Implementation
for the Masses
UNC
Implementation Science
Student Group
Dean Fixsen, Karen Blase,
Melissa Van Dyke, Allison Metz
National Implementation Research Network
FPG Child Development Institute
University of North Carolina at Chapel Hill
Implementation
Science
Science
to Service
Gap
!
 Past – Before 2005
!
 Present – 2005-2015
!
 Future – Starts today
Implementation
Defined
Science
to Service
Gap
 Implement = Use
!
!
I  mplementation Science = the study
of factors that influence the full and
effective use of innovations in
practice
!
  The goal is not to answer factual questions
about what is, but rather to produce evidence
for what is required (invent the future)
Implementation Science
Eisenhower: National System of Interstate
and Defense Highways (1956)
•  Goal of 21,185 miles (50%) reached in 1966
Kennedy: Decision to send astronauts to the
moon and return them safely (1961)
•  Goal reached in 1969
Johnson: Great Society Programs (1964)
•  Goals not reached yet in 2014
Implementation Science
Human services involve interactionbased sciences and services
•  Inherently more complex than atombased sciences
– e.g., atom-based ingredients don’t
change from one engineer to the next or
change overnight or decide to quit
National Assessment of Education Progress (NAEP)
Churning Around a Mediocre Mean
Original and Revised Assessment Formats
Federal SPENDING on K-12 Education
and NAEP READING Scores (Age 9)
It’s not (just) the money
or top-down support!
Implementation Science
Convergence in the new millennium
1.  Innovation science
2.  Implementation science
3.  Improvement science
4.  Complexity theory
Implementation Science
Innovation science
•  Rigor and relevance of data re
WHAT to do
– 
“Evidence-based” programs and
innovations
Implementation Science
A key lesson from the Great Society
is that the effects of social
programs in practice hover near
zero, a devastating discovery for
social reformers
–  Rigorous data supporting effective
innovations are necessary but not sufficient
Rossi and Wright (1984)
Implementation Science
Implementation Science (get started)
and Improvement Science (get better)
•  HOW to assure the full, effective, and
consistent use of innovations in practice
•  HOW to resolve issues of fit and function
(innovation, delivery, organizations,
systems) – never ends!
Implementation Science
Complexity Theory
•  Interactions among moving parts
•  Emergent adaptation
•  Plan for the unexpected
•  Large scale change in real time
E Pluribus Unum
•  Summaries of literature in any domain
including agriculture, business, child
welfare, complexity theory, computer
science, engineering, health, juvenile
justice, manufacturing, medicine, mental
health, nursing, social services, and others
•  Summaries of best practices by experts
doing implementation work successfully
•  Synthesis of over 40 implementation and
evaluation frameworks
Convergence
Effective
Innovations
Effective
Implementation
Socially
Significant
Outcomes
Enabling
Contexts
Convergence: Active
Implementation Frameworks
! 
! 
! 
! 
! 
! 
Usable Innovations
Implementation Stages
Implementation Drivers
Improvement Cycles
Implementation Teams
Enabling Change
Implementation Benefits
Haphazard
Implementation
Informed
Training Benefits
5 - 15% use in
80 - 95% use in
8 X More
Fidelity of use in
practice
3 X More
practice
practice (coaching)
29% EBP
81% EBP
outcomes if low
fidelity use
outcomes if use
meets criteria
Implementation
Team
4 X More
18% fidelity with
83% fidelity if
no/poor Drivers
Drivers at criteria
Training + Coaching
+ Fidelity 3 X More
22% staff retained 58% staff retained
3+ yrs.
Competency +
17% sustain 6+
Organization Drivers yrs.
5 X More
3+ yrs.
84% sustain 6+
yrs.
Zone of Complexity
Stacey (1996)
Implementation Science
•  Letting it happen
–  Recipients are accountable
•  Helping it happen
–  Recipients are accountable
•  Making it happen
–  Purposeful use of implementation practice and
science
–  Implementation Teams are accountable
Based on Hall & Hord (1987); Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou (2004);
Fixsen, Blase, Duda, Naoom, & Van Dyke (2010)
Implementation Science
Approaches to implementation of innovations in 376
organizations (public, private, profit, non-profit)
Approach
Intervention/
Facilitation
Participation/
Internal Team
Persuasion
Edict
Usage
Success
Months
8%
87%
14
18%
73%
16
37%
37%
47%
35%
21
15
Nutt (2001)
Implementation Science
Approaches to implementation of innovations in 376
organizations (public, private, profit, non-profit)
Approach
Intervention/
Facilitation
Lead and
Participation/
Support
Internal Team
Persuasion
Tell and
EdictSell
Usage
Success
Months
8%
87%
14
18%
73%
16
37%
37%
47%
35%
21
15
Nutt (2001)
Implementation Teams
Teams
!  Minimum of three people (four or more
preferred) with expertise in:
!  Operationalizing innovations
!  Using implementation methods effectively
!  Helping organizations change
!  Tolerate turnover; teams are sustainable
even when the players come and go (Higgins,
Weiner, & Young, 2012; Klest & Patras, 2011)
Implementation Teams
Teams
Prepare
Practitioners and
Staff
Prepare
Organizations
Prepare Regions
80%
Implementation
Team
Patients and
Work with
Researchers Stakeholders
Create Readiness
Prochaska, Prochaska, & Levesque (2001)
Assure
Intended
Benefits
20%
Assure Implementation
© Fixsen & Blase, 2009
Implementation Teams
Teams
Implementation Team
Simultaneous, Multi-Level Interventions
Practitioner/Staff Competence
Organization Supports
Management (leadership, policy)
Administration (HR, structure)
Supervision (nature, content)
Regional Authority Supports
State/Community Supports
Federal and National Supports
Improvement Cycles
Teams
Implementation and Innovations
 Rapid cycle (PDSA) problem solving
!
!
 Shewhart (1931); Deming (1986)
 Usability testing
!
!
 Rubin (1994); Nielsen (2000)
Improvement Cycles
Teams
Nielsen (2000)
Improvement
Cycles
Usability Testing
Teams
•  A planned series of tests of an innovation or of
implementation processes.
•  Use proactively to test the feasibility and impact
of a new way of work prior to rolling out the
innovation or implementation processes more
broadly
More is learned from 4
cycles with 5 participants
each than from 1 pilot
test with 20 participants
Implementation Teams
Teams
INNOVATION
IMPLEMENTATION
Effective
Expert Impl. Team
NO Impl. Team
80%, 3 Yrs
14%, 17 Yrs
Effective use of
Letting it Happen
Implementation
Helping it Happen
Science & Practice
Fixsen, Blase,
Timbers, & Wolf, 2001
Saldana &
Chamberlain, 2012
Balas & Boren, 2000
Green, 2008
The Nature of Systems
"All organizations [and systems] are
designed, intentionally or unwittingly,
to achieve precisely the results they
get.”
…R. Spencer Darling
Human Services are not improving as
fast as problems are changing.
The Nature of Systems
•  Innovative practices do not fare well in
existing organizational structures and
systems (crushed by established routines)
•  Organizational and system changes are
essential to successful use of innovations
–  Expect it
–  Plan for it
Enabling Contexts
Existing System
Effective Innovations
Are Changed to
Fit The System
Existing System Is
Changed To Support
The Effectiveness Of
The Innovation
Effective Innovation
Creating Enabling Contexts
•  Cannot change everything at once (too
big; too complex; too many of them and
too few of us)
•  Cannot stop and re-tool (have to create the
new in the midst of the existing)
•  Cannot know what to do at every step (we
will know it when we get there)
•  Many outcomes are not predictable (who
knew!?)
♦Look for Faulty
Assumptions &
Errors; ♦Make
Needed Changes;
♦Invite System to
Respond
Implementation
Team
Practitioners
Innovations
Children/Families
Practice Policy
Communication Loop
Policy Makers
&
Administrators
Policy Enabled
Practice
“The fault
cannot lie in
the part
responsible
for the
repair.”
Ashby
(1956)
“External” System Change Support
Creating Enabling Contexts
Implementation
Team
Practitioners
Innovations
Children/Families
Practice Policy
Communication Loop
System
Change
Policy Makers
&
Administrators
Policy Enabled
Practice
“The fault
cannot lie in
the part
responsible
for the
repair.”
Ashby
(1956)
“External” System Change Support
Creating Enabling Contexts
Adaptive Challenges
•  Duplication
•  Fragmentation
•  Hiring criteria
•  Salaries
•  Credentialing
•  Licensing
•  Time/ scheduling
•  Union contracts
•  RFP methods
•  Federal/ State laws
Regional Entity
RIT
Municipality
MIT
Local Agency
LIT
Practitioners
Innovations
Beneficiaries
Practice-Policy
Communication Loop
Executive
Management
Team
Policy Enabled
Practice
“The fault
cannot lie in
the part
responsible
for the
repair.”
Ashby
(1956)
“External” System Change Support
Implementation Infrastructure
State and Regional Capacity
Assessment
State Capacity Assessment: Fixsen, Duda, Blase and Horner, 2009
System Reinvention
•  Stop wasting time and money on things
that don’t work (and never have!)
–  Sugai’s Law: For every new initiative, stop
two current ones that have poor outcomes
–  De-scale; Avoid layering and fragmentation
•  Set aside 20% of funds for implementation
•  Require quarterly reports of fidelity data
Implementation Science
A fundamental truth:
•  People cannot benefit from
innovations they do not experience
Formula for Success
Effective
Innovations
Effective
Implementation
Socially
Significant
Outcomes
Enabling
Contexts
Active Implementation
Frameworks
! 
! 
! 
! 
! 
! 
Usable Innovations
Implementation Stages
Implementation Drivers
Improvement Cycles
Implementation Teams
Enabling Change
National Assessment of Education Progress (NAEP)
Leverage Visible Improvements!
Effective
Interventions
Effective
Implementation
Enabling
Contexts
Educationally
Significant
Outcomes
Original and Revised Assessment Formats
Science
to Service
Gap
Implementation
Science
!
  here is sufficient information to
T
support a rapidly evolving science of
implementation
!
  n the verge of creating a virtuous
O
circle where evidence-based
implementation practice improves
implementation science that
improves implementation practice …
GIC May 26-28, 2015
Dublin, Ireland
www.globalimplementation.org
Melissa Van Dyke
Allison Metz
[email protected]
[email protected]
Frank Porter Graham Child Development Institute
University of North Carolina
Chapel Hill, NC
http://nirn.fpg.unc.edu/
www.scalingup.org
www.globalimplementation.org
Implementation
Research:
A Synthesis of
the Literature
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. & Wallace, F. (2005).
Implementation Research: A Synthesis of the Literature. Tampa, FL: University of
South Florida, Louis de la Parte Florida Mental Health Institute, The National
Implementation Research Network (FMHI Publication #231).
HTTP://NIRN.FPG.UNC.EDU
Get Connected!
www.scalingup.org
@SISEPcenter
SISEP
For more on Implementation Science
http://nirn.fpg.unc.edu
www.globalimplementation.org
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