Implementation outcomes look beyond whether the intervention “worked” in order to understand how it was received in practice. They describe how well the change process is working by measuring the process of using implementation strategies.

Back in 2011, an international working group of implementation researchers identified the eight most important concepts that were used to measure implementation outcomes. (This paper is in the Reference section of this chapter). In practice, most projects only choose to measure three or four of these outcomes. Discussion with your stakeholders will help to identify which are the most important outcomes to understand how your change worked.

In the early phase of implementation, it is useful to know whether implementation strategies are acceptable, appropriate and/or feasible. Acceptability considers whether people find the change agreeable. Closely related is appropriateness, which evaluates whether the change is perceived as a good fit for the organisation. Feasibility brings in the practical dimension, questioning whether the new procedure is realistic given current staffing levels, workload, and experience. These three implementation outcomes evaluate how the implementation strategies are perceived by the users.

During implementation, it is useful to monitor progress at regular intervals, and to make comparisons between actual progress and the plan. Useful implementation outcomes include adoption, cost and fidelity. Adoption measures the intention to use or the uptake of an implementation strategy. Cost often refers to the time and resources required to introduce the change. Once in place, fidelity examines whether the change is being delivered as intended, and as described in the research evidence. These three implementation outcomes evaluate progress and should be measured at different time periods.

Finally, as change has been implemented, the implementation outcomes of penetration and sustainability are often measured. Penetration is often referred to as reach, as it evaluates how well the change has been integrated into everyday practice. It may evaluate the proportion of eligible patients who are receiving the new service. Over time, sustainability becomes critical, as a measure of what has been continued for six months or more. Often, additional implementation supports have been withdrawn, and this is a measure of whether the change is fully embedded in the service.

Together, these outcomes provide a structured way to assess not just the success of implementation, but its fit in real-world healthcare settings.

Measure implementation outcomes

Implementation outcomes can be measured using a variety of practical methods, including:

• Surveys & questionnaires: Use relevant validated tools where possible to harness the benefits from previous researchers, and if there are no suitable tools available, create templates to ask staff and patients how acceptable and feasible they find the change.

• Interviews & focus groups: Explore experiences and discuss why or how behaviour has changed.

• Routine data & audits: Track how often the new process is used.

• Behavioural observations: Watch how the change is carried out, record frequencies, or use relevant checklists.

• Routine monitoring: Use existing performance dashboards or regular reports.

Further, measurement strategies can be selected to reflect the intended mechanisms. The following table illustrates how to align measurement strategies with their underlying mechanisms of change, using practical examples.

Building a logic model requires critical discussion between stakeholders and offers a way to maintain the momentum that was generated as stakeholders agreed on and co-designed implementation strategies, as discussed in the previous chapter. A similar co-design process provides opportunities to test assumptions about what will happen and align actions with outcomes. Practically, the shared purpose for change can be clarified and ways to maintain alignment highlighted.

 

The key components of a logic model guide its creation and integrate the accumulated knowledge and understanding of change. The broad sequence is described, following.

• Identify the change goal, in terms of the desired improvement, practical benefit and importance of action.

• Define inputs in relation to required resources, including people, processes and materials.

• Clarify activities by describing the behaviour changes and the implementation strategies supporting this.

• Describe outputs, which represent the deliverables of each activity.

• Map expected outcomes and organise into short-, medium- and long-term benefits.

• Acknowledge external influences in the broader healthcare ecosystem that may influence how that change will occur

Use this table to help identify each component, in relation to a specific organisation and planned improvement.

Component	Guiding question	Examples
Inputs	What resources are required?	Staff time, data systems, training materials, technology, materials, partnerships
Activities	What is changing?	Service delivery, clinical pathways, documentation, communication, education and training
Outputs	What will be delivered?	Number of sessions held, number of tools used, materials distributed, participants reached & engaged, surveys & audits completed
Short-term Outcomes	What are the early indicators of this change?	Increased knowledge, confidence, skills Changes in routines Compliance to new processes
Medium- term Outcomes	What indicates change is happening?	Adherence to new processes & policies Maintenance of knowledge, confidence & skills Realisation of early benefits
Longer-term Outcomes	What are the broader benefits?	Realisation of all expected benefits Addressed the original challenging problem

Logic models are commonly presented as a pipeline, supporting a practical program aim, as in the diagram below.

Co-design a logic model

Once all components are clear, map the relationships between inputs, activities, outputs and outcomes. Use arrows or organise the flow within the same row on a chart. Demonstrate how implementation strategies will lead to the sequence of short-, medium- and long-term outcomes. This provides a visual theory of change.

 

Ensure that outputs (what is delivered) are not confused with outcomes (what changes). Focus on outcomes that are meaningful, observable and practical. Be mindful that many outcomes are beyond individual control. Share drafts with stakeholders to build a shared understanding.

 

A well-crafted logic model provides a shared reference point. It connects actions with outcomes and explains the theory of how the change is supposed to happen. This makes them ideal for navigating complex healthcare systems and demonstrating the progress of change. They can also form the basis for more detailed evaluation and sustainability plans.

 

Logic models are flexible tools that can evolve as staff and patient needs change. With clear mapping, they make it easier to see where adjustments are required when circumstances shift. This adaptability allows the model to capture both planned strategies and emerging changes. Another sample logic model is provided with an emphasis on change for healthcare staff.  

 

Chapter nine explores how to track progress, make sense of what unfolds, and adapt to stay responsive in complex systems.

Navigate the Paradox Between Planning and Responsiveness

A thoughtful implementation plan brings structure to improvement. By clarifying outcomes, designing implementation strategies, and mapping activities to results, the conditions for meaningful action are clear.

 

However, in complex health systems, plans are only ever part of the story.

 

Real progress requires the ability to notice what emerges and to respond accordingly. The strength of a logic model lies not in its certainty, but in its usefulness as a shared framework for learning.

 

T

The best plans are living documents that can guide action without constraining it.