# Conducting rigorous implementation evaluations in real word settings: lessons from a consensus approach to perioperative pathway implementation for elective surgery

## TL;DR

This study explores how to effectively implement standardized surgical care pathways in real-world healthcare settings using a consensus-based approach and theoretical frameworks.

## Contribution

The paper provides practical insights on conducting theory-informed implementation evaluations using the EPIS framework and NPT in real-world healthcare.

## Key findings

- Implementation was influenced most by Inner Context and Innovation constructs of the EPIS framework.
- Fidelity to clinical actions improved in only two of four surgical cohorts.
- Co-designing strategies with frontline staff improved Legitimation and Coherence.

## Abstract

Single site quasi-experimental implementation studies provide opportunities to learn about implementation in context. There is limited guidance on how to best utilise these studies to maximise opportunities for learning at scale. This study evaluated the use of a consensus process to develop and implement standardised perioperative pathways, and aimed to provide practical insights on conducting rigorous, theory-informed evaluations that can generate transferable insights for implementation science.

A multi-method quasi-experimental study was conducted in a private hospital in Australia. Six consensus-based surgical care pathways were developed and implemented by different clinical teams, following a four-stage implementation process using the Exploration, Preparation, Implementation and Sustainment (EPIS) framework. Implementation outcomes were explored through participant observations (16 h) and semi-structured interviews (n = 9), which were analysed thematically using an interpretive descriptive approach. Normalisation Process Theory (NPT) was then applied to understand the mechanisms of change in greater depth. Pathway fidelity was assessed via medical record audits from a random patient sample (n = 90) from four surgical cohorts.

Implementing standardised perioperative pathways using a multi-faceted consensus-based implementation plan was perceived as acceptable, appropriate, and feasible. However, fidelity to clinical actions improved in only two of four surgical cohorts. Implementation was operationalised through the four generative mechanisms of NPT and was influenced by factors that related to all four constructs and 12/16 elements of the EPIS framework. Factors relating to the Inner Context and the Innovation were most frequently identified as having a greater influence on implementation across all EPIS phases. The implementation plan targeted Collective Action and Coherence to a greater extent than other mechanisms. Participants linked greater uptake and implementation to the importance of co-designing implementation strategies with frontline staff (improving Legitimation and Coherence) and tailoring strategies to specific disciplines.

This project provides a practical case study for how to undertake theory-informed, implementation evaluations in real-world contexts. It offers valuable insights for others seeking to operationalise implementation science principles in everyday healthcare settings including how individual strategies may work to drive local change.

The online version contains supplementary material available at 10.1186/s43058-026-00876-4.