Implementing implementation

Across health care, practitioners and researchers grapple with the problem of implementation, reflected in terms such as ‘the theorypractice gap’, and ‘knowledge translation’. Yet the central problem remains— even apparently simple innovations and interventions, for which research evidence suggests effectiveness, do not easily transfer into the messy realities of health care practice. In health professions education (HPE), this issue is equally challenging, as educational interventions are inherently complex. Thanks to advances in scholarship, HPE globally is awash with instances of innovative, potentially transformative educational practice. While many are described in published literature, relatively few interventions achieve scale and spread beyond their local context, limiting their impact. To realise their full potential to benefit health care practice, educational innovations need to be conducted, evaluated and shared in ways that enable others to adapt and use them within their own settings. Many educators would recognise that this relies as much on understanding the people involved and their organisational and social contexts as it does on the actual intervention. Yet these features— and the process of implementation itself— receive relatively little attention in the HPE literature.


| THE IMPLEMENTATI ON PROB LEM
Thanks to advances in scholarship, HPE globally is awash with instances of innovative, potentially transformative educational practice. While many are described in published literature, relatively few interventions achieve scale and spread beyond their local context, limiting their impact. To realise their full potential to benefit health care practice, educational innovations need to be conducted, evaluated and shared in ways that enable others to adapt and use them within their own settings. Many educators would recognise that this relies as much on understanding the people involved and their organisational and social contexts as it does on the actual intervention. Yet these features-and the process of implementation itself-receive relatively little attention in the HPE literature.

Relatively few interventions achieve scale and spread beyond their local context.
In this article, we do not offer a magic elixir that guarantees successful implementation or its dissemination. What we do aim to share is an introduction to a systematic, theory-based approach to implementation within HPE, and a format by which we might communicate these efforts to implement educational interventions within our practice communities.

| INTRODUCING IMPLEMENTATION SCIEN CE
Implementation Science (IS) is the scientific study of methods and strategies whose goal is to assimilate research evidence into practice.

Widely used in disciplines such as Public Health and Health Systems
Research, IS is now gaining recognition within HPE. IS stands distinct from both conventional biomedical research and quality improvement (QI). Like QI, it focuses on how to implement and sustain change rather than how to measure interventions' effectiveness. Yet unlike QI, which is mainly concerned with local change, IS shares the research aspiration of generating results that are applicable and beneficial in different settings. To achieve this, IS follows a different process from conventional research, in which interventions are developed, tested and offered as generalisable without the need for further adaptation.  While IS may be unfamiliar, its purpose aligns well with that of HPE, in that most educators want to bring about local change while generating transferable insights. IS can deliver both more transferable interventions and theory (abstractions of interventions). This theorising can help people in other places apply an intervention whilst continuing to make it even more transferable and further developing theoretical understanding of how contexts, processes and outcomes relate to one another.
While this may sound intimidating, the sort of explanatory methodologies used in IS may well be familiar to those working in HPE.
IS can deliver both more transferable interventions and theory.

| IMPLEMENTATI ON SCIEN CE IN HPE: G E T TING S TARTED
Many different approaches can be used to support implementation research. As a comprehensive, practically oriented way into IS, we recommend the Consolidated Framework for Implementation Research, which synthesises leading theories and approaches to identify and explain key constructs that influence implementation. 1 CFIR provides a blueprint to support both doing and describing implementation.

Many different approaches can be used to support implementation research.
CFIR provides a blueprint to support both doing and describing implementation.

Article section Suggested content
Background • Within your problematisation, describe wider contextual features (e.g. at policy level) that motivated you to develop your intervention and that could affect others' ability to transfer it Approach • Describe features of your organisational context • Describe in detail your intervention, its development, its core components, how it intends to achieve its effects (known as its 'programme theory') and how it might be adapted • Consider using or linking to other theories, whether in your intervention design or your methodological approach; implementation methodology (such as CFIR) is flexible and works well alongside prior theory Implementation also changes the context and the people within it, reshaping systems, culture, behaviour and values.
Scholarly articles tackling implementation should consider these constructs and their specific components (which are described in detail within CFIR). 1 Based on these elements, Table 1 suggests specific points that authors may wish to address within each section of an implementation article.
For an example of how CFIR constructs were used to identify enablers and barriers to implementation of an educational intervention, we suggest reading 1 article, which describes their work to implement a workplace-based assessment tool. 2