Wilson and Kislov

This Element introduces and critically reflects on the contribution

of implementation science to healthcare improvement efforts.
Grounded in several disciplines, implementation science is the
study of strategies to promote the uptake of evidence-based
interventions into healthcare practice and policy. The field’s
focus is threefold. First, it encompasses theory and empirical Improving Quality and
research focused on exploring, identifying, and understanding
the systems, behaviours, and practices that influence successful Safety in Healthcare
implementation. Second, it examines the evaluation of strategies
to address barriers or enablers to implementation in a given
context. Last, it increasingly seeks to understand the process of
implementation itself: what actually gets implemented, and when,
Implementation

Implementation Science
why, and how? Despite the growing body of evidence, challenges
remain. Many important messages remain buried in the literature,
and their impact on implementation efforts in routine practice
may be limited. The challenge is not just to get evidence into
practice, but also to get implementation science into practice.
Science
This title is also available as Open Access on Cambridge Core.

About the Series Series Editors

Paul Wilson and
The past decade has seen enormous
growth in both activity and research
Mary Dixon-Woods* Roman Kislov
Katrina Brown*
on improvement in healthcare. This
Sonja Marjanovic†
series offers a comprehensive and
authoritative set of overviews of the Tom Ling†

[Link] Published online by Cambridge University Press

different improvement approaches Ellen Perry*
available, exploring the thinking Graham Martin*
behind them, examining evidence
for each approach, and identifying
*THIS Institute
areas of debate.
(The Healthcare
Improvement
Studies Institute)
†
RAND Europe

ISSN 2754-2912 (online)

ISSN 2754-2904 (print)
[Link] Published online by Cambridge University Press
 Elements of Improving Quality and Safety in Healthcare
edited by
Mary Dixon-Woods,* Katrina Brown,* Sonja Marjanovic,†
Tom Ling,† Ellen Perry,* and Graham Martin*
*THIS Institute (The Healthcare Improvement Studies Institute)
†RAND Europe

IMPLEMENTATION
SCIENCE

Paul Wilson1 and Roman Kislov2

1
Centre for Primary Care and Health Services Research, University of Manchester
2
Centre for Decent Work and Productivity, Manchester Metropolitan University
[Link] Published online by Cambridge University Press
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DOI: 10.1017/9781009237055
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 Implementation Science

Elements of Improving Quality and Safety in Healthcare

DOI: 10.1017/9781009237055
First published online: October 2022

Paul Wilson1 and Roman Kislov2

1
Centre for Primary Care and Health Services Research, University of Manchester
2
Centre for Decent Work and Productivity, Manchester Metropolitan University
Author for correspondence: Paul Wilson, [Link]@[Link]

Abstract: This Element introduces and critically reflects on the

contribution of implementation science to healthcare improvement
efforts. Grounded in several disciplines, implementation science is the
study of strategies to promote the uptake of evidence-based
interventions into healthcare practice and policy. The field’s focus is
threefold. First, it encompasses theory and empirical research focused
on exploring, identifying, and understanding the systems, behaviours,
and practices that influence successful implementation. Second, it
examines the evaluation of strategies to address barriers or enablers to
implementation in a given context. Last, it increasingly seeks to
understand the process of implementation itself: what actually gets
implemented, and when, why, and how? Despite the growing body of
evidence, challenges remain. Many important messages remain buried
in the literature, and their impact on implementation efforts in routine
practice may be limited. The challenge is not just to get evidence into
practice, but also to get implementation science into practice. This title
[Link] Published online by Cambridge University Press

is also available as Open Access on Cambridge Core.

Keywords: implementation science, de-implementation, theory,

mechanisms, dissemination

© THIS Institute 2022

ISBNs: 9781009237086 (PB), 9781009237055 (OC)
ISSNs: 2754-2912 (online), 2754-2904 (print)
 Contents

1 Introduction 1

2 What Is Implementation Science? 1

3 A Brief History of Implementation Science 2

4 Implementation Science in Action 6

5 Critiques of Implementation Science 19

6 Conclusions 29

7 Further Reading 32

List of Contributors 33

References 36
[Link] Published online by Cambridge University Press
 Implementation Science 1

1 Introduction
Establishing the effectiveness of an intervention does not guarantee its adoption
into routine practice. Although long recognised, the challenges of getting
evidence into practice have become increasingly prominent in recent years as
attention has focused on the performance of health systems and the need to
ensure that patients benefit from new evidence. Addressing the research–prac-
tice gap has spawned a new field that has come to be known as implementation
science. Grounded in several disciplines, implementation science is the study of
strategies to promote uptake of evidence-based interventions into healthcare
practice and policy. The field includes (but is not limited to) the study of
professional, patient, and organisational behaviour change. It has championed
increased use of empirical research and of theoretical approaches to understand,
guide, and evaluate implementation.
In this Element, we describe many of the ideas, theories, and strategies that
have emerged from the field over the last decade or so, highlighting how they
are or could be applied in practice. We then critically reflect on the overall
contribution of the field, outlining a range of challenges in relation to the role
and use of theory, the need for mechanism-based explanations of change, and
how best to rigorously evaluate change in complex systems.

2 What Is Implementation Science?

Implementation science is commonly defined as the scientific study of methods
to promote the systematic uptake of evidence-based clinical treatments and
practices and organisational and management interventions into routine
[Link] Published online by Cambridge University Press

practice.1 It includes the study of implementation processes, intervention adap-

tation and fidelity, and the influences on patient, professional, and organisa-
tional behaviour. Rather than clinical effectiveness, the endpoints of interest for
implementation studies are the effects of deliberate and purposive actions to
implement evidence-based interventions. Acceptability, adoption, appropriate-
ness, feasibility, fidelity, implementation cost, penetration, and sustainability
are all of interest.2 The field also encompasses research focused on the de-
implementation of interventions demonstrated to be of low or no clinical
benefit.3,4 With de-implementation, a major focus is on the type of action
necessary for de-implementation to occur and the time frame in which it should
or can be achieved.4
One important question, of course, is whether implementation science is
a science. Not really. The term itself is largely derived from the journal of the
same name, so in reality it is a publishing construct. A search for the term
‘implementation science’ in PubMed reveals no use before the journal’s
 2 Improving Quality and Safety in Healthcare

inception in 2006. But, although it is sometimes portrayed as such, this does not
make the journal’s launch year zero for the field; interest in the uptake of
evidence-based interventions and their sustainment in practice has a long lin-
eage, as we describe later in this Element (see Section 3). However, having
implementation science as an umbrella term has been useful, in particular in
giving some coherence to what is an inherently interdisciplinary, applied
research field that draws on theoretical and methodological insights across
multiple well-established social science disciplines, including psychology,
sociology, economics, and organisation studies. Accordingly, the study of
implementation is not (or at least should not be) constrained by any particular
research method.
There are of course boundaries. The focus of the field remains resolutely on
the uptake of evidence-based interventions. It is, however, engaged in con-
stant reciprocal dialogue with other fields – for example, mainstream health
services research has benefited from theoretical and methodological develop-
ments in implementation science (something particularly evident in the
evaluation of the effectiveness of complex interventions5,6). Similarly, bio-
medical and discovery science are increasingly interested in the role that
implementation science methods could play, for example, in accelerating
the translation and integration of discoveries into healthcare and ultimately
health outcomes.7
De-implementation – efforts to remove, reduce, replace, or restrict the use
of interventions that have been shown to be of no or low clinical benefit, or
that are not cost-effective when compared with alternatives – is an increasing
area of interest and investigation for implementation science.3,4 Although
[Link] Published online by Cambridge University Press

initial theoretical work suggests that behavioural theories may not distinguish
between implementation and de-implementation,8 the factors that shape
the processes of implementation and de-implementation are likely to be
different and may work in different ways.9 Frameworks for conceptualising
de-implementation are now available10,11 and, as evidence and practice
experience accumulate, so will understanding of the behaviours and processes
at play.

3 A Brief History of Implementation Science

Although implementation science is a contemporary term, concerns about
unwarranted variation in healthcare and interest in how ideas spread in social
systems have a long lineage. These issues, along with the ability to systematic-
ally codify evidence-based knowledge to enhance professional practice, have
been key drivers in the development of the field.
 Implementation Science 3

3.1 Origins of Efforts to Understand Uptake and Reduce

Unwarranted Variation
Concerns about the uptake of research findings and reducing unwarranted
variation in practice and outcomes are not new. Spiegelhalter eloquently
detailed the long history of enquiry into unwarranted variation in surgical
outcomes initiated first in the nineteenth century by Florence Nightingale
and then later championed by others, including Ernest Codman.12 Codman
advocated systematic follow-up of all patients to understand treatment out-
comes, including whether errors were due to lack of ‘technical knowledge
or skill’.

To effect improvement, the first step is to admit and record the lack of
perfection. The next step is to analyze the causes of failure and to determine
whether these causes are controllable. We can then rationally set about
effecting improvement by enforcing the control of those causes which we
admit are controllable, and by directing study to methods of controlling those
causes over which we now admit we have but little power.13

In the 1930s, emphasis started to shift towards consideration of variation in

the face of what was known to represent effective practice. Glover famously
highlighted wide variation in tonsillectomy rates across England and Wales and
argued that the only plausible explanation was that ‘it is too often performed
without adequate cause, or sufficient regard to the possibility of enlargement
being temporary, physiological, or immunological’.14
This interest was accompanied by the development of methods to improve the
quality and efficiency of healthcare, culminating in Donabedian’s paradigm-
[Link] Published online by Cambridge University Press

shifting work on structure, process, and outcome,15 which remains core to

much of measurement in health services research. Alongside this work,
Lembcke pioneered the use of audit and feedback.16 He demonstrated that by
using predetermined criteria, it was possible to collect, compare, and share data
on variation in performance with clinicians in ways that could enhance the quality
of care delivered. Interest in audit and feedback was rekindled in the 1980s
through concerns that simply identifying suboptimal performance was in itself
not sufficient to change clinicians’ behaviour.17,18 The effects of audit and
feedback are among the most researched aspects of implementation science19
(for further details, see the Element on audit, feedback, and behaviour change20).

3.2 Diffusion of Innovations

Alongside long-standing concerns about the need to reduce unwarranted vari-
ation, the roots of implementation science are deeply embedded within the
social sciences, particularly in the literature relating to diffusion of innovations.
 4 Improving Quality and Safety in Healthcare

The history of diffusion research is well described elsewhere,21,22 but essen-

tially it offers a theory of how, why, and at what rate new ideas or innovations
spread through defined populations and social systems. The influence of the
early work of Everett Rogers in rural agriculture is well known, but it is perhaps
the work of medical sociologist James Coleman that highlighted the poten-
tial of the theory, particularly to those concerned with the production and
dissemination of evidence-based clinical guidelines in the late 1980s and
early 1990s.
Working in the 1950s, Coleman et al.23 investigated the adoption of the
then-new antibiotic tetracycline by clinicians in Illinois. They interviewed
clinicians about their use of tetracycline 15 months after the drug was introduced,
and found that the social networks of participants were strongly associated
with uptake.

. . . these comparisons suggest that the process of introduction for those

doctors who were deeply embedded in their professional community was in
fact different from the process for those who were relatively isolated from it.
The highly integrated doctors seem to have learned from one another, while
the less integrated ones, it seems, had each to learn afresh from the journals,
the detail man (drug salesman), and other media of information.23

Rogers reported that later analysis suggested more influence from advertising
and pharmaceutical representatives.21 Nevertheless, Coleman’s work surfaced
the potential for strategies – opinion leaders, educational outreach, and persua-
sive communications – that could be used to promote the uptake of research
findings or, more pressingly, for codified knowledge in the form of evidence-
[Link] Published online by Cambridge University Press

based clinical guidelines. This became an increasing concern on both sides of

the Atlantic.

3.3 Growing Interest in Getting Research Evidence into Practice

The early period of evidence-based medicine focused on producing and synthe-
sising research evidence, on making it more accessible, and on promoting its use
in the development of clinical guidelines. This required the creation of methods
and supporting evidence infrastructures. In the late 1980s, the RAND
Corporation were pioneers of systematic and standardised processes to assess
health technologies.24 Also in the USA, the Agency for Health Care Policy and
Research was established in 1989 to enhance the quality, appropriateness, and
effectiveness of healthcare services.25 These early iterations of what has
become known as health technology assessment is now a mainstay of health
systems globally and one of the key building blocks of evidence-based clinical
guidelines.
 Implementation Science 5

Alongside the systematic codification of knowledge, there was renewed and

increasing interest in getting the presented evidence to be adopted and used in
practice. In Canada, Lomas et al. were recognising that guidelines alone were
unlikely to effect change in actual practice.26,27 In the USA, Soumerai et al.
were investigating strategies to improve the prescribing practices of primary
care clinicians.28 And in Europe, Grol29 and Grimshaw and Russell30 were
exploring how best to implement clinical guidelines in primary care.
In 1994, the Agency for Health Care Policy and Research convened
a conference of experts, including Everett Rogers, to discuss and provide
guidance on effective methods of guideline dissemination.31 At the same
time, in the UK these ideas were also being shared with mass audiences in the
National Health Service (NHS) via the groundbreaking Effective Health Care
series of bulletins – first through Implementing clinical practice guidelines32 in
1994 and then later through Getting evidence into practice.33 The Effective
Health Care bulletins, which were produced by the University of York and
began in 1992, predated the creation in 1999 of a national guideline infrastruc-
ture in the form of the National Institute for Clinical Excellence (NICE). The
bulletins were charged with synthesising and disseminating the best available
evidence on selected topics to inform NHS policy and practice.
The 1999 Getting evidence into practice bulletin was one of the first publica-
tions to advocate, albeit somewhat naïvely, for theoretically informed
implementation.33 More rigorous and systematic approaches to theory develop-
ment and application were to follow, most notably led by Michie and
Johnston.34 Underpinning these approaches was the principle that because
[Link] Published online by Cambridge University Press

evidence-based practice depends on human behaviour, change efforts could

be improved by drawing on theories of behaviour change.34 Advocacy for and
use of theoretical approaches to understand, guide, and evaluate implementa-
tion processes was one of the key pre-existing principles from which a new
general field of implementation science would emerge. With the launch of the
journal Implementation Science in 2006,1 the field finally had a focal point for
its outputs.

3.4 Evolution and Investment in Implementation Studies As

a Research Field
Globally, significant investment in research funding and training now supports
the field of implementation. The past decade has seen an increase in dedicated,
standalone training courses and, most recently, more formal doctoral-level
courses. These often adapt and apply methods that are drawn from spheres
such as clinical epidemiology, health services research, sociology, and
 6 Improving Quality and Safety in Healthcare

psychology to implementation science questions.35,36 This growth in bespoke

training has led in turn to the emergence of researchers who now define
themselves as implementation scientists rather than as working within
a particular discipline.
The other significant investment has been in research infrastructure. As the
potential of implementation science methods has become increasingly recog-
nised, the need to harness the expertise and resources of the field in continuous
efforts to improve healthcare systems has also been acknowledged. This recog-
nition has led to the development of new models of research and practice
partnerships. In the USA, the Veterans Health Administration has long been at
the forefront of efforts to enhance partnered research through its Health
Services Research and Development Service and the Quality Enhancement
Research Initiative (QUERI).37 Since 1998, QUERI collaborations have identi-
fied service gaps and developed evidence-based best practices, embedding them
into routine practice across the Veterans Health Administration system.38 The
key feature of QUERI has been a strong focus on rigorous comparative effect-
iveness research and the evaluation of implementation strategies to support
uptake and spread. This approach has been mirrored in other geographical
settings, most notably in the UK through Collaborations for Leadership in
Applied Health Research and Care (CLAHRCs), which were launched in
2008 and funded by the National Institute for Health Research.
CLAHRCs were collaborative partnerships between universities and sur-
rounding health service organisations and were focused on improving patient
outcomes through the conduct and application of applied health research.
[Link] Published online by Cambridge University Press

Although CLAHRCs generated a large body of knowledge and learning, the

relative lack of national impact on healthcare provision or outcomes has been
noted.39 The policy shift from CLARHCs to Applied Research Collaborations
(ARCs) in 2019 suggests efforts to address this. With a clearer focus on high-
quality applied health and care research, ARCs may be closer to the QUERI
initiative in both form and function.

4 Implementation Science in Action

Traditionally, implementation science has three areas of focus. First, it encom-
passes theory and research focused on exploring the contexts, behaviours, and
practices that can act as influences on successful implementation, specifically
exploring barriers and enablers. Second, there is a focus on the design and
evaluation of strategies to address those factors identified as helping or hinder-
ing the implementation of evidence-based interventions in a given context.
Finally, the field features an increasing focus on understanding the process of
 Implementation Science 7

implementation itself: what actually gets implemented and how, the intended
and unintended mechanisms of strategies (how and why they work or do not
work), the influence of context on implementation efforts, and ultimately the
sustainability of interventions that are implemented.
In all implementation efforts, there is a need for someone somewhere to do
something differently.40 In order to achieve this, a clear understanding is
required of what needs to change and the factors that are likely to help or hinder
any change to occur. These influencing factors could be related to:

• the nature of the intervention, practice, or policy to be introduced

• the place where change will occur
• the people involved
• the processes and resources required to ensure that change occurs
• the influence of the wider economic, political, and social environment.

Identifying and understanding the likely influencing factors is now a core

function of developmental studies in implementation research, and a large
evidence base now exists. Helpfully, insights on clearly defined barriers and
enablers have been synthesised in a range of sectors. For example, digital health
is an area of increasing implementation focus, but it is also an area where there is
considerable convergence across studies on the key factors that influence
implementation.41 Ross et al.’s review of systematic reviews highlights the
need for adequate infrastructure, engagement of key personnel, organisational
readiness, and the fit of digital innovations with workflows, processes, and
systems.41 These insights are essential to inform the design of appropriate
[Link] Published online by Cambridge University Press

implementation strategies.

4.1 Implementation Strategies

Implementation strategies are designed and deployed to bring about changes in
healthcare organisations, the behaviour of healthcare professionals, or the use of
health services by healthcare recipients.42 Put simply, they represent the ‘how
to’ element of any change initiative.43 A large number of implementation
strategies have been documented, notably by the Cochrane Effective Practice
and Organisation of Care group, and they have long been deemed to be an
essential driver for bringing about change in healthcare practice.27,43
The literature has explored the effectiveness of a wide range of strategies,
including those targeting the behaviour of individual professionals, those
targeting an organisation, and/or those targeting the wider policy context.
Table 1 presents a summary of strategies commonly used in healthcare
practice, the features that enable their successful implementation, and findings
[Link] Published online by Cambridge University Press

Table 1 Commonly used implementation strategies, their enabling features, and evidence of effects

Strategy Enabling features Evidence of effects

Audit and feedback19,44 In areas where baseline performance is low, feedback is Consistent small to moderate effects when
provided by a supervisor or colleague more than once, is optimally designed.
delivered in both verbal and written formats, and
includes explicit performance targets and an action plan.
Computerised Automated on-screen reminders to prescribe specific Consistent small to moderate effects for
reminders45,46 medications, to warn about drug interactions, to simple one-step prescribing and
provide vaccinations, or to order tests. decisions about which tests to order.
Educational meetings 47 Meetings utilising mixed (interactive and didactic) Small to moderate effects BUT poor
formats, and focusing on issues/outcomes likely to be reporting of interventions limits
perceived as priorities. Meetings did not appear to be understanding of optimal configurations.
effective for complex behaviours and were less
effective for less serious outcomes.
Educational outreach 48 Visits by credible and trained people to professionals in Consistent small to moderate effects for
their own setting to provide information on performance improving prescribing practices and test
and how to change. Face-to-face visits that occur as part ordering.
of a sustained effort to improve practices appear to be
more effective than one-time efforts.
[Link] Published online by Cambridge University Press

Facilitation49,50 Combination of external experts and internal facilitators Small to moderate effects BUT evidence
applying a range of enabling skills and improvement lacking on optimal characteristics of
strategies to implement change in a practice setting. facilitation.
Project management skills and ability to engage and
manage relationships between key agents and to
identify and negotiate barriers to implementation found
to be key. Often resource intensive.
Financial incentives51,52 Financial incentives and pay-for-performance schemes Small effects on processes of care reported
that target professional, group, or organisational-level BUT design limitations of studies limit
behaviours may improve processes of care, but benefits certainty.
on patient outcomes are less clear. Impact on processes
of care is most likely in those that are relatively simple
to measure, have room for improvement, and are
deemed to be achievable.
Local opinion leaders53 In combination with other strategies, opinion leaders can Consistent small to moderate effects BUT
enhance the tendency of healthcare professionals to poor reporting limits understanding of
follow evidence-based guidelines. Potential resource how and why strategy is effective.
implications relating to identification, training, and
sustainability.
[Link] Published online by Cambridge University Press

Table 1 (cont.)

Strategy Enabling features Evidence of effects

Printed educational Delivered personally, through mass mailings, or passively Small effects when optimally designed and
materials54 delivered through broader communication channels targeted.
(e.g. available on the internet). Can improve practice
when there is a single clear message, if the change is
relatively simple to accomplish, and there is consensus
that a change in practice is required. Can be widely
distributed at relatively low costs.
Quality improvement Core enablers include having teams from multiple Small to substantial effects reported BUT
collaboratives55,56 healthcare organisations come together to iteratively design and reporting limitations of
learn, apply, and share improvement methods, best studies and likely publication bias limit
practices, and performance data on a clearly defined certainty.
improvement goal. Often resource intensive.
 Implementation Science 11

on their effects.19,44–56 A more comprehensive classification of implementation

strategies has been compiled by the Expert Recommendations for Implementing
Change project.57 At first sight, many of the strategies presented in Table 1 look
similar to each other, but there are nuanced differences in the approaches taken.
For example, one can argue that facilitation is about helping people to change,
while opinion leaders influence people to change, and educational outreach can
be described as a form of peer-led review of performance.
With small to moderate effects reported across strategies, no single approach
appears to be more effective across settings and contexts. Although evidence
has accumulated over the past 30 years and synthesis methods have improved,
there is much similarity between the summary of findings presented in Table 1
and those of the early reviews of implementation strategies. Those early reviews
indicated that while there were no magic bullets for improving the quality of
healthcare, a range of interventions were available that, if used appropriately,
could lead to improvements in professional practice.58,59
This led to suggestions that, despite a growing literature, the science around
strategies had stagnated,60 and such concerns have since seen efforts shift away
from rudimentary replication studies to a research agenda that focuses on
understanding the underlying mechanisms of action61 in order to better tailor
and optimise interventions to maximise their effects.62–64
Although implementation strategies are often presented as discrete or single
entities, this is not always the most accurate description. For example, Box 1
shows that an educational outreach strategy, which was deployed to reduce
prescribing errors in general practices in England, was actually part of an
intervention that was both complex and multifaceted.65 In their seminal review
[Link] Published online by Cambridge University Press

of guideline dissemination and implementation strategies, Grimshaw et al.

found that nearly three-quarters of included studies were in fact evaluations of
interventions deploying multiple strategies.66
Many early trials of implementation strategies could be considered to have
been designed using Martin Eccles’s famous ISLAGIATT maxim: ‘It seemed
like a good idea at the time.’ Some strategies suffered from being poorly
conceived: little thought was given in the initial stages to the behaviours or
processes that needed to be targeted for change to occur, or to whether or not
the strategy deployed would (or could) address any underlying factors.
Strategies have also often been inconsistently labelled, poorly described,
and lacking in sufficient detail to guide their use. This has led to calls for
more detailed specification of both the strategies themselves and the behav-
iours to be targeted in order to ensure greater alignment between intervention
components and measured outcomes.40,43 Box 2 provides an overview of two
useful frameworks, one for informing strategy selection and intervention
 12 Improving Quality and Safety in Healthcare

BOX 1 USING EDUCATIONAL OUTREACH TO REDUCE MEDICATION ERRORS IN PRIMARY

CARE

The PINCER trial – a pharmacist-led intervention comprising electronic

feedback, educational outreach, and dedicated support – was found to be
more effective than simple computerised reminders for reducing a range
of medication errors in general practice.65 The PINCER intervention was
multifaceted, and activities included:

• using software to search clinical systems to identify patients at risk of

hazardous prescribing
• conducting reviews of patient records and prescribed medication
• the pharmacist meeting members of the practice team to discuss the
computer-generated feedback on patients with medication errors
• ongoing dedicated pharmacist support, using the principles of educa-
tional outreach and root cause analysis, to provide education and feed-
back on medication errors in practice
• working with practices to appoint an internal lead, and then establish
and implement a practice action plan to resolve issues identified and
prevent recurrence
• inviting patients into the surgery for a medication review with the
pharmacist, or a member of the general practice team, with the aim of
correcting errors.
[Link] Published online by Cambridge University Press

design, and one for specifying the behaviour change needed. Both have utility
for implementation in practice and provide much-needed guidance on strategy
selection.
Attention has also focused on gaining greater understanding of the influence
of context where an evidence-based intervention is introduced. A narrow
focus on what works, in isolation from the wider economic, political, and
social environment within which implementation will occur, is recognised as
no longer being sufficient for causal explanation. Rather, implementation is
better understood as a critical event in a system that can lead to new under-
standings, displacement of existing practices, and the evolution of new
processes.67 This understanding acknowledges that the context in which
implementation takes place is not static but dynamic. Health systems are not
fixed organisational structures or entities; rather, they are unfolding and
evolutionary, and go through continuous adaptions, so they require constant
work to be held together.68 As the two frameworks in Box 2 highlight, an
 Implementation Science 13

BOX 2 TWO TOOLS TO INFORM STRATEGY SELECTION AND INTENDED

BEHAVIOUR CHANGE

Proctor et al.’s Framework for Specifying Behaviour43

• Name it: name the strategy, preferably using language that is consistent
with existing literature.
• Define it: define the implementation strategy and any discrete compo-
nents operationally.
• Specify it:

◦ identify who enacts the strategy (e.g. managers, professionals,

patients, etc.)
◦ specify the precise actions, steps, or processes that need to be enacted
◦ specify the intended targets of the strategy (i.e. what are we trying to
change?)
◦ specify when the strategy is used
◦ specify the dosage of the implementation strategy
◦ identify and measure the implementation outcome(s) likely to be
affected
◦ provide empirical, theoretical, or pragmatic justification for the
choice of strategy.
Action, Actor, Context, Target, Time (AACTT) Framework for
Specifying Behaviour Change40
• Action: specify the behaviour that needs to change, in terms that can be
[Link] Published online by Cambridge University Press

observed or measured.
• Actor: specify the person/people that do(es) or could do the action
targeted.
• Context: specify the physical location, emotional context, or social
setting in which the action is performed.
• Target: specify the person/people with/for whom the action is
performed.
• Time: specify when the action is performed (the time/date/frequency).

understanding of the context of implementation is an essential prerequisite for

strategy selection.
Given all this, there is a case for arguing that the general principles for
strategy selection first outlined by Grol nearly 30 years ago – that it should be
planned on several levels and that strategies should be directed to the specific
barriers to change for specific target groups – still hold true.29
 14 Improving Quality and Safety in Healthcare

4.2 Theories and Frameworks in Implementation Science

Choice of implementation strategy is likely to be best informed by the nature of
the change desired and an informed assessment of how and why a specific
strategy is expected to be effective in a given context. Theory provides an
essential lens through which we can anticipate, identify, and describe the key
features that will influence change. The use of theory helps to clarify the nature
of the change required, together with consideration of the wider system, process,
and contextual features that need to be addressed if plans for implementation are
to be successful. There is now no shortage of implementation frameworks and
theories.69,70 (Indeed, one of the less helpful developments in the field over the
past decade has been a proliferation of ‘me too’ process models and determinant
frameworks, many of which are similarly theoretically grounded, share common
antecedents, and apply similar constructs.)
These theories and frameworks can be used to guide the process of translating
research into practice, to understand or explain what influences implementation
outcomes, or to evaluate implementation efforts generally. Table 2 describes six
commonly used theories and frameworks in implementation science. All six
have broad utility and can be thought of as evaluation frameworks because they
all specify concepts and constructs that may be put into operation and measured.
Though a plethora of options exist, this represents a core list through which
nearly all implementation issues and questions can be addressed and assessed.
Theory or framework selection can be challenging. As theories and frame-
works vary in purpose, complexity, and intended targets, practitioners have
reported struggling to identify and select appropriate frameworks to guide
[Link] Published online by Cambridge University Press

implementation in practice.83 In response to this, practical guides are now

available to facilitate the use of frameworks beyond the research setting.84–87
Box 3 highlights a pragmatic approach to theory selection proposed by Lynch
et al.,85 which seeks to encourage the use of theory to guide implementation
in practice.

4.3 Implementation Science in Practice

As this section has illustrated, a large and growing body of evidence on
implementation now exists. But, as a research-based discipline, many important
messages remain buried in the literature and have yet to disseminate out to
routine practice. The shift from CLAHRCs to ARCs (see Section 3.4) is
a reflection of growing recognition of the need to better harness the expertise
and resources of the field in efforts to improve healthcare.
Models of research and practice partnerships, such as ARCs, are increasingly
viewed as integral to the development of learning health systems,38 which seek
[Link] Published online by Cambridge University Press

Table 2 Commonly used implementation theories and frameworks

Theory or framework Defining characteristics Application

Consolidated Framework for Grounded in diffusion of innovations theory,21 the five Understanding and explaining what influences
Implementation Research domains in CFIR represent 38 constructs relating to implementation outcomes and evaluating
(CFIR)71,72 the planned intervention, the immediate and wider implementation efforts.
contexts where the implementation activities will
occur, the individuals involved, and the process of
delivering the actual intervention.
COM-B73 Implementation of evidence-based practice and public Understanding and explaining what influences
health depends on behaviour change, and behaviour implementation outcomes and evaluating
is the result of an interaction between three implementation efforts.
components: capability, opportunity,
and motivation. Capability and opportunity can
influence motivation, while enacting a behaviour
can alter capability, opportunity, and motivation.
Promoting Action on Research Successful implementation is a function of the Understanding and explaining what influences
Implementation in Health interaction of three core elements – the strength and implementation outcomes and evaluating
Services (PARIHS)49,74,75 nature of the evidence, the context or environment implementation efforts.
into which the evidence is used, and how
implementation is facilitated. The PARIHS
framework was later revised so that facilitation was
recognised as the active ingredient assessing,
aligning, and integrating the other three constructs
(innovation, recipients, and context).
[Link] Published online by Cambridge University Press

Table 2 (cont.)

Theory or framework Defining characteristics Application

Normalisation Process Theory NPT facilitates understanding of the extent to which Understanding and explaining what influences
(NPT)76,77 new processes become part of routine practice. implementation outcomes and evaluating
NPT comprises four main constructs, representing implementation efforts.
individual and collective levels of work involved in
the implementation of new practice: coherence,
cognitive participation, collective action, and
reflexive monitoring.
RE-AIM78,79 Originally developed as a framework for consistent Guiding the process of implementation and
reporting of public health and health promotion evaluating implementation outcomes.
research. RE-AIM is a planning and evaluation
framework of five constructs deemed important to
impact and sustainability: reach, effectiveness,
adoption, implementation, and maintenance.
Theoretical Domains TDF is an integrated theoretical framework Understanding and explaining what influences
Framework (TDF)80,81 synthesised from 128 theoretical constructs (from implementation outcomes. Most often used
33 theories) which were judged most relevant to in intervention development.
implementation.82 TDF is organised into 14
theoretical domains of constructs that influence
behaviour. Often used in conjunction with COM-B.
 Implementation Science 17

BOX 3 QUESTIONS TO HELP SELECT A THEORY OR FRAMEWORK TO GUIDE THE PLANNING,

DOING, AND EVALUATION OF IMPLEMENTATION

• Who are you working with: individuals, teams, or wider settings?

Consider the fit of the theoretical approaches to the organisational level
where your project is positioned, and whether more than one approach
is required to guide implementation at different levels.

• When in the process are you going to use the theory?

Some approaches lend themselves particularly to design and planning,
others to the process of implementation, and others to evaluating
implementation success.

• Why are you applying a theory?

What is your aim, and what do you need to understand? Does the theory
need to help with gaining a better understanding of barriers and enablers,
to develop knowledge about an ongoing implementation process, or to
provide a framework of relevant implementation outcomes?

• How will you collect data?

Choice of theoretical approach may be informed by what data will be
available for analysis.

• What resources are available?

The number of staff and the time available to them to participate in the
implementation project should be considered.
[Link] Published online by Cambridge University Press

Adapted from Lynch et al.85

to improve care through a continuous cycle of knowledge production and

implementation (see the Element on learning health systems88). The trailblazer
for such initiatives is the QUERI initiative of the US Veterans Health
Administration, mentioned in Section 3.4.38 A system-wide approach to accel-
erating the adoption of research-based knowledge, QUERI has long recognised
that although there are key differences between doing implementation (i.e.
actually putting into practice new evidence-based policies, procedures, or
approaches) and undertaking research on implementation, both require infra-
structure to ensure capacity and capability.
Box 4 highlights the step-based QUERI framework used to systematically
identify and develop evidence-based practices and to embed these into routine
practice across the Veterans Health Administration system.37 As can be seen,
 18 Improving Quality and Safety in Healthcare

BOX 4 IMPLEMENTATION SCIENCE IN ACTION – THE QUERI PROCESS

(1) Identify high-risk/high-volume/high-burden diseases or problems for

veterans.
(2) Identify evidence-based guidelines, recommendations, and best
practices.
(3) Explore existing practice patterns and outcomes across the Veterans
Health Administration and any current variation from identified best
practices.
(4) Identify and implement interventions to promote best practices.

• Undertake systematic searches for implementation interventions,

change strategies, and related tools.
• Develop/adapt and evaluate implementation of strategies or prac-
tice support tools.

(5) Document that best practices improve outcomes.

(6) Document that outcomes are associated with improved health-related
quality of life.

Adapted from Stetler et al.37 More detail on resources and tools can be
found on the QUERI website;89 Implementation Science has also published
a QUERI theme series of articles.90

this offers an explicit series of steps for first identifying and then addressing
[Link] Published online by Cambridge University Press

practice variations within a health system, as well as simultaneously generating

new knowledge and learning. A key feature of QUERI is its strong focus on
rigorous comparative effectiveness research, particularly through the evaluation
of implementation strategies to support uptake and spread. Since its inception,
hundreds of studies have been conducted to inform the organisation and deliv-
ery of a wide range of evidence-based services, including mental health,
substance abuse services, and diabetes prevention.38,91
QUERI can be viewed largely as a research-based initiative, but its
strength is that it is fully embedded in a health system and harnesses the
principles of co-production in the creation and implementation of research-
based knowledge. Implementation efforts are therefore truly a research-
practice partnership. As QUERI has developed, focus has increased on the
development of research tools and methods to support implementation efforts
in practice, and on building system capacity and capability to support primary
data collection and foster organisational readiness for change. Infrastructure
 Implementation Science 19

on this scale not only needs adequate year-on-year funding but also requires
a significant commitment to investment in the longer term. It is not surprising,
therefore, that the most recent developments in the QUERI framework have
focused on ensuring that the impacts of implementation efforts are captured
in ways that can facilitate operational understanding of the value of invest-
ment on this scale.92

5 Critiques of Implementation Science

Implementation science continues to mature, which is manifest in the growing
number of contributions offering critical reflections on the current state of the
field. This section will provide a brief overview of the main themes emerging
from these critiques. We will start by reflecting on the extent to which imple-
mentation science can be considered a truly multidisciplinary and interdiscip-
linary field (Section 5.1). This will be followed by a discussion of the tensions
involved in studying complex interventions in diverse implementation contexts
(Section 5.2). We will conclude by outlining criticisms of implementation
science as an applied discipline which, although it has an explicit mission to
improve patient care, has not always been successful in bridging the gap
between research and practice (Section 5.3).

5.1 Implementation Science as a Multidisciplinary and

Interdisciplinary Field
Implementation science is an inherently multidisciplinary and interdisciplinary
field. It draws, as we have mentioned, on theoretical and methodological
[Link] Published online by Cambridge University Press

insights from many disciplines and offers tools for studying implementation
at different levels of analysis. However, interdisciplinary thinking is not
always apparent in empirical implementation studies. Overall, cross-
fertilisation with other social science disciplines remains relatively limited
and somewhat unequal. Ideas imported from other fields still tend to be
dominated by approaches derived from evidence-based medicine and behav-
ioural psychology, which have been particularly influential in implementation
science.93
Broadly interdisciplinary origins of implementation science, on the one
hand, and the predominance of certain disciplinary and epistemological
ways of thinking, on the other, make an uneasy combination. This results in
a number of tensions. Approaches focusing on group, organisational, and
systemic levels of analysis tend to be less utilised than individual educational
and psychological approaches. Implementation researchers and practitioners
may stubbornly adhere to their preferred methodological orientations,
 20 Improving Quality and Safety in Healthcare

regardless of the nature of the implementation issue or contextual barriers to

be addressed. At the same time, the development of some implementation
scientists as disciplinary agnostics may cause other difficulties because they
may lack in-depth training in core social science disciplines and have a
relatively limited methodological and theoretical repertoire on which to
draw. As a result, identified implementation problems may not match with
the chosen change approaches to address them, and implementation strategies
may be poorly tailored to their contexts.64,94
Implementation science could benefit from a broader dialogue with
a variety of philosophical and theoretical orientations. This would enable
diversification of its epistemological assumptions, conceptual lenses, and
methodological approaches.95 Table 3 provides examples of diverse
approaches that could be helpful for addressing implementation questions
that have so far been overshadowed by the field’s predominantly positivist
agenda. Some of these intellectual traditions, such as critical realism and
complexity theory, have already entered the discipline. The adoption of
other, less familiar approaches has the potential to lead to the development
of novel perspectives on implementation. Engagement with these strands of
thinking must, however, take into account their underlying philosophical
and disciplinary roots as well as the internal logic and assumptions.
Multidisciplinary training programmes for implementation scientists
should therefore consider offering in-depth training in at least one core
social science discipline, which may require a fine balancing act between
multidisciplinary versatility and professional specialisation.
[Link] Published online by Cambridge University Press

5.2 Implementation Science as a Study of Complex Interventions in

Diverse Contexts
One of the recent trends is the increasing complexity and variability of
implementation interventions that unfold in diverse and changing contexts.
As we described in Section 4, these interventions often comprise multiple,
interrelated components and may target several levels within a health system.
The traditional focus on what works (i.e. did intervention X lead to outcome
Y?) is no longer sufficient for causal explanation (i.e. how, why, and under
what circumstances did intervention X lead to outcome Y?).63 Although
process evaluations of implementation interventions are now becoming
increasingly routine,77 implementation science has, to date, often offered
relatively little understanding as to how different implementation strategies
work – that is, the specific mechanisms through which they influence delivery
[Link] Published online by Cambridge University Press

Table 3 Intellectual traditions and relevance of their central questions to implementation science

Questions relevant to implementation Potential implications for the practice of

Perspective Disciplinary roots science implementation
Ethnography Anthropology What is the culture of a certain group of Observing the behaviour of people in
people (e.g. an organisation) involved in organisations or communities involved
implementation? How does it manifest in implementation in order to reveal
in the process of implementation? hidden barriers.
Critical realism Philosophy, social What are the causal mechanisms Eliciting, comparing, and refining
sciences, and explaining how and why stakeholders’ theories of change or
evaluation implementation unfolds as it does in programme theories behind each
a particular context? implementation intervention.
Constructivism Sociology What are the implementation actors’ Comparing the perceptions of multiple
reported perceptions, explanations, implementation stakeholders with one
beliefs, and world views? What another and with those of funders or
consequences do these have on commissioners; interpreting the effects
implementation? of differences in perceptions on
attainment of intervention goals.
Phenomenology Philosophy What is the meaning, structure, and Understanding how patients, families, and
essence of the lived experience of carers make sense of participation in
implementation for a certain group of implementation interventions.
people?
[Link] Published online by Cambridge University Press

Table 3 (cont.)

Questions relevant to implementation Potential implications for the practice of

Perspective Disciplinary roots science implementation

Symbolic Social psychology What common set of symbols and Understanding what is most important to
interactionism understandings has emerged to give people from organisations and
meaning to people’s interactions in the communities involved in an
process of implementation? intervention, what will need to change
for successful implementation, and what
will generate most resistance.
Semiotics Linguistics How do signs (i.e. words and symbols) Using texts and images persuasively to
carry and convey meaning in different communicate key messages, overcome
implementation contexts? resistance, and assist implementation.
Narrative Social sciences, literary What do stories of implementation reveal Learning from stories of successful and
analysis criticism about implementation actors and unsuccessful implementation, as told by
contexts? different stakeholders.
Complexity Theoretical physics, How can the emergent and non-linear Quick and effective adaptation of an
theory natural sciences dynamics of implementation and its ongoing implementation intervention in
context be captured and understood? response to its dynamic context.
[Link] Published online by Cambridge University Press

Critical theory Political philosophy How do the experiences of inequality, Challenging the traditional dominance of
injustice, and subjugation shape researchers and senior organisational
implementation? stakeholders by giving voices to those
with less power, such as service users
and junior staff.
Feminist inquiry Interdisciplinary How does the lens of gender shape and Addressing the issues of inequality and
affect our understanding and actions in injustice affecting women in the process
the process of implementation? of implementation; developing
inclusive, collaborative, and
participatory implementation
approaches.

Adapted from Kislov et al.95 and Patton.96

 24 Improving Quality and Safety in Healthcare

of care.64,97 One possible explanation is that knowledge about processes

derived from past interventions is not applied to the development or evalu-
ation of new ones. There is also, speaking more broadly, a problem of one
trend replacing another without carrying forward the previous lessons
learnt.64,94,97
Another explanation for the current lack of understanding of how different
interventions work relates to the dominant patterns of conceptual work in the
discipline. Implementation science has been criticised for favouring deter-
minant frameworks and process models. Determinant frameworks, such as
the Consolidated Framework for Implementation Research71 and the
Theoretical Domains Framework,80 describe types, classes, or domains of
factors that act as either barriers or enablers to successful implementation.
Process models, such as the knowledge-to-action cycle,98 neatly divide an
idealised implementation process into a series of phases or stages. Such
models and frameworks can helpfully alert researchers to the range of com-
ponents that should be accounted for in intervention design and evaluation.
At the same time, they have a tendency to oversimplify, reducing complex
relationships between interventions, implementers, and contexts to prescrip-
tive checklists or stages. Relatively little attention is paid to explicating
functional relationships between different determinants, causal mechanisms
through which different stages of implementation or contextual variables
influence outcomes, or additional mediators and moderators affecting these
causal pathways.64
These issues matter for a number of reasons. First, identification of enablers
and barriers is only the first step in an implementation journey and is not
[Link] Published online by Cambridge University Press

sufficient for making informed decisions about which implementation strategies

should be deployed to address different configurations of determinants. Second,
successful implementation is contingent on collective action of multiple imple-
mentation actors, such as researchers, managers, and clinicians, who constantly
adjust the process of implementation in response to an ever-changing context
rather than follow a pre-planned sequence of actions. Finally, some of the
best explanations are ‘mechanism-based’,95 detailing the cogs and wheels of
the causal processes through which implementation outcomes are brought
about.67,97,99
Box 5 shows how mechanism-based thinking has been applied by different
teams to the study of facilitation – an implementation strategy that relies on
a designated role (facilitator) encouraging others to reflect upon their current
practices to identify gaps in performance, introduce change, enable knowledge
sharing, and thus improve outcomes.101 This example highlights the benefits of
focusing on relationships and interdependencies between a relatively limited
 Implementation Science 25

BOX 5 APPLYING A MECHANISM-BASED APPROACH TO THE STUDY OF FACILITATION

Mechanism-Based Explanation in Conceptual Work on Facilitation

Berta et al.100 suggest that facilitation acts through stimulating higher-
order learning (i.e. analysis, evaluation, and reflection) through experi-
menting with, generating knowledge about, and sustaining small-scale
adaptations to organisational processes.

Mechanism-Based Explanation in Qualitative Longitudinal Research

on Facilitation
Kislov et al.101 describe three mechanisms that may lead to distortion of
facilitation over time, if it is adapted in an uncritical and uncontrolled way.
These mechanisms are:

• prioritisation of (measurable) outcomes over the (interactive) process

• reduction of (multi-professional) team engagement
• erosion of the facilitator role: shift from facilitating to doing
implementation.

Mechanism-Based Explanation in the Context of a Randomised

Controlled Trial (RCT)
A pragmatic clustered RCT of facilitation used to implement evidence-
based urinary incontinence recommendations in nursing care showed no
statistically significant differences in primary outcome (compliance with
continence recommendation between standard dissemination and two
[Link] Published online by Cambridge University Press

different approaches to facilitation).102 An embedded process

evaluation103 identified four mechanisms underpinning the success of
facilitation in those sites where it worked well:

• alignment of the intervention with the needs and expectations of facili-

tators and their organisations
• prioritisation of organisational involvement in both the study and the
facilitation programme
• collective engagement with the facilitation intervention by managers,
facilitators, and other staff
• sustained learning over time.

number of elements, such as organisational factors, characteristics of facilita-

tors, and collective processes underpinning facilitation. Mechanism-based
explanations presented here shed light on how the interplay between participating
 26 Improving Quality and Safety in Healthcare

entities (i.e. individuals, teams, and organisations), their properties (i.e. roles,
expectations, and experiences), and activities (i.e. alignment, prioritisation,
engagement, and learning) produces the effect of interest (i.e. successful or
unsuccessful facilitation).99
This example suggests that intervention fidelity should be defined function-
ally in relation to fit with the underlying causal mechanisms (i.e. what
processes does the intervention initiate and how?), rather than compositionally
(i.e. what is the composition, dose, and frequency of the intervention?).104 It
also shows that flexible longitudinal designs can be invaluable for exploring
causal pathways and uncovering the emergent and dynamic aspects of
implementation.
Adopting a mechanism-based approach can also lead to a more nuanced
understanding and capturing of implementation outcomes, which otherwise
might remain rather crude,94 as well as to a better integration of formative
and summative evaluation findings.6,94 Lewis et al. argue that more
attention should be paid to proximal implementation outcomes that occur
as a direct result of a specific mechanism of action.97 For instance, the
strategy of facilitation acts through the mechanism of enabling group
learning on the proximal outcomes of knowledge and skills to influence
distal outcomes of clinical behaviour or patient satisfaction. Identification
of proximal outcomes can be guided by asking: ‘How will I know if this
implementation strategy had an effect via the mechanism that I think it is
activating?’
By contrast, distal intervention outcomes – that is, those that an implementa-
tion process is ultimately intended to achieve – are not the most immediate
[Link] Published online by Cambridge University Press

elements in the causal pathway.97 Examples include changes in frequency of

certain clinical behaviours or improvements in patients’ symptoms. While such
indicators are often extremely informative, they do not necessarily reflect
the actual use of research knowledge in healthcare practice for a number
of reasons.

• The steps between implementation interventions and distal outcomes

may be numerous, making interpretation of causality difficult, especially
when causal pathways that make complex interventions work remain
unclear.94
• Taking research knowledge into account when making decisions does not
always mean that this knowledge will be implemented in practice.94 For
instance, research evidence can – justifiably – be overridden by individual
patient preferences.
 Implementation Science 27

• Engagement with new knowledge may lead to subtle and gradual changes in
identities, emotions, and discourses that are difficult to measure but can still
shape individual behaviours and collective practices.105

One promising avenue for future methodological research could involve

design and validation of a new generation of measures that would capture
uptake of valuable knowledge, skills, and practices. This may include a range
of intermediate indicators closely linked to the mechanisms through which
interventions work.2 When designing new measures, it is also important to
remember that implementation strategies are not without costs and compete
with other healthcare activities for finite resources.106 More economic evalu-
ation would advance the ability to understand which strategies might be suitable
for different contexts and whether improvements in implementation are worth
the added costs (see the Element on health economics107). This remains
a neglected area of inquiry for the field as whole.108,109

5.3 Implementation Science as an Applied Field

Implementation science is an inherently applied field of inquiry. Its knowledge
base has been accumulated with an explicit aim of guiding knowledge transla-
tion and achieving positive impact on the outcomes of implementation strat-
egies. A significant and increasing body of published research on how to
support implementation now exists. However, much of this learning remains
‘locked up’ within the academic community, perversely perpetuating the very
same research and practice gap that implementation science has pledged to
address. This is not particularly surprising as implementation scientists often
[Link] Published online by Cambridge University Press

operate within institutional structures, which tend to prioritise high-quality

academic outputs over generation of pragmatic insights or evidence-based
lessons learnt.
Implementation research outputs are mostly written for fellow academics and
reflect their preoccupations with methodological rigour, originality, and nov-
elty. Clinicians, managers, and policy-makers (subsequently referred to as
‘practitioners’) are likely to find the following aspects of this development
particularly frustrating.

• There has been a massive proliferation of theories, models, and frameworks

on implementation and knowledge translation. But many have not been
applied and tested in more than one study.94
• Pressures to generate novel contributions may promote ‘pseudoinnovation’:110
new implementation models and frameworks often ignore previously published
 28 Improving Quality and Safety in Healthcare

work, reinventing concepts and repackaging what is already known under new
labels.94,110
• Insufficient detail in reporting implementation interventions (e.g. why they
were selected, how they were tailored to contextual determinants, what causal
pathways they were supposed to activate to achieve outcomes, and how their
components were enacted in practice) complicates their practical assessment,
replication, and application in new settings.61,64

Evaluations of effectiveness (what works) and determinants of change (what

elements of context facilitate or hinder implementation), both of which are
evident in the mainstream literature, are not necessarily sufficient for addressing
practical concerns. What practitioners also want to know is how to address their
practical problems by selecting and designing an implementation intervention,
how to make this intervention work in practice in the face of numerous
obstacles, and how to rapidly evaluate its success. The publication of pragmatic
guides helping practitioners to choose between different theories, models, and
frameworks to inform their implementation projects is a valuable development
in this regard.85,87 Elicitation of stakeholders’ programme theories and explica-
tion of mechanisms can, in principle, also generate shared understandings and
practically applicable knowledge.111 However, if these remain exclusively
driven by the agenda of researchers, benefits for practitioners will not necessarily
materialise.
At a more fundamental level, many of these issues can be addressed by
collaborative research partnerships,39 implementation laboratories,112 and
other co-production arrangements that bring together researchers and non-
[Link] Published online by Cambridge University Press

researchers. Much practical, experiential knowledge is collectively generated

as part of these increasingly popular collaborative approaches.113 However,
uptake of co-production in implementation science is not without problems.
First, co-produced, practice-oriented knowledge is rarely captured in codified
form and thus may fail to be transferred and applied beyond its original setting.
The existing body of work, which tends to target researchers, may therefore
need to be complemented by publicly accessible literature with a more prag-
matic how-to-do focus. This will require a significant input from practitioners.
Second, despite the rhetoric of improving patient care, the co-design and co-
production of implementation studies with patients remains relatively rare, with
more attention being paid to collaboration with clinicians and managers within
healthcare organisations.39 Patients, carers, and families impact on the variabil-
ity and outcomes of interventions, in effect often becoming co-creators of
implementation, and can provide unique insights in supporting design and
evaluation.114
 Implementation Science 29

Finally, despite significant investment in co-produced forms of working

on implementation, many methods for stakeholder involvement are poorly
specified, their advantages are often taken for granted, and critical evaluation
of their application in practice is missing. Wensing and Grol argue, for instance,
that ‘it is unclear how available research evidence and theory is combined
with stakeholder involvement, if stakeholders have suggestions that contradict
existing knowledge’.94 More critical and programmatic research into the
processes, practices, and impacts of co-produced implementation strategies
is therefore a promising area for future development of implementation
science as a field. (This is explored further in the Element on co-producing
and co-designing.115)
In summary, multiple barriers to knowledge flows exist between different
intellectual traditions, between approaches focusing on determinants, mech-
anisms, and outcomes of implementation, and between the interests of
researchers, practitioners, and service users. Table 4 outlines steps that can
be taken to facilitate learning across these boundaries and thus realise the
potential of implementation science to contribute to solving real-world
healthcare problems in the interest of patients and populations. However,
only through joint working that brings together all implementation stake-
holders can this learning lead to translating the science of implementation
into practice.

6 Conclusions
The past 20 years has witnessed growing global interest in methods to
[Link] Published online by Cambridge University Press

enhance the uptake of research findings into healthcare practice and policy.
This interest has fuelled the funding of infrastructure and an ever-growing
community of dedicated researchers. Implementation science has much to
offer improvement efforts in routine practice. The field offers rigorous
evaluation methods and theoretical approaches that can be harnessed to
design, facilitate, and understand the uptake of evidence-based interventions
into practice.
A large and burgeoning body of evidence on adoption, diffusion, and imple-
mentation (and increasingly de-implementation) now exists, but challenges
remain. Many important messages remain buried within the literature and
their use in and influence on routine healthcare practice could be greater.
Implementation science as a field is at the end of the beginning. The immediate
challenge for the field is not just to get research findings into practice but also to
get implementation science into practice.
[Link] Published online by Cambridge University Press

Table 4 Directions for future development of implementation science as an applied field

Desired practice Possible strategies

Cross-fertilisation between different disciplines, theoretical • Broadening the range of questions addressed by implementation science to
orientations, and implementation methodologies better reflect the needs of health services and patients.
• Developing multidisciplinary implementation teams that bring together
experts in different approaches.
• Applying insights derived from other disciplines to solve healthcare
issues.
• Positioning new empirical investigations against previous relevant studies
and building on, rather than reinventing, previous knowledge.
Integration of knowledge about determinants, mechanisms, • Increasing the use of longitudinal designs to uncover the emergent prop-
and outcomes of implementation erties of implementation and its delayed consequences.
• Focusing data analysis on developing themes that link different elements
of the causal pathway together.
• Linking the findings of process and outcome evaluations of the same
intervention.
• Complementing existing determinant frameworks with novel approaches
to identify mechanisms of implementation and capture its outcomes
(including economic evaluations).
[Link] Published online by Cambridge University Press

Crossing the boundaries between researchers, practitioners, • Producing how-to guides on implementation with and for practitioners.
and service users • Developing and evaluating participatory approaches to implementation,
particularly those involving co-production with service users.
• Developing new approaches for achieving an adequate match between
a practical issue and a scientific approach used to address it.
• Moving away from tightly controlling interventions to more flexible
designs that enable feedback loops with all implementation stakeholders.
 32 Improving Quality and Safety in Healthcare

7 Further Reading
Much of the literature cited in this Element is freely and permanently accessible
online without subscription charges or registration barriers. The following
resources represent in our view the best introductory primers for those inter-
ested in more in-depth learning about the field.

• Brownson et al.116 – an introductory text for researchers and practitioners

focused on key concepts and critical elements in research design and
evaluation.
• National Cancer Institute117 – a workbook written by members of the insti-
tute’s implementation science team. It outlines key theories, methods, and
models and serves as a guide to how implementation science can support the
adoption of evidence-based interventions.
• Wensing et al.118 – an introductory text for practitioners and policy-makers
providing an evidence-based and practical model for implementing practice
change and innovation.
[Link] Published online by Cambridge University Press
 Contributors

Paul Wilson and Roman Kislov conceived the Element. Paul Wilson drafted the
initial manuscript with the exception of Section 5, which was drafted by Roman
Kislov. Both authors contributed equally to subsequent drafts and have approved
the final version.

Conflicts of Interest
Paul Wilson is Co-Editor-in-Chief of the journal Implementation Science and
Roman Kislov is Associate Editor of the journal Implementation Science
Communications. Paul Wilson and Roman Kislov are in receipt of funding from
the National Institute for Health Research (NIHR) Applied Research Collaboration
Greater Manchester. The views expressed in this Element are those of the authors
and not necessarily those of the NHS, NIHR, or Department of Health and
Social Care.

Acknowledgements
We thank the peer reviewers and editors for their insightful comments and
recommendations to improve the Element. A list of peer reviewers is published
at [Link]/IQ-peer-reviewers.

Funding
[Link] Published online by Cambridge University Press

This Element was funded by THIS Institute (The Healthcare Improvement

Studies Institute, [Link]). THIS Institute is strengthening
the evidence base for improving the quality and safety of healthcare. THIS
Institute is supported by a grant to the University of Cambridge from the
Health Foundation – an independent charity committed to bringing about better
health and healthcare for people in the UK.

About the Authors

Paul Wilson is a senior lecturer at the University of Manchester, Theme Lead on
Implementation Science for the NIHR Applied Research Collaboration Greater
Manchester, and Co-Editor-in-Chief of Implementation Science. His research
interests focus on the role and use of evidence to inform decisions relating to
service delivery, redesign, and disinvestment.
 34 List of Contributors

Roman Kislov is a professor of health policy and management at Manchester

Metropolitan University, and Deputy Theme Lead on Implementation Science
for the NIHR Applied Research Collaboration Greater Manchester. He
conducts qualitative research on the processes and practices of knowledge
mobilisation.
[Link] Published online by Cambridge University Press
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 Improving Quality and Safety in Healthcare

Editors-in-Chief
Mary Dixon-Woods
THIS Institute (The Healthcare Improvement Studies Institute)
Mary is Director of THIS Institute and is the Health Foundation Professor of Healthcare
Improvement Studies in the Department of Public Health and Primary Care at the University
of Cambridge. Mary leads a programme of research focused on healthcare improvement,
healthcare ethics, and methodological innovation in studying healthcare.

Graham Martin
THIS Institute (The Healthcare Improvement Studies Institute)
Graham is Director of Research at THIS Institute, leading applied research programmes and
contributing to the institute’s strategy and development. His research interests are in the
organisation and delivery of healthcare, and particularly the role of professionals,
managers, and patients and the public in efforts at organisational change.

Executive Editor
Katrina Brown
THIS Institute (The Healthcare Improvement Studies Institute)
Katrina is Communications Manager at THIS Institute, providing editorial expertise to
maximise the impact of THIS Institute’s research findings. She managed the project to
produce the series.

Editorial Team
Sonja Marjanovic
RAND Europe
[Link] Published online by Cambridge University Press

Sonja is Director of RAND Europe’s healthcare innovation, industry, and policy research. Her
work provides decision-makers with evidence and insights to support innovation and
improvement in healthcare systems, and to support the translation of innovation into
societal benefits for healthcare services and population health.

Tom Ling
RAND Europe
Tom is Head of Evaluation at RAND Europe and President of the European Evaluation
Society, leading evaluations and applied research focused on the key challenges facing
health services. His current health portfolio includes evaluations of the innovation
landscape, quality improvement, communities of practice, patient flow, and
service transformation.

Ellen Perry
THIS Institute (The Healthcare Improvement Studies Institute)
Ellen supported the production of the series during 2020–21.
 About the Series
The past decade has seen enormous growth in both activity and research on improvement
in healthcare. This series offers a comprehensive and authoritative set of overviews of the
different improvement approaches available, exploring the thinking behind them,
examining evidence for each approach, and identifying areas of debate.
[Link] Published online by Cambridge University Press
[Link] Published online by Cambridge University Press
 Improving Quality and Safety in Healthcare

Elements in the Series

Collaboration-Based Approaches
Graham Martin and Mary Dixon-Woods
Co-Producing and Co-Designing
Glenn Robert, Louise Locock, Oli Williams, Jocelyn Cornwell, Sara Donetto, and
Joanna Goodrich
The Positive Deviance Approach
Ruth Baxter and Rebecca Lawton
Implementation Science
Paul Wilson and Roman Kislov
Making Culture Change Happen
Russell Mannion
Operational Research Approaches
Martin Utley, Sonya Crowe, and Christina Pagel

A full series listing is available at: [Link]/IQ

[Link] Published online by Cambridge University Press