Karen A. Blase, PhD & Dean L. Fixsen, PhD Co-Directors, National Implementation Research Network...

Karen A. Blase, PhD & Dean L. Fixsen, PhDCo-Directors, National Implementation Research Network

Senior Scientists at the

Frank Porter Graham Child Development Institute,

UNC, Chapel Hill, North Carolina

Using Implementation Science To Inform Professional

DevelopmentAnd Guide Systems Change

Growing Collaborative Systems to Support Children with Disabilities

and their Families

NETWORKING FORUM

Stevens Point Convention CenterWisconsin

September 13, 2011

Copyright © Dean L. Fixsen and Karen A. Blase, 2008

The Focus on Evidence

The “evidence-based movement” is an national experiment to make better use of research findings in typical service settings.

The purpose is to produce greater benefits to children, adults, families, and society.


“In theory there is no difference between theory and practice;

in practice, there is.”

variously attributed to Jan La Van De Snepscheut

or Albert Einsteinor Yogi Berra

Implementation Science


There are Challenges

Science to Service Gap

■ What is known is generally not what is adopted

Implementation Gap■ There are not clear pathways to

implementation

■ What is adopted often is not used with fidelity and good effect

■ What is implemented disappears over time and with staff turnover


Learning About Effective Implementation

Craft knowledgeNational meeting of EBP Program DevelopersNational meeting of EBP Implementation SitesNational meeting of Implementation ResearchersInterviews with 64 Program DevelopersWork with Program Developers, States, Agencies across domains

Formal and scientific informationProgram Efforts and Replication Data

Review of evaluation and research literature related to implementation

Publication of Implementation Research: A Synthesis of the Literature (2005)

WHAT HAVE WE LEARNED?


There are Shared Challenges!!

Implementation is implementation is implementation in:• Agriculture and Forestry • Manufacturing and Business• Substance abuse• Child welfare, • Education, • Engineering, • Health and Medicine • Juvenile Justice, • Mental health, • Nursing, …and more

The commonalities are striking.


Implementation Math Implementation Math

Effective InterventionsThe “WHAT”

Effective Implementation

The “HOW”

Positive Outcomes

for ChildrenAnd

Families


Implementation MathImplementation Math

Effective InterventionsThe “WHAT”

Effective Implementation

The “HOW”

Positive Outcomes

for ChildrenAnd

Families

Remembering that any number times 0 is 0

from Mark Lipsey’s 2009 Meta-analytic overview of the primary factors that characterize effective juvenile offender interventions – “. . . in some analyses, the quality with which the intervention is implemented has been as strongly related to recidivism effects as the type of program, so much so that a well-implemented intervention of an inherently less efficacious type can outperform a more efficacious one that is poorly implemented.”


Data Show These Methods, When Used Alone, Do Not Result In Implementation As Intended:

Diffusion/ Dissemination of information

Training

Passing laws/ mandates/ regulations

Providing funding/ incentives

Organization change/ reorganization

Business as Usual ≠ Impact

Necessary But Not Sufficient


What works?…Fidelity Matters

Higher Fidelity is correlated with better outcomes across a wide range of programs and practices

Education – SWPBIS, HiPlaces, STEP

Children’s Services – FFT, MST, Wraparound, TFM

Adult Mental Health – ACT, IPS, IDDT

Medicine – DOTS, Texas Algorithm, OMAP

School-Based MH Prevention Programs - PATHS

Higher Fidelity is correlated with better outcomes across a

wide range of programs and practices

I didn't have potatoes, so I substituted rice.

Didn't have paprika, so I used another spice.

I didn't have tomato sauce, so I used tomato paste.

A whole can not a half can - I don't believe in waste.

My friend gave me the recipe - she said you couldn't beat it.

There must be something wrong with her, I couldn't even eat it!

~ Senior Center Newsletter

Policy Implications

1.IF THERE IS NOT THE “WILL” OR“MEANS” TO DO IT RIGHT YOU WON’T GET RESULTS

2. YOU CAN’T DO A COST-BENEFIT

ANALYSIS IF THERE IS NO BENEFIT!

WHAT WORKS ~IMPLEMENTING PROPERLY MATTERS


What works…

Successful implementation on a useful scale requires a purveyor

An individual or group of individuals representing a program or practice who actively work to implement that practice or program with fidelity and good effect

Purveyors accumulate data & experiential knowledge, & become more effective and efficient over time


Practitioner

Evidence-based Practices

Purveyor

Fidelity and OutcomeMeasures

Implementation Framework

Organizational Structures/Culture

Fixsen, Naoom, Blase, Friedman, & Wallace, 2005


Infrastructure (Train, Coach,

Evaluate)

Evidence-based Practices

Purveyor

Fidelity and OutcomeMeasures

Implementation Framework

Organizational Structures/Culture

Fixsen, Naoom, Blase, Friedman, & Wallace, 2005


Active Purveyor Role

Agencies/Providers

Management (leadership, policy)

Administration (HR, structure)

Supervision (nature, content)

Practitioners

Federal Context

Local, County, State Context

Pu

rvey

or

Simultaneous, Multi-Level Interventions


Purveyor AND Intermediary Structures and Strategies

Agency/Provider




Practitioners

Federal Context

Local, County, & State Context

Pu

rvey

or

and

Inte

rmed

iary

Simultaneous, Multi-Level Interventions


Implementation Frameworks

Multi-dimensional, Fully integrated

Implementation Drivers

Implementation Stages

Implementation Teams

Improvement Cycles







Improvement Cycles


Implementation Drivers…

Build Competency and ConfidenceDevelop, improve, and sustain competent & confident use of innovations.

Change Organizations and SystemsCreate and sustain hospitable organizational and systems environments for effective instructional and educational services

Provide Leadership that Matches the Challenge

Core Implementation

Components

Core Implementation

Components

© Fixsen & Blase, 2008

Improved Child, Family, Adult Outcomes

Com

pete

ncy

Driv

ers

Com

pete

ncy

Driv

ers O

rganization Drivers

Organization D

rivers

LeadershipLeadership

EBP/Program/Initiative/Framework for Effective Practices & System Change

How:

What:

Why:

Capacity to provide direction, vision, & the

“right” leadership approach

Staff capacity to support children/families with the selected practices

Institutional capacity to support staff in implementing practices with fidelity

Professional Development/Professional

Learning

Professional Development/Professional

Learning


Performance Assessment

Coaching

Training

Selection

Com

pete

ncy

Driv

ers

Com

pete

ncy

Driv

ers


Implementation Drivers =

Infrastructure

Implementation Lens


OUTCOMES(% of Participants who Demonstrate Knowledge, Demonstrate

new Skills in a Training Setting, and Use new Skills in the Classroom)

TRAININGCOMPONENTS

KnowledgeSkill

DemonstrationUse in the Classroom

Theory and Discussion

10%

5% 0%

..+Demonstration in Training

30%20%

0%

…+ Practice & Feedback in Training

60% 60% 5%

…+ Coaching in Classroom

95% 95% 95%

Joyce and Showers, 2002

Staff Training & Coaching

Copyright © Dean L. Fixsen and Karen A. Blase, 2008© Dean Fixsen, Karen Blase, Robert Horner, George Sugai, 2008

Sobering Observations

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

R. Spencer DarlingBusiness Expert



Coaching

Training

Selection

Systems Intervention

Facilitative Administration

Decision Support Data SystemC

ompe

tenc

y D

river

s

Organization D

rivers

Organization D

rivers

Graphics by Steve Goodman,2009


Infrastructure




EXISTING SYSTEM

Effective Innovations are Changed to Fit the

System

Or Operate in the Shadows

(The Ghost System)

System Stability


EXISTING SYSTEM

Effective Innovations are Changed to Fit the

System

Or Operate in the Shadows

(Ghost System)

Effective System Change

EXISTING SYSTEM IS

CHANGED TO SUPPORT

THE EFFECTIVENESS OF

THE INNOVATION

(Host System)

EFFECTIVE INNOVATION



Coaching

Training

Selection



Decision Support Data System

Adaptive Technical

Com

pete

ncy

Driv

ers O

rganization Drivers



Infrastructure




Types of Leadership Needed

Different strategies for different challenges

Technical Leadership

Adaptive Leadership

According to Ron Heifitz and his colleagues, one of the biggest mistakes “leaders” make is to incorrectly identify the type of challenge they are facing

Using technical approaches for adaptive issues


The Adaptive Work of the Leader

Get on the Balcony

Identify the Adaptive Challenge

Regulate Distress

Maintain Disciplined Attention

Give the Work Back to the People

Protect All Voices» R. Heifetz and D. Laurie: The Work of

Leadership. Harvard Business Review, 1998.



Coaching

Training

Selection



Decision Support Data System

Adaptive Technical

Com

pete

ncy

Driv

ers O

rganization Drivers



Infrastructure



Integrated & Compensatory







Improvement Cycles

Stages of Implementation

2 – 4 Years

EXPLORATIO

N

IN

STALLATIO

N

INIT

IAL

IMPLE

MENTATIO

N

FULL

IMPLE

MENTATIO

N

Implementation Takes Time


Stages of Implementation

You don’t get to skip any!

If you make a judgment about “effectiveness” too early you might be making a mistake.

Activities need to match the stage.

Different stages for multiple initiatives

“Where are we now with this initiative?”

Stages will need to be “revisited” – important!

New providers, new communities, new Ministers, new government officials, new families



Letting it happen

Recipients are accountable

Helping it happen

Recipients are accountable

Making it happen

Implementation teams are accountable

Based on Hall & Hord, 1987, Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou, 2004







Improvement Cycles


Implementation Team(s)

■A group that knows the innovation very well (formal and practice knowledge)

■A group that knows implementation very well (formal and practice knowledge)

■A group that knows improvement cycles to make intervention and implementation methods more effective and efficient over time


Agencies and Local Partnerships




Practitioners

County and Local Context

Service Systems

Imp

lem

enta

tio

n T

eam

sSimultaneous, Multi-Level Interventions

National Context



Implementation Team


Prepare Communities

Prepare staff & administrators

Work with TA & Researchers

Assure Implementation

Prepare Agency & State Systems Assure

Benefits

Create Readiness

Parents & Stakeholders



At multiple levels

Integrated and InterlockingAgency TeamsCommunity TeamsState Team

Focus is on Supporting Quality Implementation DriversFidelity & Outcomes, Alignment (funding and policy)Problem-Solving and Sustainability







Improvement Cycles


PDSA Cycles

Shewhart (1924); Deming (1948); Six-Sigma (1990)

Plan – Develop specific things to do

Do – Do them (make sure)

Study – See what happens

Act – Make adjustments

Cycle – Do over and over again until the goal is reached (again)


What Do They Have in Common?

Policy to Practice to Policy Cycles

Transformation Zones

Rapid Cycle TeamsProblem-solvingPractice Improvement

Usability Testing


Improvement Cycles

Policy to Practice to Policy Cycles

Transformation Zones

Rapid Cycle TeamsProblem-solvingPractice Improvement

Usability Testing


Improvement Cycle Uses

Why Policy-Practice Feedback Cycles?

Because the Current System is perfectly designed to get the current results!

And Systems Can Trump Programs!


Implementation Team

Executive Management

Team

PractitionersInnovations

Benefits

Sys

tem

C

han

ge

Adaptive Challenges• Duplication• Fragmentation• Hiring criteria• Salaries• Credentialing• Licensing• Time/ scheduling• Union contracts• Contract methods• Laws

“Ex

tern

al”

Sy

ste

m C

ha

ng

e S

up

po

rt

Pra

ctic

e In

form

ed

Po

licy

Po

licy

En

ab

led

P

ractic

e

System Reinvention


System Alignment

State Department

Communities, Regions

Provider Agencies

Practitioners

Effective Practices

AL

IGN

ME

NTFederal

Departments

Imp

lem

enta

tio

n T

eam

s

FORM SUPPORTS FUNCTION







Improvement Cycles


What Will It Take to Effectively Support Children With Disabilities and Their

Families?

Science Related to…. Interventions and Programs

Implementation, Organization, and Systems Change

Funded Infrastructure (Drivers)

Informed & engaged consumers & communities

Linked TeamsSkillful Purveyors & Intermediaries

Competent Providers

Supportive Organizations

Engaged communities and stakeholders

Hospitable & Aligned Systems

Leadership at All Levels


Keep the “Big Picture” in Mind



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).

Download all or part of the monograph at:

http://www.fpg.unc.edu/~nirn/resources/detail.cfm?resourceID=31

Implementation Research: A Synthesis of the Literature


For More InformationFor More InformationDean L. Fixsen, Ph.D.

919-966-3892

[email protected]

Karen A. Blase, Ph.D.

919-966-9050

[email protected]

At the Frank Porter Graham Child Development Institute

University of North Carolina

Chapel Hill, NC

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

http://www.fpg.unc.edu/~nirn/resources/publications/Monograph/


For More Information

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).

Download all or part of the monograph at:

http://www.fpg.unc.edu/~nirn/resources/publications/Monograph/

To order the monograph go to:

https://fmhi.pro-copy.com/

Date post:	29-Dec-2015
Category:	Documents
Upload:	britney-rice
View:	216 times
Download:	0 times

Karen A. Blase, PhD & Dean L. Fixsen, PhD Co-Directors, National Implementation Research Network...

Documents