implementation and change management
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Implementation and Change Management. Dean L. Fixsen, Ph.D. National Implementation Research Network Louis de la Parte Florida Mental Health Institute. The Problem. Each year, more research is done - PowerPoint PPT PresentationTRANSCRIPT
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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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)
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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….
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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.
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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How to Change
Effective NOT Effective
EBP
NOT Effective
IMPLEMENTATION
INT
ER
VE
NT
ION
High Fidelity Low Fidelity
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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.
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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)
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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For More Information
Dean L. Fixsen
813-974-4446
Karen A. Blase
813-974-4463
National Implementation Research Network
At the Louis de la Parte Florida Mental Health Institute
University of South Florida
http://nirn.fmhi.usf.edu
Copyright © Dean L. Fixsen and Karen A. Blase, 2005
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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