Table 1.

Substantive theory for acting scientifically and pragmatically – challenges and corresponding actions required for successful evidence translation and improvement

Act scientifically and pragmatically
Common challenges	Simple rules: strategies for overcoming challenges
Pre-selected interventions may not solve the problems of the local system  - People will not be motivated to change if they do not perceive a problem exists, or if wider concerns prevail  - Varying perceptions of current practice  - Conflicting views of problem and improvement approach	Understand the problem and opportunities - Draw on evidence and local knowledge to understand the problem and opportunities - Understand perceptions of local needs and priorities - Identify common improvement goals
‘Evidence’ and interventions need to be perceived as locally relevant and actionable  - Varying perceptions of evidence  - Interventions may not be used or work effectively  - Interventions need to fit with or modify existing practices, behaviours and competencies  - Interconnected challenges emerge as changes are made  - Changes have unintended consequences  - Multiple interventions are likely to be required	Identify, test and iteratively develop potential solutions - Identify intervention ideas based on evidence and build theory of change - Incremental experimental approach to introduce changes - Identify and respond to emergent challenges - Identify adverse effects in other parts of the system - Modify and refine change theory in response to learning - Review and balance investment of effort across problems and potential interventions to maximise impact
Individual perceptions of system performance are unreliable  - System performance and characteristics can be hard to see from any individual perspective as they do not take into account system complexity  - Objective measures can reveal how the system is performing but may not reveal why or what changes are required  - A lack of data and narrative limits learning, including within teams, organisations or for research	Assess whether improvement is achieved, capture and share learning - Carefully select a small number of measures as an objective indication of system performance - Use regular measurement to assess impact and inform actions - Use formal and informal methods to obtain feedback that can explain performance and guide future actions - Capture change narrative and use for organisational memory, to spread learning and to inform research
Interventions need to be reviewed and adapted as systems evolve over time  - Healthcare is a continually changing dynamic system  - Competing factors threaten long-term success - New evidence, priorities and opportunities emerge	Invest in continual improvement - Anticipate, plan and monitor for threats to sustainability - Proactively identify and incorporate new evidence - Continually respond to new ‘problems’ and opportunities