Operationalising the i-PARiHS framework through iterative PDSA cycles to redesign a transcatheter aortic valve implantation program: a theory-driven implementation study

The integrated Promoting Action on Research Implementation in Health Services (i-PARiHS) framework conceptualises successful implementation as a function of innovation (evidence), recipients, context, and, importantly, facilitation. Although implementation science frameworks such as i-PARiHS are widely cited as tools that clinical teams use to implement change, they are often applied retrospectively or superficially, limiting their utility for guiding real-time decision-making and sustainment. This study examined how the i-PARiHS framework was prospectively operationalised to guide implementation strategy selection and adaptation during a complex transcatheter aortic valve implantation (TAVI) program redesign. A single-site, theory-informed implementation study was conducted at a Canadian tertiary care hospital. i-PARiHS was prospectively integrated with iterative Plan-Do-Study-Act (PDSA) cycles to assess innovation, recipient readiness, contextual conditions, and facilitation needs and to guide implementation strategy selection and adaptation across five phases of TAVI program redesign. Routinely collected operational data, prospective field notes, and stakeholder feedback were reviewed following each PDSA cycle using a utilisation-focused, framework-informed process evaluation. Analysis focused on how i-PARiHS assessments informed implementation decisions and how changes in recipients, context, and innovation characteristics shaped facilitation over time. Operationalising i-PARiHS enabled repeated assessment of innovation characteristics, recipient readiness, contextual conditions, and facilitation needs throughout implementation. Across five phases of TAVI program redesign, these assessments informed changes in implementation strategy selection, sequencing, and facilitation intensity. Early phases emphasised role clarification, cross-site coordination, and intensive facilitation in response to contextual complexity and variable recipient readiness. Later phases emphasised co-design, workflow standardisation, graduated training, and increasing local autonomy as recipient readiness evolved. Cycle-by-cycle analysis demonstrated how observed misalignment among innovation, recipients, and context prompted targeted adaptation of implementation strategies. When applied at the onset and throughout implementation, the i-PARiHS framework functions as an active guide and provides a practical structure for translating framework assessments into implementation decisions. This study illustrates how repeated assessment can support dynamic tailoring of implementation strategies and provides an in-depth empirical example of how the i-PARiHS framework can be operationalised to support transformational change in complex healthcare redesign. The findings contribute to the limited literature examining framework use in real-world implementation practice.