Implementation for the Masses

Dean Fixsen, Karen Blase,

Melissa Van Dyke, Allison Metz National Implementation Research Network

FPG Child Development Institute

University of North Carolina at Chapel Hill

UNC Implementation Science

Student Group

!  Past – Before 2005

!  Present – 2005-2015

!  Future – Starts today

Science to Service Gap Implementation Science

!  Implement = Use

!  Implementation Science = the study of factors that influence the full and effective use of innovations in practice !   The goal is not to answer factual questions

about what is, but rather to produce evidence for what is required (invent the future)

Science to Service Gap Implementation Defined

Eisenhower: National System of Interstate and Defense Highways (1956)

•  Goal of 21,185 miles (50%) reached in 1966

Kennedy: Decision to send astronauts to the moon and return them safely (1961)

•  Goal reached in 1969

Johnson: Great Society Programs (1964) •  Goals not reached yet in 2014

Implementation Science

Human services involve interaction-based sciences and services

•  Inherently more complex than atom-based sciences – e.g., atom-based ingredients don’t

change from one engineer to the next or change overnight or decide to quit

National Assessment of Education Progress (NAEP)

Churning Around a Mediocre Mean

Original and Revised Assessment Formats

Federal SPENDING on K-12 Education and NAEP READING Scores (Age 9)

It’s not (just) the money or top-down support!

Convergence in the new millennium 1.  Innovation science 2.  Implementation science 3.  Improvement science 4.  Complexity theory

Innovation science •  Rigor and relevance of data re

WHAT to do –  “Evidence-based” programs and

innovations

A key lesson from the Great Society is that the effects of social programs in practice hover near zero, a devastating discovery for social reformers – Rigorous data supporting effective

innovations are necessary but not sufficient

Rossi and Wright (1984)

Implementation Science (get started) and Improvement Science (get better)

•  HOW to assure the full, effective, and consistent use of innovations in practice

•  HOW to resolve issues of fit and function (innovation, delivery, organizations, systems) – never ends!

Complexity Theory •  Interactions among moving parts •  Emergent adaptation •  Plan for the unexpected •  Large scale change in real time

•  Summaries of literature in any domain including agriculture, business, child welfare, complexity theory, computer science, engineering, health, juvenile justice, manufacturing, medicine, mental health, nursing, social services, and others

•  Summaries of best practices by experts doing implementation work successfully

•  Synthesis of over 40 implementation and evaluation frameworks

E Pluribus Unum

Socially Significant Outcomes

Effective Innovations

Effective Implementation

Enabling Contexts

Convergence

!  Usable Innovations !  Implementation Stages !  Implementation Drivers !  Improvement Cycles !  Implementation Teams !  Enabling Change

Convergence: Active Implementation Frameworks

Haphazard Implementation Informed

Training Benefits 5 - 15% use in practice

80 - 95% use in practice (coaching)

Fidelity of use in practice

29% EBP outcomes if low fidelity use

81% EBP outcomes if use meets criteria

Implementation Team

18% fidelity with no/poor Drivers

83% fidelity if Drivers at criteria

Training + Coaching + Fidelity

22% staff retained 3+ yrs.

58% staff retained 3+ yrs.

Competency + Organization Drivers

17% sustain 6+ yrs.

84% sustain 6+ yrs.

Implementation Benefits

8 X More

3 X More

4 X More

3 X More

5 X More

Stacey (1996)

Zone of Complexity

•  Letting it happen – Recipients are accountable

•  Helping it happen – Recipients are accountable

•  Making it happen – Purposeful use of implementation practice and

science –  Implementation Teams are accountable Based on Hall & Hord (1987); Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou (2004);

Fixsen, Blase, Duda, Naoom, & Van Dyke (2010)

Approach Usage Success Months Intervention/Facilitation 8% 87% 14

Participation/Internal Team 18% 73% 16

Persuasion 37% 47% 21 Edict 37% 35% 15

Nutt (2001)

Implementation Science Approaches to implementation of innovations in 376 organizations (public, private, profit, non-profit)

Approach Usage Success Months Intervention/Facilitation 8% 87% 14

Participation/Internal Team 18% 73% 16

Persuasion 37% 47% 21 Edict 37% 35% 15

Nutt (2001)

Implementation Science Approaches to implementation of innovations in 376 organizations (public, private, profit, non-profit)

Tell and Sell

Lead and Support

!  Minimum of three people (four or more preferred) with expertise in: !  Operationalizing innovations !  Using implementation methods effectively !  Helping organizations change

!  Tolerate turnover; teams are sustainable even when the players come and go (Higgins, Weiner, & Young, 2012; Klest & Patras, 2011)

Implementation Teams Teams

Implementation Team

Prepare Organizations

Prepare Practitioners and Staff

Work with Researchers

Assure Implementation

Prepare Regions Assure Intended Benefits

Create Readiness

Patients and Stakeholders 20%

Prochaska, Prochaska, & Levesque (2001)

Organization Supports Management (leadership, policy)

Administration (HR, structure) Supervision (nature, content)

Practitioner/Staff Competence

State/Community Supports Regional Authority Supports

Simultaneous, Multi-Level Interventions

Federal and National Supports

Implementation and Innovations !  Rapid cycle (PDSA) problem solving

!  Shewhart (1931); Deming (1986)

!  Usability testing !  Rubin (1994); Nielsen (2000)

Improvement Cycles Teams

Improvement Cycles

Nielsen (2000)

Usability Testing

•  A planned series of tests of an innovation or of implementation processes.

•  Use proactively to test the feasibility and impact of a new way of work prior to rolling out the innovation or implementation processes more broadly

Improvement Cycles

More is learned from 4 cycles with 5 participants each than from 1 pilot test with 20 participants

Expert Impl. Team NO Impl. Team

Effective

Effective use of Implementation Science & Practice

IMPLEMENTATION

80%, 3 Yrs 14%, 17 Yrs

Balas & Boren, 2000

Green, 2008

Fixsen, Blase, Timbers, & Wolf, 2001

Saldana & Chamberlain, 2012

Letting it Happen Helping it Happen

"All organizations [and systems] are designed, intentionally or unwittingly, to achieve precisely the results they get.” …R. Spencer Darling

Human Services are not improving as fast as problems are changing.

The Nature of Systems

•  Innovative practices do not fare well in existing organizational structures and systems (crushed by established routines)

•  Organizational and system changes are essential to successful use of innovations – Expect it – Plan for it

The Nature of Systems

Existing System

Effective Innovations Are Changed to Fit The System

Existing System Is Changed To Support The Effectiveness Of

The Innovation

Effective Innovation

Enabling Contexts

•  Cannot change everything at once (too big; too complex; too many of them and too few of us)

•  Cannot stop and re-tool (have to create the new in the midst of the existing)

•  Cannot know what to do at every step (we will know it when we get there)

•  Many outcomes are not predictable (who knew!?)

Creating Enabling Contexts

Implementation Team

Policy Makers &

Administrators

Practitioners Innovations

Children/Families

“Ext

l” S

Policy Enabled Practice

♦Look for Faulty Assumptions & Errors; ♦Make Needed Changes; ♦Invite System to Respond

“The fault cannot lie in

the part responsible

for the repair.” Ashby (1956)

Implementation Team

Policy Makers &

Administrators

Children/Families

Adaptive Challenges • Duplication •  Fragmentation • Hiring criteria •  Salaries • Credentialing •  Licensing •  Time/ scheduling • Union contracts • RFP methods •  Federal/ State laws

“Ext

l” S

Local Agency LIT

Executive Management

Beneficiaries

“Ext

l” S

Implementation Infrastructure

Municipality MIT

Regional Entity RIT

State and Regional Capacity Assessment

State Capacity Assessment: Fixsen, Duda, Blase and Horner, 2009

•  Stop wasting time and money on things that don’t work (and never have!) – Sugai’s Law: For every new initiative, stop

two current ones that have poor outcomes – De-scale; Avoid layering and fragmentation

•  Set aside 20% of funds for implementation •  Require quarterly reports of fidelity data

System Reinvention

A fundamental truth: •  People cannot benefit from

innovations they do not experience

Effective Innovations

Enabling Contexts

Socially Significant Outcomes

Formula for Success

!  Usable Innovations !  Implementation Stages !  Implementation Drivers !  Improvement Cycles !  Implementation Teams !  Enabling Change

Active Implementation Frameworks

National Assessment of Education Progress (NAEP)

Leverage Visible Improvements!

Original and Revised Assessment Formats

Educationally Significant Outcomes

Effective Interventions

Enabling Contexts

!  There is sufficient information to support a rapidly evolving science of implementation

!  On the verge of creating a virtuous circle where evidence-based implementation practice improves implementation science that improves implementation practice …

Science to Service Gap Implementation Science

GIC May 26-28, 2015 Dublin, Ireland

www.globalimplementation.org

Allison Metz allison.metz@unc.edu

Melissa Van Dyke melissa.vandyke@unc.edu

Frank Porter Graham Child Development Institute University of North Carolina

Chapel Hill, NC

http://nirn.fpg.unc.edu/ www.scalingup.org

HTTP://NIRN.FPG.UNC.EDU

Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. & Wallace, F. (2005). Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231).

Implementation Research: A Synthesis of the Literature

Get Connected!

www.scalingup.org

SISEP @SISEPcenter

For more on Implementation Science http://nirn.fpg.unc.edu

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Implementation for the Masses

Documents

Innovation for the Masses

Magic for the Masses - Mycotopia

SUNDAY MASSES DAILY MASSES CONFESSIONS

Moving data for the masses

Zembly: Applications for the Masses by the Masses

Relevance for the masses

Machine Learning For the Masses

Mountains for the Masses Sample

Time Table for masses

WEEKEND MASSES WEEKDAY MASSES

Femtozellen – Basestation For The Masses

Light Scattering for the Masses

Vending Mobility For The Masses

Monitoring for the masses

Nanoseconds for the Masses

Cloud Data Protection for Masses

Typology for the masses - MPG.PuRe

Data Mining for the Masses

Financial Reporting for Masses

gaming formats for the masses