By Peter van Splunteren and Barbara van der Linden, members of Kwaliteit in Zorg (KiZ)

The first European Implementation Event (EIE) took place on 26 and 27 May 2021. The meeting, originally planned in Rotterdam, was held digitally and was organized by a consortium of EIC and organizations in the Netherlands led by ZonMw, the Dutch health research funder. The EIE showed the state of the art of implementation knowledge, expertise and related matters that are necessary for the further development of the implementation profession.

Netherlands Implementation Collective

During the EIE, outgoing Secretary-General of VWS Erik Gerritsen launched the NIC (Netherlands Implementation Collective), which is supported by ZonMw. This collective, consisting of a network of implementation professionals, was given an unmistakable assignment: ensure that implementation knowledge and expertise is widely distributed among Dutch professionals and citizens. Gerritsen sees the use of implementation knowledge as a solution to major challenges in healthcare, such as resistance to change, the increasing shortage of health care workers, increased use of health-promoting interventions and network approaches.

Frameworks

During the EIE it became clear that we are in the phase of implementing implementation knowledge. Resrach was presented on the use of implementation models and frameworks: the Consolidated Framework for Implementation Research (CFIR), the Normalization Process Theory (NPT), and the Exploration, Preparation, Implementation, Sustainment (EPIS) framework contain factors that are important in the different phases of implementation.

The Effective Practice and Organization of Care (EPOC) taxonomy lists implementation strategies and the Implementation Outcomes Framework (IOF) describes implementation outcomes. These frameworks are now widely used in projects where various interventions are systematically implemented in various sectors. The results and experiences presented show that often small patient numbers have been included and that sustained changes in practice are often limited.

Focus

There is an increasing focus on understanding the mechanisms behind implementation strategies and the relationships and balance between them. In the past, the focus was on fidelity in the implementation of evidence-based interventions. Now adaptation to local practice and patient preferences is recognized as inevitable and essential for successful implementation. Interventions may even improve from adaptation. Maintaining core elements of an intervention and  monitoring the adaptations and the effectiveness of the intervention is important.

Continuous improvement

As David Chambers (National Cancer Institute, USA) argued in his keynote, the success of small isolated projects is limited and we need to move towards continuous learning and improvement systems: dynamic sustainability. Specific attention must be paid to scaling up and de-implementation. The factors involved in those are similar to those for successful implementation: the possibility of adaptation of the intervention; the involvement of relevant stakeholders; the availability of sufficient time and budget and adequate project management; the presence of monitoring and action research.

Sound preparation using analyses, describing and learning from past experiences (including failures!) and understanding what drives people to keep providing redundant care practices (e.g. pressure from patients, interests of the organization) are essential.

Expertise and training

Well-trained implementation experts are needed to support this continuous learning and improvement by healthcare professionals. The demand for implementation professionals is rising and the expectations of them are growing. But access to adequate training is still limited and their position in organizations is often unclear. There was much discussion during the EIE on the competencies implementation experts need, but little about financing the training and practical matters such as the location of the training and the place where the experts work. And also: how to convince organizations to hire and retain an implementation specialist and how to demonstrate the added value?

There is a growing need for more formal education for implementation experts. Early Career Implementation Professionals (ECIP’s) need certified training opportunities and support from experienced colleagues.

Competency lists (such as the EIC/NIRN Implementation support guide) now exist and EISEN has taken the initiative to set up a European master and PhD program (European Implementation Science Education Network).

Until now, much attention has been paid in training to the technical side (tools/methodology/effectiveness measurements) of implementation, often with the evidence based intervention as a starting point. Now the focus must shift to implementation experts personal development for example (stakeholder) management and leadership skills.

Continuous exchange between implementation experts and healthcare professionals is also central here. Training and coaching health care organization leaders to promote an implementation climate is also important.

There are questions about which levels of training are necessary for (generalist) healthcare professionals and implementation specialists. Implementation (research) training is usually at postdoc level. Few introductory courses with basic knowledge exist that raise broad awareness about the need for implementation.

Agenda for the coming years

The general conclusion at the EIE was that implementation is becoming recognized as a profession and discipline and increasingly seen as an essential part of health care. And that certainly applies to the Netherlands. These achievements have been made over the past thirty years, but much work remains to be done.

The main issues emerging from the EIE were:
– Discussion is needed on the higher goal of implementation, for example: utilization of evidence-based medicine or reducing health differences;
– Transfer of knowledge and expertise from research networks to practice and vice versa;
– Supporting young researchers in learning networks;
– Combining studies so that results can have more impact;
– Expanding possibilities for education and research on implementation;
– Building systems for continuous learning and improvement and establishing relationships with the fields of change management and quality improvement.

In the Netherlands, the NIC will act as a national network for implementation professionals. In the coming period the NIC will focus on stimulating implementation research, ensuring a sufficient number of well-trained implementation professionals and facilitating the interaction between them to learn together. The role that research funder ZonMw is taking to support this network until it can operate independently serves as an example for other countries.

The agenda is full and challenging, there is a lot of work to do. At the next EIE conference in two years’ time in Basel, Switzerland, we will hear about the progress made on the issues raised at the 2021 EIE.