What Is Implementation Science?
How can it guide rapid responses to COVID-19?
Posted Jan 15, 2021
Authors: Tatiana Elisa Bustos & Aksheya Sridhar
COVID-19: Impacts on health care services
COVID-19 has led to the disruption of health care services and delivery across various contexts. Clinicians and community-based organizations must respond quickly to the evolving and ongoing public health challenges related to the pandemic, while also balancing other community-level needs. As clinical and community practitioners, we have seen abrupt changes firsthand in the delivery of mental health services via telehealth, policies related to hand-washing, PPE usage, quarantining, and/or procedures for walking into your own office on campus. These changes have occurred out of necessity, with rapid adaptations needed to respond to evolving policies across states and countries. However, we must consider ways to stay engaged in systematic and evidence-based rapid implementation of changes in health care delivery, particularly in clinical and community contexts, to minimize any potential harm, and increase health equity, for communities most impacted by this public health crisis.
Rapid implementation science can guide systematic and evidence-based responses to COVID-19
Implementation science refers to the “scientific study of methods and strategies that can improve the uptake of research findings and other evidence-based practices (EBPs) into routine practice to improve the overall effectiveness of health services.” Implementation practice, on the other hand, is focused on the applied context, “the act of using strategies or interventions to support people, organizations, and/or systems to use evidence to change practice.” Both implementation science and practice aim to reduce the 17-year research to practice gap that demonstrates the delay in translating practices (e.g., mental health interventions) developed in research settings to low-resource, usual-care, and community-based settings.1,2
In response to COVID-19, virtual health care services and prevention policies are implemented quickly; however, such rapid processes can compromise implementation quality, leading to poorer service and individual-level outcomes.3 Additionally, rapid processes may overlook the need for de-implementation of practices that do not work or lack evidence supporting their use.4 Thus, there is an increased demand and value for rapid implementation science to make more informed decisions. Rapid implementation science responds effectively and efficiently to the public health crisis and related policy changes, as well as systematically translates knowledge about treatments that work into usual care settings.5
The role of rapid implementation science in practice
While still relatively new, rapid implementation science has been characterized as, “incorporating speed and efficiency, while having the ability to adapt methods and trial design to suit the needs of complex studies.”6 In clinical practice, this might refer to strategies for adapting the delivery of evidence-based therapy or intake procedures into telehealth services, in response to COVID-19 guidelines. To some extent, rapid implementation science in practice challenges traditional implementation science because of its explicitly responsive nature. For instance, rapid implementation practices encourage the use of patient-centered designs, where patients' voices are incorporated into decision-making processes to ensure relevant and meaningful tactics.5 Some may view this as a compromise to rigour, but the field has called for a “redefinition of rigour” and for more pragmatic, responsive implementation to reflect the complex, real-world problems we are facing to date.5,6
Engaging with rapid implementation practices to inform decisions
While many clinicians and practitioners are indeed applying EBPs tailored to pandemic responses, evidence indicates that implementation science principles are not being utilized to guide evidence-informed decision-making.7 To this end, we emphasize the value of training in implementation science to inform our practice as clinicians and community practitioners and to inform decisions about rapid implementation. Treatments should not only work but must also be delivered with evidence-informed implementation, regardless of rapid processes. With this in mind, we encourage clinicians and practitioners to consider the following components of rapid implementation:
- Embrace and respond to context. As cases worsen, we need to embrace dynamic contexts to allow for a better understanding of how systems function together. COVID-19, in particular, has highlighted significant disparities in rates of infection, service access, and treatment. With best practices in rapid implementation, attention is paid to dynamic systems and their interconnectedness, such as those encircled around health policies, health care systems, and community, highlighting the importance of implementing policies or treatments that consider multi-level and multi-sectoral components of health care systems and communities overall.
- Prioritize processes that are collaborative and patient-centered. Stakeholder engagement throughout the phases of implementation is vital to tailoring practices, policies, or treatments that are more relevant and meaningful to the community context. With rapid implementation science principles at the forefront, alterations to health care services made during this time should integrate patient-centered values that reflect their surrounding communities. For instance, checking in with community-based organizations involved in health service delivery via brief surveys or calls to understand what the current barriers are and taking action on those issues to alleviate burdens in implementation. Such participatory approaches can increase the impact of policies and treatments.
- View adaptations as essential components of the implementation process. One example of this relates to the implementation of telehealth. To guide the uptake of telehealth in a university training clinic, ongoing adaptation of resources and materials were made to deliver treatment virtually (e.g., symptom questionnaires, treatment manuals, in-session activities, and homework). To maintain the fidelity of telehealth, clinicians and supervisors underwent rapid and ongoing training in order to make evidence-informed decisions about adaptations to delivery of services and implementation strategies (e.g., resource-sharing). Many other health care settings are facing similar adaptations to adhere to COVID-19 guidelines and fidelity of treatments in virtual settings. Models, such as FRAME or MADI, can guide these modifications more systematically in response to ongoing changes from the pandemic.
Training Resources on Implementation Science
1. Balas, E. A., & Boren, S. A. (2000). Managing Clinical Knowledge for Health Care Improvement. Yearbook of medical informatics, (1), 65–70.
2. Green, L. W., Ottoson, J. M., García, C., & Hiatt, R. A. (2009). Diffusion theory and knowledge dissemination, utilization, and integration in public health. Annual Review of Public Health, 30, 151–174. https://doi.org/10.1146/annurev.publhealth.031308.100049
3. Durlak, J. A., & DuPre, E. P. (2008). Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation. American Journal of Community Psychology, 41(3-4), 327.
4. Norton, W. E. & Chambers, D. A. (2020). Unpacking the complexities of de-implementing inappropriate health interventions. Implementation Science, 15(1), 2.
5. Øvretveit J. (2020). Implementation researchers can improve the responses of services to the COVID-19 pandemic. Implementation Research and Practice, 1, 1-6. https://doi.org/10.1177/2633489520949151
6. Smith, J., Rapport, F., O’Brien, T. A., Smith, S., Tyrrell, V. J., Mould, E. V., ... & Braithwaite, J. (2020). The rise of rapid implementation: a worked example of solving an existing problem with a new method by combining concept analysis with a systematic integrative review. BMC Health Services Research, 20, 1-14.
7. Hirschhorn, L., Smith, J. D., Frisch, M. F., & Binagwaho, A. (2020). Integrating implementation science into COVID-19 response and recovery. British Medical Journal, 369, 1-2.