1. Barbara Sims Dean L. Fixsen Karen A. Blase Michelle A. Duda
Implementation for a Change
RtI Best Practices Institute
Barbara Sims
Dean L. Fixsen
Karen A. Blase
Michelle A. Duda
Wrightsville Beach, NC
October 2012
© 2012 Karen A. Blase and Dean L. Fixsen

2. Complex Problems Human services involve interaction-based sciences
Inherently more complex than atom-based sciences
E.g., atom-based ingredients don’t refuse to be ingested, talk back, or run away

3. Ineffective Approaches
Best data show these methods, when used alone, Do Not result in uses of innovations as intended:
Diffusion/ Dissemination of information
Training
Passing laws/ mandates/ regulations
Providing funding/ incentives
Organization change/ reorganization
5 to 10% return on investment
NECESSARY BUT NOT SUFFICIENT
Paul Nutt (2002). Why Decisions Fail

4. EXISTING SYSTEM EFFECTIVE INNOVATIONS ARE CHANGED TO FIT THE SYSTEM
System Change
EXISTING SYSTEM EFFECTIVE INNOVATIONS ARE CHANGED TO FIT THE SYSTEM
EXISTING SYSTEM IS
CHANGED TO SUPPORT
THE EFFECTIVENESS OF
THE INNOVATION
EFFECTIVE INNOVATION

5. Why Focus on Implementation?
Implementation Gap
Implementation is defined as a specified set of activities designed to put into practice an activity or program of known dimensions.
RESEARCH
IMPLEMENTATION
PRACTICE
GAP
as a nation we have invested significantly in the research base in what works, finding interventions that might make a difference. And we have developed some very nice interventions in education that have been shown, particularly in highly-supported research settings, that they can be very effective.

But— when we check in to see to what extent those interventions are occurring in practice, it's not looking as good.
"What is that that is preventing us from really benefiting from the research?" And we're going to say, "Well, there probably are many things, but implementation is significant."

A set of mechanisms, a set of strategies that really offer us a guide to bring from research into practice
what it takes to do good work we think could be very helpful.
Why Focus on Implementation?
“Students cannot benefit from interventions they do not experience.”

6. Developing the Capacity to Implement Well
“A serious deficiency is the lack of expertise to implement best practices and innovations effectively and efficiently to improve student outcomes.”
Rhim, Kowal, Hassel, & Hassel (2007)
Rhim, L. M., Kowal, J. M., Hassel, B. C., & Hassel, E. A. (2007). School turnarounds: A review of the cross-sector evidence on dramatic organizational improvement. Lincoln, IL: Public Impact, Academic Development Institute.

7. Implementation Science
Implementation science is the scientific study of variables and conditions that impact changes at practice, organization, and systems levels; changes that are required to promote the systematic uptake, sustainability and effective use of evidence-based programs and practices in typical service and social settings.
~Blase and Fixsen, 2010
National Implementation Research Network

8. Implementation Science
Effective
NOT Effective
from Mark Lipsey’s 2009 Meta-analytic overview of the primary factors that characterize effective juvenile offender interventions –
“. . . in some analyses, the quality with which the intervention is implemented has been as strongly related to recidivism effects as the type of program, so much so that a well-implemented intervention of an inherently less efficacious type can outperform a more efficacious one that is poorly implemented.”
Actual Benefits
Inconsistent; Not Sustainable; Poor outcomes
Effective
INTERVENTION
Unpredictable or poor outcomes;
Poor outcomes; Sometimes harmful
NOT Effective
(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)

9. Formula for Success = X Effective Intervention practices
Effective Implementation practices
Improved Outcomes X =
1.0 X
0.0 = 9

10. Plan for Change
District is the point of entry for systemic support of school improvement
Use short-term infusion of resources
Establish long-term, district-based capacity for quality

11. Shifting Accountability
Student
Practitioner
System
SISEP 2012

12. Cascading Logic Model Improve student outcomes
Improve teacher instruction
Improve school supports for teachers
Improve district supports for schools
Improve regional supports for districts
Improve State supports for outcomes
Re-define relationships among system components
Focus fully on student outcomes
© 2012 Karen A. Blase and Dean L. Fixsen

13. Active Implementation Frameworks
Implementation Drivers
Implementation Stages
Implementation Teams
Improvement Cycles
Briefly Summarize the Four Implementation Frameworks
Set the Context for
Tools and Resources
State and RRC Examples
Table Discussion
© 2012 Karen A. Blase and Dean L. Fixsen

14. Active Implementation Frameworks
Successful implementation on a useful scale requires. . .
Active use of implementation core components “best practices”– “IMPLEMENTATION DRIVERS”
Purposeful matching of critical implementation activities to the stage of the process – “STAGES OF IMPLEMENTATION”
Organized, expert assistance – “IMPLEMENTATION TEAMS”
A focus on continuous, purposeful improvement – “IMPROVEMENT CYCLES”
(c) Dean Fixsen and Karen Blase, 2008 14

15. IMPLEMENTATION DRIVERS
Common features of successful supports to help make full and effective use of a wide variety of innovations

16. Improved educational outcomes
Consistent Use of
Educational Innovations
Interventions meet
Implementation
Performance Assessment
(Fidelity)
Coaching
Systems
Intervention
Facilitative
Administration
Competency Drivers
Training
Organization Drivers
Integrated & Compensatory
Decision Support
Data System
Selection
Leadership
Adaptive
Technical
© Fixsen & Blase, 2008 16

17. Performance Assessment
(Fidelity)
Coaching
Competency Drivers
Training
Selection
Technical
© Fixsen & Blase, 2008
© Fixsen & Blase, 2008 17

18. Build Competency and Confidence
Competency Drivers
Build Competency and Confidence
Develop, improve, and sustain competent & confident use of innovations

19. Performance Assessment
Measure fidelity
Ensure implementation
Reinforce staff and build on strengths
Feedback to agency on functioning of
Recruitment and Selection Practices
Training Programs (pre and in-service)
Supervision and Coaching Systems
Interpretation of Outcome Data
(c) Dean Fixsen and Karen Blase, 2004

20. Selection Select for the “unteachables” Screen for pre-requisites
Set expectations
Allow for mutual selection
Improve likelihood of retention after “investment”
Improve likelihood that training, coaching, and supervision will result in implementation
(c) Dean Fixsen and Karen Blase, 2004

21. Training Develop Training Plan Define critical components
Aspects requiring new knowledge
Aspects requiring new skills
Prioritize training topics
Identify or develop fidelity measures
(c) Dean Fixsen and Karen Blase, 2004

22. Coaching Develop Coaching Plan Ensures fidelity Ensures implementation
Provides feedback to selection and training processes
Grounded in “Best Practices”
(c) Dean Fixsen and Karen Blase, 2004

23. Training and Coaching OUTCOMES 10% 5% 0% 30% 20% 60% 95% Knowledge
% 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

24. Performance Assessment
(Fidelity)
Systems
Intervention
Coaching
Training
Facilitative
Administration
Competency Drivers
Organization Drivers
Decision Support
Data System
Selection
Leadership
Adaptive
Technical
© Fixsen & Blase, 2008 24

25. Reflection Implementation Drivers
How do we support the development of the infrastructure needed to implement well?
How do we promote more hospitable organizational environments?
How relevant are leadership issues? What’s our role?
Supporting
New Ways of Work 25

26. Active Implementation Frameworks
Successful implementation on a useful scale requires. . .
Active use of implementation core components “best practices”– “IMPLEMENTATION DRIVERS”
Purposeful matching of critical implementation activities to the stage of the process – “STAGES OF IMPLEMENTATION”
Organized, expert assistance – “IMPLEMENTATION TEAMS”
A focus on continuous, purposeful improvement – “IMPROVEMENT CYCLES”
(c) Dean Fixsen and Karen Blase, 2008 26

27. STAGES OF IMPLEMENTATION
Purposeful matching of critical implementation activities to the stage of the process
SISEP 2012

28. Stages of Implementation
INITIAL IMPLEMENTATION
FULL IMPLEMENTATION
Integrated & Compensatory
Competency Drivers
Organization Drivers
Leadership
2 - 4
Years
INSTALLATION
EXPLORATION
Stages of Implementation
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005

29. Exploration Formalize Team Structures Develop Communication Plan
Determine Need and Identify Options
Assess “Fit” and Feasibility
Promote “Buy in” for the innovation and for implementation supports
“Pay now or pay later.”
What happens during Exploration?
Formalize Team Structures
Develop Communication Plan
Determine Need and Identify Options
Assess “Fit” and Feasibility
Promote “Buy in” for the innovation and for implementation supports
Make recommendations

30. Installation Structural and functional changes are made
First implementers selected
Define and initiate training of first implementers
Develop coaching plans
Evaluate readiness and sustainability of data systems
Establish communication links and protocols
Structural and functional changes are made
Selection protocols developed
First implementers selected
Define and initiate training of first implementers
Develop coaching plans
Evaluate readiness and sustainability of data systems
Analyze and problem-solve sustainability
Establish communication links and protocols

31. Initial Implementation
Initiate training plan
Provide coaching
Make use of improvement cycles
Communication links and protocols
PDSA to resolve systems issues
Usability testing of selection, training and coaching
Get started, then get better!
Learn from mistakes
Celebrate progress
Continue “buy-in” efforts
Make systemic changes
Manage expectations
All the components of the program or innovation are in place and the implementation supports begin to function.

32. Full Implementation “What Change?....This is our way of work!”
Skillful practices by all staff
Evaluation for expected outcomes
Full use of Implementation Drivers
Policy changes/development for sustainability
“The only thing worse than failing and not knowing why you failed, is succeeding and not knowing why you succeeded.” ~ Jane Timmons-Mitchell
“What Change?....This is our way of work!”
Skillful Teaching and School Practices
Skillful Use of the Drivers
Drivers experience their own Improvement Cycles
Data Systems in use, reliable, efficient, and used for Decision-Making at multiple levels to regenerate and improve
Policy to Practice and Practice to Policy Feedback Cycles

33. ACTIVITY Stages of Implementation Analysis
What are you already doing that is “stage-based”?
What are the facilitators and barriers to doing stage-based work?
Discuss the Exploration and Installation Stage indicators.
Supporting
New Ways of Work 33

34. Active Implementation Frameworks
Successful implementation on a useful scale requires. . .
Active use of implementation core components “best practices”– “IMPLEMENTATION DRIVERS”
Purposeful matching of critical implementation activities to the stage of the process – “STAGES OF IMPLEMENTATION”
Organized, expert assistance – “IMPLEMENTATION TEAMS”
A focus on continuous, purposeful improvement – “IMPROVEMENT CYCLES”
(c) Dean Fixsen and Karen Blase, 2008 34

35. IMPLEMENTATION TEAMS
Organized, expert assistance to develop and sustain an accountable structure

36. Implementation Team 80%, 3 Yrs 14%, 17 Yrs IMPLEMENTATION Impl. Team
NO Impl. Team
80%, 3 Yrs
14%, 17 Yrs
Effective
INTERVENTION
Balas & Boren, 2000
Making it Happen
Letting it Happen Helping it Happen
Fixsen, D. L., Blase, K. A., Timbers, G. D., & Wolf, M. M. (2001). In search of program implementation: 792 replications of the Teaching-Family Model. In G. A. Bernfeld, D. P. Farrington & A. W. Leschied (Eds.), Offender rehabilitation in practice: Implementing and evaluating effective programs (pp ). London: Wiley.
It takes an estimated average of 17 years for only 14% of new scientific discoveries to enter day-to-day clinical practice (Balas & Boren, 2000)
Balas EA, Boren SA. Yearbook of Medical Informatics: Managing Clinical Knowledge for Health Care Improvement. Stuttgart, Germany: Schattauer Verlagsgesellschaft mbH; 2000.
Green, L. A., & Seifert, C. M. (2005). Translation of research into practice: Why we can't "Just do it". Journal of the American Board of Family Practitioners, 18(6),
With the use of competent Implementation Teams, over 80% of the implementation sites were sustained for 6 years or more (up from 30%) and the time for them to achieve Certification was reduced to 3.6 years.
Fixsen, Blase, Timbers, & Wolf, 2001
Balas & Boren, 2000 Green & Seifert, 2005

37. Linked Team Structures
School-based
Implementation Team
District-based
Regionally-based
State-based
Think again about the NAEP scores. They’ve stayed flat for 40 years. How is that possible?
I think this quote from Senge speaks to a piece of it.
often times we focus at a particular place in the system as if that one place could then emanate its changes out kind of organically, or through some kind of mechanism that we've yet to describe.

We would suggest that there probably needs to be a real formalized structure that ensures that we have implementation capacity at every level.
“We tend to focus on snapshots of isolated parts of the system and wonder why our deepest problems never seem to get solved (Senge, 1990)

38. ACTIVITY Table Talk: Implementation Teams
In your experience, who supports the change process?
How is the transition made from external expertise to building internal capacity?
Supporting
New Ways of Work 38

39. Active Implementation Frameworks
Successful implementation on a useful scale requires. . .
Active use of implementation core components “best practices”– “IMPLEMENTATION DRIVERS”
Purposeful matching of critical implementation activities to the stage of the process – “STAGES OF IMPLEMENTATION”
Organized, expert assistance – “IMPLEMENTATION TEAMS”
A focus on continuous, purposeful improvement – “IMPROVEMENT CYCLES”
(c) Dean Fixsen and Karen Blase, 2008 39

40. IMPROVEMENT CYCLES Changing on purpose to support the new way of work
SISEP 2012

41. Types of Improvement Cycles
Plan-Do-Study-Act Cycles
Usability testing (Neilson; Rubin)
Practice-policy communication loops
Deming, W. E. (1986). Out of the crisis. Cambridge, MA: MIT Press.
Shewhart, W. A. (1931). Economic control of quality of manufactured product. New York: D. Van Nostrand Co.
Shewhart, W. A. (1939). Statistical method from the viewpoint of quality control: Dover Publications.
Nielsen, J. (2000). Why you only need to test with 5 users. Retrieved April 22, 2007, from
Rubin, J. (1994). Handbook of usability testing: How to plan, design, and conduct effective tests. New York: John Wiley & Sons.
Fixsen, D., Blase, K., Metz, A., & Dyke, M. V. (in press). Statewide implementation of evidence-based programs. Exceptional Children (Special Issue). 41

42. PDSA

43. Usability Testing

44. Policy Practice Feedback Loops
Expert Implementation Support
Policy (Plan)
Policy
Practice
Policy Enabled Practices
(PEP)
Practice Informed Policy
(PIP)
Structure
Feedback
Study - Act
Procedure
So again, we've got the organized, expert assistant out on the side, trying to connect what we're learning at the practice level to the policy level, so that we really do have structures and procedures that are aligned to support new and effective practice, with the goal being, over time, an aligned system.

A system where our effective practices are really quite easily implemented by our practitioners, who are supported by agencies, who are supported by their regions, who are supported by their state department, who are supported by their national leadership, so that each level receives what it needs to effectively implement, really, the best services. The services we would want anyone to receive.
Practice (Do)
FORM SUPPORTS FUNCTION
(c) Dean Fixsen and Karen Blase, 2008 44

45. ACTIVITY Table Talk: Improvement Cycles and Communication Loops
How can we make use of improvement cycles in developing and implementing our improvement activities?
Linking Communication Protocols
Supporting
New Ways of Work 45

46. Summary
Conceptualize a change process so that effective interventions for children and families can become embedded and sustained in socially complex settings
“stage-matched activities to guide the process
“implementation drivers” to build the infrastructure
Improvement processes are critical
the work is never done because the environment is in motion
Invest in the development of organized, “expert” implementation support
(c) Dean Fixsen and Karen Blase, 2010

47. For more on Implementation Science
Stay Connected!
@SISEPcenter
SISEP
For more on Implementation Science 47