Implementation Matters

Implementation Matters

Imagine spending years on research that could save lives, improve health, or transform communities—only to see it gather dust in a journal, never making a difference outside academia. This is the challenge that implementation science tackles head-on: making sure discoveries don’t just stay on paper but actually change lives.

Why Implementation Science Matters

Implementation science is a field dedicated to closing the gap between what we know and what we do. It sits at the intersection of research and practice, helping to move evidence-based innovations from the lab into hospitals, clinics, and communities where they can make a real impact.

Nearly two decades since the launch of the journal Implementation Science in 2006, we’ve made significant progress in understanding how to implement evidence-based innovations in real-world settings. Yet, the field still lacks the recognition, investment, and global coordination needed to achieve its full potential.

Why? Partly because implementation science exists in a liminal space — between generating evidence and applying it, between research and practice, and between theory and action. Its purpose is to ensure that discoveries don’t just sit on the shelf but are translated into meaningful improvements in health outcomes and the well-being of our planet.

How Is Research Evidence Used?

Recognizing the importance of implementation science begins with understanding that not all evidence is used the same way. Sometimes it directly informs decisions (instrumental use), sometimes it influences how people perceive an issue (conceptual use), and other times it is used to justify positions already adopted (symbolic use)1. Most often, research affects thinking and awareness more than it prompts immediate action. This may be because much of the research evidence we generate is conceptual and not easily applied. Nonetheless, we acknowledge that a substantial body of evidence exists that could be implemented but is not.

A related issue is one of equitable dissemination. Over half of published articles are never read beyond their authors, reviewers, and editors. Up to 90% are never cited. Only 10–30% of research is accessed by practitioners or policymakers who could use it. That means about 70% of research ready for application goes unused—wasted potential and missed opportunities to improve health and well-being1.

Rethinking Evidence in Clinical Practice

Understanding the various types of evidence in clinical practice can significantly aid informed decision-making. There are three main types: first, evidence on etiology and burden; second, evidence on the effectiveness of interventions; and third, guidance on implementing these interventions within specific contexts. Interestingly, we tend to have more evidence for the first type, but much less for the third, which is highly dependent on local environments and complex adaptive systems2. That’s where implementation science comes in.

Five Core Issues to Consider

Researchers and implementers ought to consider how the evidence base is developed, the context in which it’s developed and used, its implications for health equity, the policies involved, and the perspectives of those who will actually use or apply the knowledge. Implementation science has prompted us to adopt broader study designs3 and involve interest holders beyond traditional randomized controlled trials, thereby better matching complex real-world scenarios.

Why Should We Act?

So why is integrating implementation science into healthcare so crucial? Well, it can prevent unnecessary deaths and wasted opportunities. Evidence-based innovations could save tens of thousands of lives each year if we scaled up their implementation2. There’s also a significant lag between research discovery and routine practice—about 15 to 17 years—which implementation science helps to shorten4.

Beyond saving lives, employing these methods improves overall outcomes and promotes health equity, sustainability, and relevance. To truly make a difference, we need to involve implementation scientists early in the process, recognize the value of implementation data, incorporate assessments into research plans, and build collaborative partnerships. It’s also vital to distinguish between the research environment and real-world factors, rely on experts to troubleshoot issues, and prioritize scaling and sustaining successful initiatives. Continuous learning, adaptation, and knowledge sharing are key to strengthening our systems.

We need a paradigm shift. First, funders must rebalance priorities and invest more in implementation. This is starting to happen, but it needs to accelerate and expand. Second, universities and research institutes must bolster implementation science capacity; it should be recognized as a core discipline alongside epidemiology, biostatistics, and clinical trials. Third, we must engage leaders beyond academia, including patient partners, policymakers, health system executives, and professional associations. All of them need to see implementation science as essential to quality improvement and equity. Only when these steps are in place can we realize the potential of discovery research; the world knows more than ever about how to enhance health and well-being. Implementation science ensures this knowledge is actively applied. It is time to build a movement around implementation science.

Making Implementation Simpler

In January 2018, my colleague Jacquie Brown and I were invited to Alberta to teach a workshop for Policy Wise for Children and Families. The conference organizers had planned to assemble about 80 people who work to support families and communities, and they wanted us to lead a workshop on evidence implementation. 

As we considered the request and the audience, we thought about how we would introduce the basic elements of implementation science and practice to a group of hard-working practitioners. We knew we would lose our audience if we got too geeky. Jacquie and I collaborate often. When we teach together, I tackle the academic science while Jacquie focuses on implementation practice. It’s a rewarding and complementary partnership – she’s brilliant.

Introducing the science of implementation to this audience required me to talk about implementation in a way that wouldn’t have people running from the room or tuning out within the first few minutes. What did I want them to know and how would I make the message ‘sticky’?

The 5 Core Elements of Implementation

Implementation science has been around for roughly 15 years, give or take, and in that time has produced a great many empirical and theoretical insights about how to improve the application of evidence in real space. Many facets of knowledge have emerged, and it can be a lot to take in. What we now know about implementation is vast and dense and can appear daunting to many. 

Helping people to make meaning from a considerable volume of knowledge requires a “keep it simple” approach. The 5 Core Elements of Implementation are the simplest distillation of the core components1 one must consider in any implementation endeavour, based on the science of implementation. They provide a foundation from which learning can evolve.

These are my 5 core elements of implementation: implementation teams, implementation process, implementation factors (barriers and facilitators), implementation strategies, and implementation outcomes. All elements are core components required for effective, evidence-informed implementation. Each element is underpinned by an implementation theory, model or framework (TMF). If you can tackle these 5 elements (and there’s a method to the madness), then you’re on a path to achieving quality implementation.

The 5 core elements form the foundation for The Implementation Roadmap© TIR, a learning and planning resource I introduced as a beta version at the Policy Wise workshop and launched in 2019. TIR is undergoing revisions from its original inception – The Implementation Game. Using a roadmap analogy, it integrates the core elements of implementation to ground learners through the process. These same core elements are the base for an implementation software platform, The Implementation Playbook(c), now under development in my implementation lab at SickKids, funded by CIHR – stay tuned for that ground-breaking technology!

Each core element is based in implementation science. The concept of implementation teams stems from the work of the National Implementation Research Network. The implementation process is based on several process models/frameworks (Active Implementation Frameworks2, Quality Implementation Framework3). Factors refer to barriers and facilitators and are rooted in determinant frameworks (Consolidated Framework for Implementation Research4), while strategies provide mitigations to barriers and stem from the work of the ERIC consortium5. Finally, implementation outcomes reference Proctor’s Implementation Outcomes Taxonomy6. 

The Implementation Kitchen Analogy(c)

One can’t get a whole lot simpler than a grouping of five, however, these 5 elements can still appear foreign to new learners. Over the next year, I pondered how could I make the core elements more concrete, memorable and resonant. And just like that, the implementation Kitchen Analogy© was born. 

To understand implementation begins with recognizing that it’s an intentional, explicit, and systematic process. In this respect, it’s analogous to other processes in which we engage in our everyday lives, like cooking. Cooking is universal; it resonates with everyone’s experience. To cook means to take into account who is cooking, where they are cooking, what they are cooking, the myriad of factors that can impact the cooking, who they are cooking for, and how the cooking will be assessed. 

Cooking requires one to consider several things: the cooking environment (home kitchen, campfire, campervan), the tools required (heat, water source, gadgets and implements), who is doing the cooking (the number and experience of each cook/s), the recipe (whether implicit or explicit, new or tried-and-true), the ingredients (are they handy, or missing), the cooking skills and strategies that facilitate the process (blending, chopping, frying; substitutions), the chemistry of the ingredients that give rise to taste, form and texture, the adaptations made to accommodate preferences, cost, availability, allergies (a muffin can have nuts or berries; either way, it’s still a muffin), the diners who will consume the dish, and appraisal of the end result (the look, taste, cost, and nutritive content of the resulting dish).

Similarly, implementing an innovation requires an implementation setting (the implementing organization or setting), enabling organizational functions and workflows), an implementation team (those in the implementing organization who will do the implementation work), an innovation and its core components, consideration of the barriers that can upend or improve implementation (determinant factors), strategies and tools that can facilitate the process (implementation strategies like education, partnership, restructuring, financing), mechanisms of change (how strategies mitigate barriers), adaptations that retain the intervention core components but accommodate contextual variation, the innovation deliverers and recipients, and evaluation of the outcome (implementation, practice, system outcomes).

Overcoming Absorptive Capacity

I use this analogy frequently in my consulting and teaching, and find learners find it very helpful. As learners develop their knowledge about what’s required for effective implementation, the core elements provide markers. This anchors their learning journey and keeps them on an evidence-based path. When the knowledge becomes overwhelming and breaches absorptive capacity, and it will, learners can return to these markers and regroup to stay on task. 

Fundamental Considerations for the Implementation of Evidence in Practice

Implementation science is the scientific study of methods that support the adoption of evidence based interventions into a particular setting (e.g., health, mental health, community, education, global development).  Implementation methods take the form of strategies and processes that are designed to facilitate the uptake, use, and ultimately the sustainability – or what I like to call the ‘evolvability’ – of empirically-supported interventions, services, and policies into a practice setting (Palinkas & Soydan, 2012 ; Proctor et al., 2009); referred to herein as evidence-based practices (EBPs).

The National Implementation Research Network refers to implementation as a specified set of activities designed to put into practice an activity or program of known dimensions.  NIRN makes the point that implementation processes are purposeful and are described in sufficient detail such that independent observers can detect the presence and strength of the “specific set of activities” related to implementation.  The intent is that the activity or program being implemented can be described in sufficient detail so that independent observers can detect its presence and strength and its implementation can be replicated in similar contexts.

Implementation is commonly considered one of the last stages of the intervention research process that follows the results of effectiveness studies. It sets out to explore the role of context, how best to prepare for evidence adoption and scale up, the practical considerations of implementation, and how best to facilitate sustainability.

Implementation focuses on taking interventions that have been found to be effective using methodologically rigorous designs (e.g., randomized controlled trials, quasi-experimental designs, hybrid designs) under real-world conditions, and integrating them into practice settings (not only in the health sector) using deliberate strategies and processes (Powell et al., 2012 ; Proctor et al., 2009; Cabassa, 2016).  Hybrid designs have emerged relatively recently to help us explore implementation effectiveness alongside intervention effectiveness to different degrees (Curran et al,  2012).

Cumulative experience and evidence in implementation science suggests several fundamental considerations for success. What follows are my own musings about what these fundamental considerations are, and these will likely evolve as I progress in my own research and follow the work of my implementation colleagues worldwide.

Fundamental Considerations for Evidence Implementation

  1. The implementation of empirically supported interventions or practice innovations is a dynamic social process.  One does not manage this in isolation of colleagues, partners, stakeholders, leaders or champions.
  2. Implementation is shaped by the context in which the practice innovation takes place, by the people involved in this process (those who provide the new intervention and those who receive it), the characteristics of the intervention, and the characteristics of the inner and outer systems (see Damschroder et al., 2009).
  3. Implementation unfolds over time through stages, requiring transformation of the practice context and, often, some degree of adaptation of the innovation (Cabassa & Baumann, 2013). Transformation of the setting (readiness or preparation) takes time, to build the organizational conditions for practice change success before training takes place, and when this is disregarded (as it often is), it leads to unsuccessful change.  System change has implications for leadership expectations in rolling out and scaling up EBPs across a system. Organizations and individuals reach absorptive capacity for implementation, and so timelines and system expectations need to be paced accordingly.
  4. One must consider the costs of implementation and allow organizations and system to budget for the changes that will take place, often over several years including and beyond the initial implementation.  The context in which implementation occurs has important implications for cost and sustainability.  Consider who is driving the change and paying for it: a research grant, an organization, a government, or a purveyor.
  5. Adaptation of EBPs requires knowledge of the active ingredients of the intervention and fidelity (competence and adherence) to these elements.
  6. Implementation often requires co-creation (see Metz 2015), involving the interaction, collaboration, and participation of stakeholders or knowledge users at multiple levels of an organization and system of care (Aarons, Horowitz, et al., 2012). Implementation teams require the engagement of organizational leaders, directors, managers, administrators, service providers, frontline staff, clients, and their family members, as implementation entails a multitude of social processes, including planning, decision making, negotiating, prioritizing, problem solving, service delivery, restructuring, and the allocation of resources (Cabassa 2016). Implementation complexity calls for greater social interaction and involvement of stakeholders who can facilitate the process and can bring knowledge and expertise about the intervention, and locally grounded knowledge, skills, and understanding about the settings and communities in which the intervention will be used. Implementation science is a collaborative endeavor (Cabassa 2016).
  7. Implementation is inherently about change management and involves a new way of doing things within an organization or system.It overlaps with but differs in important ways from quality improvement (see Bauer et al, 2015). Implementation involves a change in the status quo that requires adaptations and adjustments in attitudes, social norms, practices, procedures, work flow, behaviors, and policies. The change process is is guided by a combination of project management and implementation strategies and processes  (Powell et al., 2012).
  8. Implementation of evidence-based care/practices fundamentally involves two content areas: the evidence related to the innovation and the evidence on implementation science. Relatedly, this means that evaluation of implementation efforts and indicator tracking fundamentally requires evaluation of the innovation target (i.e., health outcome) and implementation outcomes (see Proctor et al., 2012).
  9. Implementation science is an emerging and dynamic field. Current best evidence about IS can be instructive but it is a moving target, and we are still learning a range of things in this field, including:
    1. What constructs/factors are important to consider for implementation success
    2. How to measure these key factors
    3. What processes work best in what contexts and for what types of evidence
    4. Identify the best research methods for IS and train health scientists
    5. Optimal reporting of IS research (StaRI Guidelines); important so we can learn what works (See BMJ Open, in print, Pinnock et al; two papers)
    6. Development of methods/measures for tracking and measuring implementation costs
    7. Research what implementation success looks like, including expectations of sustainability (and what I call “evolvability”)
    8. How best to measure implementation outcomes
    9. Develop resources and tools to support implementation, done independently or with technical assistance.
  10. There is growing global expertise in implementation practice and science, as manifest in theGlobal Implementation Initiative, the Global Implementation Conference, the Society for Implementation Research Collaboration, and  jurisdictional implementation communities.
  11. We need to build capacity for implementation within systems and within organizations, and this includes building organizational competencies and a workforce of implementation specialists (requiring the development of requisite training programs and curricula). Some thinking is occurring around this issue, such as the Global Implementation Society hosted by the Global Implementation Initiative.
  12. Implementation of evidence involves embedded implementations – at the clinical level, organizational, and systems level. This means implementing change at all levels (i.e., new ways of doing business, changing processes, building transformative leadership and organizational conditions for change), not only implementing the evidence in practice.
  13. Implementation is not a ‘make it so’ proposition, but rather is complex and time consuming (varying time and complexity for different situations), and it is in our best interest to recognize these challenges whilst trying to fulfill political and real world expectations.
  14. Implementation is not a one size fits all enterprise. We should not expect to arrive at a menu of implementation theories/frameworks, approaches and/or strategies that can be mapped to sector, context, health issue, or population. It will always be an iterative process.
  15. There are likely some factors that are universally important for implementation success across contexts (i.e., heath, mental heath, community, global health, education), and some that are unique to  a particular setting.  Research is working to parse this in a way that can help us to better plan for an engineer successful change (Barwick 2016; and Barwick et al submitted).
  16. Implementation planning and ultimately its success will depend, in part, on the implementation context or the mechanisms driving the implementation. Whether the implementation initiative is driven by the motivation of the organization, government, funder, EBP purveyor, or research study likely matters for planning, costs, and most especially for sustainability (Barwick 2016; and Barwick et al., submitted).

As mentioned above, this list of implementation fundamentals is ‘evergreen’, and will evolve over time.  Please feel free to contribute a comment; what is missing, and is there face validity to those identified in this list?