Effective implementation supports for the use of effective innovations are new ways of work that are not part of the status quo. Systems must change and new structures, roles, and functions must be established to sustain and improve outcomes over time. The goal is not just to change a system one time but to establish an enabling context for producing socially significant outcomes for whole populations.
For implementation and scaling the goal is not just to change a system one time to establish an enabling context for implementation and innovations. As noted by Weick (1987, p. 119), “People need to see that inertia is a complex state, that forcefield diagrams have multiple forces acting in opposed directions, and that reliability is an ongoing accomplishment. Once situations are made reliable, they will unravel if they are left unattended.” Because of the continuing “multiple forces acting in opposed directions” an additional goal is to develop and embed in systems the capacity for continual change (Zahra & George, 2002) so that future innovations can be incorporated and supported readily – “an ongoing accomplishment.”
While the need for systemic change is widely acknowledged, there are few examples based on practice. The Active Implementation Systemic Change framework is the product of extensive reviews of the literature, examination of examples of system change efforts, and learning from doing the intensive and purposeful work to change large systems. Some examples of documented experience and data related to systemic change are accumulating (Fixsen et al., 2013; Foege, 2011; Folker & Lauridsen, 2017; Glennan Jr. et al., 2004; Huaynoca, Chandra-Mouli, Yaqub Jr, & Denno, 2013; Khatri & Frieden, 2002; J. A. Klein, 2004; Kotter, 1996; Morgan & Ramirez, 1983; Nord & Tucker, 1987; Omimo et al., 2018; J. M. Prochaska et al., 2001; Schofield, 2004; Tikkanen, Pyhältö, Soini, & Pietarinen, 2016; Vernez et al., 2006). The purposeful Active Implementation work in systems has led to the development of systemic change methods that are teachable, learnable, doable, assessable, and scalable in practice (Fixsen, Ward, Jackson, et al., 2018; Ryan Jackson et al., 2018). The goal is to assure that the structures, roles, and functions within a system are more enabling than hindering in their impact on the services provided and the degree to which socially significant outcomes can be achieved.
“If you do what you’ve always done ….”
It is a truism that all organizations and systems are perfectly designed to achieve exactly the results they obtain. This statement does not impute intention to the design of human service systems (Barber & Fullan, 2005; Greenhalgh et al., 2009; Ulrich, 2002). Quite the contrary. Human service systems are legacy systems that are the product of “decades of quick fixes, functional enhancements, technology upgrades, and other maintenance activities [that] obscure application functionality to the point where no one can understand how a system functions” (Ulrich, 2002; p 41-42). Legacy systems represent a layered history of well-intentioned but fragmented change efforts.
The cumulative nature of current (legacy) systems means that it is futile to objectively analyze “how they work” as a prelude to systemic change. The best way to know a system is to engage in changing the system. It is only then that the complex and unplanned linkages, informal communication channels, and ghostly ways of work start to appear as facilitators and barriers to change. And, once the system is engaged in a change process it responds and changes in ways that could not be predicted in advance.
System change is initiated when an innovation is introduced to solve a serious problem identified during the Exploration Stage. In their study of system change, Svensson, Tomson, and Rindzeviciute (2017, p. abstract) conclude that “The analysis demonstrates the ways in which the resources needed to perform institutional work are created through the enactment of practice, and through the application of resourcing techniques.”
Change the status quo
The “enactment of practice” is the essence of initiating systemic change. As shown on the left side of Figure 1, when effective innovations and effective implementation are introduced into a system, they disturb the status quo and disrupt existing ways of work. When the status quo is disturbed, “local change typically has to fight significant organizational inertia and seldom survives continual attacks from the organization at large” (J. A. Klein, 2004). In the absence of purposeful systemic change methods, legacy systems sustain the status quo and adapt key features of innovations to fit the usual ways of work in the system (put new names to current ways of work). Effective innovations that are not used as intended (with fidelity) in practice have no chance to produce the intended outcomes.
Figure 1. The status quo is powerful and the existing system typically changes (adapts) key features of effective innovations to fit the existing system. Enabling Contexts are created when the existing system is changed to support high fidelity and sustained use of effective innovations.
As shown on the right side of Figure 1, the task is to use effective innovations with fidelity then discover all the ways in which staff behavior, organization units, and system supports need to change so that the innovation can be used unimpeded by the old status quo routines. Systemic Change in the Active Implementation Frameworks is based on best practices and the best available evidence. Examples of data and documented experience related to systemic change are provided by Fixsen, Blase, Metz, and Van Dyke (2013); Glennan Jr., Bodilly, Galegher, and Kerr (2004); Khatri and Frieden (2002); Klein (2004); Kotter (1996); Morgan and Ramirez (1983); Nord and Tucker (1987); Prochaska, Prochaska, and Levesque (2001); Schofield (2004); and Vernez, Karam, Mariano, and DeMartini (2006).
Systemic Change framework
The approach to Systemic Change is illustrated in Figure 2. Executive Management Teams (federal, state, regional) establish policies and regulations intended to improve practices and improve outcomes for recipients of human services. The task of accomplishing change is delegated to an Implementation Team that has the expertise to make full and effective use of the Active Implementation Frameworks to support practitioners learning, using, and sustaining an innovation with fidelity that results in good outcomes for recipients.
The development of expert implementation teams and the full and effective use of the Active Implementation Frameworks and innovations in practice disturb the status quo. Kalita, Zaidi, Prasad, and Raman (2009, p. 57) note “there is a strong need for trained, motivated, empowered and networked health personnel. It is precisely at this level that a lack of technical knowledge and skills and the absence of a supportive network or adequate educational opportunities impede personnel from making improvements.” Thus, the first task is to begin using the effective innovation with the support of effective implementation in the form of an expert and experienced implementation team. This allows engagement with the system to discover how this unique system currently works and what needs to change.
Figure 2. The approach to Systemic Change.
Role of Implementation Teams
The development of expert Implementation Teams and the full and effective use of the Active Implementation Frameworks and innovations in practice disturb the status quo. When engaged in Systemic Change, reactions from individuals and groups who are impacted by the change process are to be expected. To cope with these reactions, the Implementation Team has frequent communication with the Executive Management Team so the leaders can constructively intervene, clear barriers, and strengthen facilitators. In this way, legacy systems are changed in functional ways and innovations are not crushed by the already established routines that sustain the status quo (Nord & Tucker, 1987).
Practice-policy communication cycle
The practice-policy communication cycle is the timely communication from the practice level to the policy level to inform policymakers of the intended and unintended consequences of their policies and guidelines. The “cycle” is completed as the policy makers create and improve polices and see the results that enable the full and effective use of innovations. The cycle continues as those changes are further evaluated for impact and improvement or are deemed functional enough to be embedded in policies and guidelines. With the Practice-Policy Communication cycle in place and Implementation Teams functioning as sensors of alignment and misalignment at the practice level, the Executive Management Team has the ability to continually “monitor and question the context in which it is operating and to question the rules that underlie its own operation” (Morgan & Ramirez, 1983, p. 15).
The purpose of the “External” System Change Support shown in Figure 2 is to facilitate the use of the Active Implementation Systemic Change processes. “External” is in quotes because there are ways to have individuals already within an organization perform the external facilitation role. “Outsiders within” (Klein, 2004) can function as “paradoxical managers” (Crom, 2007) who are excused from standard roles and functions and given authority to consider changes in standard organization structures, roles, and functions so that innovations can be incorporated and outcomes improved.
Disturbing the status quo creates a chaotic context (Snowden & Boone, 2007) that demands rapid responses to issues as they arise. The Executive Management Team must be prepared for frequent (weekly, monthly) communication from the front line and be prepared to engage in constructive problem solving with constituents within and outside the system. As roles, functions, and structures are strengthened and barriers are eliminated, coherence is created as system components and resources are aligned with system goals and intended outcomes. The Practice-Policy Communication Cycle is the timely communication from the practice level to the policy level to inform policymakers of the intended and unintended consequences of policies and guidelines. The “cycle” is completed as the policy makers create and improve polices that enable the full and effective use of innovations. The cycle continues as those changes are further evaluated for impact and improvement, or are deemed functional enough to be embedded in policies and guidelines.
An intended outcome of disturbing the system is to provide leaders with opportunities to design new system roles, functions, and structures – in essence, develop a new system on purpose. A system developed on purpose can be changed on purpose in the future. Using the Systemic Change processes, the resulting roles and functions of units are known and the relationships among units are known. With the Practice-Policy Communication feedback loop in place and Implementation Teams functioning as sensors of alignment and misalignment at the practice level, the Executive Management Team has the ability to continually “monitor and question the context in which it is operating and to question the rules that underlie its own operation” (Morgan & Ramirez, 1983, p. 15).
In human service systems, services cannot be shut down, reconfigured, re-skilled, and restarted in some new and hopefully more effective mode. The requirement to develop an Enabling Context in the midst of continuing to operate a legacy system adds yet another degree of complexity to attempts to purposefully change systems.
To prevent change leaders and external facilitators from being overwhelmed by systemic issues that need to be resolved, systems change is initiated in a Transformation Zone (Fixsen, Blase, & Van Dyke, 2012). A Transformation Zone is a vertical slice of the entire system from the practice level to the policy level and includes all major levels within the system. The slice is big enough to encounter nearly all the issues that likely will arise in system change, and small enough to keep issues at a manageable level until the beginnings of the “new system” are established and functioning well.
A Transformation Zone is the place to develop the features of a “high reliability system” (Weick, 1987). According to Weick, high reliability systems start with a centralized structure where a set of core values, decision premises, and assumptions are developed and operationalized so that people can understand, buy into, and engage in new ways of work. Doing system change work in a Transformation Zone has the advantages noted for “continuous delivery” (Humble & Farley, 2011) where enabling system components are developed and tested in real time allowing effective functions, roles, and structures to be established and errors to be quickly detected and corrected in daily practice.
As work progresses in the Transformation Zone, a coherent system is established as the improvement cycles are used to develop supports for effective implementation of effective innovations. A coherent system reduces reliance on managerial authority, formal rules and procedures, and narrow divisions of work. A purposefully designed system, once established, creates a coherent and aligned set of working assumptions and decision premises that produce high levels of fidelity that rely on practical and reliable data systems to generate data for improvement and sustainability. By developing Implementation Teams that assure the availability of effective implementation supports in a system, Executive Management Teams can delegate responsibility and accountability far down the hierarchy in a task-driven, process-sensitive, outcome-oriented organization (Beer, Eisenstat, & Spector, 1990). Implementation Teams help fulfill the promise made by Elmore (2002): “For every increment of performance I demand from you, I have an equal responsibility to provide you with the capacity to meet that expectation” (p 5).
Case Example: Eradicating Smallpox Globally
In 1798 Edward Jenner published his findings that cowpox immunizes people against smallpox. By the 1950s and 1960s mass inoculations were aimed at accomplishing “herd immunity” by inoculating entire populations of people who might come into contact with an infected person. Lethal outbreaks continued until the “surveillance and containment” strategy was developed and used intensively to eliminate smallpox globally by 1979. The globally scaled innovation is examined through an implementation lens.
Read More: Eradicating smallpox – Implementation
Case Example: U.S. Department of Education Office of Special Education Programs
In 2006 the U.S. Department of Education Office of Special Education Programs (OSEP) was the first federal agency to recognize the potential benefits of implementation science for improving student outcomes. In 2012 OSEP announced its approach to Results Driven Accountability that intends to change the relationship between a federal agency and state education systems. The new relationship being initiated by OSEP is to turn compliance into support.
Case Example: Northern European Public Sector
Northern European states, regarded as world leaders in social welfare, have for a long time viewed implementation as enactment of legislation that is communicated top-down to the public and stakeholders. This study reports on interviews with 30 public sector executives in Northern Europe about how to achieve successful implementation. They confirm the necessity of the “Making it Happen” strategy that corresponds with implementation science.
Read More: Ramboll-PolicyImplementationEU-2016