Select, tailor and implement interventions

Making change often requires multiple approaches (or implementation interventions) to address the assessed barriers and facilitators (as discussed in the previous section of the KTA Framework). Learn more about these  strategies in the section below. 

Once barriers and facilitators to knowledge use are identified, you are ready to select, tailor and implement the practice change in your setting. To effectively implement the practice change in your setting, you must use effective implementation strategies. Through careful planning, you can use these strategies to address the barriers you identified in the previous action cycle phase.

This phase requires careful planning – helps you select the right strategies, and tailor them to your local context. 

Implementation strategies

Implementation strategies are methods or techniques used to enhance the uptake, implementation, and sustainability of an intervention, program, or practice (Proctor et al., 2013). There is a huge range of strategies, addressing different scales, intended outcomes, settings into which they are applied and the nature of the practice change or interventions to be supported. For example, the Expert Recommendations for Implementing Change (ERIC) taxonomy (Powell et al., 2015) has 73 implementation strategies and the Behaviour Change taxonomy has 93 strategies (Michie et al., 2013) for health-care settings that vary in their impact and feasibility (Powell et al., 2015; Waltz et al., 2015).

Here are some examples of implementation strategies from the ERIC taxonomy (Powell et al., 2015):

• capture and share local knowledge
• conduct educational outreach visits to inform others about the innovation
• identify and prepare champions
• inform local opinion leaders about the innovation
• develop a formal implementation plan
• distribute educational materials
• provide clinical supervision
• remind clinicians

To access the paper that outlines the ERIC taxonomy, look for the “More resources” section below. 

Tailored implementation strategies are more likely to support implementation efforts. Contextual factors can influence implementation outcomes through their effects on the ways that support systems or delivery systems enact strategies or how strategies function (Leeman and Nilsen, 2020).

Two examples:

1. Staffing shortages in a busy intensive care unit may affect the staff's ability to fully engage in implementation processes, resulting in low use of the new intervention.

• Implementation processes may need to be refined to involve less frequent and/or shorter meetings.

2. Staffing shortages may also limit the number of staff that the unit sends to a learning collaborative.

• The learning collaborative may need to be converted to a blended format that combines one brief in-person meeting with a series of conference calls.

Positive change is more likely to occur if you take the time needed to plan effective implementation. Unfortunately, many strategies are implemented without a planned process – they are often chosen based on “common sense” or what has worked in another organization (Michie, 2011). 

Consider reviewing a range of strategies and planning and using a process to identify those most likely to be effective (Michie 2011). For example, you can use a planned approach to select strategies that address barriers and leverage facilitators in your local setting.

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Avoid the “ISLAGIATT” principle* (It Seemed Like A Good Idea at the Time)
*Coined by Marin Eccles, implementation researcher, for implementing change.

• Select and tailor implementation strategies based on the practice barriers you want to address in your context. 

• Choose implementation strategies that can be used in combination or independently, depending on your objectives and your context. No single strategy is effective in all contexts/settings – there is no “one size fits all”. In some cases, it may be more effective to use a single strategy and focus on one key problem of implementation instead of trying to tackle numerous problems using complex, multifaceted strategies. (Lau et al., 2015; Squires et al., 2014) 

• Using more strategies at the same time does not always lead to higher chances of implementation success (Wuchner et al., 2014).
• The complexity of strategies may dilute the key benefits of the practice change and reduce the ability of health professionals to understand or acquire the information they need to change practice (LaRocca et al., 2015). 
• Use simple or single implementation strategies as they can be as effective as multiple interventions, or interventions with multiple parts.

• Engage various staff and others to help determine who can help you identify the barriers in your setting. 

• Identify strategies early in the change process.

• Prioritize the strategies that can both address potential barriers and are feasible to implement.

The table below displays a list of features of effective and ineffective strategies (LaRocca et al., 2012; Lau et al., 2015; Squires et al., 2012; Yost et al., 2015). 

Features of effective strategies: Interactive Actively delivered (delivered to decision-makers rather than requiring them to access it independently)   Tailored to the needs of end-users Tailored to address barriers relevant to the setting High or positive status of the individual or group delivering the strategy (for example, multidisciplinary opinion leader teams; respected educators) Highly accessible

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Features of ineffective strategies: Reliance on didactic teaching formats only Feedback not obtained frequently Use of a one-size-fits-all approach  Limited exposure to or training on the intervention – for example, an educational session of only one day may not have an impact on participants' practice

Methods to select and tailor strategies

We outline three approaches to select and tailor strategies in the table below, that we’ve taken from the literature. We will then describe intervention mapping and concept mapping in more detail.

Main approaches to select and tailor strategies

SOURCE: Table adapted from Powell et al., 2017.

Looking in-depth: Steps to intervention mapping and concept mapping 

1. Sometimes, you might want to promote a new practice or a new intervention to persons with lived experience. There are many strategies that can be used to engage this group of individuals. Broadly, the Health System Evidence Taxonomy broadly classifies person-centred strategies into six categories (Chapman et al., 2020):
2. Information or education provision: strategies to enable consumers to know about their treatment and their health.
3. Behaviour change support: interventions that focus on the adoption or promotion of health and treatment behaviors at an individual level, such as adherence to medicines.
4. Skills and competencies development: strategies that focus on the acquisition of skills relevant to self-management.
5. (Personal) support: interventions that provide assistance and encouragement to help patients cope with and manage their health and ongoing medical issues, such as counseling and follow-up on treatment efficacy.
6. Communication and decision-making facilitation: strategies to involve consumers in decision-making about health care.
7. System participation: interventions to involve patients and caregivers in decision-making processes at a system level.

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Linking this phase to the elements of the Social Movement Action Framework

You and your change team’s capacity in the “Select, tailor and implement interventions” phase may be enhanced or accelerated by adding in some of the elements of the Social Movement Action (SMA) Framework, as the two frameworks are complementary. There can be many other points of connection between the two frameworks. Below are three examples for you to consider:   

• Social movements and their exemplars are visible: By understanding social movements, their exemplars and strategies; you and your change team may identify strategies that were used in social movements that can also be applied to this KTA phase. For example, mobilizing individual and collective action involves people coming together to collaborate for a shared purpose. Applying social movement thinking and their exemplars to selected, tailored and implementation interventions may strengthen the approach to change.   
• Public visibility: One key component of the social movement action framework is to increase public visibility of individual and collective actions. You and your change team can use public visibility as a strategy to spotlight your practice change. Public visibility, such as using social media increases awareness, adds credibility to the change and supports the building of a critical mass of supporters and others engaged in the change (Serna-Restrepo, et al 2018). 
• Momentum: You and your change team may consider engaging key partners to build momentum when you mobilize your practice change. Momentum – a key component in social movements – is created through strategic planning by a group of people who are actively engaged in the change.  Momentum acts as a force of energy that fuels change – in contrast when momentum is absent, the lack of energy surrounding the change may negatively impact the uptake of the practice (Serna-Restrepo, et al, 2018).

For more discussion about the dynamic links between the elements of the SMA Framework to the KTA Framework, see the section "Two complementary frameworks".