for planning or selecting implementation strategies.[6]

Implementation Mapping involves five tasks:

  1. Conduct an implementation needs assessment and identify program adopters and implementers
  2. State adoption and implementation outcomes and performance objectives, identify determinants, and create matrices of change objectives
  3. Choose theoretical methods (mechanisms of change) and select or design implementation strategies
  4. Produce implementation protocols and materials
  5. Evaluate implementation outcomes

[6]

Classification by Level[edit | edit source]

To facilitate implementation effort, much debate exists about how to classify these strategies. One method is to classify the implementation strategies into 3 levels:

  1. Service and systems to include resources, champions and leadership
  2. Providers to include training, support tools and reimbursement
  3. Patients to include logistics and funding

Classification by Implementation Driver[edit | edit source]

Another approach is to classify implementation strategies is by the implementation drivers or what strategies can drive successful implementation of an intervention.[7] Three distinct clusters of implementation drivers have been identified, including:

  1. Competency drivers which are mechanisms to develop, improve, and sustain an individual’s ability to implement a new innovation or strategy with intended benefits.
  2. Organisation drivers which intentionally develop the organizational supports and systems interventions needed to ensure that the individuals carrying out the innovation or strategy are effectively supported and that data are used for continuous improvement, and
  3. Leadership drivers which ensure that leaders are using the appropriate strategies to address implementation challenges.

Classification by Action Target[edit | edit source]

Given the complexity of both rehabilitation and implementation, the level that an implementation strategy targets as it will be more pragmatic.  Five classes of implementation strategies have been suggested (see Box 9).

Conclusion[edit | edit source]

Given the multiple challenges to implementing rehabilitation interventions and the multiple implementation strategies available to support implementation efforts, one must be intentional when designing an implementation strategy.

Although implementation science has seen significant progress in recent years, findings are only beginning to emerge specific to the rehabilitation professionals.  Implementation strategies such as educational meetings, audit and feedback techniques, and the use of clinical reminders hold promise for increasing the use of evidence by rehabilitation professionals. However, there is still little guidance for how these findings can be operationalised within across the rehabilitation specialties.

Further research is needed to help determine which implementation strategies are best suited for the unique and often complex context that is rehabilitation, this will lead to better and more meaningful impact on rehabilitation practice and patient outcomes.[9]Such reserach is limited from low-middle income countries, likely due to funding limitations.[10]

Resources[edit | edit source]

Please view this approximately 17-minute video for a detailed description of implementation strategies.

[11]

Recommended Reading:

References[edit | edit source]

  1. Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F, Burns B, Carter W, Paulson R, Schoenwald S, Barwick M, Chambers D. Implementation research: A synthesis of the literature.
  2. Proctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendations for specifying and reporting. Implementation Science. 2013 Dec;8(1):1-1.
  3. Lewis CC, Klasnja P, Powell BJ, Lyon AR, Tuzzio L, Jones S, Walsh-Bailey C, Weiner B. From classification to causality: advancing understanding of mechanisms of change in implementation science. Frontiers in public health. 2018 May 7;6:136.
  4. Bauer MS, Kirchner J. Implementation science: What is it and why should I care?. Psychiatry research. 2020 Jan 1;283:112376.
  5. Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor EK, Kirchner JE. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science. 2015 Dec;10(1):1-4.
  6. 6.0 6.1 Fernandez ME, Ten Hoor GA, Van Lieshout S, Rodriguez SA, Beidas RS, Parcel G, Ruiter RA, Markham CM, Kok G. Implementation mapping: using intervention mapping to develop implementation strategies. Frontiers in public health. 2019 Jun 18;7:158.
  7. Fixsen D, Blase K, Naoom S, Duda M. Implementation drivers: Assessing best practices. Chapel Hill, NC: University of North Carolina at Chapel Hill. 2013.
  8. Leeman J, Birken SA, Powell BJ, Rohweder C, Shea CM. Beyond “implementation strategies”: classifying the full range of strategies used in implementation science and practice. Implementation Science. 2017 Dec;12(1):1-9.
  9. Morris JH, Bernhardsson S, Bird ML, Connell L, Lynch E, Jarvis K, Kayes NM, Miller K, Mudge S, Fisher R. Implementation in rehabilitation: a roadmap for practitioners and researchers. Disability and rehabilitation. 2020 Oct 22;42(22):3265-74.
  10. Hailemariam M, Bustos T, Montgomery B, Barajas R, Evans LB, Drahota A. Evidence-based intervention sustainability strategies: a systematic review. Implementation Science. 2019 Dec;14(1):1-2.
  11. Youtube. Implementation Strategies | IRL. Available from: https://www.youtube.com/watch?v=0iRH51tAzrc [last accessed 11/05/2022]