Scaling Up: Balancing Adaptations and Implementation Supports
By Dr. Julia E. Moore, Executive Director
6-min read
Over the past year, it seems like there has been an increasing desire to scale programs and practices. As a result, we’ve had many conversations and discussions about scale-up. From our perspective, there is an interesting new tension emerging around how to support implementing sites in planning for adaptations. A tension related to balancing adaptations and the intensity and type of implementation supports that are being provided.
Acknowledging the importance of adaptations
Globally, even in settings that have historically shied away from adaptations and advocated for strict adherence, we have noticed an increasing interest, recognition, and desire to make adaptations when scaling. This seems to be related to two factors. During the pandemic, people realized that adaptations were often inevitable and required, which meant that people were forced to experience adaptations, and saw that they were not always detrimental. Simultaneously, there has been a significant push to be more equitable in what we implement and how it is implemented. To implement equitably requires adaptations.
We are hearing more and more examples of people who are implementing in organizations and communities expressing that they will not participate in an initiative unless they can make adaptations to it. However, it's important to note that not everyone wants to make adaptations. Burnout has become a significant problem across numerous systems, and many people who are asked to implement new initiatives only feel comfortable doing so if they are given a lot of guidance and are not required to make many decisions along the way. Making adaptations can require a significant mental load, and in a context with increased workload and stress, sometimes the additional burden of having to think about and plan for adaptations is unwelcome. Balancing these two competing priorities is a challenge.
Implementation supports for scale-up
In recent years, it has become increasingly evident that implementation efforts cannot be scaled up without providing adequate support. There are several frameworks and approaches that people are using to provide implementation support, including the Interactive Systems Framework and the evidence-based system for implementation supports (EBSIS). A common combination that many organizations and groups are using a combination of a learning collaborative model and coaching to provide support to implementing sites. It is exciting to see these approaches being used in practice, with people evaluating what is working well and what could be improved in the learning collaboratives and coaching models. They are brainstorming ways to provide these supports more cost-effectively.
Right-sizing implementation supports to plan for adaptations during scale up
We at TCI strongly believe in accepting adaptations during scale-up and providing adequate support for the same. These approaches align with our philosophical beliefs and are backed by the literature. However, we’ve also noticed a concerning combination of adaptations and supports that is sometimes occurring.
As people increasingly recognize the value of allowing site-level adaptations, we’ve noticed that there is a lot more freedom given to sites so that they can adapt. At the same time, budget constraints have meant that many scale-up efforts are reducing the amount of coaching support that is provided. That means that sites are being asked to do more implementation and adaptation planning, with less support from people who understand the science of implementation, and from people who deeply understand the programs and practices that they are implementing.
We believe that adaptations are an essential component of scale-up, but it is important that they are done thoughtfully, and in a way that allows people to make adaptations that align with the needs, values, and logistics of where something is being implemented, while also maintaining the core functions of the different activities embedded within the programs/practices and change strategies that have been selected. Most implementing sites don’t have team members with a deep enough understanding of implementation science to know how to adapt, without changing the core functions. In fact, they rarely have knowledge and skills of the foundations of implementation science (e.g., WHO is being asked to do WHAT differently, and HOW are they being supported to change); we cannot expect them to make rigorous and thoughtful adaptations without significant support.
It's important to provide the proper implementation support when sites make significant adaptations. Otherwise, we run the risk of scaling things that won't be effective and won't improve outcomes for those who should benefit from this work. This could be a serious problem.
A path forward: balancing adaptations and supports during scope
We wrestled with these challenges – how can we support people to make adaptations while discouraging adaptations to the core functions of an initiative and acknowledging that some staff and organizations do not have the capacity to make many decisions at the moment? We believe one solution is to create “decision-free” implementation guidance for those who want that and highlight possible decision points where people are encouraged to reflect on possible adaptations.
This means describing initiatives in a way that includes the WHOs, the WHATs, the HOWs (change strategies), and the implementation plan in a format that does not require any decisions if a site would like to implement utilizing the least resources possible from the organization/community.
At the same time, we believe that the same combination of WHOs, WHATs, HOWs, and implementation plans can include key decision points where sites might make adaptations. These decision points can be strategically selected so that they highlight places and aspects of the initiative and implementation plan that do not affect the core functions of the WHATs or HOWs, and are likely to address differing local needs, fit, and contextual factors.
For example, imagine one of the WHATs is a screening process. You could provide guidance on what is typically done and flag the alternative ways the screening process could be delivered for different types of professionals in different types of organizations. If one of the HOWs (i.e., change strategies) is to have local champions, you could provide a standard way that champions have been trained and supported, and then highlight another way sites have support champions - for example, through building a community of practice for the champions. If the implementation plan includes data collection, you could provide guidance on the ideal data collection methods and present 2 to 3 alternatives if the original plan does not seem feasible.
Creating this “decision-free” implementation guidance, while also flagging possible decision points and examples of different adaptations requires much more work centrally for those who are building out resources and support to those who are ultimately going to implement. However, the potential benefits are huge. As implementing sites are struggling with resources, staffing, capacity, and burnout, and there’s an increasing desire to encourage adaptations to meet local needs, we need to find ways to set sites up for success as we scale our initiatives.
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