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Using Implementation Science
To Inform Professional
Development
And Guide Systems Change
Growing Collaborative Systems
to Support Children with Disabilities
and their Families
Karen A. Blase, PhD & Dean L. Fixsen, PhD
NETWORKING FORUM
Co-Directors, National Implementation Research Network
Senior Scientists at the
Stevens Point Convention Center
Wisconsin
September 13, 2011
Frank Porter Graham Child Development Institute,
UNC, Chapel Hill, North Carolina
The Focus on Evidence
The “evidence-based movement” is an
national experiment to make better
use of research findings in typical
service settings.
The purpose is to produce greater
benefits to children, adults, families,
and society.
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Science
“In theory there is no difference
between theory and practice;
in practice, there is.”
variously attributed to
Jan La Van De Snepscheut
or Albert Einstein
or Yogi Berra
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
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 across
domains
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 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
Implementation Math
Effective
Interventions
The “WHAT”
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Effective
Implementation
The “HOW”
Positive
Outcomes
for Children
And
Families
Implementation Math
from Mark Lipsey’s 2009 Metaanalytic overview of the
primary factors that
characterize effective juvenile
offender interventions –
“. . . in some analyses,
the quality with which the
Positive
intervention
is
Effective
Effective
Outcomes
implemented
has been as
Implementation strongly for
Interventions
related
to
Children
recidivism effects as the
The “HOW”
The “WHAT”
And
type of program, so much
Families
so that a wellimplemented intervention
of an inherently less
efficacious type can
outperform
Remembering that any number
timesa0more
is 0
efficacious one that is
poorly implemented.”
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Business as Usual ≠ Impact
Data Show These Methods, When Used
Alone, Do Not Result In Implementation
As Intended:
Diffusion/ Dissemination of information
Training
Passing laws/ mandates/ regulations
Providing funding/ incentives
Organization change/ reorganization
Necessary But Not Sufficient
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
What works?…Fidelity Matters
Higher Fidelity is correlated with better
outcomes across a wide range of
programs and practices
Education – SWPBIS, HiPlaces, STEP
Children’s Services – FFT, MST,
Wraparound, TFM
Adult Mental Health – ACT, IPS, IDDT
Medicine – DOTS, Texas Algorithm,
OMAP
School-Based MH Prevention Programs PATHS
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
I didn't have potatoes, so I
substituted rice.
Didn't have paprika, so I
used another spice.
I didn't have tomato sauce,
so I used tomato paste.
A whole can not a half can I don't believe in
waste.
WHAT WORKS ~
IMPLEMENTING PROPERLY MATTERS
Higher Fidelity is correlated
with better outcomes across a
wide range of programs and
practices
Policy Implications
My friend gave me the
recipe - she said you
couldn't beat it.
1. IF THERE IS NOT THE “WILL” OR
“MEANS” TO DO IT RIGHT
YOU WON’T GET RESULTS
There must be something
wrong with her, I
couldn't even eat it!
2. YOU CAN’T DO A COST-BENEFIT
ANALYSIS IF THERE IS NO
BENEFIT!
~ Senior Center Newsletter
What works…
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, & become
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 and 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
Practitioners
Agencies/Providers
Management (leadership, policy)
Administration (HR, structure)
Supervision (nature, content)
Local, County, State Context
Federal Context
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Purveyor AND Intermediary Structures
and Strategies
Simultaneous, Multi-Level Interventions
Intermediary
Purveyor and
Practitioners
Agency/Provider
Management (leadership, policy)
Administration (HR, structure)
Supervision (nature, content)
Local, County, & State Context
Federal Context
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Frameworks
Multi-dimensional, Fully integrated
Implementation Drivers
Implementation Stages
Implementation Teams
Improvement Cycles
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Frameworks
Multi-dimensional, Fully integrated
Implementation Drivers
Implementation Stages
Implementation Teams
Improvement Cycles
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Drivers…
Build Competency and Confidence
Develop, improve, and sustain competent &
confident use of innovations.
Change Organizations and Systems
Create and sustain hospitable organizational
and systems environments for effective
instructional and educational services
Provide Leadership that Matches the
Challenge
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Why:
What:
Improved Child, Family, Adult Outcomes
EBP/Program/Initiative/Framework for
Effective Practices & System Change
Professional
Staff capacity to
support
Development/
children/families
Professional
with the selected
Learning
How:
practices
Institutional capacity to
support staff in
implementing practices
with fidelity
Core
Implementation
Components
Leadership
Capacity to provide
direction, vision, & the
“right” leadership approach
© Fixsen & Blase, 2008
Improved Child, Family, Adult Outcomes
EBP/Program/Initiative/Framework for
Effective Practices & System Change
Performance Assessment
Coaching
Implementation
Drivers =
Infrastructure
Training
Implementation Lens
Selection
© Fixsen & Blase, 2008
Staff Training & Coaching
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
Copyright © Dean L. Fixsen©and
Karen Fixsen,
A. Blase, 2008
Dean
Karen
Blase, Robert Horner, George Sugai, 2008
Improved Child, Family, Adult Outcomes
EBP/Program/Initiative/Framework for
Effective Practices & System Change
Implementation
Drivers =
Infrastructure
Performance Assessment
Coaching
Training
Selection
Graphics by Steve Goodman,2009
Systems
Intervention
Facilitative
Administration
Decision Support
Data System
© Fixsen & Blase, 2008
System Stability
EXISTING SYSTEM
Effective Innovations are
Changed to Fit the
System
Or Operate in the Shadows
(The Ghost System)
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Effective System Change
EXISTING SYSTEM
EXISTING SYSTEM IS
CHANGED TO SUPPORT
THE EFFECTIVENESS OF
THE INNOVATION
Effective Innovations are
Changed to Fit the
System
Or Operate in the Shadows
(Ghost System)
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
(Host System)
EFFECTIVE INNOVATION
Improved Child, Family, Adult Outcomes
EBP/Program/Initiative/Framework for
Effective Practices & System Change
Implementation
Drivers =
Infrastructure
Performance Assessment
Systems
Intervention
Coaching
Facilitative
Administration
Training
Decision Support
Data System
Selection
Leadership
Adaptive
Technical
© Fixsen & Blase, 2008
Types of Leadership Needed
Different strategies for different
challenges
Technical Leadership
Adaptive Leadership
According to Ron Heifitz and his
colleagues, one of the biggest mistakes
“leaders” make is to incorrectly identify
the type of challenge they are facing
Using technical approaches for adaptive
issues
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
The Adaptive Work of the Leader
Get on the Balcony
Identify the Adaptive Challenge
Regulate Distress
Maintain Disciplined Attention
Give the Work Back to the People
Protect All Voices
» R. Heifetz and D. Laurie: The Work of
Leadership. Harvard Business Review,
1998.
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Improved Child, Family, Adult Outcomes
EBP/Program/Initiative/Framework for
Effective Practices & System Change
Implementation
Drivers =
Infrastructure
Performance Assessment
Systems
Intervention
Coaching
Facilitative
Administration
Training
Integrated &
Compensatory
Selection
Decision Support
Data System
Leadership
Adaptive
Technical
© Fixsen & Blase, 2008
Implementation Frameworks
Multi-dimensional, Fully integrated
Implementation Drivers
Implementation Stages
Implementation Teams
Improvement Cycles
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Takes Time
Stages of
Implementation
Stages of Implementation
You don’t get to skip any!
If you make a judgment about “effectiveness”
too early you might be making a mistake.
Activities need to match the stage.
Different stages for multiple initiatives
“Where are we now with this initiative?”
Stages will need to be “revisited” – important!
New providers, new communities, new Ministers,
new government officials, new families
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 Hall & Hord, 1987, Greenhalgh, Robert, MacFarlane, Bate,
& Kyriakidou, 2004
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Frameworks
Multi-dimensional, Fully integrated
Implementation Drivers
Implementation Stages
Implementation Teams
Improvement Cycles
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Team(s)
■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 Teams
Implementation Teams
Simultaneous, Multi-Level Interventions
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Practitioners
Agencies and Local Partnerships
Management (leadership, policy)
Administration (HR, structure)
Supervision (nature, content)
Service Systems
County and Local Context
National Context
Implementation Team
Prepare
Communities
Prepare Agency
& State Systems
Prepare staff &
administrators
Implementation
Teams
Assure
Benefits
Work with TA & Parents &
Researchers
Stakeholders
Create Readiness
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Assure Implementation
Implementation Teams
At multiple levels
Integrated and Interlocking
Agency Teams
Community Teams
State Team
Focus is on
Supporting Quality Implementation Drivers
Fidelity & Outcomes,
Alignment (funding and policy)
Problem-Solving and Sustainability
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Frameworks
Multi-dimensional, Fully integrated
Implementation Drivers
Implementation Stages
Implementation Teams
Improvement Cycles
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
What Do They Have in
Common?
Policy to Practice to Policy Cycles
Transformation Zones
Rapid Cycle Teams
Problem-solving
Practice Improvement
Usability Testing
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Improvement Cycles
Policy to Practice to Policy Cycles
Transformation Zones
Rapid Cycle Teams
Problem-solving
Practice Improvement
Usability Testing
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Improvement Cycle Uses
Why Policy-Practice Feedback
Cycles?
Because the Current System is
perfectly designed to get the
current results!
And Systems Can Trump
Programs!
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation
Team
Practitioners
Innovations
Benefits
Practice Informed
Policy
System
Change
Executive
Management
Team
Policy Enabled
Practice
“External” System Change Support
System Reinvention
Adaptive Challenges
• Duplication
• Fragmentation
• Hiring criteria
• Salaries
• Credentialing
• Licensing
• Time/ scheduling
• Union contracts
• Contract methods
• Laws
System Alignment
ALIGNMENT
State
Department
Communities,
Regions
Provider
Agencies
Practitioners
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
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
What Will It Take to Effectively Support
Children With Disabilities and Their
Families?
Science Related to….
Interventions and Programs
Implementation, Organization, and Systems Change
Funded Infrastructure (Drivers)
Informed & engaged consumers & communities
Linked Teams
Skillful Purveyors & Intermediaries
Competent Providers
Supportive Organizations
Engaged communities and stakeholders
Hospitable & Aligned Systems
Leadership at All Levels
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Keep the “Big Picture” in Mind
Copyright © Dean L. Fixsen and Karen A. Blase, 2008
Implementation Science
Implementation
Research:
A Synthesis of the
Literature
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/detail.cfm?resourceID=31
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
[email protected]
[email protected]
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/
To order the monograph go to:
https://fmhi.pro-copy.com/
Copyright © Dean L. Fixsen and Karen A. Blase, 2008