Implementation Science: Implementation Stage

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

Top Contributors - Stacy Schiurring, Tarina van der Stockt, Kim Jackson and Jess Bell  

Introduction

Implementation is not an event but “a specified set of activities designed to put into practice an activity or program”, involving multiple decisions, actions, and corrections to change structures and conditions necessary for success.

Changing practice is complex, just half of all new interventions are implemented as intended. Therefore, systematic implementation strategies are needed to increase the probability of successful 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. These strategies are the active ingredients of implementation—the 'how to' component of changing healthcare practice. Critically, implementation strategies must be linked to the mechanisms (processes) hypothesised to produce desired implementation outcomes.

• Implementation Facilitation is a key multifaceted strategy that helps rehabilitation professionals identify and address implementation challenges while leveraging positive influences related to the intervention, context, and stakeholders. Implementation facilitators need work collaboratively with all rehabilitation service providers, embracing diverse experiences that 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.

Selecting Implementation Strategies

Implementation researchers have identified over 70 discrete implementation strategies for use in healthcare and health services.  Deciding which to select can be overwhelming. Ideally, strategies should respond to barriers identified during pre-implementation.

Inability to appropriately implement interventions can limit the potential for patients and communities to benefit from advances in health promotion, medicine, and public health. Fernandez et al. (2019) propose using Implementation Mapping, which involves the following:

1. Conduct an implementation needs assessment and identify programme 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

Implementation Strategy Classifications

Given the complexity of rehabilitation and implementation, multiple classification approaches exist. Understanding these helps match strategies to specific implementation challenges. The literature describes three main ways to classify implementation strategies, each useful for different implementation scenarios:

1. Classification by Level

Classify the implementation strategies into 3 organisational 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

2. Classification by Implementation Driver

This approach focuses on what drives successful implementation . 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 organisational 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.

3. Classification by Action Target

This pragmatic approach categorises strategies by what they aim to change. Five classes of implementation strategies have been suggested.

Box 9: Implementation Strategies

1. Implementation process strategies - targets the implementation process – from selecting, adopting or even integrating new intervention. For example, stakeholder engagement, assessing practice setting context (individual staff and organisation needs, readiness and capacity)
2. Dissemination strategies – targets key stakeholder awareness, knowledge, attitudes and intention to adopt the intervention. For example, developing intervention advertising / messaging targeted to specific participants   
3. Integration strategies - targets factors that facilitate or impede optimal integration of an interventions into a practice setting. For example, establishing reminder systems, providing supervision or coaching, reviewing existing staff roles, organisation processes and procedures
4. Capacity building strategies - targets the motivation & capability of individual and organisations to engage in implementation process strategies. For example, providing training to build capacity, provide technical assistance, tools and facilitation to support implementation processes, establishing opportunities for peer networking
5. Scale up strategies – targets motivation and capacity to integrate intervention into practice inner and outer setting. For example, providing training across multiple settings to build intervention specific capacity, or providing technical assistance, tools and facilitation, reviewing organisation infrastructure to support implementation of interventions.

Which classification should you use? Select based on your implementation context:

• Use level-based when addressing hierarchical organisational structures
• Use driver-based when focusing on core implementation capabilities
• Use action target when matching strategies to specific barriers identified in pre-implementation

Conclusion

Successful implementation requires intentional strategy selection matched to identified barriers. The three classification approaches presented, by level, by implementation driver, and by action target, provide complementary frameworks for organizing and selecting from the extensive array of available implementation strategies. Your choice of classification should align with your specific implementation context and the barriers identified during pre-implementation.

While implementation science has progressed significantly, evidence specific to rehabilitation remains limited, particularly from LMICs due to funding constraints. Educational meetings, audit and feedback, and clinical reminders show promise for rehabilitation professionals, but further research is needed to determine which strategies work best in rehabilitation's unique and complex contexts, particularly in resource-limited settings.

Resources

Optional Video:

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

Recommended Reading:

• Bauer MS, Kirchner J. Implementation science: What is it and why should I care?. Psychiatry research. 2020 Jan 1;283:112376.
• 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.
• Proctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendations for specifying and reporting. Implementation Science. 2013 Dec;8(1):1-1.