CSANZ 2021: Implementation Science – The Road to Best Practice CV Management

Speaking at Amgen’s CSANZ 2021 Breakfast Session, Professor Gerald Watts, Consultant Physician at Royal Perth Hospital and the University of Western Australia, and Dr Andrew Black, Staff Specialist, Cardiology Department at the Royal Hobart Hospital discussed the role of implementation science in the context of acute chest pain clinics as part of best practice clinical care and coronary prevention.

Dr Black set the scene by highlighting the burden of disease and current gaps between clinical evidence and best practice in preventive cardiology. Prof. Watts addressed the importance of implementation science to develop clinical services that meet best practice standards.

Addressing Gaps in the Translation and Implementation of Clinical Guidelines

Effective and sustainable services should be developed using the tools and frameworks of implementation science. Implementation science practice affords multiple strategies for implementing change and better practice. In this way, a systematic approach may be employed to develop services that may be readily adopted. This change does not happen spontaneously, but requires the focused efforts that are the domains of implementation science. Implementation science and practice is a team sport that is steeped in reality that closes the gap between best practice and delivered care. It is a mission-driven process that needs to be deliberate and structured. There are many frameworks, such as, ERIC (expert recommendations for implementing change) that can guide the process,” explained Prof. Watts.

Three critical components to implementation science and practice to survive in the “real world”:1

  • Service plans need to match your local context
  • Planning needs to be deliberate, structured and organised
  • Tools are available to help direct decision-making, adoption, implementation and sustainability

Strategies to Implement a Best Practice Lipid Service Program

Prof. Watts presented the Best Practice Lipid Service – an Amgen educational initiative designed to improve patient outcomes by providing a framework for the best practice management of lipid disorders.

“The Best Practice Lipid Service was a program I participated in that aimed to provide translatable, scalable and practical strategies and resources to establish a lipid service. It also sought to drive multidisciplinary referral networks and improve the management of high-risk patients,” explained Prof. Watts.

One framework that has been developed for implementing change is the Expert Recommendations for Implementing Change (ERIC) framework. While there are numerous strategies that can be employed as outlined by Powel et al., in principle it’s a process you go through looking for barriers and enablers. For example you might consider a needs assessment, stakeholders, finance, incentives, location, facilities, support for clinicians, consumer involvement, and administration.2 By identifying barriers and enablers at each step in the process it enables you to work on those to improve the service” said Prof Watts.

Prof. Watts explained, “The Best Practice Lipid Service Program had three modules: first, a didactic series of lectures on lipids and coronary prevention; second, self-directed learning that focussed on multidisciplinary care; and third, workshops that utilised implementation science protocols to help clinicians plan how to set up a new service or improve existing services.”

Key highlights of the program:

  • 53 physicians with a special interest in dyslipidaemia participated in the program
  • Participants most commonly committed to developing a lipid service within 6 to 12 months
  • 100% of survey respondents said the program helped motivate them to implement and build their lipid service

Importantly, some of the outcomes and statements of intent arose from these workshops as people collectively noted they needed to:

  • Recognise barriers/stumbling blocks
  • Establish a model of care and public clinics
  • Visit existing lipid clinics as models of best practice
  • Promote lipid and CV prevention service in local area
  • Start small, scale up
  • Improve existing service
  • Obtain funding for cascade testing
  • Explore funding models
  • Improve GP/non-GP specialist communication
  • Work closely with GPs regarding a multidisciplinary approach
  • Identify suitable partners (e.g. cardio-diabetes)
  • Enquire about access to support staff from existing services
  • Engage allied healthcare professionals for an integrated approach
  • Establish a service for those at high risk of CV and familial hypercholesterolaemia
  • Improve the use of genetic testing for relatives of index cases
  • Explore how to use a registry

We saw elements of the ERIC framework were used throughout. The ERIC framework gives a good set of strategies to enable service development using an implementation science approach. Skills training in implementation science and practice is recommended in order to improve service delivery in healthcare, and particularly in the context of developing preventative cardiology, cardiometabolic medicine and constituent specialities,” noted Prof. Watts.

A metaphor as a cognitive tool for the steps to implement a plan



The “six-action shoes” metaphor devised by Edward de Bono is a tool for taking action having decided on an implementation strategy. It’s a reminder of the steps you need to take,” explained Prof. Watts. “When you want to take action, someone has to put on the purple riding boots at the top. The navy formal shoes represent the protocols and formal procedures, also a must. There’s a time for the grey sneakers to be on the lookout for new information coming in all the time. Things will be tough going at times, and you need to be able to put on the brown brogues to take the sensible course of action, while for those emergency times in the clinic, the orange gumboots need to be put on. But don’t forget the pink slippers – because after all we’re human and need to act with compassion towards patients and colleagues alike. I like this metaphor for the way it relates to setting up a best practice service,” said Prof. Watts.

Finally, you do need to be a good communicator to be an effective implementationist, and bring about a change in behaviour, particularly as you need to interact and engage with patients, healthcare providers and organisations,” concluded Prof. Watts.


  1. Bauer et al. BMC Psychology 2015;3:32.
  2. Powell BJ et al. Implementation Science 2015;10:21.

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