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Step 3: Identify implementation strategy or strategies

What is an implementation strategy?

Implementation science is fundamentally concerned with identifying effective strategies for implementing evidence-based interventions. Therefore, it is critical to understand the difference in what is meant by implementation strategies and evidence based interventions.

Evidence based interventions are the what that is being implemented. Implementation strategies are how we seek to get evidence based interventions into normal practice in clinical or community settings. This distinction between “what” and “how” is useful for distinguishing implementation strategies from evidence based interventions.

Implementation strategies are the actions taken to enhance adoption, implementation, and sustainability of evidence based interventions.

Evidence based interventions are programs, practices, principles, procedures, products, pills, or policies that have been demonstrated to improve health behaviors, health outcomes, or health-related environments.

For an in-depth explanation of implementation strategies, read Kirchner and colleagues' excellent introduction in Psychiatry Research (2019).

Grouping implementation strategies

Implementation strategies can target determinants at any level of the social ecological model, and can be used individually or in combination with other strategies.

Implementation strategies can be a single strategy (e.g. training), or a bundle of strategies to address multiple implementation barriers (e.g. the use of both reminders and role revisions), or blended strategies that are multiple strategies packaged and branded for use (e.g. the Leadership and Organizational Change Intervention). The decision to use one or more implementation strategies should be tied to specific target determinants and the part of the implementation ecosystem they exist in, as well as the available evidence that the strategy or strategies will be effective for this purpose.

In 2015, the Expert Recommendations for Implementing Change (ERIC) project published a refined compilation of implementation strategy terms and definitions compiled by systematically gathering input from stakeholders across implementation science and clinical practice. The resulting table of 73 implementation strategies can be found here or in the original Open Access (✪) article in the journal Implementation Science.

Waltz and colleagues then used concept mapping to characterize relationships among the 73 implementation strategies and assess their feasibility and importance, resulting in nine clusters of implementation strategies. While not exhaustive, below we provide examples of the different strategies found in each of the nine distinct clusters.
 

The IS Research Pathway

Find Examples

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Browse our Library of UW community co-authored publications to see examples of research on a selection of implementation strategies.

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Open Access articles will be marked with ✪
Please note some journals will require subscriptions to access a linked article.

Use Evaluative/Iterative Strategies

  • Assess for readiness, identify barriers/facilitators
  • Audit and provide feedback
  • Purposefully re-examine the implementation
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Assess for readiness and identify barriers and facilitators
Audit and provide feedback
Purposefully re-examine the implementation

Engage Consumers

  • Increase demand
  • Use mass media
  • Involve patients/consumers, family members

Utilize financial strategies

  • Alter incentive and/or allowance structures
  • Access new funding
  • Fund and/or contract for the innovation
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Alter incentive and/or allowance structures
Access new funding
Fund and/or contract for the innovation

Train and educate stakeholders

  • Conduct ongoing training
  • Distribute educational materials
  • Use train-the-trainer techniques

Provide interactive assistance

  • Facilitation
  • Provide local technical assistance
  • Provide clinical or workplace supervision
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Facilitation
Provide local technical assistance
Provide clinical or workplace supervision

Adapted from: ✪ Waltz, TJ., Powell, BJ., Matthieu, MM. et al. Use of concept mapping to .... Implementation Sci 10, 109 (2015) doi:10.1186/s13012-015-0295-0

Adapt and tailor to context

  • Tailor strategies
  • Promote adaptability
  • Use data experts
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Tailor strategies
Promote adaptability
Use data experts

Develop stakeholder relationships

  • Identify and prepare champions
  • Organize implementation team meetings
  • Identify early adopters
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Identify and prepare champions
Organize implementation team meetings
Identify early adopters

Support Clinicians/Employees

  • Provide reminders
  • Revise professional roles
  • Facilitate relay of data to employees/clinicians
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Provide reminders
Revise professional roles
Facilitate relay of data to employees/clinicians

Change infrastructure

  • Mandate change
  • Change record systems
  • Change physical structure and equipment

Strategy Spotlight: SAIA

Developed by Program core faculty Dr. Kenneth Sherr and colleagues, the Systems Analysis and Improvement Approach is an evidence-based cascade analysis method that combines system engineering tools into a five-step, facility-level implementation strategy package to give clinic staff and managers a system-wide view of their cascade performance, identify priority areas for improvement, discern modifiable opportunities for improvement, and test workflow modifications.

The process is iterative, which means health care teams can continue to use the package to further improve care and respond to new bottlenecks that arise. Visit www.saia-strategy.com to learn more about this method and about projects currently using SAIA.

SAIA examples

Why assess barriers and facilitators before selecting implementation strategies?

Implementation strategies are most effective when they are chosen to address specific factors that may influence implementation success. Before selecting strategies, implementation teams should assess potential barriers and facilitators within the setting, organization, workforce, community, and broader environment. This process helps teams understand what challenges may impede implementation, what strengths can be leveraged, and which factors are most likely to influence adoption, implementation, and sustainment. Without a structured assessment of barriers and facilitators, implementation strategies may be poorly aligned with the needs of the setting, resulting in unnecessary effort, reduced effectiveness, or missed opportunities to support successful implementation.

A variety of tools, frameworks, and resources can support barrier and facilitator assessment. Some resources help teams conduct rapid practical assessments, while others provide comprehensive frameworks for organizing determinants and understanding their influence on implementation outcomes. Qualitative assessment tools can help teams gather stakeholder perspectives through interviews and focus groups, and strategy-matching resources can assist in selecting implementation approaches that address identified barriers. Together, these resources can help researchers, practitioners, and organizational leaders move from understanding implementation challenges to selecting strategies that are responsive to local context and stakeholder needs.

The resources below offer several approaches to identifying, organizing, and acting on implementation determinants. Whether you are planning a new implementation effort, adapting an existing program, or evaluating ongoing implementation, these tools can help ensure that strategy selection is informed by a systematic understanding of barriers and facilitators.

  • The Barriers and Facilitators Assessment Toolkit (Knowledge Translation Program, St. Michael’s Hospital, Unity Health Toronto): Rapid, practical determinant assessment. Particularly useful for beginners and applied projects. Helps users identify barriers and facilitators at the patient, provider, and health-system levels and suggests response strategies.
  • CFIRGuide.org: A comprehensive determinant framework and collection of tools for systematically identifying and organizing implementation barriers and facilitators across intervention, individual, organizational, and external-context domains.
  • CFIR Construct Example Questions (CFIRGuide.org): Examples of open-ended questions aligned with CFIR constructs and broader implementation topics. These questions can be adapted to the needs of a specific project and incorporated into interviews, focus groups, and other data collection activities to assess implementation barriers and facilitators.
  • CFIR-ERIC Matching Tool (CFIRGuide.org): Identifies implementation strategies that may address barriers identified through determinant assessments.
  • Barrier Buster Tool (Dissemination-Implementation.org): A brief implementation assessment that helps teams identify potential barriers and facilitators during planning and implementation.

Specifying and Reporting Implementation Strategies for Replicability

Specifying the implementation strategy in your research is crucial for several reasons, and should be clearly delineated in all publications about your research.

It ensures reproducibility, allowing other researchers to replicate your study, which is fundamental for scientific validation. Transparency is another key aspect, as it allows others to understand how you arrived at your conclusions. This level of detail also enhances the credibility of your work, demonstrating that your findings are based on a rigorous and well-documented process. Additionally, it helps reviewers and readers evaluate the validity and reliability of your research. Finally, sharing your strategies contributes to the collective knowledge in your field, positioning it to guide future research and innovations.

Proctor, Powell, and McMillen's stragegy for reporting implementation strategies in a manner that allows for measurement and replication.

Adapted from Proctor EK, Powell BJ, McMillen JC. Implementation strategies: Recommendations for specifying and reporting. Implement Sci. 2013;8(139).

Researchers aim to identify the processes or events that drive these outcomes, often referred to as mechanisms of change. This involves developing causal models that link strategies to their effects, considering various factors such as context, barriers, and facilitators. To achieve this, researchers can use a combination of qualitative and quantitative methods to explore and validate these mechanisms.

One of the tools used to understand mechanisms of change are detailed causal pathway diagrams that map out the relationships between strategies and outcomes, including any moderators or preconditions that might influence these relationships. CPDs typically include elements such as implementation strategies, intermediate outcomes, moderators, and final outcomes, providing a clear and structured way to hypothesize and test how and why certain strategies work.

By illuminating these causal pathways, implementation scientists can provide more precise guidance on which strategies are most effective in different contexts. This helps practitioners select and tailor strategies to address specific implementation challenges, ultimately improving the delivery and impact of evidence-based practices. You can learn more about causal pathway diagramming in implementation science at ImpSciMethods.org.

Visualizing Implementation Strategy Mechanisms

The study of causal mechanisms in implementation science focuses on understanding how and why specific strategies lead to desired outcomes when implementing evidence-based practices.

In addition to causal pathway diagrams, several other methods are used to understand mechanisms of change in implementation science:

Logic Models: These are systematic and visual representations of the relationships between resources, activities, outputs, and outcomes. Logic models help in planning, implementing, and evaluating programs by clearly outlining the steps needed to achieve desired outcomes.

Implementation Mapping: This method involves a series of steps to identify and select appropriate implementation strategies. It includes conducting a needs assessment, defining outcomes and performance objectives, choosing theoretical methods, and developing implementation protocols. Implementation mapping ensures that strategies are tailored to the specific context and needs of the target population.

Mechanism Mapping: This approach focuses on identifying and understanding the specific mechanisms through which implementation strategies achieve their effects. It involves linking strategies to their mechanisms of action and evaluating these linkages through empirical research. Mechanism mapping helps in refining and optimizing implementation strategies for better effectiveness (see Kilbourne et al, 2023 for example).

Agile Science: This involves iterative testing and refinement of implementation strategies using rapid-cycle evaluation methods. Agile science emphasizes flexibility and adaptability, allowing researchers to quickly test hypotheses about mechanisms of change and adjust strategies based on real-time data.

These methods collectively enhance the precision and effectiveness of implementation strategies by providing a deeper understanding of the underlying mechanisms of change. By using these tools, implementation scientists can develop more targeted and context-specific strategies, ultimately improving the adoption and sustainability of evidence-based practices. For tools to create CPDs and to learn more about implementation mechanisms, visit ImpSciMethods.org.

If [implementation strategies] are to be scientifically tested, communicated clearly in the literature, and accurately employed in actual healthcare practice, they must be specified both conceptually and operationally.

Proctor, Powell, & McMillen, 2013

Videos from our friends

How to Really Use Implementation Strategies, with Dr. Shari Rogal (University of Pittsburgh DISC)
Implementation Science Strategies, with Dr. Debbie Passey (University of Melbourne Centre for Digital Transformation of Health)

EQUITY CHECK: Pause and reflect

Does the proposed implementation strategy (or strategies):

❯ address barriers experienced by populations who face the greatest obstacles to access and participation?

❯ reduce rather than increase implementation burdens on under-resourced organizations, providers, or communities?

❯ provide flexibility for local adaptation while preserving core functions?

❯ support meaningful engagement and shared decision-making with affected communities?

❯ account for differences in organizational capacity, staffing, funding, infrastructure, and technology access?

❯ consider whether some groups may benefit more than others and include plans to address those disparities?

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