SISC Implementation Science Simcoe Muskoka

Kathy Simpson

Agenda1. Introduction

2. Implementation Science Overview– Stages– Drivers– Teams (SISC Implementation Team) – Improvement Cycles (Use of QI)– Learnings

3. Questions & Discussion

4. Installation/Implementation Planning

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Implementation Science

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   or Google National Implementation Research Network

Implementation Research: A Synthesis of the Literature

Today’s Objectives1. Deepen your understanding of implementation

science as it is being applied in the Service Collaborative project

2. Understand the drivers critical to successful implementation

3. Understand Implementation Planning context and content

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Implementation Science Overview

What is implementation?

“A specified set of purposeful activities at the practice, program, and system level designed to put into place a program or intervention of

known dimensions with fidelity.”

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Implementation Science

• An intervention is one thing(Serum, software)

• Implementation is something else altogether(Syringe, hardware)

• Neither one is useful without the other

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Getting results

Effective NOT Effective

Effective

NOT Effective

IMPLEMENTATION

INT

ER

VE

NT

ION Actual Benefits

(Institute of Medicine, 2000; 2001; 2009; New Freedom Commission on Mental Health, 2003; National Commission on Excellence in Education,1983; Department of Health and Human Services, 1999)

Inconsistent; Not Sustainable; Poor outcomes

Poor outcomes Poor outcomes; Sometimes harmful

Implementation Stages Implementation Drivers Implementation Teams Improvement Cycles

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Active Implementation’s Four Frameworks(“make it happen”)

ImplementationStages

Conducting stage-appropriate implementation activities is

necessary for successful service and system change (Metz & Bartley, 2012)

Stages of Implementation• Exploration

• Installation (Implementation Planning)

• Initial Implementation

• Full Implementation

• Decide What to adopt and implement

• How will it happen. Plan what needs to be in place to implement the What

• Put the plan on the ground and implement the What

• Make sure it works, then do it better (PDSA) and make it “business as usual”

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• Stages are not linear, overlap occurs• Sustainability planning is important at all stages

Cluster 1: Milestones

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March-October 2012

November-March 2013 April-July 2013

Exploration

Installation

Initial Implementation

Full Implementation

August 2013

Implementation Drivers

Developing implementation components (a.k.a. Drivers) results in an implementation infrastructure that supports competent and sustainable

service delivery (Metz & Bartley, 2012)

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Improved outcomes for Children and Youth

Competency Drivers

1. Recruitment and Selection• Identify roles and responsibilities for all participants• Organizations select knowledgeable and appropriate staff to deliver intervention

2. Training• Participants acquire knowledge and skills necessary to support implementation • Practitioners must acquire the necessary skills to use the intervention

3. Consultation and coaching• Successful implementation requires ongoing guidance for participants

(supervision, teaching, assessment/feedback, and emotional support)

4. Performance assessment (fidelity)• Is the intervention being implemented as intended? (evaluation question)• Frequent performance reviews and feedback on adherence to the core

intervention components (fidelity) are important for continued success

Organization Drivers

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5. Systems Intervention• Internal and External leadership is in place to support ongoing

implementation and sustainability (e.g. funding, human resources)

6. Facilitative Administration• Internal leadership at agency/regional/ systems level is in place and

using data to inform their decisions and support necessary infrastructure for ongoing implementation and sustainability

• There is a strong leadership “connection” to external partners to promote the use of this initiative.

7. Decision Support Data Systems• Program evaluation and process data are routinely collected, analyzed

and shared• Overall assessment of the initiative assures continuing implementation

and outcomes of core components over time

Leadership Drivers

Effective Implementation requires Leadership at all levels and for all drivers.

8. Technical – to support ‘technical’ changes e.g. management sign off to include 5 additional questions on intake form

9. Adaptive – to support changes in the way work is done e.g. reduce office based time and increase time mental health worker is allocated to be in school to implement a school-based program.

Identifying champions at all levels!

Implementation Teams

Creating Implementation Teams that actively work to implement

interventions results in quicker, higher-quality implementation

(Metz & Bartley, 2012)

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SISC Project:SC Implementation Team

• Develop project charter• Develop the implementation plan• Develop evaluation and communication plans• Consult with larger SC as needed• Execute implementation plan• Develop and execute sustainability plan

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Improvement Cycles: Where IS meets QI

The use of QI and IS in SISC

• Implementation Science is an approach that uses QI tools and processes where appropriate (at any stage).

• Example, fishbone can be used in Exploration but also Initial implementation, etc….

• To evaluate the success of implementation, PDSA cycles will be critical throughout the process but especially at initial implementation

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Continuous Improvement Cycles: Rapid Cycle Improvement (PDSA)

PLAN

STUDY

ACT

DO

PLAN Determine a plan for implementing the change idea or project

DO Actually implement the plan by conducting a test and identify any problems or barriers encountered

STUDY Evaluate the test results and reflect on what was learned

ACT Adapt and improve on the change idea based on the feedback from the test cycle

NIRN has advocated for QI approaches as a way to help

with continuous decision making and to better understand the core

intervention components. PDSA cycles can be included

at a number of NIRN’s stages.

Policy-practice feedback loops: A Quality Improvement Method

Policy Practice Feedback Loops

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Policy

Practice

Policy

Structure

Procedure

Practice

Metz & Bartley, 2012

Lessons Learned

In the exploration phases, securing funding is crucial.In the later phases, fidelity monitoring and feedback

is essential.Committed leaders who motivate and inspire

participants are beneficial at all stages.

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Lessons Learned

Competency Drivers:• Tailor materials to the specific needs of users• Match engagement method to user’s “stage of change”• Involve practitioners that are receptive to using the new

practice• Reduce the lag time between training and implementation• Offer opportunities to trial the intervention on a small scale• Connect users with peers who may have been through a

similar implementation initiative, or who are using the EBP already

• Balance negative feedback • Share successes! (of all sizes)

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Lessons LearnedOrganization Supports: • Get buy-in from key influencers (e.g. formal and informal)• Tap into existing communication pathways• Alter the workflow to support the EBP• Encourage organizational structures that support the EBP & an EBP that is

adaptable to such structures

Leadership:• Have onsite leaders at all levels in organizations• Support an organizational culture that is motivated towards improvement• Advocate for changes needed

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Questions?

INSTALLATION

From Practice Profile to

Implementation Driversto

Implementation Plan

Installation: Active implementation planning

• Determining the composition of the implementation team

• Establishing the resources needed to carry out the intervention with fidelity

• Identifying structural, functional changes and work flow processes

• Address barriers and propose system solutions (MACRO)

• Planning for each implementation driver

Installation: SISC activities• Develop the project charter

• Identify structural and functional changes needed

• Develop implementation plan

• Develop evaluation plan

• Develop communication plan

Implementation Plan Developed!

Implementation Planning

• Practice Profile Part 2– Identifies, at a high level, the knowledge, skills and abilities

needed to execute the practice profile as described in Part 1 as well as the ‘outcome’ ie how we will prove that things have been implemented as planned

• Implementation Drivers: A guide to planning– Provides a chart structure and probing questions to

develop a detailed plan as to how what’s needed is going to be put in place

Practice Profile/Driver Examples

DRIVER PRACTICE PROFILE

Selection Identify agencies that would like to participate in TIP ModelIdentify employees from each organization that would like to participate

Decide who will participate in this first round of training

Practice Profile/Driver Examples

DRIVER PRACTICE PROFILE

Training Provide training for front line workers & their supervisors on use of TIP guidelines and Core PracticesProvide training for supervisors in how to support and monitor front line workers’ implementation of above.Provide training for TIP workers to become SM Site-based trainers.

Practice Profile/Driver Examples

DRIVER PRACTICE PROFILE

Coaching Workers are supported to deliver TIP Model appropriatelyDetermine how coaching, consultation and/or mentoring will be sustained throughout the life of the initiative.Determine who within each organization is going to provide supervision and consultation to ensure fidelity.

Practice Profile/Driver Examples

DRIVER PRACTICE PROFILE

Fidelity/Performance Measures

There is evidence that TIP Model Guidelines and Core Practices are being implemented appropriately (TIP Model Fidelity Assessment Measures)Determine performance, fidelity and outcome data that need to be collected at youth, program/service and TAY system levels to monitor, performance, fidelity and outcomes

Practice Profile/Driver Examples

DRIVER PRACTICE PROFILE

Systems Interventions

Commitment from organizations working with TAY to adopt TIP Model Guidelines and Core Practices.Establishment and on-going support of cross-sector TIP teams in each geographical area.Program guidelines for weekly LIFT-like Supper Clubs

Practice Profile/Driver Examples

DRIVER PRACTICE PROFILE

Facilitative Admin Supports

Establishment and on-going support of SM regional oversight/TAY Network to provide leadership, monitoring and oversight to the TAY Network as well as assessing TIP Implementation across the Network.Identification of staffing and funding for LIFT-like Supper Club in all geographical areas.

Practice Profile/Driver Examples

DRIVER PRACTICE PROFILE

Decision Support Data Systems

Determine how performance, fidelity and outcome data will be collected, analyzed, reported; who and how it will be shared; where it will be housed.Determine what systems exist and are capable of supporting the decision support data requirements.

Questions?