What if implementation is not the problem? Exploring the missing links between knowledge and action.

Given all the available knowledge about effective implementation, why do many organizations continue to have-or appear to have-an implementation problem? Analysis of a 7-year corpus of reports by a Canadian health region's "embedded" research and evaluation unit sought to discover the source of the region's intractable difficulty implementing improvement. Findings suggested that the problem was neither a lack of knowledge (decision-makers displayed sophisticated understanding of fundamental issues) nor an inability to take action (there existed sufficient capacity to implement change). However, managers' high-level knowledge was not made actionable, and micro-level decision-making often produced piecemeal actions inadequately informed by existing knowledge. The problem arose at the stage of "operationalization"-the identification of concrete, executable actions fully informed by knowledge of complex, system-level issues. Yet this crucial phase is a focus of neither the implementation nor knowledge translation (KT) literatures. The organizational decision-making literature reveals how decision-makers initiate operationalization (i.e., by setting the direction for a discovery approach) but not how they can ensure its successful completion. The focus of KT research and practice should expand to explicating and improving decision-making, lest KT become an exercise of infusing content into a broken process.