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“Although the goals of [quality improvement and implementation science] seem complementary, they interact only sporadically and superficially, often at odds, and remain isolated from each other not only through their distinct methodology, but also through their effect on and engagement with the health care system.” – Koczwara and colleagues (2018)

Quality improvement and implementation science developed as two distinct yet related fields. What is often emphasized is their distinctions but not their relatedness - consequently, opportunities to leverage the strengths of each approach are lost. We can do better to use both quality improvement and implementation in tandem to improve health care.

Shared goals and different origins

The goals of both quality improvement and implementation science are the same - to improve patient outcomes.

How each field approaches this goal is different, based on how the fields originated. Quality improvement began by looking at the various processes within an organization and attempting to improve and optimize current practices. Implementation science arose as evidence-based programs and practices were developed. Researchers, policymakers, and practitioners realized that the existence of evidence-based programs did not guarantee anyone would adopt them. Today, quality improvement efforts emphasize rapid cycling in an effort to “trial” what might work best, while implementation science emphasizes evidence and theory to guide the process.

The recent push toward evidence-based guidelines, medicine, and programs has broadly impacted the field of quality improvement. Increasing emphasis is being placed on the importance of evidence and theory, resulting in a movement toward bringing quality improvement and implementation science closer together.

Opportunities to integrate quality improvement and implementation science

We now have an incredible opportunity to integrate components of quality improvement and implementation science to enhance our efforts toward improving patient outcomes. While many elements overlap, each field remains distinct and their distinctive features highlight gaps in the alternate field. For example, quality improvement excels at rapid cycle testing, while rapid cycles are rarely embedded in implementation science efforts. As a result, efforts to remain rigorous are a time-consuming element of implementation science.

There is also the valuable prospect of applying implementation science evidence to quality improvement initiatives (i.e., improving high-quality implementation based on evidence). Presented below are three examples of opportunities for implementation science to enhance quality improvement initiatives. If done well, these approaches could be integrated into a blended QI/IS approach.

1. Using behaviour change theory

One of the documented weaknesses of quality improvement is that behaviour change theory does not guide the selection or use of its change strategies. Given that the goal of QI initiatives is to modify behaviour, and extensive research and theories on how to achieve this are available, this is essentially a lost opportunity. Implementation scientists have succeeded in applying individual, organizational, and system change theories to implementation projects. If QI could adopt one single component of implementation science, I would argue that using behaviour change theories would be the element to add. Theories could be embedded with relative ease. For example, one aspect of behaviour change theory involves collecting barriers and facilitators data, and this presents an uncomplicated opportunity to merge behaviour change theory with existing QA tools (for example, the fishbone diagram).

2. Assessing organizational readiness

Implementation scientists have carried out extensive research on the importance of organizational readiness for any change initiative to be successful. In fact, almost 3/4 of all change projects fail because an organization is not ready for change. Valid and reliable quantitative surveys and qualitative and team-based tools are available to assess readiness. Adding these readiness tools and strategies to quality improvement efforts has been shown to enhance the likelihood of success. Essentially, if you know an organization is not ready, the likelihood they will fail is significant. Why proceed in these situations? Let’s pause, develop readiness strategies, and move forward only when people and organizations are ready for change.

3. Plan for sustainability

Third, even if we do achieve positive results, we know that behaviour change and outcomes attained through change initiatives are rarely sustained. Implementation scientists have placed a major emphasis on sustainability in the past few years, creating better definitions of sustainability, understanding the factors that predict sustainability, developing tools to assess sustainability, and determining the best ways to plan for sustainability. If change efforts are not sustained, the time, resources, and money invested are wasted. By directly applying the sustainability knowledge from implementation science to QI projects, the anticipated improvements in patient outcomes can be achieved.

These three examples illustrate a few of the ways in which implementation science is able to enhance quality improvement efforts. Other opportunities exist, such as incorporating fidelity assessment and using implementation teams to narrow the timeline between research and practice from 17 to 3 years. As health systems across the province, nationally, and worldwide are being transformed, this is our opportunity to leverage the best of what each field has to offer. Rather than viewing these approaches and methods as being in opposition to one another, let’s build on what we know in order to create the best possible systems, implement the best possible evidence, and achieve the best possible patient outcomes.

Dr. Julia E. Moore is the Senior Director at the Center for Implementation. To learn more about applying implementation science check out the Center for Implementation’s monthly Implementation in Action bulletin or sign up for our free online mini-course, Inspiring Change.