September 2019 Bulletin

Bridging the gap - Fall.png

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.

Thoughts or questions, we would love to connect on Twitter at @TCI_ca

Free online-mini course is returning for a few weeks – enroll on October 7.

After an incredible pilot of our free online mini course, Inspiring Change, we are re-launching the mini-course for a second round. We had unexpected enrolment (over 1600 participants), amazing engagement, and received great feedback from participants. The mini-course will go live again on October 7.  Please share with any colleagues or networks you think would be interested. 

It won’t be available again for almost 6 months, so now is the time to enroll!

How are intermediary organizations influencing the implementation system?

By Julia E. Moore

Senior Director, The Center for Implementation

This month’s Implementation in Action bulletin includes a reflection on a theme from the Society for Implementation Research Collaboration (SIRC) conference held this month in Seattle.

Throughout the conference, I spent quite a bit of time in sessions with and talking to people who are part of intermediary organizations. An intermediary organization is an organization that does not directly deliver an evidence-based program or practice, but serves as part of the support system for those who are implementing evidence-based programs and practices (if you are not familiar with the support system, this post highlights the different roles in the implementation system using the Interactive Systems Framework).

As someone who has worked for three intermediary organizations over the past decade, I am intrigued by the commonalties and distinctions between different intermediaries, how they function, and how they create change. During the SIRC 2019 conference, I was particularly struck by the distinction between intermediary organizations that are supporting people to implement programs in which new staff are being hired to deliver the program (e.g., many of the community-based interventions that receive funding to hire program implementers) and those looking to implement programs which require professionals (e.g., social workers, nurses, psychologists, doctors) to deliver the program, and hence do their jobs differently.  

The role of the support system when hiring the implementers

These intermediary organizations implementing community-based interventions place a large emphasis on creating change in policy and funding, convincing governments and non-profits to fund the implementation of these evidence-based programs that require hiring new staff. In order to deliver these evidence-based programs, government and non-government organizations must find new funding. Essentially these intermediaries are trying to change the system through policy and funding levers.

For example, an intermediary may work with state or provincial policymakers to fund the implementation of specific evidence-based programs (e.g., to prevent youth substance use). In these situations, where new staff are hired to implement the intervention, we still heavily rely on a “train and pray” approach to implementation – where the intermediary organizations trains implementers to deliver these interventions. We know that training alone is rarely sufficient to create the level of change that we are hoping to achieve, but it is easy to default back to the assumption that people only need the knowledge and skills to effectively implement evidence-based programs. There are amazing examples of intermediary organizations building implementation infrastructure, but this is not yet the norm across intermediaries.

The role of the support system when changing professional roles or responsibilities

There are other intermediaries working on supporting the implementation of evidence-based programs and practices which require professionals who already have a job in that organization or setting to do their job differently. For example, asking a nurse to complete new protocols or interact differently with patients. During these implementation efforts, when professionals must actively choose to do their jobs differently, the intermediary organization’s change efforts shift from focusing on policy and funding to figuring out how to motivate and inspire professionals to do their jobs differently. Essentially, they have a different locus of control, even though they also function as an intermediary organization. A colleague attending SIRC 2019 commented that there is even a distinction between situations where professionals are asked to add something new to their role and the situations in which they are asked to stop doing something they currently do. Policy and funding continue to have a role, but their impact is not a strong, and the “train and pray” approach to creating change as far from effective. 

In better understanding the target of our own change efforts and the target of others, we can better position ourselves to understand the experiences, successes, and challenges of other organizations. Without understanding these contextual factors, some of the lessons learned seem disjointed and irrelevant. By placing these roles in context, the ways in which we operationalize process models and frameworks begins to make more and more sense. 

This month’s Project Spotlight features work from two intermediary organizations, Amanda Fixsen, the Director of Implementation at Invest in Kids in Colorado and Matthew Billings, Deputy Director of the Children and Youth Cabinet of Rhode Island (CYCRI).

Intermediary organizations building infrastructure and partnering with the community

By Amanda Fixsen (Invest in Kids) and Matthew Billings (Rhode Island Department of Children, Youth, and Families)

At Invest in Kids we draw heavily on the Active Implementation Frameworks (there are 6 of them!) to support the use of evidence-based prevention programs in communities throughout Colorado. As an intermediary we work to enact all of the Implementation Drivers to ensure high fidelity use of the programs, and then work to engage the other five Active Implementation Frameworks to create and sustain an enabling context in Colorado.

Through developing an appreciation for the Implementation Stages and stage-based implementation support, we came to realize that engaging in a purposeful and proactive Exploration Stage was an area we needed to leverage. Over the last three years we have worked hard to understand and bolster site readiness for The Incredible Years program.

We have found it so useful to use the Heptagon Tool as a guiding framework as we facilitate conversations around readiness during Exploration. The seven areas of the tool allow for a thoughtful discussion to take place between a site considering use of the program and our staff here at Invest in Kids. While the fit of the program with the site and community is clearly a priority during this time, we have also found that through the Resource Availability section of the tool we can dig in to the expectations that Invest in Kids has of a site for them to engage fully in the implementation supports we offer. We know from our 15+ years of supporting community use of The Incredible Years in Colorado that you must focus on implementation of the implementation support!

Given that Invest in Kids is an intermediary, we provide, and then work to build capacity so that we can transfer responsibility for most of the Implementation Drivers and supports that the Resource Availability section covers.  

At CYCRI, each program we support has a designated Implementation Team. Implementation teams meet monthly, have an identified set of Key Performance Indicators, and answer the following questions: “how much, how well, what’s different, and what are our barriers that need busting to achieve the best results”.  Implementation teams consist of eight members including CYCRI staff, funders, residents, and program providers.  Engaging public systems leadership in our Implementation Teams has become our primary driver for Systemic Change.

Intermediary organizations engaging with community partners

The Rhode Island Department of Children, Youth, and Families (RI DCYF) invests in evidence, and wants to shift those investments to a more comprehensive and systemic prevention framework.  Winsome, a resident of Southside Providence has been deeply invested in CYCRI’s work for more than six years.  She attended our initial community conversations, helped residents prioritize their own risk and protective factors, and played an integral role in selecting Evidence-Based Programs through an Annie E Casey initiative called Evidence2Success.  After our program portfolio was collaboratively selected, Winsome approached us and wanted to play a more active role in supporting the implementation of CBITS.  She told us that she thought she could help us identify what was most important to youth in the neighborhood, because she and her daughter live in the neighborhood.

 Winsome joined our CBITS Implementation Team and over time she began to explain her role at RI DCYF.  At the time she oversaw all of the providers who were delivering services to RI DCYF families.  She did more than give the Implementation Team critical community context and expertise, she began taking the Implementation Team work back to RI DCYF leadership. She became a champion in the community and in her workplace for our suite of programs.  Over time, we were asked to present to RIDCYF leadership and discuss why programs that have been designed for communities of color, by developers of color, are an important investment and can be sustained over time.

In addition to opening doors for contracts that support Familias Unidas and Strong African American Families, Winsome has also ensured that these programs are available to all families at risk, rather than just those who have an open case with RI DCYF, a significant step in shifting investments from treatment to prevention. Winsome has also ensured that other members of her staff team are participating in CYCRI’s other implementation teams. 

Systemic change can be daunting, overwhelming, and difficult to identify where to begin.  By harnessing policy/performance loops, CYCRI has found an entry point that is working in the State of Rhode Island. 

Implementation Resources - September Picks

We are switching it up this month with two new literature articles (we will return to the classic and new literature next month).

New Literature: Scaling up evidence-based interventions in US public systems to prevent behavioral health problems: challenges and opportunities.

This article presents considerations and factors related to scaling up evidence-based interventions (in this case specific to prevention) – great example for situations when trying to influence policy and funding.

New Literature: Energise: the secrets of motivation

This book is an incredibly easy read that illustrates what we know about how to motivate people – it is written as a conversation between a behavior change expert and his son.