Implementation Stages

It is becoming clear that implementation is a process that occurs in discernable stages and that there are common components (Drivers) of successfully implemented programs.  Active implementation methods incorporate best practices related to the Stages of Implementation and Implementation Drivers.  Implementation best practices have been derived from concept mapping and nominal group meetings with those who have been implementing evidence-based programs successfully for several years (Blase et al., 2005).  Implementation Stages and Drivers were established as a result of an extensive review and synthesis of the implementation evaluation literature (Fixsen et al., 2005; Wallace, Blase, Fixsen, and Naoom, 2008).  It should be noted that Stages and Drivers are not linear or separate; each is embedded in the other in interesting combinations.  For present purposes, they will be outlined with the complexity removed.

The Stages of Implementation are Exploration, Installation, Initial Implementation, and Full Implementation (Fixsen et al., 2010).  The Stages are dynamic within organizations such as schools and clinics, moving back and forth among Stages as personnel and circumstances change.  Understanding Stages is important so the work of Implementation Teams can be matched to the Stage of the provider organization.

Exploration Stage

The functions of the Exploration Stage are a critical starting place for work with States, districts, and others.  Taking the time for exploration saves time and money (Romney, 2011) and improves the chances for success (Saldana, Chamberlain, Wang, & Brown, 2011; Slavin, Madden, Chamberlain, & Cheung, 2010).  During Exploration, readiness is assessed by an Implementation Team.  To the extent an organization is not ready the Implementation Team is accountable for helping create readiness, an important function when the goal is to reach an entire population.

Installation Stage

The function of the Installation Stage is to acquire or repurpose the resources needed to do the work ahead.  Selecting staff, identifying sources for training and coaching, providing initial training for staff, finding or establishing performance assessment (fidelity) tools, locating office space, assuring access to materials and equipment, and so on are among the resources that need to be in place before the work can be done effectively (Fixsen et al. 2005; Saldana et al., 2012). During the Exploration Stage Implementation Teams help organizations recognize the need for these resources and during the Installation Stage Implementation Teams help organizations secure the needed resources to do the work ahead and prepare staff for the new practices.

Organization managers often think of evidence-based programs as “plug and play” and are surprised by the need for preparation and resources. Many attempts to use evidence-based programs end at this Stage.  Implementation Teams help provider organizations anticipate these needs and help them prepare for the next Stage.

Initial Implementation

Initial Implementation is the time when the innovation is being used for the first time.

During this Stage, practitioners and staff are attempting to use newly learned skills (e.g., the evidence-based program) in the context of a provider organization that is just learning how to change to accommodate and support the new ways of work.  This is the most fragile Stage where the awkwardness associated with trying new things and the difficulties associated with changing old ways of work are strong motivations for giving up and going back to comfortable routines (business as usual).

The Initial Implementation Stage is a real challenge. Establishing and sustaining changes to the point of integration into daily work is not likely unless there is external support for change at the practice level (support from coaches; Joyce & Showers, 2002), organization level (support from Implementation Teams; Aladjem & Borman, 2006; Nord & Tucker, 1987), and system level (support from Implementation Teams; Schofield, 2004).

Implementation Teams using the Implementation Drivers are essential to success (80% vs. 14%; Fixsen, Blase, Timbers, & Wolf, 2001; Balas & Boren, 2000) during the Initial Implementation Stage.  Implementation Teams help to develop the staff competencies required by the evidence-based program, help administrators adjust organization roles and functions to align with the program, and help leaders in the provider organization fully support the process of using the program and incorporating the necessary implementation supports.

Comparison of Intervention Effect With and Without an Implementation Team

 

Full Implementation

Full Implementation is reached when 50% or more of the intended practitioners, staff, or team members are using an effective innovation with fidelity and good outcomes.  For example, if there are 10 practitioners who are attempting to use an innovative approach for Dialectical Behavior Therapy, 5 of the therapists would need to be using the innovation as intended as measured by a performance assessment.  Full Implementation is difficult to achieve and sustain without the necessary implementation supports described herein (Fixsen, Blase, Timbers, & Wolf, 2001; U.S. Department of Education, 2011).

In the Full Implementation Stage the new ways of providing services are now the standard ways of work where practitioners and staff routinely provide high quality services and the implementation supports are part of the way the provider organization carries out its work.  Implementation Teams remain essential contributors to the ongoing success of using the evidence-based program.  Practitioners, staff, administrators, and leaders come and go and each new person needs to develop the competencies to effectively carry out the innovation and its implementation supports.  Managers and administrators come and go and need to continually adjust organizational supports to facilitate the work of practitioners.  Systems continue to change and impact organizations and practitioners.  Evidence-based programs continue to be developed and programs already in place continue to be improved.  The number of variables and complexity of issues probably qualify as “wicked problems” as described by Rittel and Webber (1973).  The work of Implementation Teams is to ensure that the gains in the use of effective practices are maintained and improved over time and through transitions of leaders and staff.

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