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Transformation for Consumer Benefits

Transformation for Consumer Benefits. Dean L. Fixsen, Ph.D. Karen A. Blase, Ph.D. National Implementation Research Network Louis de la Parte Florida Mental Health Institute. Kentucky Cabinet for Human Resources 2006. The Problem.

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Transformation for Consumer Benefits

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  1. Transformation for Consumer Benefits Dean L. Fixsen, Ph.D. Karen A. Blase, Ph.D. National Implementation Research Network Louis de la Parte Florida Mental Health Institute Kentucky Cabinet for Human Resources 2006

  2. The Problem "... the mental health delivery system is fragmented and in disarray ... lead[ing] to unnecessary and costly disability, homelessness, school failure and incarceration." New Freedom Commission on Mental Health, 2003

  3. The Problem Human services are characterized by highly variable, often ineffective, and sometimes harmful services to consumers Institute of Medicine, 2001; U.S. Department of Health and Human Services, 1999; 2001

  4. The Problem Practices seem to be "influenced by fads and fashions that are adopted overenthusiastically, implemented inadequately, then discarded prematurely in favor of the latest trend.“ Walshe & Rundall (2001) reporting on health systems

  5. The Problem "All organizations are designed, intentionally or unwittingly, to achieve precisely the results they get." R. Spencer Darling

  6. Transformation • Transformation means change • Establish new ways of functioning in human services

  7. Transformation Goals • Mental Health Care Is Consumer and Family Driven • Disparities in Mental Health Services Are Eliminated • Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice • Excellent Mental Health Care Is Delivered New Freedom Commission on Mental Health, 2003

  8. Transformation • Establish new ways of functioning in human services • Beyond the rhetoric, how can human service systems be transformed?

  9. Transformation • System is the solution • Continually search for problems • Improve every aspect of the system and services • Barrier busters, error eradicators • Clear communication • Open, two-way, teamwork

  10. Transformation • Dedication to continuous quality improvement • High expectation of quality • Low tolerance for delays, mistakes, poor efforts (fix the problem, not the blame) • Maximize quality to minimize overall social cost, not just initial cost • Cost is infinite if benefit is zero

  11. Transformation • Invest in the workforce • Train directors, train managers, train supervisors, train practitioners • Effective on the job coaching is key to improving performance • Increase use of effective systems, processes, and practices

  12. Transformation • Transformation is disruptive • Transformation requires resources • Transformation requires courage • Transformation requires dogged persistence

  13. Transformation • Transformation can be facilitated • Transformation can be effective • Transformation can be fun

  14. Transformation Agenda

  15. Initiate & manage change W. Edwards Deming (1948) Deming was invited to Japan at the end of World War II by Japanese industrial leaders and engineers. They asked Dr. Deming how long it would take to shift the perception of the world from the existing paradigm that Japan produced cheap, shoddy imitations to one of producing innovative quality products.

  16. Initiate & manage change Shewhart (1924); Deming (1948); Six-Sigma (1990) • Plan – develop policies • Do – try new practices • Study – analyze practice/system impacts, goal approximation • Act – make policy/system adjustments • Cycle – do over and over again

  17. Policy Structure Procedure Practice Policy - Practice - Feedback Policy (Plan) Feedback Study - Act Practice(Do) Form follows Function

  18. Initiate & manage change • Innovation Zones • Suspend the usual rules • Establish the operational value of a system change, EBP, or innovation • A zone may be a region, an agency, a part of a system • Depends on where you choose to start

  19. Initiate & manage change • Cannot change a whole system at one time • Manage the old while creating the new • Retain the best (of the old) while changing the rest • Reduce impact of mistakes (minimize damage, increase flexibility, repair rapidly)

  20. Information Economics Kenneth Arrow (1972)

  21. Initiate & manage change Unlike other economic resources, knowledge is not depleted but gains in value with use. • Knowledge-based economies include: • computer software applications, • the internet, • franchised operations, and • transformed human service systems .

  22. Initiate & manage change • "Knowledge is experience. Everything else is just information." Albert Einstein .

  23. Initiate & manage change • Need a repository of knowledge gleaned from experience • Transformation Implementation Team

  24. Initiate & manage change • Transformation Implementation Team (policy enablers, barrier busters, facilitation creators) • Practice-Level Team (do the innovation, test policies) • Weekly / Monthly Meetings (frequent, unfiltered, goal focused)

  25. Transformation Agenda Transformation starts with a process to initiate and manage change: • Policy - Practice - Feedback systems • Innovation zones • Implementation Team

  26. Transformation Agenda • Initiate and manage change • Implement innovations and other new ways of work • Develop a sustainable infrastructure for transformation management and continuous consumer benefit

  27. Implement Innovations • The act of accomplishing some aim or executing some order • To put into practical effect; carry out • Pursue to a conclusion – Dictionary.com Implementation of innovations with benefits to consumers.

  28. Teaching–Family Replications The First 794 Attempted Replications (1967 – 1982) Fixsen, Blase, Timbers, & Wolf (2001) 900 300 800 700 250 600 200 500 CumulativeHomes 150 400 300 100 CumulativeCouples 200 50 100 0 0 ≤1972 1974 1976 1978 1980 1982

  29. The NIRN • Craft knowledge • EBP purveyors (program developers) • EBP implementation site managers • Implementation researchers • Survey of EBP program developers • Scientific information • CRUSK, Follow Through, Lodges, et al. • Program development and replication data • Synthesis of the implementation evaluation and research literature

  30. Literature Review • Human service prevention and treatment programs (e.g. substance abuse, adult / children’s MH, justice, health, education) • Advanced manufacturing technologies • Research-based clinical guidelines • Engineering: bridge maintenance • Hotel service management • National franchise operations • Cancer prevention & treatment

  31. Literature Review “The main difference between service and manufacturing is the service department doesn't know that they have a product.” W. Edwards Deming

  32. Implementation Attempts • Homebuilders national implementation grants: $500 million, 5 years • Program / system change grants plus TA for co-occurring disorders, systems of care, state transformation, school reform, medical clinical guidelines, etc: $?? billion a year

  33. Implementation Attempts • In business, change initiatives that are heavily dependent on people (reengineering, TQM, culture change) fail 80-90% of the time • About 10% of what is taught in training gets transferred to the job • "Up to 70% of the failures in business are not due to poor strategy or a lack of good ideas, but to flawed execution." R. W. Rogers, 2002

  34. Implementation Success • PMTO program in Norway: National implementation of parent management program (NIDA funded research) • DOTS program in India: National implementation of TB treatment protocol, 1 million patients in 4 years • MST program in USA: National implementation of homebased interventions for juvenile offenders

  35. Common to Success • Good science and technology • Baseline / decision support data • Expanding commitment & flexibility • Purposeful workforce development • Organizational change & supports • Alignment of system functioning • Knowledgeable purveyor, constant monitoring, feedback, intervention Khatri & Frieden, 2002

  36. Implement Innovations Effective intervention practices + Effective implementation practices = Good outcomes for consumers

  37. Implement Innovations IMPLEMENTATION Effective NOT Effective Performance Implementation Paper / Procedure Implementation Effective INTERVENTION NOT Effective

  38. Paper Implementation • Review of TQM adoptions in 5,492 hospitals • "If organizations can minimize evaluation and inspection of their internal operations by external constituents through adoption alone, they may neglect implementation altogether, decoupling operational routines from formally adopted programs." Westphal, Gulati, & Shortell (1997)

  39. Implement Innovations IMPLEMENTATION Effective NOT Effective High Fidelity Low Fidelity EBP INTERVENTION NOT Effective

  40. Teaching-Family Model Bedlington, et al., 1979 2.0 50% rs = – .94 1.9 1.8 40% 1.7 Delinquency 1.6 30% Mean Self ReportedDelinquency Ratings PercentParental-Teaching With Youths 1.5 1.4 20% 1.3 Teaching 1.2 10% 1.1 1.0 0% 1 2 3 4 5 6 Homes

  41. Implement Innovations • An evidence-based program is one thing • Implementation of an evidence- based program is a very different thing

  42. Feedback Implementation Framework Influence Destination CommunicationLink Source Fixsen, Naoom, Blase, Friedman, & Wallace, 2005

  43. Stages of Implementation • Implementation is not an event • A mission-oriented process involving multiple decisions, actions, and corrections

  44. 2 – 4 Years Stages of Implementation Implementation occurs in stages: • Exploration • Installation • Initial Implementation • Full Implementation • Innovation • Sustainability Fixsen, Naoom, Blase, Friedman, & Wallace, 2005

  45. Implementation Stages:Non-Linear Processes Installation Initial Implementation

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

  47. EBPs: The Source • The usability of a program has little to do with the quality or weight of the evidence regarding that program • Evidence on intervention effectiveness for specific populations helps us choose what to implement • Evidence on the effectiveness of the intervention does not help implement the program or practice successfully

  48. EBPs: The Source Core intervention components • Clearly described (what/how) • Practical measure of fidelity • Fully operationalized (do/say) • Field tested (iterative revision) • Contextualized (org./systems fit)

  49. Implementation Site: The Destination • Defined Need • Identified Resources • Fully informed consent re: innovation and implementation • Top level commitment to change and agreement re: access

  50. Implementation Site: The Destination • 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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