The Science and Practice of
Implementation:
Frameworks to Support Fidelity
and Sustainability
National Addiction
Technology Transfer
Network Meeting
Karen A. Blase, Ph.D.
December 3, 2008
Michelle Duda, Ph.D.
Dean L. Fixsen, Ph.D.
Sandra Naoom, MSPH
Melissa Van Dyke, LCSW
Evidence Based Movement
The “evidence-based movement” is an
international experiment to make
better use of research findings in
typical service settings.
The purpose is to produce greater
benefits to consumers and society.
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
We want to:
Reliably produce…
…predictable and positive
outcomes for children,
adolescents, adults,
families, and communities
…that improve every year
…for the next 50 years
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implications for the ATTC
Network
What Might “This” Mean for Our
Mission, Way of Work, Leadership ??
The Science of Implementation
The Practice of Implementation
The Work of Change at Many Levels
Practice
Organization
Systems
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Problem
Adults, adolescents, children
and families cannot benefit from
interventions they do not
experience
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
What Works
INTERVENTION
IMPLEMENTATION
Effective
NOT Effective
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Effective
NOT Effective
Performance
Implementation
(High Fidelity)
Paper Implementation
Procedure
Implementation
(Low Fidelity)
Learning About Effective
Implementation
Craft knowledge
National meeting of EBP Program Developers
National meeting of EBP Implementation Sites
National meeting of Implementation Researchers
Interviews with 64 Program Developers
Work with Program Developers, States, Agencies
Formal and scientific information
Program 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?
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
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
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
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.
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
There Are Shared Challenges!!
Despite tremendous variability in the
content and context across
domains….
They have similar implementation
problems
They have similar implementation
solutions
We can learn more …more
quickly
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Positive Intervention Outcomes
≠ Implementation
Implementation has not been achieved
by doing more or better research on
interventions.
The usability of a program or practice
has nothing to do with the weight of
the evidence regarding that program
–“Evidence” on effectiveness helps
you select what to implement for
whom
–“Evidence” on outcomes does not
help you implement the program
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Insufficient Methods
Diffusion/dissemination of information
by itself does not lead to successful
implementation
Training alone, no matter how well
done, does not lead to successful
implementation
Policies and funding alone do not lead
to successful implementation
Copyright © Dean L. Fixsen©and
Karen Fixsen,
A. Blase, 2008
Dean
Karen
Blase, Robert Horner, George Sugai, 2008
New Knowledge
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, more
effective and efficient over time
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Framework
Organizational
Structures/Culture
Practitioner
Purveyor
Evidence-based
Practices
Fidelity and Outcome
Measures
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Framework
Organizational
Structures/Culture
Infrastructure
(Train, Coach,
Evaluate)
Purveyor
Evidence-based
Practices
Fidelity & Outcome
Measures
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Active Purveyor Role
Simultaneous, Multi-Level Interventions
Purveyor
Practitioner
Organization
Management (leadership, policy)
Administration (HR, structure)
Supervision (nature, content)
System of care
State, County and Local Context
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Purveyor AND Intermediary
Structures and Strategies
Simultaneous, Multi-Level Interventions
Intermediary
Purveyor and
Practitioner
Organization
Management (leadership, policy)
Administration (HR, structure)
Supervision (nature, content)
System of care
State, County and Local
Context
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Fidelity Matters
Higher Fidelity is correlated with better
outcomes across a wide range of
programs and practices
Adult Mental Health – ACT, IPS, IDDT
Medicine – DOTS, Texas Algorithm,
OMAP
Children’s Services – FFT, MST,
Wraparound, TFM
Education – HiPlaces, SWPBS, STEP
School-Based MH Prevention Programs PATHS
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation
Successful scale-up requires attention
to the science and practice of
implementation
Requires change at the
Practice Level (Clinician, Front-line Staff,
Counselor)
Organization Level (Supervisor,
Administrator)
System Level (Funders, Government,
Regulatory Bodies)
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Frameworks
Multi-dimensional, Fully integrated
Implementation Drivers
Implementation Stages
Implementation Teams
Improvement Cycles
Stages of Change
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Frameworks
Multi-dimensional, Fully integrated
Implementation Drivers
Implementation Stages
Implementation Teams
Improvement Cycles
Stages of Change
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Consumer Benefits
Performance Assessment
(Fidelity)
Coaching
Competency
Training
Selection
Implementation Lens
© Fixsen & Blase, 2008
OUTCOMES
(% of Participants who Demonstrate Knowledge, Demonstrate
new Skills in a Training Setting,
and Use new Skills in the Classroom)
Knowledge
Skill
Demonstration
Use in the
Classroom
Theory and
Discussion
10%
5%
0%
..+Demonstration
in Training
30%
…+ Practice &
Feedback in
Training
60%
60%
5%
…+ Coaching in
Classroom
95%
95%
95%
TRAINING
COMPONENTS
20%
0%
Joyce and Showers, 2002
Sobering Observations
"All organizations [and systems] are
designed, intentionally or unwittingly,
to achieve precisely the results they
get."
R. Spencer Darling
Business Expert
“The tyranny of the status quo.”
Fritz Oser
Educator
Copyright © Dean L. Fixsen©and
Karen Fixsen,
A. Blase, 2008
Dean
Karen
Blase, Robert Horner, George Sugai, 2008
Consumer Benefits
Performance Assessment
(Fidelity)
Coaching
Competency
Training
Selection
Systems
Intervention
Organization
Facilitative
Administration
Decision Support
Data System
© Fixsen & Blase, 2008
Consumer Benefits
Performance Assessment
(Fidelity)
Systems
Intervention
Coaching
Competency
Adaptive
Organization
Facilitative
Administration
Training
Selection
Technical
Decision Support
Data System
Leadership
© Fixsen & Blase, 2008
Consumer Benefits
Performance Assessment
(Fidelity)
Systems
Intervention
Coaching
Competency
Adaptive
Training
Integrated &
Compensatory
Selection
Technical
Organization
Facilitative
Administration
Decision Support
Data System
Leadership
© Fixsen & Blase, 2008
Implementation Frameworks
Multi-dimensional, Fully integrated
Implementation Drivers
Implementation Stages
Implementation Teams
Improvement Cycles
Stages of Change
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Consumer Benefits
Stages of Implementation
•ExplorationPerformance Assessment
(Fidelity)
•Installation
Coaching
•Initial Implementation
Innovation
Adaptive
Training
•Full Implementation
•Innovation
Integrated &
Compensatory
Selection
•Sustainability
Systems 2 – 4 Years
Intervention
Technical
Organization
Facilitative
Administration
Decision Support
Data System
Leadership
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
Implementation Frameworks
Multi-dimensional, Fully integrated
Implementation Drivers
Implementation Stages
Implementation Teams
Improvement Cycles
Stages of Change
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Science
Letting it happen
Recipients are accountable
Helping it happen
Recipients are accountable
Making it happen
Implementation teams are
accountable
Based on Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou, 2004
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Team
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
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Team
Prepare
Communities
Prepare State
Systems
Prepare agencies
and staff
Implementation
Team
Assure
Consumer
Benefits
Consumers &
Work with
Researchers Stakeholders
Create Readiness
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Assure Implementation
Implementation Frameworks
Multi-dimensional, Fully integrated
Implementation Drivers
Implementation Stages
Implementation Teams
Improvement Cycles
Stages of Change
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
PDSA Cycles
Shewhart (1924); Deming (1948); SixSigma (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)
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Improvement Cycle Uses
Rapid Cycle Teams
Problem-solving
Practice Improvement
Transformation Zones
PEP – PIP Cycles
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Practice (Do)
Policy
Policy Enabled Practices
(PEP)
Feedback
Practice Informed Policy
(PIP)
Policy (Plan)
Study - Act
“External” System Change Support
Policy
Practice
Feedback Loops
Structure
Procedure
Practice
Form Supports Function at every level (National, State,
County, Municipal, Agency)
System Alignment
ALIGNMENT
State
Department
Regions
Agencies
Practitioners/ Staff
Effective Practices
FORM SUPPORTS FUNCTION
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Teams
Federal
Departments
Implementation Frameworks
Multi-dimensional, Fully integrated
Implementation Drivers
Implementation Stages
Implementation Teams
Improvement Cycles
Stages of Change
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Resistance to Change
There is no such thing – only
inadequate preparation
It is not “their” problem, it is
ours.
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Stages of Change
Pre-contemplation (Say what?)
Contemplation (Let me think about it.)
Preparation (I think I will do that.)
Action (I am trying it now.)
Implementation (I am working out the
bugs as I try to do it.)
Maintenance (Say what?)
Hall & George, 1978
Prochaska & DiClemente, 1982
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Functional Systems
Policies
Bureaucracy
Agencies
Staff
Outcomes for
Children, Families,
& Communities
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Summary
We need to invest in “what works” – science matters
Research results help us “choose” what to implement
But “implementation” is a practice and science unto itself
Print materials and training alone won’t work
Fidelity Matters
Selection, Training, Coaching, Fidelity Measures help
change and support new practitioner behavior and skills
Data systems need to be used to make decisions
Facilitative administrative practices & systems
interventions create hospitable environments
Purveyors and Implementation Teams help with system
and service change
Policy enables new practice but practice needs to inform
policy
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
For More Information
Karen A. Blase, Ph.D.
Dean L. Fixsen, Ph.D.
919-966-9050
919-966-3892
blase@mail.fpg.unc.edu
fixsen@mail.fpg.unc.edu
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/
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
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/
Order monograph at:
https://fmhi.pro-copy.com/
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
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The Science and Practice of Implementation