Implementation Defined

Implementation is defined as a specified set of activities designed to put into practice an activity or program of known dimensions.  According to this definition, implementation processes are purposeful and are described in sufficient detail such that independent observers can detect the presence and strength of the "specific set of activities" related to implementation.  In addition, the activity or program being implemented is described in sufficient detail so that independent observers can detect its presence and strength. 

It is common to read about "implementation" of a program or practice as if it were an accomplished fact when the context of the statement makes it clear that some process (more or less clearly described) had been put in place to attempt the implementation of that program or practice.  When faced with the realities of human services, implementation outcomes should not be assumed any more than intervention outcomes are assumed.

When thinking about implementation the observer must be aware of two sets of activities (intervention-level activity and implementation-level activity) and two sets of outcomes (intervention outcomes and implementation outcomes). 

A formula for successful uses of evidence-based programs in typical human service settings can be characterized as:

 

 

The formula for success involves multiplication.  If any component is weak then the intended outcomes will not be achieved, sustained, or used on a socially significant scale.  Like a serum and a syringe, innovations are one thing and implementation is something else entirely different.  Doing more research on a serum will not produce a better syringe; doing more research on an innovation will not produce better implementation methods.

The Active Implementation Frameworks help define WHAT needs to be done (effective interventions), HOW to establish what needs to be done in practice and WHO will do the work to accomplish positive outcomes in typical human service settings (effective implementation), and WHERE effective interventions and effective implementation will thrive (enabling contexts).

Researchers have produced a large number of practices, programs, and other effective innovations.  Many of these are summarized on websites and rated on various dimensions of scientific rigor (e.g. research design, participant selection and retention, effect size of results; http://www.nrepp.samhsa.gov; http://www.colorado.edu/cspv/blueprints/criteria.html). While few of these “evidence-based” innovations meet the criteria for “programs” outlined in this website (e.g. usable interventions), there is considerable evidence regarding WHAT to do to improve outcomes for human services. 

Evidence-based programs are interesting but not much help unless they can be put into practice and produce the same good results in practice that they produced under laboratory conditions.  The Active Implementation Frameworks summarized in this website synthesize the literature and best practices for HOW to make full and effective use of effective interventions in practice.

The identification of Implementation Teams answers the question of WHO does the work of implementation.  The research and evaluation literature has identified practitioner readiness, organization readiness and support, and system variables that facilitate or impede the use of evidence-based programs in practice.  This is important information and begs the question of WHO will assure practitioners and organizations are ready, WHO will help organizations to be supportive, and WHO will help change systems to facilitate hospitable environment WHERE the new ways of work embodied in any innovation can be used fully and effectively.

The Active Implementation Frameworks used by skilled Implementation Teams provide ways to increase the likelihood that the good outcomes achieved in well-controlled studies can be reproduced in the complex conditions that exist in human services and society.  Implementation Teams don’t have to wait for readiness; they can help create readiness by using Implementation Stages and Implementation Drivers.  Implementation Teams don’t have to wait for a champion to appear; they can help organizations and systems change to provide more hospitable environments for effective innovations and for the necessary implementation supports.  Active Implementation “recreates a complex, causally ambiguous set of routines in new settings and keeps it functioning.  The [Implementation Team] gradually hones its ability to manage such a process through experience and repetition" (Winter & Szulanski, 2001; p. 741).

Implementation, diffusion, and dissemination

Clarity is needed regarding popular terms in the field.  Implementation includes difussion but is not defined by it.  Similarly, implementation includes dissemination but is not defined by it.  Diffusion and dissemination focus on the innovation.  Implementation focuses on how to use innovations as intended and achieve the promised results in typical practice settings. 


Diffusion, dissemination, and implementation align with three categories of leadership described by Hall & Hord (1987), three categories of research identified by Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou (2004) in their systematic review of the literature, and three categories of scaling literature summarized by Fixsen, Blase, Metz, & Van Dyke (2013): 

  1. The letting it happen literature is populated with studies of diffusion of information about innovations (Rogers, 1962; 1995).  An outcome of diffusion is adoption of an innovation (i.e. people saying they will use an innovation). 
  2. The helping it happen literature is characterized by studies of the contributions of practitioner and organization readiness, system influences, websites, clinical guidelines, training, and other forms of communication that urge understanding and use of innovations (Brownson, Colditz, & Proctor, 2012).  An outcome of dissemination is attempts to use an innovation in practice (i.e. one or more individuals learn about an innovation and try to make use of that innovation in their work). 
  3. The making it happen literature concerns factors contributing to the uses of innovations as intended (Fixsen et al., 2005).  An outcome of implementation is the actual use of an innovation with good results in practice (i.e. the goal of using an innovation is pursued until the core elements of that innovation are being used and are delivering promised results in practice). 

In their review of the literature, Greenhalgh et al. (2004; p 614) stated: "A striking finding of this extensive review was the tiny proportion of empirical studies that acknowledged, let alone explicitly set out to study, the complexities of spreading and sustaining innovation in service organizations."  A review of the implementation evaluation literature (Fixsen et al., 2005) and best practices (Blase, Fixsen, Naoom, & Wallace, 2005) focused on this “tiny proportion” and contributed to further understanding of how to make it happen.  The resulting Active Implementation Frameworks direct attention to the uses of letting it happen and helping it happen strategies to achieve making it happen results. 

A helpful review of a variety of diffusion, dissemination, and implementation frameworks has been produced by Meyers, Durlak, and Wandersman (2012).


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