March 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.
Do you know your role in the implementation system?
By Julia Moore
Senior Director, The Center for Implementation
The Importance of Role Clarity
A substantial source of conflict when working on implementation projects is role clarity. Role clarity issues occur at the frontline implementation level, but often there are also bigger role clarity questions at a system level. For example, you might have multiple organizations that are implementing a new evidence-based program or practice, a program developer or researcher as part of the team, and another organization that is helping them through that process. You may also have a funder that is involved by supporting the implementation project financially and possibly in other ways.
The absence of good role clarity can snowball into different challenges. Redundancy can occur when multiple system stakeholders are trying to work on the same tasks. Inefficiencies may be apparent when there is a lack of ownership and responsibility, and key activities slip through the cracks. A lack of role clarity can also incite emotional reactions such as anger, confusion or frustration towards stakeholder partners. If any of these resonate with you, it’s a great idea to think about how you could use a framework to understand the different key stakeholders and their roles in the implementation system.
The Interactive Systems Framework for Dissemination and Implementation
The Interactive Systems Framework for Dissemination and Implementation (ISF; Wandersman et al., 2008) was designed specifically for this purpose. Although the framework was originally developed for prevention, it is been adopted and used in a range of settings, including public health, healthcare, community, education, and juvenile justice.
The ISF includes three key stakeholder groups: 1) the synthesis and translation system (bottom); 2) delivery system (top), and 3) support system (middle).
The synthesis and translation system are those who are responsible for synthesizing and translating evidence. For example, if you are building an intervention using an evidence-based guideline and selecting implementation strategies (ideally using theory and evidence), those activities would fit in this bottom box.
The delivery system includes those who are responsible for delivering an intervention. This is the implementation team. These people often work within the setting where the intervention is being delivered, and are supporting people in that setting to change their behavior. For example, if the intervention is happening in a long-term care home, the implementation team might be made up of a nurse manager, a personal support worker, a nurse, and an occupational therapist. Their role is to deliver the intervention within their organization.
Many implementation efforts also include a support system, which resides between the synthesis and translation, and delivery systems. People in the support system serve as a liaison, brokering relationships between the front line implementers and those people who are developing and synthesizing the interventions. The support system is comprised of people who have expertise in implementation science and the intervention itself, to support those on the frontline with intervention-specific questions and implementation challenges.
The ISF depicts the basic structure of an implementation system. At times, the system may be more complex, particularly as the intervention grows larger in size and scope. For example, I have recently worked with several organizations that have two “layers” of a support system. They may have a large number of people providing implementation support (with roles or job titles like implementation coach, implementation facilitator, or technical assistance provider). Since there are no university or graduate school programs specifically designed to teach people how to become an implementation coach, organizations have increasingly been working with a master implementation coach, to help train and support people to become implementation coaches and effectively support frontline implementation. This results in having two types of support systems embedded in one another.
Encompassing the implementation system is the larger context, which provides inputs to, or impacts the operation of, the implementation system. This includes macro-level policies, politics, funding, availability of research, political and societal priorities, etc. The model is not always this clear-cut; I’ve seen several situations where the funder plays a more integrated role, not only funding projects, but serving as a support system for the frontline implementers. This means that stakeholders in the system may not have just one role, but can occupy multiple roles in the system.
Once you and your stakeholder partners are able to identify your positions and roles in the implementation system, it may become clearer who occupies what role and where the various responsibilities for implementation fall. If it isn’t clear to you, bringing the ISF to a team meeting is a great way to start the conversation in providing better role clarity.
In this month’s Project Spotlight, Lisa Lachance highlights how Wisom2Action used the Promoting Action on Research Implementation in Health Services (PARiHS) framework to provide mentorship support to community-based non-profit organizations.
Project Spotlight: Interorganizational Mentoring - a PARIHS-inspired approach to facilitation in knowledge mobilization
By Lisa Lachance
Wisdom2Action was funded through the Networks of Centres of Excellence Knowledge Mobilization program from 2011-2019, and continues on as a social entreprise providing services in engagement, evaluation and KMb (wisdom2action.org). W2A has used the Promoting Action on Research Implementation in Health Services (PARiHS) framework to conceptualize its work since 2013 through gathering diverse research, practice and lived evidence, contextualizing the evidence for service providers, and facilitating the uptake of best and promising practices (Kitson, Harvey, & McCormack, 1998; Harvey et al., 2002). We have had a particular focus on supporting youth-serving sector to increase its use of evaluation, evidence and engagement.
Community-based non-profit organizations (CBOs) rarely have access to research or evaluation evidence to inform their programs and often lack the capacity to gather or use this information independently. In 2016, W2A launched an inter-organizational mentorship program to facilitate the implementation and sharing of best and promising practices within community-based programs for young people. CBOs were invited to review the W2A online evaluation and KMb toolkit, and then apply for 100 hours of free mentorship support to use one of the tools or meet another KMb goal. Through W2A and its regional Hubs, mentors worked with mentees on one-year project workplans, and over the lifespan of the project, 24 organizations were mentored. A developmental evaluation of the mentorship program reinforced the importance of establishing connected relationships and understanding context in mentoring relationships, creating adaptive and responsive work plans, ensuring consistent communication, and maintaining a focus on capacity-building if knowledge mobilization is to occur.
For more information on the work of Wisdom2Action, please check out our website at wisdom2action.org or contact W2A President Lisa Lachance at Lisa.Lachance@dal.ca
Harvey, G., Loftus-Hills, A., Rycroft-Malone, J., Titchen, A., Kitson, A., McCormack, B., & Seers, K. (2002). Getting evidence into practice: the role and function of facilitation. Journal of Advanced Nursing, 37(6), 577–588. https://doi.org/2126 [pii]
Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: a conceptual framework. Quality and Safety in Health Care, 7(3), 149–158. https://doi.org/10.1136/qshc.7.3.149
Implementation Resources - March Picks
Article illustrating the functions and relationships of the support system in the Interactive Systems Framework.
An interesting article that distinguishes between bridging social capital and bonding social capital, including the strengths and challenges of each.