Transformation for Consumer Benefits

Copyright © Dean L. Fixsen and Karen A. Blase, 2006

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Dean L. Fixsen, Ph.D.

Karen A. Blase, Ph.D.National Implementation Research Network

Louis de la Parte Florida Mental Health Institute

Transformation for Consumer Benefits

Kentucky Cabinet for Human Resources 2006


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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


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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


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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


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The Problem

"All organizations are designed, intentionally or unwittingly, to achieve precisely the results they get."

R. Spencer Darling


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Transformation

Transformation means change

Establish new ways of functioning in human services


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Transformation GoalsMental 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


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Transformation

Establish new ways of functioning in human services

Beyond the rhetoric, how can human service systems be transformed?


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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


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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


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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


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Transformation

Transformation is disruptive

Transformation requires resources

Transformation requires courage

Transformation requires dogged persistence


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Transformation

Transformation can be facilitated

Transformation can be effective

Transformation can be fun


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Transformation Agenda

ImplementInnovations

SustainableInfrastructure

Initiate & ManageChange


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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.


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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


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Policy - Practice - Feedback

Policy (Plan)

Practice (Do)

Structure

Procedure

Policy

Practice

Form follows Function

Fee

db

ack

Stu

dy - A

ct


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Innovation ZonesSuspend 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


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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)


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Information Economics

Kenneth Arrow

(1972)


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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


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"Knowledge is experience.

Everything else is just information."

Albert Einstein

....


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Need a repository of knowledge gleaned from experience

Transformation Implementation Team


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Transformation Implementation Team (policy enablers, barrier busters, facilitation creators)

Practice-Level Team (do the innovation, test policies)

Weekly / Monthly Meetings (frequent, unfiltered, goal focused)


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Transformation starts with a process to initiate and manage change:

1. Policy - Practice - Feedback systems

2. Innovation zones

3. Implementation Team


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Initiate and manage change

Implement innovations and other new ways of work

Develop a sustainable infrastructure for transformation management and continuous consumer benefit


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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.


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0

100

200

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400

500

600

700

800

900

≤1972 1974 1976 1978 1980 1982

0

50

100

150

200

250

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CumulativeCouples

CumulativeHomes

The First 794 Attempted Replications (1967 – 1982)

Fixsen, Blase, Timbers, & Wolf (2001)

Teaching–Family Replications


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Craft knowledgeEBP purveyors (program developers)

EBP implementation site managers

Implementation researchers

Survey of EBP program developers

Scientific informationCRUSK, Follow Through, Lodges, et al.

Program development and replication data

Synthesis of the implementation evaluation and research literature

The NIRN


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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


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Literature Review

“The main difference between service and manufacturing is the service department doesn't know that they have a product.”

W. Edwards Deming


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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


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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


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Implementation SuccessPMTO 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


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Common to SuccessGood 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


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Effective intervention practices

+Effective implementation practices

=Good outcomes for consumers


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Effective NOT Effective

Effective

NOT Effective

IMPLEMENTATION

INT

ER

VE

NT

ION Performance

ImplementationPaper / Procedure Implementation


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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)


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Effective NOT Effective

EBP

NOT Effective

IMPLEMENTATION

INT

ER

VE

NT

ION

High Fidelity Low Fidelity


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Bedlington, et al., 1979

0%

10%

20%

30%

40%

50%

Homes

1.0

1.2

1.5

1.7

1.9

2.0

1.1

1.4

1.6

1.8

1.3

Delinquency

Teaching

rs = – .94

Per

cent

Par

enta

l-Tea

chin

g W

ith Y

outh

s

Mean S

elf Reported

Delinquency R

atings

1 2 3 4 5 6

Teaching-Family Model


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An evidence-based program is one thing

Implementation of an evidence-based program is a very

different thing

InfluenceInfluence

Destination

Source

CommunicationLink

Feedback

Implementation Framework

Fixsen, Naoom, Blase, Friedman, & Wallace, 2005


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Stages of Implementation

Implementation is not an event

A mission-oriented process involving multiple decisions, actions, and corrections


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Stages of Implementation

Exploration

Installation

Initial Implementation

Full Implementation

Innovation

Sustainability

Implementation occurs in stages:


2 – 4 Years


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Installation

Initial Implementation

Implementation Stages:Non-Linear Processes

Practitioner

Evidence-based Practices

Purveyor

Fidelity & OutcomeMeasures


Organizational Structures/Culture



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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


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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)


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Implementation Site: The Destination

Defined Need

Identified Resources

Fully informed consent re: innovation and implementation

Top level commitment to change and agreement re: access


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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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PurveyorExcellent 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)

Ev Rogers’ summaries of diffusion research are well diffused but an adoption decision is not implementation


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PurveyorExcellent experimental evidence for

what does not workTraining alone, no matter how well

done, does not lead to successful implementation

With a variety of designs and measures, information dissemination and training by themselves repeatedly have been shown to be ineffective in human services, education, health, business, and manufacturing


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Active Purveyor Role

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 (information economics, K. Arrow)


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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.


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Organization

Management (leadership, policy)

Administration (HR, structure)

Supervision (nature, content)

Practitioner

State policies

System of care

Pu

rvey

or

Simultaneous, Multi-Level Interventions

Purveyor Activities (N = 577 items)

Implementation Stages

Explore Install Init Impl

Assessment 97% 1% 2%

Planning 20% 32% 48%

Training 3% 31% 66%

Coaching 8% 6% 86%

Evaluation 3% 23% 73%

Org Development 11% 16% 73%

System Intervention 37% 30% 33%


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Ready Fire

Aim

Service systems are moving targets.

A process, not an event.

Real World Implementation Strategy: Change is a constant


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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


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0102030405060708090

100

Tx Unit Strategy Org. Development Strategy

% H

om

es

Op

en

6+

Yrs

.

N = 84 N = 219

Teaching-Family Model

Fixsen, Blase, Timbers, & Wolf (2001)

Program Sustainability


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Search for ResearchDatabases=Current Contents, BIOSIS Previews, Web of Science; Time span=2001-2005

1 “Research & Staff Selection”

13,577 “Research & Training”

576 “Research & Supervision”

119 “Research & Coaching”

394 “Research & Fidelity”

11,081 “Research & Administration”


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Initiate and manage change

Implement innovations and other new ways of work

Develop a sustainable infrastructure for transformation management and continuous consumer benefit


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Sustainable Infrastructure

A state-based infrastructure to

accumulate, dispense, and

implement knowledge for the

benefit of consumers and

public health

....


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Work with communities, human service systems, provider groups, program developers, and purveyors to encourage and support the implementation of innovations that improve consumer benefits (e.g. evidence-based programs)


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Independence, flexibility, & authority to mediate state, provider, and purveyor interests and needs

Accumulate knowledge re: intervention processes & outcomes and implementation processes & outcomes


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Develop new position descriptions related to transformation (system coach, implementation specialist, decision support data manager)

Expand innovation zones

Create new state systems (continuous transformation process)


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Contract with purveyors of evidence-based practices and programs

Monitor (not all the same)

Maximize local learning

Be the purveyor of innovations

A program development function coupled with implementation functions


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Consumers, family members, and stakeholders as full partners

A community of practice to improve consumer benefits and public health


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Be an echo-holic

Become addicted to feedback and assessments of results

InfluenceInfluence

Destination

Source

CommunicationLink

Feedback




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The feedback loop enables the learning process (echo-holic)

The feedback loop provides a trusted guidance system

Approximations to the overall goals of the system at each level

Prompts action in the plan – do – study – act – cycle


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Most rapid learning comes from studying extreme cases and failures (PDSA Cycle)

Frustrating to succeed and not know why (can’t do it again)


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Measure benefits to consumers and society, don’t assume them

Too many variables to assume that high fidelity implementation will automatically result in significant consumer benefits

Level of Functioning system in Michigan’s Children’s MH


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Policy

Practice

Structure

Procedure

Policy

Practice

Consumer Benefits

Policy

Practice

Structure

Procedure

Culture

Climate

Policy

Practice

Structure

Procedure

Consumer Benefits

Inte

gra

ted

an

d S

ust

ain

able

Form follows Function

Fee

db

ack


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ImplementInnovations

SustainableInfrastructure

Initiate & ManageChange


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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

(ORC Macro sub-contract for SOC analyses of implementation; implementation strategies grants)

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)


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For More Information

Dean L. Fixsen

813-974-4446

[email protected]

Karen A. Blase

813-974-4463

[email protected]

National Implementation Research Network

At the Louis de la Parte Florida Mental Health Institute

University of South Florida

http://nirn.fmhi.usf.edu


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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

Transformation for Consumer Benefits

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