Implementation and Change Management

Dean L. Fixsen, Ph.D.National Implementation Research Network

Louis de la Parte Florida Mental Health Institute

Implementation and Change Management

Copyright © Dean L. Fixsen and Karen A. Blase, 2005

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The ProblemEach year, more research is done

More careful methods are crafted for reviewing research and identifying evidence-based practices and

programs

More attention is directed to evidence-based practices and programs in journals, conferences, and meetings

Yet, there are few sustainable benefits for consumers


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The ProblemScience to Service Gap

What is known is not what is adopted to help children, families, and adults

Implementation Gap

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

What is implemented with fidelity disappears with time and staff turnover


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Science to Service

In the past 30 years:

Probably 60,000+ experimental studies of effective interventions in physical and behavioral health (e.g., over 15,000 RCTs just for pain mgmt)

Perhaps 40 experimental studies concerning the factors important to the implementation of those treatments


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Science to Service

About 99% of the annual NIH research budget is spent on understanding etiology and developing new treatments

About 1% is spent on finding ways to effectively use those treatments (up from ¼ of 1% in the 1970s)


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Change Projects

DOTS program in India: National implementation of TB treatments

PMTO program in Norway: National implementation of parent management program

EBPs in Oklahoma: Statewide implementation of EBPs

CiMH in California: Program to enable evidence-based programs statewide


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What’s Common?

Human service treatment programs (e.g. substance abuse prevention and treatment, adult MH, children’s MH, justice, health, education)

Advanced manufacturing technologies

Interstate highway bridge maintenance

Hotel service management

National franchise operations

Cancer prevention & treatment

Education innovations


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What’s Common?

They have similar implementation problems

They have similar implementation solutions

Despite tremendous variability in the content and context across domains….


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WHO to ChangeIn most human services, the PRACTITIONER IS THE INTERVENTION

Do the right thing for the right reason at the right time with the right person to maximize progress

Operate within wide ranging inputs (individuals and their functional ecologies)

Challenge and the Promise of EBP’s - Be effective, consistently


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Who to Change

Practitioners impact consumers

It is the job of directors, managers, and funders to align policies and structures to facilitate effective practitioner practices

There is no such thing as an “administrative decision” – they are all treatment decisions


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Evidence on effectiveness helps us select what we want to implement

Evidence on outcomes does not help us implement the program

HOW to Change

The usability of a program has little to do with the weight of the evidence regarding program outcomes


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How to Change

Effective intervention practices

+Effective implementation practices

=Good outcomes for consumers

No other combination of factors reliably produces desired outcomes for consumers.


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How to Change

Effective NOT Effective

EBP

NOT Effective

IMPLEMENTATION

INT

ER

VE

NT

ION

High Fidelity Low Fidelity


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How to ChangeExcellent experimental evidence for what does not work

Dissemination of information by itself does not lead to successful implementation (research literature, mailings, promulgation of practice guidelines)

Training alone, no matter how well done, does not lead to successful implementation


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How to Change

With a variety of designs and measures, these two widely used strategies repeatedly have been shown to be ineffective in human services, education, health, business, and manufacturing


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How to Change

Change the behavior of adult human service professionals

Change organizational structures, cultures, and climates

Change the thinking of system directors and policy makers

Successful and sustainable implementation of evidence-based practices and programs always requires organizational change.


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How to Change

Successful implementation on a useful scale requires a purveyor

A group of individuals with detailed knowledge of a program who actively work to implement that program with fidelity and good effect

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

Practitioner

Evidence-based Practices

Purveyor

FidelityMeasure

Implementation Framework

Organizational Structures/Culture

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


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Active Purveyor Role

Organization

Management (leadership, policy)

Administration (HR, structure)

Supervision (nature, content)

Practitioner

State, County and Local Context

System of care

Pu

rvey

or

Gro

up

Simultaneous, Multi-Level Interventions


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Active Systems AlignmentNo matter how good the program may be, if

national policy changes and certain services are no longer funded, those services will disappear

Without hospitable leadership and organizational structures, core components cannot be installed and maintained

Without adequate pay, skillful evidence-based practitioners will be hard to find and keep and programs will falter


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Stages of Implementation

Implementation is not an event

A mission-oriented process involving multiple decisions, actions, and corrections

Implementing an evidence-based program takes 2 to 4 years


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Stages of Implementation

Exploration

Installation

Initial Implementation

Full Implementation

Innovation

Sustainability

Implementation occurs in stages:

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

2 – 4 Years


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INTEGRATED & COMPENSATORY

CONSULTATION & COACHING

CONSULTATION & COACHING

STAFF PERFORMANCE EVALUATION

STAFF PERFORMANCE EVALUATION

FACILITATIVE ADMINISTRATIVE

SUPPORTS

FACILITATIVE ADMINISTRATIVE

SUPPORTS

RECRUITMENT AND SELECTION

RECRUITMENT AND SELECTION

PRESERVICE TRAINING

PRESERVICE TRAINING

SYSTEMSINTERVENTIONS

SYSTEMSINTERVENTIONS

Implementation Drivers

DECISION SUPPORT DATA SYSTEMS

DECISION SUPPORT DATA SYSTEMS

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


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Managing the Change Process

Policy

Practice

Structure

Procedure

Policy

Practice

Outcomes

Policy

Practice

Structure

Procedure

Culture

Climate

Policy

Practice

Structure

Procedure

Outcomes

Inte

gra

ted

an

d S

ust

ain

able

Form follows Function


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“Systems trump programs.” (Patrick McCarthy, Annie E. Casey Foundation)

Organizations exist in a shifting ecology of community, state, and federal social, economic, cultural, political, and policy environments that variously and simultaneously enable and impede implementation and program operation efforts

Managing the Change Process


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Implementing Change

Avoid Shooting Stars: Promote sustainability and consumer benefits

Pass the Sobriety Test: Fully explore a program before committing resources

Make the Vow of Celibacy: Fully implement with fidelity before innovating

From failure to Anticipatory Guidance: Use data from past experiences to anticipate/ forestall/ cope with problems


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Thank YouWe thank the following for their support

Annie E. Casey Foundation (EBPs and cultural competence)

William T. Grant Foundation (implementation literature review)

Substance Abuse and Mental Health Services Administration (SOC analyses of implementation; implementation strategies grants; NREPP reviews; implementation awards)

Centers for Disease Control (implementation research contract)

National Institute of Mental Health (research and training grants)

Juvenile Justice and Delinquency Prevention (program development and evaluation

grants)


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For More Information

Dean L. Fixsen

813-974-4446

[email protected]

Karen A. Blase

813-974-4463

[email protected]

National Implementation Research Network

At the Louis de la Parte Florida Mental Health Institute

University of South Florida

http://nirn.fmhi.usf.edu


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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).

E-mail us for a free copy or download all or part of the monograph at:

http://nirn.fmhi.usf.edu/resources/publications/Monograph/index.cfm

Documents

Implementation and Change Management