Implementation Team Activities

Active Implementation Stages, Drivers, and Improvement Cycles are carried out by skilled individuals with the expertise to help individuals, organizations, and systems negotiate the uneven path to successful use of evidence-based programs and other innovations.  WHO helps organizations successfully negotiate the Stages of Implementation!  WHO provides the selection, training, coaching, evaluation, and administrative support services at an implementation site?  WHO intervenes with larger systems when needed?  Will this be done by people inside the organization or contracted to individuals or groups outside the implementation site?

The literature is not always clear about the activities of an Implementation Team.  For example, the Quantum Opportunity Program (Maxfield, Schirm, & Rodriguez-Planas, 2003) was implemented in several sites in a major, multi-state test of the program.  The report of the findings simply noted that the originators of the program had received funding to provide technical assistance to the implementation sites.  Given the uneven results, it is unfortunate that there was no link back to Implementation Team activities.

In other cases, the "Implementation Team" is not so readily identified nor are the activities well described.  For example, the Assertive Community Treatment program and the Wraparound approach seem to have several individuals who act as consultants to communities and agencies interested in adopting those programs.  The Wraparound group has recognized the problem of multiple definitions of their approach being used by different Implementation Teams and have formed a national association to develop a common definition of the approach and a common set of processes for assessing the fidelity of new implementation sites (Bruns, Suter, Leverentz-Brady, & Burchard, 2004; Bertram, Suter, Bruns, O’Rourke, 2012).

Nevertheless, in all of these instances, an Implementation Team works in more or less organized ways with the intention to implement a specified practice or program at a particular location.  Over the years an Implementation Team also has been described as a “change agent” (Fairweather et al., 1974; Havelock & Havelock, 1973), "linking agent" (Kraft, Mezoff, Sogolow, Neumann, & Thomas, 2000), "program consultant" (Gendreau et al., 1999), and "site coordinator" (Blase et al., 1984).

Multisystemic Treatment

Implementation sites using Multisystemic Therapy participate in a complex mix of implementation drivers.  Practitioners in new Multisystemic Therapy implementation sites are selected by the implementation site based on MST Services, Inc. criteria, trained by MST Services, Inc. at a central location in South Carolina, coached by local consultants who are trained and coached by MST Services, Inc. consultants, evaluated via monthly submissions of fidelity results to the MST website, and administratively supported by the implementation site (Schoenwald et al., 2000).  At least initially, interventions in larger systems issues (referrals, funding streams, interagency collaboration) are carried out jointly by MST Services, Inc. and the implementation site.

Multidimensional Treatment Foster Care

For Multidimensional Treatment Foster Care (MDTFC), the implementation site identifies a core group to be trained (an administrator, supervisor, therapist, and a foster-parent trainer/recruiter) in a 3-day training session in Oregon that includes training and exposure to the important aspects of a fully-operational program (Chamberlain, 2003).  Next, two trainers from Oregon go to the implementation site to train the first cohort of foster parents, conduct additional training with the core staff group, and introduce them to the parent daily report (PDR) web site.  After youths are placed in the foster homes, the Oregon staff monitors the PDR data, and the Oregon staff provide weekly telephone consultation to the program supervisor and therapist.  During the first year of implementation, the Oregon staff provide 3 additional 2-day training sessions at the implementation site.

Tool Kits

A similar hybrid system for providing implementation drivers is used with the adult mental health "tool kits" (Drake et al., 2001; Bond, et al., 2001; Mueser, Torrey, Lynde, Singer, & Drake, 2003). Although not as organized and purposeful as MST Services, Inc. or MDTFC, adult tool kit practitioners are selected by the implementation site, trained at the implementation site by contracted trainers, supervised by the implementation site with (usually) telephone consultation from a contracted expert in the adult mental health program, perhaps evaluated by the implementation site, and administratively supported by the implementation site.

Nurse-Family Partnership

The Nurse-Family Partnership (Olds, 2002; Olds, Hill, O'Brien, Racine, & Moritz, 2003) has formed the National Center for Children, Families, and Communities to replicate their program in new communities.  As the Implementation Team of the Nurse-Family Partnership, the National Center works with communities to assure that sufficient capacity exists to carry out the program with fidelity and sustain it over time.  The Implementation Team works with the community to assure adequate need, consensus that the program will benefit the community, and that the program is a good fit with the community and the host organization.  A detailed program implementation plan is negotiated with the community and organization (re: client and staff recruitment, space and technological support for staff, organizational policies and operating culture, coordination and fit with other early intervention services, and funding).  Funding is scrutinized to assure that it is sustainable, allows for the full range of services to infants and mothers (health, parenting, life course), is a case rate (not per visit), and is sufficient to attract and retain skilled nurse visitors. The plans are put into a contract and signed by all parties.  An implementation site begins with a minimum of 4 full-time nurse visitors and a supervisor.  Selection of nurses is based on a minimum BSN degree and "basic personal qualifications" to do the work.  Staff training is done by the Implementation Team with a thorough orientation to the program and training on guidelines and techniques.  Supervisors are trained as well.  Training is conducted over 18 months with different modules designed to coincide with the developmental stages of infants and toddlers encountered by a Nurse in his or her first group of families.  Program evaluation and quality improvement are assessed via the Clinical Information System, a web-based system designed to collect data on a set of outcome variables for every family.  Data are used to assess progress at new sites and used to inform feedback and corrective action for each site.  Data also are used to change the program itself to make it more usable and effective, and used to assess how data from "typical applications" differ from the randomized clinical trials.  Implementation Teams consult with implementation sites monthly via phone calls to discuss program management, community coordination, funding, and any issues with the services being provided.  Implementation Teams also intervene in systems at local and state levels to assure adequate funding and support for the program over time.

Use of Intermediary Organizations

In these systems, the ongoing operations of an implementation site are always tied to the work of outside contractors.  While these hybrid systems probably retain the compensatory benefits discussed above, ongoing integration of functional treatment components and implementation driver functions may be difficult to achieve and maintain over the years.

A different approach is to develop regional implementation sites that have the full capacity to provide all of the core implementation components within their own organization (these are sometimes called "intermediary organizations").  For example, in the Teaching-Family Model, staff members employed by an implementation site are specially trained to provide selection, training, coaching, evaluation, facilitative administration, and systems interventions for treatment group homes within easy driving distance (Blase et al., 1984; Wolf et al., 1995).  In this approach, each implementation site becomes the source of its own core implementation components without continuing reliance on outside contractors.  For these implementation sites, fidelity is measured at the practitioner level to assure competent delivery of the core intervention components and measured at the implementation site level to assure competent delivery of the core implementation components (see section on fidelity below).  Implementation Teams of Functional Family Therapy also work to develop self-sufficient implementation sites (Sexton & Alexander, 2000) and MST Services, Inc. develops "network partners" to provide training and support services at a more local level.