What Does it Take for Effective Implementation to Get to Outcomes?

By Renée Boothroyd, Scientist and Senior Implementation Specialist, Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill

Getting to outcomes is not as simple as selecting an effective practice model or strategy (“the WHAT”). The process of supporting use of any practice model or strategy (“the HOW”) is just as, if not more important, for creating supportive systems and improving outcomes. 

WHAT x HOW graphic

Effective Implementation

Effective implementation is a process of building and ensuring the resources and abilities of both people and organizations to support change(1-4). In order for practitioners to deliver the “WHAT” as intended, they need training and ongoing coaching to build competence and confidence. They also need guidance and active support from supervisors, who also need it from managers, who also need it from executive leadership. The environment in which change happens needs to foster the kind of conditions necessary for hosting change. So, paying attention to “HOW” means ensuring deliberate time, effort and processes for adaptive leadership and management strategies for modeling behaviors, eliminating barriers, and creating pathways for change. It is about partnering with communities and systems to identify problems and strategies to address them. And it is about using data to understand and improve the behavior of people and organizations for the benefit of children and families. 

Promising Approaches to Implementation

The most promising approaches to implementation address known challenges (3,5-9). In particular, four common features (10) are key to developing local implementation capacity and effective performance to support use of the practice model for getting to improved outcomes: 

  • Linked, local leadership and implementation teams (Organizational Readiness Building). People at multiple levels of an organization are specifically resourced and tasked to come together and attend to the day-to-day and ongoing leadership and management activities necessary for effective implementation. Teams of executive leaders, staff and other partners have functional roles and dedicated, on-the-job resources for implementation. Organizational and system practices facilitate progress and problem-solve implementation challenges (6,11-16). Tools and resources focus on assessing, monitoring, and improving organizational culture, climate, functional structures, and processes to support implementing change.
  • Workforce and Professional Development. Ongoing professional development plans and practices (often referred to as training and coaching) for the practice model are in place and build on adult learning best practices. This capacity builds the confidence and skills of staff at all levels—those delivering the practice model and the supervisors, managers, and other leadership who support them. This focus on continuing support to deliver the innovation as intended is another key challenge identified in research and practice (17-19). Tools and resources focus on assessing diverse staff needs, supporting the coaching role of supervisors, and strengthening staff retention.
  • Engagement, Relationships and Partnership. Internal stakeholders, community, tribal members and system partners are actively involved in co-creating implementation capacity to support getting the practice model into real-world practice. Partners play active roles in listening to identify strengths/barriers, establishing culturally relevant supports and services, detecting practice changes, addressing system barriers and communication and feedback for improvement (20-22). Tools and resources focus on defining and formalizing partnering roles and the adaptive and other leadership behaviors necessary to support them.
  • Quality, Outcome and System Monitoring for Improvement. Information and data about implementation, delivery of the practice model, and outcomes are gathered, shared, reviewed, and used by the right people at the right time in order to address problems and improve practices. Organizational and system practices support this ongoing quality improvement work (14,15,23,24). Tools and resources focus on identifying “What do we want to know? How will we know it?” and using data to understand and reinforce what is going well and to address challenges.

So What Does Paying Deliberate Attention to the Process of Implementing a Strategy Mean to You and Your Agency?

People often get trained in something, and then come back to their same organizational environment and expected to “do it” well and as intended, even though the environment—active support from leadership; resources such as parent partners to help staff engage families; ongoing coaching to help them apply “it” in different situations; and getting and using data to understand and improve “what it takes” for it to work—is not really supporting it. There is no one-size-fits-all approach to the process of implementation. You must make it relevant and feasible based on your own local context. 

What might you take on that could help your county strengthen “what it takes” to effectively support the use of change strategies? Focus deliberately on the four features of effective implementation, and whatever you start on, it will be great!

 

References

  1.    Aarons GA, Hurlburt M, Horwitz SM. Advancing a Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors. Administration & Policy in Mental Health and Mental Health Services Research. 2011;38(1):4-23.
  2.    Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework. Implementation Sci. 2009;4(1):1-15.
  3.    Weiner BJ, Lewis MA, Clauser SB, Stitzenberg KB. In search of synergy: strategies for combining interventions at multiple levels. Journal of the National Cancer Institute. Monographs. 2012(44):34.
  4.    Metz A, Albers B. What does it take? How federal initiatives can support the implementation of evidence-based programs to improve outcomes for adolescents. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. Mar 2014;54(3 Suppl):S92-96.
  5.    Aarons GA, Sommerfeld DH. Leadership, innovation climate, and attitudes toward evidence-based practice during a statewide implementation. Journal of American Academy of Child and Adolescent Psychiatry. Apr 2012;51(4):423-431.
  6.    Waltz TJ, Powell BJ, Matthieu MM, et al. Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study. Implementation Sci. 2015;10(1):1.
  7.    Spoth R, Rohrbach LA, Greenberg M, et al. Addressing core challenges in next generation of type 2 translation research and systems: the translation science to population impact (TSci Impact) framework. Prev Sci. Aug 2013;14(4):319-351.
  8.    Leeman J, Calancie L, Hartman MA, et al. What strategies are used to build practitioners’ capacity to implement community-based interventions and are they effective?: a systematic review. Implementation Sci. 2015;10(1):1-15.
  9.    Fixsen DL, Naoom SF, Blase KA, Friedman RM. Implementation research: a synthesis of the literature. Tampa, Florida, University of South Florida, Louis de la Parte Florida Mental Health Institute, NIRN 2005.
  10. 10. Aldridge WAI, Boothroyd RI, Fleming WO, et al. Transforming community prevention systems for sustained impact: embedding active implementation and scaling functions. Translational Behavioral Medicine. 2016;6(1):135-144.

    11. Meyers DC, Durlak JA, Wandersman A. The quality implementation framework: a synthesis of critical steps in the implementation process. Am J Community Psychol. Dec 2012;50(3-4):462-480.

    12. Rabin BA, Brownson RC, Haire-Joshu D, Kreuter MW, Weaver NL. A glossary for dissemination and implementation research in health. J Public Health Manag Pract. 2008;14.

    13. Aarons GA, Ehrhart MG, Farahnak LR, Sklar M. Aligning leadership across systems and organizations to develop a strategic climate for evidence-based practice implementation. Annual review of public health. 2014;35:255-274.

    14. Torrey WC, Bond GR, McHugo GJ, Swain K. Evidence-based practice implementation in community mental health settings: relative importance of key domains of implementation. Admin & policy in mental health.2012;39(5):353-364.

    15. Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical &practical challenges. Implem Sci. 2008;3(1):1-12.

    16. Fixsen D, Blase K, Metz A, Van Dyke M. Statewide Implementation of Evidence-Based Programs. Except Children. 2013;79(2):213-230.

    17. Steele CB, Rose JM, Chovnick G, et al. Use of evidence-based practices and resources among comprehensive cancer control programs. Journal of Public Health Management and Practice. 2015;21(5):441-448.

    18. Davies B, Edwards N, Ploeg J, Virani T, Skelly J, Dobbins M. Determinants of the sustained use of research evidence in nursing: Final report. Nursing Best Practice Research Unit, Canadian Health Services Research Foundation. 2006.

    19. Flaspohler P, Duffy J, Wandersman A, Stillman L, Maras MA. Unpacking prevention capacity: an intersection of research-to-practice models and community-centered models. Am J Community Psychol. 2008;41.

    20. Chambers DA, Azrin ST. Research and services partnerships: partnership: a fundamental component of dissemination and implementation research. Psychiatr Serv. Jun 2013;64(6):509-511.

    21. Bodison SC, Sankaré I, Anaya H, et al. Engaging the Community in the Dissemination, Implementation, and Improvement of Health-Related Research. Clinical and Translational Science. 2015;8(6):814-819.

    22. Barnes M, Schmitz P. Community Engagement Matters (Now More Than Ever). Stanford Social Innovation Review: Stanford Center on Philanthropy and Civil Society, Stanford University; 2016:16.

    23. Rabin BA, Glasgow RE, Kerner JF, Klump MP, Brownson RC. Dissemination and implementation research on community-based cancer prevention: a systematic review. Am J Prev Med. 2010;38.

    24. Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implementation Science. 2013;8(1):1-11.

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