Organization Drivers

Decision Support Data System

The name of this driver says it all: use data to drive decision making at every level within an organization.  Typically, organizations have data on finances and compliance-oriented variables so that they can maintain and increase services and funding.  Funders require careful collection and entry of financial information with regular internal and external audits to assure accuracy and validity.

It also is typical that the data most useful to support the full and effective use of innovations in organizations are not available.  While more organizations have data on intended outcomes, it still is rare to find organizations that have data on how skillfully and respectfully practitioners actually deliver intended services.  A systematic review of Lean improvement applications in health revealed few consistent measures of practitioner behavior and little use of data to improve whole organizations (D’Andreamatteo, Ianni, Lega, & Sargiacomo, 2015).  Yet, if practitioners don’t deliver services as intended then outcomes likely will not improve as intended.

A word of caution about the use of data and the difference between assessment of and accountability for outcomes.  Active Implementation includes collecting and using data for feedback and improvement.  To be useful, data-based feedback is always constructive and supportive.  For example, fidelity is an assessment of practitioner performance and data regarding a practitioner is promptly fed back to the practitioner so she can see the results.  Accountability for improving fidelity resides with the Implementation Team that provides training and coaching to develop practitioner competencies.  Perhaps coaching frequency needs to be increased or needs to focus on neglected dimensions of a practitioner’s use of an innovation.  Perhaps other team members need to join a session or two to assess how well the coach is providing coaching support.  In any case, accountability for improving fidelity rests with the implementation team and facilitative administrators.  Data are used to improve support; never to levy sanctions.

If for some reason the Implementation Team is not able to provide the needed support, accountability for Implementation Team performance resides with leadership in the organization.  And, if leadership is not able to provide needed support, then accountability shifts upward via the system intervention driver.  Practitioners produce the benefits an organization is expected to (paid to) produce.  Other staff (Implementation Team members, leaders, administrators, members of the Board of Directors, system administrators) are accountable for supporting practitioners so they have the knowledge, skills, and abilities and other support they need to do their job as effectively and efficiently as possible.  Accountability for practitioner performance rolls uphill.

Decision Support Data Systems are an important part of continuous quality improvement for interventions, implementation supports, and organization functioning (e.g. used as the “study” part of the never-ending plan-do-study-act cycle).  Implementation Teams help organizations establish and evolve their data systems so information is immediately accessible and useful to practitioners, trainers, coaches, and managers for short-term and long-term planning and improvement at clinical and organizational levels.

Human service organizations and systems are dynamic, so there is ebb and flow to the relative contribution of each component to the overall outcomes (e.g. Panzano, Seffrin, Chaney-Jones, Roth, Crane-Ross, Massatti, et al., 2004).  The decision support data system feedback loops appear to be critical to keeping an evidence-based program “on track” in the midst of a sea of change.  If the feedback loops (staff performance evaluations and decision support data systems) indicate needed changes, then the organization adjusts the integrated system to improve effectiveness and efficiency.

Facilitative Administration

Facilitative administration sometimes is confused with the leadership drivers.  While there are similarities, the difference is leaders are the executive staff who can change structures, roles, and functions within an entire organization and who regularly interact with other organizations, systems, and community groups outside the organization.  On the other hand, administrators and managers have more limited authority and can change roles, functions, and operating procedures in one or more sub-units within an organization. While individuals may, at times, be administrators and leaders, for implementation purposes the roles and functions are distinct.

Facilitative administrators look for ways to support practitioners’ use of an innovation.  Any impediment to achieving and sustaining high fidelity use of an innovation is the concern of facilitative administrators.  In their study of health providers, Foote and Town (2007, p. 1640) found that, “Contractors lack the infrastructure to manage implementation of advances in EBM [evidence-based medicine], especially when the process of change is administratively complex (e.g. assuring relevant information/ data; aligning policies, practices, and incentives; providing education and support for changes).”  The lack of facilitative administration is an impediment to using innovations with fidelity and good outcomes.  Facilitative administrators reduce barriers in order to facilitate the direct service to recipients and ensure that paperwork is both minimized and functional. In addition, resources and supports are created to ensure that the implementation drivers (e.g. selection, training, coaching) are fully developed, utilized and improved over time. Such issues as practitioner workload, safety, remuneration, communication, and feedback are proactively addressed by the administration to the satisfaction of the practitioners and ultimately to the benefit of the children, adults and family members receiving services.

In well-run organizations managers also may be coaches.  In that case, the role of a manager representing the organization needs to be separated from the role of a coach representing the full and effective use of an innovation.  This has worked well in programs where conveying management messages is done in one meeting (e.g. the latest on travel reimbursement rates, new forms for documenting admissions and departures, new schedule for holidays, revised emergency procedures) and coaching is done in separate individual meetings.  Managers are careful to maintain trust and do not use the more personal and detailed information gained from coaching visits as a reason for making management decisions about a given practitioner.

Facilitative administrative support is proactive, vigorous and enthusiastic attention by the administration to reduce implementation barriers and create an administratively hospitable environment for practitioners. In an organization that ‘hosts’ an evidence-based program or practice, facilitative administration includes internal policy analyses and decisions, procedural changes, funding allocations and a culture that is focused on what it takes to implement with fidelity and good outcomes.

Systems Intervention

Not all performance and implementation problems can be solved within an organization.  There are many licensing rules and regulations, requirements that accompany funding, professional accreditation standards, referral issues, state and federal laws and mandates, and so on.  Any of these may impinge on the ability of an organization to assure the full and effective use of an innovation and reliably realize the intended benefits.  It is incumbent on leaders within an organization to work with groups and individuals external to an organization to clear away barriers and strengthen facilitators.  System barriers are common when innovations are being attempted for the first time.  System intervention is to be expected and planned for from the beginning and is an important role for leaders within an organization.

Some issues may be resolved readily.  Others may take a few years.  The important thing is for the leaders to persist until any key issue is resolved.  In the early days of the Teaching-Family Model, regulations were encountered regarding the staffing of a group home.  Several states required a certified social worker to be the director of a licensed group home.  In Teaching-Family homes, the Teaching-Parents are the directors and they are the staff along with an Assistant Teaching-Parent; being a social worker was not part of the selection criteria.  In these cases, Teaching-Family Site staff (implementation team members) convened meetings with state licensing and regulation staff, described the program and the outcomes, and outlined the training, coaching, and certification (fidelity) assessments for Teaching-Parents.  In every case, state regulators granted exceptions for licensing Teaching-Family Model group homes that met these conditions.

Implementation teams supporting other programs have offered similar examples and learned to convene meetings with funders and regulators before beginning work in a state or other jurisdiction.  The Behavior Tech company that supports the use of Dialectical Behavior Therapy (DBT) negotiates acceptable payment rates with insurance companies before providing training for any therapists to work in a state.  The MSTS group that supports the use of Multisystemic Therapy negotiates acceptable referral methods and payment rates before developing a MST team in a jurisdiction.  Using Nominal Group Processes to structure meetings with a variety of purveyors of evidence-based programs, the results showed that over 1/3 of all system intervention activities occurred during the Exploration Stage of implementation then continued throughout the process of using effective innovations for the first time.  For innovations that do not have the support of experienced purveyors like Behavior Tech and MSTS who resolve many issues during the exploration process, the only choice for others is to encounter systemic problems then reactively use the system intervention driver to rectify those problems.

Systems are designed to support current organizations that produce current results.  Innovations and the use of Active Implementation supports are disruptive to the status quo and systems interventions continue long after Full Implementation is reached for any organization.  The methods to convene and intervene in system issues outside an organization are discussed more fully in the section on the leadership driver.

Systems intervention requires attending to multi-level alignment, maintaining leadership and focus, creating and staying connected to champions, intervening to change policies and funding contingencies, and remaining vigilant at local, state and federal levels for both windows of opportunity and threats to fidelity and sustainability are all fertile arenas for systems intervention. Leadership and responsibility for this systems alignment function must be clearly articulated at each level and with an overall structure to support the communication within and among these levels.