Incorporating implementation science principles into curricular design

Abstract

Implementation science (IS) is an approach focused on increasing the application of evidence‐based health interventions into practice, through purposive and thoughtful planning to maximize uptake, scalability, and sustainability. Many of these principles can be readily applied to medical education, to help augment traditional approaches to curriculum design. In this paper, we summarize key components of IS with an emphasis on application to the medical educator.

INTRODUCTION

Implementation science (IS) is “the scientific study of methods to promote the systematic uptake of research findings and other [evidence‐based practices] into routine practice to improve the quality and effectiveness of health services.” ¹ There are often notable time delays when translating knowledge into practice, with some literature suggesting that the process may take up to 17 years. ² , ³ IS evolved out of a need to improve translation of evidence‐based medicine to practice and has been increasingly utilized for clinical applications. ⁴ By planning the design and implementation of an intervention with a focus on uptake, scalability, and sustainability, implementation scientists seek to ensure a broader and more successful intervention.

Educators are often tasked with similar challenges when creating curricula to train learners in core content. In fact, many parallels can be drawn between IS principles in health interventions and educational interventions (Table 1). A common model used for curricular design is Kern's six‐step approach to curricular development. ⁵ While this model can serve as a valuable foundation, IS principles can build on this by offering a unique lens geared toward implementation, dissemination, and sustainability. In the following sections, we provide a brief overview of IS and discuss how IS principles can be applied to curricular design to enhance the uptake, scalability, and sustainability.

TABLE 1.

Comparison of IS components in health interventions versus educational interventions.

IS components	Health intervention examples	Educational intervention examples
Evidence‐based practice	Clinical interventions with an established evidence base	Core curriculum requirements Teaching learners to implement evidence‐based medicine in practice
Determinants	Clinical setting Patient population Clinicians Hospital leadership/administration	Educational environment Learner population Faculty Educational leadership/administration
Process	Implementation strategies Staff educational sessions Flyers Intervention monitoring and staff feedback	Learning activities Group work Simulation sessions Handouts Quizzes Feedback sessions
Outcomes	Rate of intervention Occurrence Patient and staff acceptability Changes in practice	Attendance Participation, assignment completion Clinical application of knowledge or skills acquired Improvements in patient care

Abbreviation: IS, implementation science.

Implementation Science

IS can be divided into three key components: determinants, process, and outcomes. ⁴ Determinants refer to the factors that may influence the implementation outcome and can include both positive factors (facilitators) and negative factors (barriers). Process refers to strategies and mechanisms used to implement a given intervention and should directly link to the determinants. Outcomes refer to measures used to identify the success of a given implementation strategy. Each of these components plays a key role in the implementation of a program and are interlinked (Figure 1). ⁶

FIGURE 1.

Implementation research logic model. From “The Implementation Research Logic Model: a method for planning, executing, reporting, and synthesizing implementation projects,” by Smith JD, Li DH, Rafferty MR, 2020, Implement Sci, 15 (1), p. 84. Copyright 2007 by Smith JD. Reprinted with permission. ⁶

APPLICATION TO MEDICAL EDUCATION

IS principles could be directly applied to medical education in a multitude of areas to help enhance the design and implementation of these educational interventions. Herein, we present a case example of an emergency medicine residency program seeking to revise its ultrasound training. We demonstrate how an IS‐informed approach can enhance traditional curricular design approaches, using the Kern six‐step model as an example. ⁵

Step 1: Problem identification and general needs assessment

This begins by identifying a problem, followed by analysis of the current approach and comparison with the ideal approach. ⁵ In this case, program faculty identify a problem of having insufficient ultrasound training for their residents. They identify several affected groups, including learners, faculty, and patients and then compare the current approach with national guidelines (e.g., ACGME, ACEP). ⁷ , ⁸ This stage would parallel the guideline‐ or evidence‐based practice in IS models.

Step 2: Targeted needs assessment

In practice, this often involves a literature review, interviews, focus groups, or surveys of learners. ⁵ Applying IS principles would expand the needs assessment to include a broader range of participants and contributing factors to identify a more expansive list of key determinants. ⁹ , ¹⁰ While several IS frameworks exist, the Consolidated Framework for Implementation Research (CFIR) is one of the most common (Table S1). ¹¹ Adapting CFIR to a medical education context, one could begin with innovation‐specific determinants, such as the source (e.g., ultrasound‐trained faculty), relative advantage (e.g., improved format/structure), resources (e.g., ultrasound machines, simulators), and cost (e.g., time required to run the curriculum). They could assess the inner setting (e.g., ultrasound faculty, nonclinical time available for teaching, leadership support, middleware for ultrasound examination storage and quality improvement) and outer setting (e.g., institutional support, expectation of adequate ultrasound training upon graduation). ⁷ , ¹² They could assess individual characteristics among implementation facilitators (i.e., ultrasound faculty), midlevel leaders (e.g., core faculty), high‐level leaders (e.g., chair, program director), and innovation recipients (e.g., residents/students). They could also assess process factors (e.g., competing curricular priorities from faculty/residents, key roles/responsibilities). While educators do not need to assess each CFIR construct, they can use this as a guide to consider the broader range of potential determinants in their needs assessment. By accounting for these determinants (both positive and negative) across a wider range of domains and components, educators can design their curricula with a more tailored model to enhance implementation success.

Step 3: Goals and objectives

Goals communicate the curriculum's overall purpose, whereas objectives guide the educational and evaluation methods. ⁵ Seen through an IS lens, goals and objectives serve to frame the overarching program and implementation, ranging from the selection of determinants through outcomes assessed to ensure continuity throughout each stage. Using the implementation research logic model framework from Figure 1, each item added to a box should be directly linked to the others. For example, if one specific objective was “by completion of residency, all residents will be able to perform a cardiac ultrasound with ≥80% accuracy” then the program faculty might build their approach by assessing how their determinants align with their cardiac ultrasound objective (e.g., faculty interest/skills in cardiac ultrasound, volume of ultrasound available, machine capabilities, availability of simulators) and then specifically tailor the intervention, implementation, and outcome approaches to either build upon strengths or improve weaknesses identified.

Step 4: Education strategies

Education strategies are the means by which the curricular intervention is achieved. ⁵ This step closely aligns with the clinical interventions used in IS and should closely align with the other implementation components. Importantly, when determining interventions, educators should consider the ideal approach and contextualize it within their current state (identified by the determinants in the needs assessment stage). Educators can then use the implementation strategies to help bolster and ensure fidelity to the intended intervention. Using the cardiac ultrasound objective, faculty may determine the best approaches include a combination of didactics, simulation, and hands‐on practice. In the next step, we will discuss how to use implementation strategies to optimize the buy‐in and conduct of these strategies.

Step 5: Implementation

Implementation includes both the IS strategies and the proposed mechanisms by which they work. The Expert Recommendations for Implementing Change (ERIC) provides a robust list of implementation strategies spread across nine domains: using evaluative and iterative strategies, providing interactive assistance, adapting and tailoring context, developing stakeholder interrelationships, training and educating stakeholders, supporting clinicians, engaging consumers, utilizing financial strategies, and changing infrastructure. ¹³ While the exact number of strategies can vary across the curricular innovation, one must consider available resources and ensure consistent alignment across all components when selecting implementation strategies. Examples could include tailoring the ultrasound curriculum based on postgraduate surveys, identifying local ultrasound champions within and external to the department (e.g., cardiology, critical care), identifying academic partnerships (e.g., shared training sessions, resident ultrasound rotation exchange program), engaging opinion leaders (e.g., core faculty, chief residents), actively involving participants (i.e., residents) in the process, more frequent evaluations of quality and fidelity to the curriculum, and supporting/incentivizing faculty (e.g., nonclinical time, incentive compensation).

Step 6: Evaluation and feedback

Program evaluation is contingent upon the implementation and fidelity of the curriculum. For example, an intervention seeking to improve residents’ ability to perform cardiac ultrasound will likely be unsuccessful if there is varied attendance and disinterested faculty due to poor implementation, despite a well‐designed intervention. Therefore, it is important to use a wider lens that includes evaluation of the program and its implementation.

Multiple outcome frameworks have been described in the IS literature. ¹⁴ The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE‐AIM) framework is a common and practical tool that can evaluate the implementation longitudinally from the initial reach of the program through sustained maintenance over time (Table 2). ¹⁵ , ¹⁶ RE‐AIM is versatile and has been previously used to evaluate several online medical education curricula during COVID‐19 ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ as well as mentoring programs for faculty underrepresented in medicine. ²¹ RE‐AIM has advantages over narrower tools, such as the Kirkpatrick model, ²² by providing a more expansive view of the effect of the innovation and its implementation. A more in‐depth review of RE‐AIM with practical examples and tools is available at https://re‐aim.org/.

TABLE 2.

Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE‐AIM) framework.

Construct	Definition
Reach	The absolute number, proportion, and representativeness of individuals who are willing to participate in a given initiative, intervention, or program.
Effectiveness	The impact of an intervention on important outcomes, including potential negative effects, quality of life, and economic outcomes.
Adoption	The absolute number, proportion, and representativeness of settings and intervention agents (i.e., people who deliver the program) who are willing to initiate a program.
Implementation	At the setting level, implementation refers to the intervention agents’ fidelity to the various elements of an intervention's protocol, including consistency of delivery as intended and the time and cost of the intervention. At the individual level, implementation refers to clients’ use of the intervention strategies.
Maintenance	The extent to which a program or policy becomes institutionalized or part of the routine organizational practices and policies. Within the RE‐AIM framework, maintenance also applies at the individual level. At the individual level, maintenance has been defined as the long‐term effects of a program on outcomes ≥6 months after the most recent intervention contact.

Source: Adapted from https://re‐aim.org/learn/what‐is‐re‐aim/.

Applying RE‐AIM to the ultrasound curriculum, faculty could assess the reach by tracking total resident didactic attendance at lectures and representativeness of those attendees (e.g., postgraduate year, prior ultrasound experience). They could assess effectiveness using participant satisfaction, multiple‐choice test questions, objective structured clinical examinations, and standardized direct observation tools. ²³ Adoption could include measures of faculty willingness to help teach the curricula. Implementation could be assessed via adherence to the educational intervention, tracking of any adaptations made, and focus groups with faculty and participants to solicit feedback. Finally, maintenance could be assessed by continuation of the educational program in subsequent years and sustained engagement. ²⁴

PLANNING FOR SUSTAINABILITY AND SCALABILITY

While not an explicit step in Kern's six‐step model, curricular maintenance, enhancement, and dissemination are discussed as additional relevant elements. ⁵ These also serve as critical components within IS, often referred to as sustainability and scalability. This should be considered and planned for early in developing a program/curriculum. One IS framework is the Designing for Dissemination and Sustainability (D4DS) model. ²⁵ In D4DS, a dedicated design‐focused phase is emphasized early in the process, wherein the program is analyzed from both product and dissemination design (i.e., messaging, packaging, distribution). ²⁵ This approach emphasizes active engagement of participants and influencers, using the following: (a) participatory codesign and end‐user involvement; (b) application of dissemination and IS theories/frameworks; (c) incorporation of marketing and business theories; (d) context‐ and situation‐specific analysis; (e) using systems, engineering, and complexity science approaches; and (f) incorporating tools from communication fields and the arts (e.g., media production, advertising, graphic design). ²⁵

Similar models could be applied for curricular design. At the program level, this should include deliberate attention to building sustainability by identifying the strategies that can sustain well beyond the initial implementation period (e.g., developing future leaders and pathways to leadership, identifying sustainable funding mechanisms). At the classroom level, this could include developing standardized materials (e.g., handouts, instructor guides, presentation slides). These approaches should also consider how to enhance scalability through development of train‐the‐trainer materials for other programs to launch similar initiatives or virtual expansion through massive open online courses.

CONCLUSIONS

Implementation science is an approach to increase incorporation of evidence‐based interventions that emphasizes purposive and thoughtful planning to maximize uptake, scalability, and sustainability. Many of these principles align well with medical education and can augment traditional approaches to curriculum design. By utilizing the strategies described above, faculty can help ensure more robust curriculum implementation, evaluation, and sustainability.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Table S1. Consolidated framework for implementation research constructs and definitions. Adapted from Damschroder et al. ¹¹

Gottlieb M, Bobitt J, Kotini‐Shah P, Khosla S, Watson DP. Incorporating implementation science principles into curricular design. AEM Educ Train. 2024;8:e10996. doi: 10.1002/aet2.10996