In 2018, we were invited to join the team of associate editors for Implementation Science Communications (ISC), a new journal – companion to Implementation Science – devoted to the study of how health care programs and services are taken up, adapted, and sustained. As a Canadian funder-researcher (Holmes) and an American implementation scientist (Hamilton), we seized the opportunity to support an emerging field that has tremendous potential to improve patient care and public health.
Who knew that the world would soon face a global pandemic that would put implementation science, and indeed the scientific enterprise itself, to the test? Over the course of the past year, researchers have focused on how implementation science is faring during what English et al call “the globe’s single largest and most concentrated health services redesign effort.” In this post we comment on implementation science embeddedness, capacity, and complexity in the context of the pandemic and how these phenomena present opportunities for further growth in the field.
Setting the scene
To start, some definitional context: the US terms dissemination and implementation and the Canadian term knowledge translation (KT) are roughly parallel. All three terms encompass processes to promote the adoption of evidence-based health and health care practices into routine use. Dissemination and implementation sciences, and KT science, respectively, are the study of these processes.
Implementation science is the scientific study of methods to promote the systematic uptake of proven clinical treatments, practices, organizational, and management interventions into routine practice.
Implementation science, specifically, is “the scientific study of methods to promote the systematic uptake of proven clinical treatments, practices, organizational, and management interventions into routine practice, and hence to improve health.” Implementation scientists are experts in individual, group, organizational and system behavior change.
Our observation is that the field is less well developed in Canada than in the US. The distinction between implementation as a practice versus implementation as a science is sometimes confused in the broad research community, including among funders, and the small pool of Canadian implementation scientists is stretched thin responding to calls for support. The good news is the keen interest on both sides of the border in understanding how best to implement and de-implement evidence-based practices.
Opportunity 1: Embedding implementation science in health care
The world has seen remarkable innovation on many pandemic-related fronts at global, national, jurisdictional, and community levels, in everything from face masks to funeral practices, but particularly in health care services.
We wonder how many of these innovations could have been more effective if implementation science, and implementation scientists themselves, were embedded in health care. There has been little time to reflect on evidence for and theory behind the successful uptake of interventions. Perhaps there is too little understanding of why such reflection is important: that it saves time and resources in the long run. Where are implementation scientists positioned among the public health and healthcare professionals critical to the pandemic response? Have they also been critical? Has implementation knowledge at least been critical? If not, why?
We are aware of productive relationships between implementation scientists and those implementing interventions in some jurisdictions; we also know organizations that value implementation science and make use of its theories and frameworks in practice, even if they don’t always involve scientists in their work. However, we argue that health care systems on the whole are not maximizing the knowledge gained from implementation science, resulting in unclear outcomes. As Taylor notes, it is sometimes impossible to say whether an intervention fails because it’s not effective, or because it wasn’t implemented effectively.
It is sometimes impossible to say whether an intervention fails because it’s not effective, or because it wasn’t implemented effectively.
Healthcare systems are overburdened and implementers are working under unfathomably complex and demanding circumstances, often without enough time to eat, sleep, and see their families. We are not laying blame on them – or on implementation scientists. We are simply – and optimistically – noting an opportunity to further embed implementation science into health care.
Opportunity 2: Building implementation science capacity
Part of the reason implementation scientists are not playing a larger role in health care is that there aren’t enough of them. Unfortunately, there is neither a sufficient number nor diversity of opportunities available to increase capacity. The training currently available is outstanding, but highly competitive. And though online resources are increasingly accessible, they may not be robust enough to develop the necessary cadre of implementation scientists.
It’s time to acknowledge that the pool of experts on implementation methods is too small. Therefore, it is necessary to attract trainees, as well as emerging and established investigators, to the field.
It’s time to acknowledge that the pool of experts on implementation methods is too small.
Many commentaries have noted the incalculable effects of the pandemic on the entire health research enterprise, with bleak perceptions of science as a viable job prospect and considerable challenges with maintaining the production of science. Implementation science, more nascent than other fields, may suffer from this pall over science as a profession, but we believe it is more relevant and viable than ever.
Finally, we note two other capacity gaps: implementation science review capacity as it relates to journal submissions and funding opportunities, and receptor capacity in the health care system. On the latter, implementation training for health care staff would certainly help, but ultimately a health-system-wide commitment to the production and use of research evidence for better health care is needed.
Opportunity 3: Bringing a complexity lens to implementation science
Over the last decade there has been much talk about the need to account for complexity in health system change. However, when it’s time to act – especially during a crisis – it seems a natural human tendency to try to simplify, rather than work within, complexity.
We suggest the pandemic, as a complex problem within complex systems, provides an opportunity to demonstrate the importance and practicality of implementation science. There is heightened attention to a range of interventions, all of which involve a range of stakeholders, organizations, and sectors with various accountabilities, responsibilities, allegiances, power, and influence. The world is not standing still as these interventions are implemented, and indeed, interventions themselves have their own systemic impacts.
Implementation scientists live and breathe this reality, and their efforts to move ‘context assessment’ beyond an up-front and one-time activity have realized results. We hope implementation scientists take the opportunity to incorporate more complex systems approaches into their work, advancing knowledge that will be useful for years to come as the world recovers from the effects of the pandemic.
Summary: Where to from here?
Our commitment to the field of implementation science has only strengthened during this past year of rapid and unprecedented changes to healthcare and societies, and the resulting opportunities we see.
How can these opportunities be realized? Who needs to do what? There is no shortage of advice for implementation scientists in recent pandemic-related commentaries. However, implementation scientists can’t bring about the changes needed to maximize the potential contributions of the field alone. There is a role for funders in advancing the science of implementation through grants – especially those that provide for time to develop the relationships needed to study change in complex systems. Funders can also partner with universities to develop implementation science talent. Health system leaders can build implementation science capacity in organizations by encouraging evidence generation and use, supporting skill development, providing resources, and partnering with academia.
And finally, journals such as Implementation Science Communications can increase their efforts to promote this critical field of study, encouraging and publishing a wide range of articles that can practically contribute to improved health care delivery and health outcomes.
About the authors:
Bev Holmes, PhD., is President and CEO of the Michael Smith Foundation for Health Research, British Columbia’s health research funding agency.
Alison Hamilton, Ph.D., M.P.H., is Chief Officer of Implementation and Policy at the VA Center for the Study of Healthcare Innovation, Implementation & Policy at the Greater Los Angeles Healthcare System, and a Professor-in-Residence in the Department of Psychiatry and Biobehavioral Sciences at UCLA.