Implementation science and translating evidence into practice — formative SAQs

SAQ 1 — Diagnosing and closing a paediatric evidence-practice gap (10 marks)

A paediatric emergency department has a sepsis guideline endorsed by the college, yet only 52% of eligible children receive the first antibiotic within the recommended hour. The department has emailed the guideline to all staff and posted it on the intranet, with no measurable change over a year. The head of department has asked you to lead a proper implementation effort. [1] [3]

Questions

1. Define implementation science and explain why the email-and-intranet approach failed, naming the distinction that matters most. (3 marks) [1] [9]
2. Using the Cabana framework, describe how you would diagnose why the guideline is not followed, and state at least one barrier from each of the three tiers. (4 marks) [3]
3. Outline how you would select implementation strategies matched to the diagnosed barriers, and name the resource you would use. (3 marks) [8]

Model answer

Definition and why it failed (3). Implementation science is the scientific study of methods to promote the systematic uptake of research findings into routine care. The email-and-intranet approach is dissemination — the passive spread of information — and dissemination alone changes behaviour almost nothing. The problem was one of implementation: active, tailored strategies to change the behaviour that delivers the bundle. Dissemination is not implementation; that distinction is the single most tested idea on the topic. [1] [9]

Cabana diagnosis (4). Cabana's framework decomposes non-adherence into three tiers, and I would assess each with structured staff interviews and a short survey. Knowledge: clinicians may lack awareness the guideline exists or familiarity with its hour-one target. Attitudes: some may disagree that it applies to febrile infants, lack self-efficacy in escalation, or be caught in the inertia of previous practice. Behaviour/external: the workflow may lack pre-mixed weight-based antibiotics, clear escalation triggers, or decision support in the record. Each tier calls for a different strategy, which is the whole point of the diagnosis. [3]

Strategy selection (3). I would map each diagnosed barrier to a strategy from the Expert Recommendations for Implementing Change (ERIC) compilation — seventy-three discrete strategies clustered into families. An awareness barrier calls for educational strategies and clinical opinion leaders; an attitude barrier for local champions and consensus; an environmental barrier for a sepsis trolley, an opinion-led escalation pathway and visible decision-support reminders. I would build a parsimonious bundle of two or three matched strategies rather than an untargeted pile, because Grimshaw's synthesis shows tailored strategies outperform untargeted ones. [8] [9]

SAQ 2 — Measuring implementation outcomes and protecting equity (10 marks)

An evidence-based therapy for adolescent depression has been implemented across a community mental health service. The service reports that symptom scores improved on average, yet when you ask, no one checked whether therapists actually delivered the therapy as designed, and reach data were never broken down by subgroup. [5] [7]

Questions

1. Define the implementation outcome that was never measured, and explain why its absence makes the result uninterpretable. (3 marks) [7]
2. Using the Proctor taxonomy, name four implementation outcomes you would measure and state why each matters. (4 marks) [7]
3. Using RE-AIM, explain why reporting reach by subgroup is essential, and describe the equity risk if it is not done. (3 marks) [5]

Model answer

Fidelity (3). Fidelity is the degree to which a practice is delivered as designed. It was never measured here, so the service cannot distinguish a therapy that is a poor fit for this context from a therapy delivered so inconsistently that it never had a fair chance — both produce a null-looking result. Without fidelity, a clinical outcome alone cannot explain a success or a failure. [7]

Four Proctor outcomes (4). Adoption — did the therapists take up the therapy at all? Fidelity — is it delivered as designed, monitored for drift? Penetration — how far has it reached into the eligible adolescent population? Sustainability — will it persist after the project funding ends, or decay when the lead rotates? (Acceptability, appropriateness, feasibility, cost are also valid.) Each matters because a silent failure on any one can hide behind an improving clinical average. [7]

Reach by subgroup (3). Reach is the proportion of eligible individuals who receive the intervention, and RE-AIM requires it be reported by subgroup. If reach is reported only as an average, the service cannot see that Indigenous, migrant or socioeconomically disadvantaged adolescents may never have received the therapy at all — an improving average that hides an untouched subgroup has widened an equity gap under cover of success. Equity-focused implementation makes reach-by-subgroup an explicit aim from day one. [5]