Implementation is a process, not an event. The process is marked by implementation stages that have been identified in practice. To use innovations and Active implementation in practice takes time and effort. Exploration, Installation, Initial Implementation, and Full Implementation Stages guide organization and system investments in innovations supported by implementation science.
Implementation is a process, not an event. The process is marked by Implementation Stages that have been identified in practice and are used to guide organization and system investments in innovations supported by implementation science. To use innovations and Active implementation in practice takes time and effort.
The Stages of Implementation are Exploration, Installation, Initial Implementation, and Full Implementation. The availability of a skilled Implementation Team facilitates the expeditious movement from Exploration to Full Implementation. Without an Implementation Team, organizations and individuals will struggle with what should be predictable issues as well as the many unpredictable issues that always arise as attempts are made to use an innovation in practice. The issues will be there with or without an Implementation Team. The question is, who will resolve stage-based issues effectively and efficiently?
The stages of implementation are not linear. They are additive and interactive with movement back and forth with changes in environments, people, and implementation supports. The stages are specific to an innovation. A given organization might be in the Full Implementation Stage with one innovation and in the Exploration Stage with another. With experience, skilled Implementation Teams can anticipate and prevent issues and help move an innovation to Full Implementation more quickly across innovations within an organization and across organizations. And, organizations can learn to learn (develop “absorptive capacity”) and improve their ability to identify, assimilate, and apply innovations more quickly (Cohen & Levinthal, 1990; Jiménez-Barrionuevo, García-Morales, & Molina, 2011). For example, in the Teaching-Family Model the time for whole organizations to reach site certification (organization fidelity) criteria was reduced substantially while success improved. For Teaching-Family group homes, 23% sustained for 5 years or more without the support of an Implementation Team and 84% sustained for 6 years or more with the support of a site based Implementation Team. And, the time to develop site based Implementation Teams was reduced from 6.4 to 3.7 years as site development processes were operationalized (Fixsen & Blase, 2018; Fixsen, Blase, Timbers, & Wolf, 2007) – a 6 fold increase in benefits to a recipient population. As the site development Implementation Teams gained experience, they were able to anticipate problems and do better Exploration and Installation work with organizations to help them be successful more quickly and with more certainty.
The stages of implementation outlined here are descriptive rather than prescriptive. By describing identifiable stages, Implementation Teams and others can adjust their inputs to match the stage for achieving full, effective, and sustained use of an innovation. Too often, precious time and resources are wasted on trying to insist that organizations and practitioners use an innovation when they have not yet decided it is a good idea (Romney, Israel, & Zlatevski, 2014). Poorly-informed or half-hearted attempts to appear to do what is mandated consume enormous resources and yield few socially significant outcomes.
Exploration Stage activities include shared communication about the strengths and needs of recipients, identification of possible effective innovations that might help fill the gaps in current approaches, assessment of the Implementation Drivers needed to support practitioners and others, discussion of resources required and their sources, and so on. Exploration activities include executive leadership and stakeholders who consider need, risks and risk management, and contextual factors. The result of Exploration is a common understanding and acceptance of the innovation and the required implementation supports, and a collective decision to proceed (i.e. mutually informed agreement).
The Exploration Stage is not just to assess readiness; it is designed to create readiness. Creating readiness for change in individuals and organizations is an important part of the work and effectiveness of Implementation Teams. Prochaska, Prochaska, and Levesque (2001) found that at a given point in time about 20% of individuals and organizations in their studies were “ready for change.” Thus, creating readiness is an essential function for uses of effective innovations and a core activity in the Exploration Stage. Clarifying goals, establishing collaborations, locating and developing resources, securing agreements, and so on are good uses of Exploration Stage discussions.
The functions of the Exploration Stage are a critical starting place for work with organizations, systems, 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).
The function of the Installation Stage is to acquire or repurpose the resources needed to fully and effectively engage in the new ways of work. Resources and activities during Installation are focused on creating new job descriptions, establishing interview methods and preparing interviewers to select practitioners and staff to do the new work, employing people to do the work, developing data collection sources and protocols, establishing access to timely training, preparing a coaching service delivery plan, and so on. While these topics are discussed and debated during the Exploration Stage (promises made), the resources must materialize during the Installation Stage (promises kept).
Because of the changes required, the Installation Stage is replete with adaptive leadership challenges. The attention given to the innovation and implementation supports may lead to dissatisfaction among existing staff members who feel devalued and ignored in the rush to do the new things. Some stakeholders who were enthusiastic advocates during Exploration do not follow through on promises they made. Funders get anxious when funds are being spent and no “real work” with recipients has started. And so on.
Implementation Team members and leaders need to be ready to exercise adaptive leadership to resolve these issues as supports for the new ways of work are being developed. Knowing that adaptive issues abound during Installation and Initial Implementation, Implementation Teams use this as an opportunity to develop the adaptive leadership capacity in an organization and establish the practice-policy communication cycles from the beginning of the process (see Systemic Change). The issues give the Implementation Team and leaders many opportunities to teach, learn, and practice the new ways to provide adaptive and effective leadership in the organization.
A challenge during the Exploration and Installation stages is finding or developing the expertise to use the Implementation Drivers to select, prepare, and support the first group of practitioners. Very few organizations or systems already have a functioning Implementation Team in place. As a result, accessing outside expertise is a good option to get started (Nord & Tucker, 1987). This is the approach Ogden and colleagues used to initiate the use of effective innovations in Norway. Once a program was underway, they recruited “home grown” staff who had been high fidelity practitioners to be the first members of an implementation team (e.g. trainers, coaches, fidelity assessors) to support the next generations of practitioners (Tommeraas & Ogden, 2016). However, very few evidence-based practices or innovations have purveyors (program-specific Implementation Teams) that support the effective use of the innovation. Thus, most organizations and systems are left to “do it yourself” and that approach has not proved to be very effective (C. H. Brown et al., 2014; Durlak & DuPre, 2008; Vernez et al., 2006).
Initial Implementation Stage
The Initial Implementation Stage begins when the first practitioners attempt to use an innovation with recipients for the first time. Active Implementation staff refer to this as the awkward stage where the new ways of work are not comfortable for practitioners, managers, and leaders. It “doesn’t feel right” to interact with others in the new ways and “it is confusing” when the units within an organization are not yet fully functional and integrated. Very few attempts to use innovations are able to successfully negotiate the difficulties encountered during Initial Implementation where the challenges are many, the supports for change are weak, and the inertia of the status quo is strong.
During the Initial Implementation Stage, newly selected practitioners and staff are attempting to use newly learned skills (e.g. the innovation) in the context of an organization that is just learning how to change to accommodate and support the new ways of work. This is a fragile stage where the awkwardness associated with trying new things and the difficulties associated with changing old ways of work provide strong motivations for giving up and going back to the familiar, comfortable, and well supported status quo. The status quo is powerful and resilient and readily bounces back from efforts to change it (Jalava, 2006; Oser, 2000; Zimmerman et al., 1998; Zucker, 1987).
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 Use With and Without an Implementation Team
Full Implementation Stage
The Full Implementation Stage is reached when at least 50% of the practitioners in an organization meet fidelity criteria on a given day. The 50% criterion is a benchmark established by the Active Implementation Research Network as an indicator of Full Implementation. That is, if the goal is to have 20 practitioners use an innovation in an organization, Full Implementation is reached on the day when 10 (50%) of those practitioners are at or above fidelity criteria. It often takes 2 to 4 years to reach Full Implementation when it is achieved at all (C. H. Brown et al., 2014; Brunk et al., 2014; Fixsen et al., 2007; Sabatier, 1986; Swales et al., 2012)
The first time the 50% benchmark is reached is cause for celebration. However, it likely will not be sustained for very long. Once a current high fidelity practitioner leaves it will take a few months for the replacement to be selected, trained, coached, and finally meet fidelity criteria. In the meantime, if that one practitioner was the tipping point for reaching the 50% benchmark then the organization will fall short of the 50% benchmark. If key people on the Implementation Team leave, the Competency Drivers may suffer and it may take longer for practitioners to meet and sustain high fidelity performance. Eventually, for the few organizations that reach and sustain Full Implementation, the new ways of providing innovation-based services become the standard ways of work and the implementation supports become the standard way the organization functions (Fixsen & Blase, 2018). The use of the innovation and the Implementation Drivers becomes the new status quo.
Note that sustaining Full Implementation requires two things: a) it requires using the Implementation Drivers effectively to generate new high fidelity practitioners routinely and b) it requires keeping current high fidelity practitioners employed. If high fidelity practitioners leave faster than new ones can be developed to meet fidelity standards, then the 50% criterion for Full Implementation will never be reached or sustained. The pool is draining faster than it is being filled. The Leadership and Organization Drivers are designed to keep improving supports for practitioners so they can continue to provide high fidelity results for many years, even when doing demanding work (Aarons et al., 2009; Glisson, Schoenwald, et al., 2008; Strouse, Carroll-Hernandez, Sherman, & Sheldon, 2004).
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.