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. Copyright © 2014 John Wiley & Sons, Ltd.