1. Translating Aspiration to Operation: Developing Active Implementation Capacity and Infrastructure W. Oscar Fleming; MSPH Tuesday, September 29 th 2:30-4:00pm (repeat 4:15 – 5:30pm).

2. Agenda 1.Orientation to Implementation Science 2.Introduction to the Active Implementation Frameworks 3.Reflection and Action Planning Objectives: Participants will: Learn the definition and purpose of implementation science. Understand and apply the Active Implementation to contextually relevant Title V opportunities. Plan for further learning & action in support of local Title V programs. 2

3. Methodology Brief content review Individual and Small group Application Group reflecting and discussion

4. Introduction & Affiliations MCH Workforce Development Center offers: State and territorial Title V leaders training, collaborative learning, coaching and consultation in implementing health reform. Cutting edge tools and techniques No Cost to States/Territories http://mchwdc.unc.edu/ National Implementation Research Network (NIRN) provides technical Assistance and collaborative research to… Advance the science of implementation across human service domains. Inform policies that promote implementation science and best practices in human services. Ensure that the voices and experiences of diverse communities and consumers influence and guide implementation efforts. http://nirn.fpg.unc.edu/

5. Definition Implementation: A specified set of activities designed to put into practice an activity or program of known dimensions 1

6. Why it Matters Women, children and families do not benefit from interventions they do not receive. Developing and identifying evidence-based/informed programs and practices has improved significantly… The science and practice of Implementing these programs with fidelity, in real-world settings, has lagged behind… …but the science is emerging rapidly

7. Evolution of the Science Letting it happen – Diffusion; networking; communication Helping it happen – Dissemination; manuals; websites Making it happen – Purposeful and proactive use of implementation practice and science

8. System: Policy and Infrastructure Organizational Leadership Site Leadership Providers Constituents External Supports Systems Context Funding Policy Culture History Economy Know How

9. A word on Evidence… Implementation is at the nexus of evidenced-based practice and practice-based evidence. Evidence can be co-created Regardless of what you are working with, the implementation science can inform what you do and how you do it

10. Contextualize Have in mind an NPM and related programs you are considering as we work through the Active implementation Frameworks

11. Effective Interventions Effective Implementation Enabling Contexts Significant Outcomes Implementation Equation

12. Active Implementation Frameworks Frameworks Usable Interventions Stages Teams Drivers Improvement Cycles

13. The “How” Implementation Stages: Describe and guide how the work unfolds over time. Implementation Drivers: Identify the capacity and infrastructure linked to effective intervention delivery across the stages. Effective Implementation StagesDrivers

14. ExplorationInstallation Initial Implementation Full Implementation 2-4 Years Implementation Stages Stages

15. Applied Exploration

16. Pulse Check Discuss: – How will you gather the necessary information to compare and contrast alternative programs? – Who will be involved? Capture: – What are your next steps? Stages

17. The “Who” Implementation Teams: Integrate the use of implementation stages, drivers and improvement cycles to support the implementation, sustainability, and scale- up of usable interventions Teams “MAKE IT HAPPEN ” Effective Implementation

18. Site Implementation Team Regional Implementation Team State Implementation Team State Implementation Team Implementation Teams have… -Competencies Know the Interventions/Programs Know and apply Implementation Science (e.g. AI Frameworks) Facilitate Organization and Systems Change –Minimum of three people four or more preferred Teams Implementation Teams

19. EFFECTIVE INTERVENTIONS YESNO 80% 3 Years 14% 17 Years EXPERT IMPLEMENTATION TEAM? Implementation Teams (Balas & Boren, 2000; Green, 2008) (Fixsen, Blase, Timbers, & Wolf, 2001) (Saldana & Chamberlain, 2012) Evidence

20. Imp. ComponentTime 1Time 2Time 3 Selection1.442.00 1.89 Training1.331.50 1.10 Coaching1.271.73 1.83 Fidelity Assessment0.781.34 2.00 DSDS0.181.36 2.00 Fac. Administration1.382.00 Systems Intervention1.291.86 2.00 Average Composite Score 1.11.68 1.83 Fidelity (% of cases) 18%83% Metz, et al. (2013). Stages, Drivers, & Teams Evidence Teams

21. Pulse Check Discuss: – Who can be engaged in an Implementation Team to support more effective intervention selection, preparation, delivery and improvement? Capture: – What’s your next step? Teams

22. All too often…

23. The “What” Neither “Rigorous evidence” for evidence-based/informed interventions nor promising results from emerging practice is enough… Interventions must be teachable, learnable, doable, assessable, and repeatable in practice Effective Interventions

24. The “What” 1.Clear Description of the program  Philosophy, values, principles  Inclusion – exclusion criteria 2.Identified Core Components (aka, active ingredients, essential functions) 3.Operational Definitions of core intervention components (what practitioners do, say) 4.Practical Fidelity Assessment Operational Definitions Clear Description Performance Assessment Essential Functions Usable Interventions

25. Pulse Check Discuss: – How could you use the Usable intervention criteria in the context of developing your local strategies? Capture: – What’s your role? What could you do differently?

26. The “How” Implementation Stages: Describe and guide how the work unfolds over time. Implementation Drivers: Identify the capacity and infrastructure linked to effective intervention delivery across the stages. Effective Implementation StagesDrivers

27. ExplorationInstallation Initial Implementation Full Implementation 2-4 Years Implementation Stages Stages

28. Fidelity Assessment Coaching Training Selection Systems Intervention Facilitative Administration Decision Support Data System Competency Drivers Organization Drivers Leadership Drivers Consistent Uses of Innovations Reliable Benefits Integrated & Compensatory Implementation Drivers Effective Implementation

29. Competency Drivers  Build provider confidence and competence to deliver intervention with fidelity – Selection – Training – Coaching – Fidelity Assessment

30. Organizational Drivers  Align organizational and system resources to support high fidelity delivery -Decision Support Data System -Facilitative Administration -Systems Intervention

31. Leadership Drivers Promote Active Implementation – Communicate importance of effective implementation methods Support Learning – Encourage learning from success and failure Respond appropriately – Recognize adaptive from technical challenges Sustain Attention & Resources – Keep goals in focus and resourced

32. ExplorationInstallation Initial Implementation Full Implementation Assess needs Examine intervention components Consider Implementation Drivers Assess fit Assess needs Examine intervention components Consider Implementation Drivers Assess fit Acquire Resources Prepare Organization Prepare Implementation Drivers Prepare staff Acquire Resources Prepare Organization Prepare Implementation Drivers Prepare staff Activate Data Systems Manage change Strengthen Implementation Drivers Initiate Improvement Cycles Activate Data Systems Manage change Strengthen Implementation Drivers Initiate Improvement Cycles Achieve and improve Fidelity and Outcomes Monitor & manage Implementation Drivers Achieve and improve Fidelity and Outcomes Monitor & manage Implementation Drivers Drivers and Stages Together Effective Implementation 2-4 Years

33. Drivers Assessment A comprehensive evaluation model of a practice/program measures the following: ImpactFidelity CapacityScale How well are we implementing Project XYZ’s critical components as intended? How many communities are implementing Project XYZ? And what is their current stage of implementation? How well are we using evidence-based implementation processes to support the use of the Project XYZ model? How are intended outcomes improving?

34. Drivers Assessment ImpactFidelity CapacityScale How well are we using evidence-based implementation processes to support the use of the Project REACH model? Drivers Best Practices Assessment measures the capacity of local sites to implement evidence-based programs.

35. Drivers Assessment Composite Scores for each Driver: – Assign values to “in place” (2), “partially in place” (1), and “not in place” (0) – Add values together – Divide the total value by the number of items in each scale

36. Pulse Check Discuss – Which drivers need more attention in your context? Capture: – What are your next steps?

37. Quality Improvement “Getting Started, Getting Better” Rapid Cycle Improvement Usability Testing Practice Policy Feedback Loops Enabling Contexts

38. Form Supports Function Policy Practice Do External Implementation Support Policy Practice Structure Procedure StudyAct Practice Informs Policy Policy Enables Practice Plan Practice Policy Feedback Loops Quality Improvement

39. Pulse Check Are robust practice policy feedback loops in place? What’s your role? What could you do differently? Teams

40. Discussion

41. Oscar Fleming Oscar.fleming@unc.edu http://nirn.fpg.unc.edu/ www.globalimplementation.org http://implementation.fpg.unc.edu/ Additional Resources Website: http://mchwdc.unc.edu/ Website: http://www.amchp.org 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). Implementation Research: A Synthesis of the Literature

42. Health Resources and Services Administration (Maternal and Child Health Workforce Development Center) Annie E. Casey Foundation (EBPs and Cultural Competence) William T. Grant Foundation (Implementation Literature Review) Substance Abuse and Mental Health Services Administration (Implementation Strategies Grants; National Implementation Awards) Centers for Disease Control & Prevention (Implementation Research) National Institute of Mental Health (Research And Training Grants) Juvenile Justice and Delinquency Prevention (Program Development And Evaluation Grants) Office of Special Education Programs (Scaling up and Capacity Development Center) Administration for Children and Families (Child Welfare Leadership; Capacity Development Center) The Duke Endowment (Child Welfare Reform) Recognition

43. ©Copyright Oscar Fleming, Dean Fixsen and Karen Blase This content is licensed under Creative Commons license CC BY-NC-ND, Attribution-NonCommercial- NoDerivs. You are free to share, copy, distribute and transmit the work under the following conditions: Attribution — You must attribute the work in the manner specified by the author or licensor (but not in any way that suggests that they endorse you or your use of the work); Noncommercial — You may not use this work for commercial purposes; No Derivative Works — You may not alter or transform this work. Any of the above conditions can be waived if you get permission from the copyright holder. http://creativecommons.org/licenses/by-nc-nd/3.0