Step 1: Identify the practice area

There are many important considerations when looking to change policy and practice, particularly when it comes to implementation. Implementation is far more likely to be successful when the questions being answered are relevant to key stakeholder groups (be they policy makers, managers, clinicians, patients/consumers) (Pearson, Jordan & Munn 2012). This is a key argument for why changes in policy or practice should be led by those who work in the area, rather than by external agencies. Clinicians and those supporting clinical practice are well situated to consider changes to the structures and processes of care. The context-rich knowledge practitioners bring has immense significance to policy or practice change processes.

Working in clinical practice and the management or administrative aspects of health service delivery raises many questions about how we might act to improve the provision of care. Sometimes these questions come from our own observations, from colleagues or from the people we care for. There are many valid and useful approaches to identifying areas of concern where practice might not be based on good evidence, or where there is a known problem or issue (Institute for Healthcare Improvement 2003). The first step is to ask as a team, “What are we trying to accomplish?” (Institute for Healthcare Improvement 2003; Langley et al. 1996). Topic identification may be supported by data such as hospital reports, adverse events, clinical pathway variance reports, morbidity and mortality data. Additionally, team members may know of better results occurring elsewhere for the same issue and be aware that evidence-based practice is not being followed (Institute for Healthcare Improvement 2003). Some approaches for identifying topic areas for evidence-based implementation projects include aspects of care that are:

• High cost
• High frequency (regardless of cost)
• High risk (known poor process or outcome)
• Topic of local concern
• Known variability in practice
• Flagged through critical incident review
• Practice area addressed by recent evidence-based guidelines.

Sometimes it is helpful to review a process of care simply because it has been an accepted routine procedure or process, and no one has previously considered whether current practice is best practice, potentially making no difference or even causing harm.

The importance of teamwork cannot be over stressed in determining the long-term success/sustainability of an implementation project.

It is important to choose a topic relevant to your clinical area of interest to which the clinical team can relate.  If you do not have the support of the team (and broadly across the organisation) from the outset, the likelihood of achieving sustainable change will be challenging at best.  All evidence implementation projects are soundly grounded in a multidisciplinary team effort. No single healthcare professional group is responsible for excellent patient care. The first activity to be completed during this step is to construct a rationale, using the data that you have gathered, to demonstrate that the lack of evidence implementation within the organisation is causing a problem. By providing this data to key stakeholders, you will hopefully be able to achieve the critical buy–in from both your key stakeholders and your executive leadership group.

Healthcare delivery is a collaborative activity, with people working in teams, units, departments and divisions in order to bring together different strengths, skills and expertise to best serve the needs of particular groups of people. As such, identifying areas for improvement should be a collaborative process (Cranley et al. 2012). Consider who the key stakeholders are for the area of care; the patients (or clients or residents) who may be impacted by the change; the identification of relevant leaders and leadership skills that need to be accepting and engaged; and the organisational communications channels, committees and reporting requirements. This identification process means considering the trajectory of a project from start to finish, and knowing (or learning) the organisational pathways or processes to facilitate the successful completion of an evidence implementation study. Modern healthcare provision is team-based, multidisciplinary and integrative, bringing together organisational resources to efficiently and effectively meet healthcare needs.

When preparing to undertake an implementation project, consideration needs to be given to the human as well as the technical resources needed to complete the project.  A project of this nature will require a team of people to engage with others and enact a process of change and change management. It is recommended that this team is established well before confirmation of the project topic, scope and direction to ensure the project is feasible and will be accepted across the organisation.

The degree to which engaging with stakeholders influences a project or process may vary, from being passively informed through to being truly active partners. A dominant theme in all literature about change management, and therefore implementation science, is the acknowledgement that leadership support is essential—particularly when it comes to large, complex organisations such as hospitals (Redfern & Christian 2003; Salmela, Eriksson & Fagerström 2012; Kitson, Alison et al. 1996; Redfern & Christian 2003; McGrath et al. 2008; Shanley 2007). Informing and persuading leadership of the need for change is critical to the long-term success of the project. The executive leadership support becomes invaluable in the constructive management of the identified barriers to the proposed change. Once you have leadership support, they will be able to direct you to the key stakeholders who should be involved. The identification of a project team that reflects the key stakeholders impacted by the project is a crucial activity during this phase of the project. The key principles governing the working party for an evidence implementation project are as follows:

• Establishing clear goals, aims or objectives
• Obtaining support (and representation where possible) from executive leadership
• Creating a clear communications strategy for the organisation
• Including representatives from all sites across the organisation or where the implementation will take place
• Ensuring an inter-professional team
• Selecting key opinion leaders, as well as representatives with knowledge in areas such as evidence-based practice, quality improvement and the evidence implementation project topic

Stakeholders reflect those who are involved in all aspects of clinical practice (generating policy on delivering and receiving care). The methods used to engage members of the stakeholder group should be transparent and allow the sharing of ideas in ways that permit ongoing feedback. When seeking stakeholder involvement, the agenda should be focused and the purpose and outcomes should be transparent and clearly articulated. Table 2 presents the core principles of stakeholder engagement.

Table 2: Core Principles of Stakeholder Engagement

Stakeholder engagement can be facilitated by the following methods:

• Establishing a project steering committee
• Ensuring representative working group membership
• Ensuring all people who will be affected by the project have a chance to provide input and feedback
• Ensuring the project is transparent
• Ensuring feedback is provided frequently.