Chapter 10 Implementation the way forward

It takes, on average, 17 years to turn 14% of original research findings into practice

 Suzette Woodward, 2008

The recognition of the failure of our approach at the NPSA – in simply disseminating guidance and expecting people to know about it, read it, adopt it and embed it into everyday practice – led to me pursuing a doctorate in patient safety implementation.

I studied the factors which can help and hinder effective implementation.  I spoke to loads of frontline staff and as this was a professional doctorate produced a kit for people to use to help them implement.  Professional doctorates are the same as PhDs but instead of stopping at a thesis – the professional doctorate has to add a practical output of your learning to help people use what you have learnt.  So not just showing what you know but helping people use that knowledge.  In itself the professional doctorate mirrors what we should be doing in implementing research or theory into practice and action.

What did I find out?

There is not enough attention paid on how to execute, how to implement in relation to patient safety and now enough written about how implementation occurs, and under what conditions it is favourable.

There is a growing science of implementation; which is the study of methods to promote the systematic uptake of research findings and other evidence based practices into routine practice (Eccles and Mittman 2006).

Implementation requires thoughtful action, it requires expertise and effort and there is no easy way of doing it.

Each stage, dissemination, adoption, embedding, spread and sustainability requires special thought.

There are many factors or principles that can be used in order to maximize the chances that the good idea being finally sustained.

Very few get it right; effective implementation of knowledge, research and information into healthcare practice remains for many an unconquered challenge.

Implementation is a slow and haphazard process.   To my surprise implementation research has found that it takes, on average, 17 years to turn 14% of original research findings into practice.  And even when implemented in some way we fall at the final hurdle; there is a sustainability failure rate of up to 70% of organisational change (Elwyn et al. 2007).

Implementation requires dedicated resources, funding and time and a shift away from the short term approach. It is a fantasy to think that an idea can be implemented through to sustained change in just three to five years. This is in part because implementation requires a culture shift; a culture whereby the embedded idea it still used even when politics, or policies or people change.  Understanding the simple reality that implementation takes times is important but we can also aim to reduce the time from the average of 17 years.

How do we help people to notice the things they need, when they may only have five minutes in their day to sit down and look beyond their daily activity?

There are a number of influencing factors that can both help and hinder effective implementation.  The book describes the list of factors (too long to mention here) I found which affect the success of adoption and implementation which include:

  • Demonstrate visibly with numbers, feelings, experiences that the change is better than status quo
  • Make it as easy and as intuitive as possible
  • Improve the quality of the guidance associated with the idea or solution ; do not produce a 100 page manual
  • Reduce reliance on hours of training
    • and so on….

Key references:

Diffusion of Innovations in Health Service Organisations; A systematic literature review by Trisha Greenhalgh, Glenn Robert, Paul Bate, Fraser Macfarlane and Olivia Kyriakidou published in 2005.  This book is of major significance for anyone responsible for implementation.  As Sir Liam Donaldson said in his foreword, it genuinely breaks new ground in conceptualizing and mapping a vase intellectual terrain in a way that provides insight and adds practical value.  This book is a towering work of remarkable scholarship.  I could not have put it better myself.

Eccles M, Mittman B (2006) Welcome to Implementation Science Implementation Science 1:1 DOI: 10.1186/1748-5908-1-1 Available at:  http://implementationscience.com/content/1/1/1.

Elwyn G, Taubert M, Kowalczuk J (2007) Sticky knowledge: A model for investigating implementation in healthcare contexts: A Debate. Implementation Science. 2: 44.