Implementation and Change Management

1. Implementation and Change Management Dean L. Fixsen, Ph.D. National Implementation Research Network Louis de la Parte Florida Mental Health Institute

2. The Problem • Each 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

3. The Problem • Science 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

4. 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

5. 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)

6. 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

7. 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

8. What’s Common? Despite tremendous variability in the content and context across domains…. • They have similar implementation problems • They have similar implementation solutions

9. WHO to Change • In 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

10. 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

11. HOW to Change The usability of a program has little to do with the weight of the evidence regarding program outcomes • Evidence on effectiveness helps us select what we want to implement • Evidence on outcomes does not help us implement the program

12. How to Change Effective intervention practices + Effective implementation practices = Good outcomes for consumers No other combination of factors reliably produces desired outcomes for consumers.

13. How to Change IMPLEMENTATION Effective NOT Effective High Fidelity Low Fidelity EBP INTERVENTION NOT Effective

14. How to Change • Excellent 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

15. 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

16. 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.

17. 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

18. Fidelity Measure Implementation Framework Organizational Structures/Culture Practitioner Purveyor Evidence-based Practices Fixsen, Naoom, Blase, Friedman, & Wallace, 2005

19. Practitioner • Organization • Management (leadership, policy) • Administration (HR, structure) • Supervision (nature, content) System of care State, County and Local Context Active Purveyor Role Simultaneous, Multi-Level Interventions Purveyor Group

20. Active Systems Alignment • No 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

21. 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

22. 2 – 4 Years Stages of Implementation Implementation occurs in stages: • Exploration • Installation • Initial Implementation • Full Implementation • Innovation • Sustainability Fixsen, Naoom, Blase, Friedman, & Wallace, 2005

23. Implementation Drivers STAFF PERFORMANCE EVALUATION CONSULTATION & COACHING DECISION SUPPORT DATA SYSTEMS INTEGRATED & COMPENSATORY FACILITATIVE ADMINISTRATIVE SUPPORTS PRESERVICE TRAINING RECRUITMENT AND SELECTION SYSTEMS INTERVENTIONS

24. OUTCOMES (% of Participants who Demonstrate Knowledge, Demonstrate new Skills in a Training Setting, and Use new Skills in the Classroom) TRAINING COMPONENTS Knowledge Skill Demonstration Use 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

25. Policy Policy Policy Policy Structure Structure Structure Culture Integrated and Sustainable Outcomes Outcomes Climate Procedure Procedure Procedure Practice Practice Practice Practice Managing the Change Process Form follows Function

26. Managing the Change Process • “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

27. 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

28. Thank You We 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)

29. Dean L. Fixsen 813-974-4446 dfixsen@fmhi.usf.edu Karen A. Blase 813-974-4463 kblase@fmhi.usf.edu For More Information • National Implementation Research Network • At the Louis de la Parte Florida Mental Health Institute • University of South Florida • http://nirn.fmhi.usf.edu

30. 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 For More Information