April 2019 Bulletin
Welcome to Implementation in Action, a monthly bulletin for implementers and intermediary organizations who are seeking to apply implementation science in a thoughtful and systematic way. Implementation in Action includes an overview of the issue's theme, a Project Spotlight, and links to two resources - one from the foundational literature on the topic and another more recently published resource.
NEW: The Center for Implementation had an article featured in the Institute for Healthcare Improvement (IHI) blog about unleashing intrinsic motivation called The Missing Piece in Improvement: Understanding How to Motivate Change.
Struggling to use a framework? Maybe your framework is at the wrong level
By Julia Moore
Senior Director, The Center for Implementation
When people first learn about implementation frameworks, it’s pretty common to enter with a combination of excitement and trepidation. After teaching hundreds of people about implementation, I’ve found that it’s easiest to start at the individual level and work your way up. First you think about individual-level changes, then you work on organization-level changes, then you think about the system-level changes. Since changes at the individual level are the least complex (i.e., there are less factors affecting an individual change than a system-level change), it’s easy to envision how those will play out.
While this might be a fairly logical sequence to learn about implementation, real world implementation efforts are not as clear-cut. In fact, many implementation projects start at a systems level or an organization level, and people may only think about individual-level change as an afterthought. This is likely because people are tasked with change at those levels, so only think about the level of change at which they work, even though change at each level is linked.
Another common occurrence is for people to come across a framework (e.g., the theoretical domains framework) and feel like it does not fit their project. They may then push back and say that implementation science does not provide the answers they need, or that frameworks are not a useful tool. But just because one framework does not help in a particular situation and does not mean the framework is not helpful, it means that framework is not the right fit for what you were trying to accomplish. The theoretical domains framework is a very individual framework, so it’s not going to be as helpful if you are trying to understand organizational or system level factors.
Frameworks are like tools in your toolbox. A screwdriver is amazing if you are inserting a screw, but if you have a nail it’s going to feel like a useless tool. That doesn’t mean you throw out your screwdriver, it means you return to your toolbox and figure out what is a better tool for this situation. Implementation frameworks are just like these tools. They each have a function.
If you want to figure out what framework you should use, figure out what you were trying to accomplish and then find the appropriate tools (i.e., implementation framework) to fit that function.
If you are looking for an individual level framework, check out the theoretical domains framework (TDF).
If you want to better understand the organizational context, the consolidated framework for implementation research is a fabulous place to start.
If you want to consider system level factors, the ABLe change framework is one to consider.
What level of framework do you need?
In this month project spotlight, Dr. Brian Bumbarger highlights two different ways in which it’s important to think about these different levels of implementation, which drives the kinds of frameworks you need to consider. Brian presents how the state of Pennsylvania built a center to provide technical assistance and support for the implementation of evidence-based interventions, but he later realized some of the repercussions of focusing so heavily on high-quality implementation of these evidence-based interventions. These realizations lead to much larger questions about organizational and system level changes that need to be considered when creating large scale change.
Applying Implementation Science at 3 Levels: Practitioner, Organization and System
Visiting Research Associate, Colorado State University Prevention Research Center
Adjunct Research Fellow, Griffith University Institute of Criminology
Consultant on Community and Public Systems Capacity Building
For nearly three decades I’ve sought to bridge research, practice and policy by understanding facilitators and barriers to greater use of evidence-based interventions (EBIs). From 1998-2016 at Penn State University’s Prevention Research Center, I supported state agencies who funded many EBIs but struggled to have them delivered with quality and fidelity. These programs were often more complex and difficult to implement well than “business as usual”. This need led to the development of the Evidence-based Prevention and Intervention Support Center (www.EPISCenter.psu.edu), one of the first state-level intermediaries to support the scale-up of EBIs. The large scale of the initiative (over 200 grantees) and diversity of EBIs offered a “living laboratory” to study and support implementation. The initial focus of support was on individual practitioners who needed to understand and apply implementation science (even if we didn’t yet call it that). These EBIs often represented significant departures from the way practitioners had been trained, and they needed in-service retrofitting of their skills to deliver EBIs with quality and fidelity. We realized however that these practitioners, and the organizations they worked for, weren’t ONLY delivering EBIs, and by helping them apply Implementation Science principles only in the context of a specific program, we were unintentionally creating a disparity within their program portfolios, making programs with the strongest evidence seem the least attractive (because they required greater attention to the details of implementation). We discovered Wandersman’s Interactive Systems Framework (ISF), which emphasizes both intervention-specific support and general (i.e. organizational) support, and found it to be a helpful heuristic. We shifted our support from practitioners to organizations, generalizing the Implementation Science principals to everything a provider organization offered.
More recently I have recognized that we must also consider how these provider organizations are embedded within, and constrained by, (public) systems. I co-chair a Task Force of the Society for Prevention Research which has recently drafted a white paper to examine the need for applying implementation science within public systems. If we hope to effectively scale EBIs while maintaining the quality and fidelity necessary to move the needle on population public health, we will need to broaden our lens to acknowledge this level of the socio-ecological model.
Implementation Resources - April Picks
This was the first paper to review and synthesize existing theories, models, and frameworks (although Nilsen’s paper had not yet come out so all three were grouped together). At the time, they found 61 existing frameworks. Since then other reviews have found even more, but this is a great foundation to identify the prominent frameworks.
New Literature: Implementation Science at a Glance
This incredible new resource is a practical guide to implementation science just launched by the National Cancer Institute that makes the science of implementation much more accessible. If you want to apply implementation science in practice, it’s definitely worth checking out!