Steps for successful implementation of The toolkit

The following five steps on how to use The toolkit (define, diagnose, intervene, measure impact and sustain) have been adapted from the HCOASC  'how to' guide, 'Turning knowledge into practice in the care of older people' available at

Five steps for successful implementation

Five steps for successful implementation of the Best Care for Older People Everywhere toolkit - define, diagnose, intervene, measure impact and sustain

The five steps for successful implementation of The toolkit are:

1. Define

Project definition phase involves identifying the 'area of interest' or potential problem area. This is when to ask 'What do we want to achieve?'

All quality improvement projects begin with the question 'What are we trying to accomplish?' This involves identifying an 'area of interest', which, depending on your setting and the patient or client population, could be as broad as 'improving the care of older people', or it could be as specific as 'the prevention of falls of older people in hospital' or 'the introduction of a process to reduce post operative delirium'.

So how do you actually decide where to start in improving care for older people?

If there are no clear priorities for addressing the care of older people in your organisation, or if there seem to be conflicting priorities, a formal group exercise called Quality Impact Analysis can be useful.

This is a brainstorming type activity, which enables structured consideration of the potential problems and opportunities for improvement. As with all brainstorming activities, it is important that you involve relevant stakeholders in this activity to avoid bias.

Based on a list of problems or potential quality initiatives, as well as supporting data, copies of the relevant knowledge resources and other inputs, the group may be asked to identify:

  • five things that are done frequently in relation to the care of older people
  • five things that involve risk for older people
  • five things that are of concern to staff or clients in relation to the management of older people.

Participants are then asked to score each item based on the frequency, risk level and general level of concern. Scoring may be, for example, from one to three, where one equals low frequency, risk or concern, and three equals high frequency, risk or concern.  The highest scoring topics should indicate the priority of topics for attention and may be confirmed if appropriate data is available. The activity may be adapted to address a range of other criteria, such as cost or clinical effectiveness.

2. Diagnose

There are several steps to consider in diagnosing priority areas for implementation:

Baseline data collection and identification of gaps in service provision

  • Some domains contain audit tools to help diagnose the current status of care. These audit tools can be used to collect baseline data and assess gaps in service provision.
  • Other methods to identify priority areas include complaints data, consumer reference groups, incident reports, key performance indicators, clinical indicators and opinions of staff.
  • The toolkit can be used to implement a number of domains across the continuum of care or a targeted approach can be used to identify one specific issue in one specific ward.

Prioritise guideline recommendations

  • It is important to identify a starting point for implementation.
  • The starting point should be an area in which there is good support, adequate resources and in which visible gains can be more easily achieved.  Early successes will help generate further support for more complex and risky implementation.
  • Diagnosing the current status of the health service will help identify priorities.
  • As the domains are interdependent, sustained implementation of one domain will lead to improvements in other domains.

Identify facilitators

  • It is important to identify and utilise facilitators in implementation.
  • Quality committees are important resources to approach. They have expertise and resources that can assist in implementation.
  • Senior staff and clinical leaders are also critical champions for supporting implementation.

Identify barriers

  • It is important to recognise that there will be barriers to implementation.
  • Potential barriers to implementation should be identified early in the planning phase and strategies developed to overcome them.
  • Barriers related to infrastructure can be challenging to overcome.

Plan for sustainability

  • It is important to plan for ongoing sustainability of changes.
  • Refer to the “Sustain” section for how to incorporate sustainability into planning.

Plan for evaluation

  • It is important to plan to evaluate the implementation from the beginning. Evaluation data can be used to demonstrate uptake and sustainability and generate support for the implementation.
  • Refer to the “Measure impact” section for further evaluation methods.

Assess costs

  • Implementation may have associated costs.
  • It is important to research and estimate costs and benefits to provide reasons for undertaking the implementation.

3. Intervene

  • The toolkit provides the resources to use during the implementation phase.
  • Select and adapt the resources best suited to the needs of your health service.

Every recommendation does not need to be implemented to be successful and improve care.

4. Measure impact

  • Your health service may have developed performance indicators that can be used to measure performance.
  • Baseline data can also be collected again to compare the results pre and post implementation. This may include complaints data, consumer reference groups’ views on specific issues, incident reports, key performance indicators, clinical indicators and opinions of staff.

5. Sustain

There are many strategies to build sustainability into the proposed changes.

Redesigning systems

  • Redesigning systems that support implementation is a powerful way to build in sustainability.
  • Adjusting systems that support implementation provides a solid support for ongoing sustainability.
  • Redesigning systems can be a large and complex task, requiring support from many different stakeholders.


  • Appropriate documentation is necessary to measure implementation and sustainability.

Documentation can act as both a reference and a communication tool. It also can help in training and education and measuring the impact of changes.


  • It is important to include measures to monitor implementation to provide both accountability and transparency in measuring progress.
  • Regularly record and establish a feedback protocol. This will allow staff to monitor their progress and see how implementation is changing the care they provide.

Training and education

For ongoing sustainability, it is necessary to provide adequate training for staff and service users to effectively use, and benefit from, implementation. This may need to include both initial and refresher training and ensure training is available for new staff

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