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. 

This blog post was revised on 17 August 2022

1. “Core components are the most essential and indispensable components of an intervention practice or program (“core intervention components”) or the most essential and indispensable components of an implementation practice or program (“core implementation components”)” https://preventionsolutions.edc.org/sites/default/files/attachments/What-Are-Core-Components%20and-Why-Do-They-Matter_0.pdf
2. National Implementation Research Network. Active implementation Frameworks. Retrieved from https://nirn.fpg.unc.edu/ai-hub
3. Myers DC, Durlak JA & Wandersman A. (2012). The Quality Implementation Framework: A synthesis of critical steps in the implementation process. American Journal of Community Psychology, 50(3-4): 462-80.
4. Damschroder L., Aron D, Keith R, Kirsh S, Alexander J, & Lowery J. (2009) Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science, 4(1), pp. 50. 10.1186/1748-5908-4-50.
5. Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor EK & Kirchner JE. (2015). A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science 10:21.
6. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, Griffey R, & Hensley M. (2011) Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health, 38(2), pp. 65-76. doi: 10.1007/s10488-010-0319-7.