1. Scaling Up: From Research to National Implementation
Policy Maker’s Summit
Center for Evidence-Based Practice:
Young Children with Challenging Behavior
Washington, DC
November 17, 2006
Karen A. Blase, Ph.D.
Dean L. Fixsen, Ph.D.
National Implementation Research Network
Florida Mental Health Institute
(c) Dean Fixsen and Karen Blase, 2004

2. The Overall Puzzle Each 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, it is a challenge to realize sustainable benefits for children, families, and caregivers on a broad scale
(c) Dean Fixsen and Karen Blase, 2004

3. The Center’s Pieces of the Puzzle
Focus of research has been on making a difference in the world…the child’s natural environment
Wisdom and commitment to:
Attend to values and “fit” for caregivers and children – What matters and for whom!
Recognize multi-level influences (e.g. workforce development issues, policy, organizational culture)
Build caregivers capacity and practitioner ability (e.g. attending to the independent variables)
Inspire and create hope….tell the story and tout the science
(c) Dean Fixsen and Karen Blase, 2004

4. Naming The Challenge Science to Service Gap Implementation Gap
What is known is not what is adopted to help children, families, and caregivers
Implementation Gap
“….While we have good evidence that the trajectory of a child’s social and emotional development can be changed, the field lacks the necessary information to ensure adoption and sustainability of these program practices…” Recommended Practices: Program Practices for Promoting the Social Development of Young Children and Addressing Challenging Behavior - Fox
We talk about ebp’s as though they are taking over the service sectors from mental health intervention to primary prevention…from older adults to infants. While the fact of the matter is that what is known is not what is generally adopted to help children, families and adults.
Along with the Science to Service Gap there is the Implementation Gap:
There are not clear pathways from a series of rigorous scientific studies to widespread use of a practice or program.
When adoption does occur what is is adopted is often not done with fidelity and benefits to consumers are not realized.
And often with staff turnover, the practice or program walks out the door with the exiting staff.
(c) Dean Fixsen and Karen Blase, 2004

5. Going to Scale: What Would It Take?
How many implementations of a program or practice will be needed to address needs nationally?
800 child care and referral agencies
14,310 school districts
51,000 incorporated child care centers
906,993 children enrolled in Head Start
11.6 million children under age 5 (with estimates of 10 to 15% with mild to moderate problems)
We need to produce THOUSANDS of replications of effective programs and practices across the country.
We need to learn to work in hospitable and difficult implementation sites.
We need to develop and replicate effective and robust implementation systems.
We need both a science and practice of implementation.
(c) Dean Fixsen and Karen Blase, 2004

6. Research to Service GAP RESEARCH IMPLEMENTATION SERVICE
(c) Dean Fixsen and Karen Blase, 2004

7. The Implementation Gap
It is one thing to say with the prophet Amos, “Let justice roll down like mighty waters,” and quite another to work out the irrigation system.
William Sloane Coffin
Social activist and clergyman
(c) Dean Fixsen and Karen Blase, 2004

8. The National Implementation Research Network (NIRN)
Craft knowledge
EBP purveyors (program developers)
EBP implementation site managers
Implementation researchers
Survey of EBP program developers
Scientific information
Program development and replication data
Synthesis of the implementation evaluation and research literature
(c) Dean Fixsen and Karen Blase, 2004

9. From the Synthesis of the Literature We Know That…
Implementation issues are common across widely diverse domains
Implementation solutions are common across widely diverse domains
HOPE – Implementation research findings likely have broad practice implications across domains!
(c) Dean Fixsen and Karen Blase, 2004

10. Puzzle Pieces
Effective intervention practices and programs +
Effective implementation practices =
Good outcomes for children, families and consumers
The usability of a program has little to do with the weight of the evidence regarding program outcomes
Evidence on effectiveness helps us select what we want implement
Evidence on outcomes does not help us implement the program
No other combination of factors reliably produces desired outcomes for children, families, and caregivers
(c) Dean Fixsen and Karen Blase, 2004

11. Puzzle Pieces IMPLEMENTATION Effective NOT Effective
Paper & Process Implementation
(Low or No Fidelity)
Performance Implementation
(High Fidelity)
Effective
INTERVENTION
NOT Effective
So if we are to close the science to service gap we must also close the implementation gap…effective interventions and effective implementation are both necessary.
Implementation can be effective when it is focused on performance implementation, that is practitioners and program personnel are doing the program “as intended” …..
It is also possible to have a highly effective intervention that is NOT effectively implemented. Too often paper implementation occurs, the mandates, the policies and the rhetoric are all in place and available for a paper or verbal “audit”.
Or process implementation occurs. Didactic training and orientation to the new practice occurs, but supervision systems don’t change, data are collected but are not available in a timely understandable format and not used for decision-making. But these changes do significantly impact front line practice or generate consumer benefits.
Only performance implementation of an effective intervention that changes behavior at the practitioner, program and system level makes a difference.
(c) Dean Fixsen and Karen Blase, 2004

12. Puzzle Pieces Excellent 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
While the science is not strong the science that does exist is clear about a couple of things.
Spray and pray strategies don’t work. This is likely not the type of faith-based initiative that the Federal Gov’t is interested in.
Information dissemination alone does not lead to successful implementation.
Training alone, no matter how well done does not lead to successful implementation
(c) Dean Fixsen and Karen Blase, 2004

13. Puzzle Pieces Excellent experimental evidence for what does not work
Implementation by edict does not work
Implementation by “following the money” does not work
Implementation without supporting role and function changes does not work
Paul Nutt (2002). Why Decisions Fail
(c) Dean Fixsen and Karen Blase, 2004

14. What Seems to be Required
Integration of Implementation Factors
Core Implementation Components:
Training, Coaching, Performance Measurement
Organizational Components:
Selection, Program Evaluation, Administration, Systems Intervention
Influence Factors:
Social, Economic, Political
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
(c) Dean Fixsen and Karen Blase, 2004

15. What Seems to be Required
Successful implementation on a useful scale requires a purveyor
An individual or group of individuals representing a program or practice who actively work with organizations and communities to help them implement that practice or program with fidelity and good effect
Purveyors accumulate data & experiential knowledge to become more effective and efficient over time
(c) Dean Fixsen and Karen Blase, 2004

16. Implementation Framework Organizational Structures/Culture
Practitioner
Purveyor
Fidelity & Outcome
Measures
Evidence-based
Practices
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
(c) Dean Fixsen and Karen Blase, 2004

17. Implementation Framework Organizational Structures/Culture
Infrastructure
(Train, Coach,
Evaluate)
Purveyor
Fidelity & Outcome
Measures
Evidence-based
Practices
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
(c) Dean Fixsen and Karen Blase, 2004

18. Simultaneous, Multi-Level Interventions
Active Purveyor Role
Simultaneous, Multi-Level Interventions
Organization
Management (leadership, policy)
Administration (HR, structure)
Supervision (nature, content)
Practitioner
State, County and Local Context
Service Systems
Purveyor
Purveyors also quickly learn that the Influence Factors are critical to the success of the implementation effort and over time take on a very active, simultaneous and multi-level intervention role to help increase the likelihood that such meta-contingencies as funding, licensing, referral mechanisms, regulations, and reporting requirements are aligned to support the new way of work
Federal Context
(c) Dean Fixsen and Karen Blase, 2004

19. Purveyor Sources and Strategies
Purveyor group organized and promoted by the originators (e.g. Success for All, Positive Behavior Support)
Implementation team with the knowledge, skill, freedom, and authority to act (e.g. within a larger organization or a collaboration of agencies)
An Intermediary Purveyor Organization that becomes expert in implementation and a “bridge” or expert with multiple EBPs (a new way of doing T & TA).
(c) Dean Fixsen and Karen Blase, 2004

20. What Seems to be Required
Purveyors Help Ensure the Integration of Implementation Factors
Core Implementation Components:
Training, Coaching, Performance Measurement
Organizational Components:
Selection, Program Evaluation, Administration, Systems Intervention
Influence Factors:
Social, Economic, Political
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
(c) Dean Fixsen and Karen Blase, 2004

21. Implementation Drivers
Implementation Drivers Coordinate and Operationalize
the Core Implementation Components and
the Organizational Components
Implementation Drivers are mechanisms that
Help to develop, improve, and sustain practitioners’ ability to implement an intervention to benefit children
Help ensure sustainability and improvement at the organizational level
(c) Dean Fixsen and Karen Blase, 2004

22. Implementation Drivers
STAFF PERFORMANCE
EVALUATION
SUPERVISION & COACHING
DECISION SUPPORT DATA SYSTEMS
INTEGRATED & COMPENSATORY
FACILITATIVE ADMINISTRATIVE SUPPORTS
PRESERVICE &
INSERVICE
TRAINING
RECRUITMENT AND SELECTION
SYSTEMS
INTERVENTIONS
(c) Dean Fixsen and Karen Blase, 2004

23. Integrated and Compensatory
Consistency in philosophy, goals, knowledge and skills across these processes (S/T/C/E/A/SI)
Compensatory
At the Practitioner Level
At the Program Level
(c) Dean Fixsen and Karen Blase, 2004

24. Implementation Drivers
STAFF PERFORMANCE
EVALUATION
SUPERVISION & COACHING
DECISION SUPPORT DATA SYSTEMS
INTEGRATED & COMPENSATORY
FACILITATIVE ADMINISTRATIVE SUPPORTS
PRESERVICE &
INSERVICE
TRAINING
RECRUITMENT AND SELECTION
SYSTEMS
INTERVENTIONS
(c) Dean Fixsen and Karen Blase, 2004

25. ..+Demonstration in Training …+ Practice & Feedback in Training
Coaching Impact
 OUTCOMES
% of Participants who Demonstrate Knowledge, Demonstrate New Skills in a Training Setting,
and Use new Skills in the Classroom
TRAINING
COMPONENTS
Knowledge
Skill
Demonstration
Use in the
Classroom
Theory and Discussion
10% 5% 0%
..+Demonstration in Training
30%
20%
…+ Practice & Feedback in Training
60%
…+ Coaching in Classroom
95%
Joyce and Showers, 2002
(c) Dean Fixsen and Karen Blase, 2004

26. Stages of Implementation
Implementation occurs in stages:
Exploration
Installation
Initial Implementation
Full Implementation
Innovation
Sustainability
2 – 4 Years
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
(c) Dean Fixsen and Karen Blase, 2004

27. 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
(c) Dean Fixsen and Karen Blase, 2004

28. Organizational Change: Top to Bottom
Facilitate or Hinder
Settings
Practitioners
State policies. coordination, funding, support
Federal policies, coordination, funding, supports
System of care
Active alignment of policies and coordination of efforts in support of practitioner’s use of effective practices to benefit children, families, and caregivers
(c) Dean Fixsen and Karen Blase, 2004

29. Policy - Practice - Feedback
Policy (Plan)
Structure
Procedure
Policy
Practice
Feedback
Study - Act
Practice (Do)
Form follows Function
(c) Dean Fixsen and Karen Blase, 2004

30. Organizational Change
Successful and sustainable implementation of evidence-based practices and programs always requires organizational change at multiple levels.
Changing the behavior of adult human service professionals
Changing organizational structures, cultures, and climates
Changing the thinking of system directors and policy makers
(c) Dean Fixsen and Karen Blase, 2004

31. Getting From Here to There
Who is going to do the work of implementation?....at each level?
Who will be the “purveyors”?
What/who will be the source of implementation drivers?
Who will facilitate efficient and effective movement through implementation stages?
How can we build the practice and science of implementation?
(c) Dean Fixsen and Karen Blase, 2004

32. Summary
We need to pay attention to implementation as a separate set of issues, strategies and procedures.
We need to know more about the science of implementation.
Implementation likely requires:
Knowledgeable “purveyors”
Implementation Drivers to support practitioner and organizational change (Select, Train, Coach, Evaluate, etc)
Matching implementation activities to Stages
Multi-level organizational change that creates alignment to support and sustain new ways of work (Federal, State, Regional, Local, Organizational)
(c) Dean Fixsen and Karen Blase, 2004

33. Don’t mistake a clear view for a short distance.
Grand Canyon Hiking Advice
(c) Dean Fixsen and Karen Blase, 2004

34. Thank You We thank the following for their support
W. T. Grant Foundation (implementation literature review grant)
Substance Abuse and Mental Health Administration (ORC Macro sub-contract for SOC implementation analyses; Implementation Strategies Grant, Mental Health Services Gap Grant)
National Institute of Mental Health (research and training grants)
Juvenile Justice and Delinquency Prevention (program development and evaluation grants)
(c) Dean Fixsen and Karen Blase, 2004

35. For More Information Dean L. Fixsen, Ph.D. Karen A. Blase, Ph.D.
Karen A. Blase, Ph.D.
National Implementation Research Network
At the Louis de la Parte Florida Mental Health Institute
University of South Florida
(c) Dean Fixsen and Karen Blase, 2004