Dean L. Fixsen, Ph.D. Karen A. Blase, Ph.D. National Implementation Research Network Louis de la Parte Florida Mental Health Institute Voice and Choice: The Consumer / Family Role in Transformation Kentucky Meeting, 2006
Mar 19, 2016
Dean L. Fixsen, Ph.D.Karen A. Blase, Ph.D.
National Implementation Research NetworkLouis de la Parte Florida Mental Health Institute
Voice and Choice:The Consumer / Family Role in Transformation
Kentucky Meeting, 2006
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Transformation Agenda
Effective services
Implementation of effective services
Consumer, family, advocacy role in transformation
Discussion
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Transformation GoalsMental Health Care Is Consumer
and Family DrivenDisparities in Mental Health
Services Are EliminatedEarly Mental Health Screening,
Assessment, and Referral to Services Are Common Practice Excellent Mental Health Care Is
Delivered New Freedom Commission on Mental Health, 2003
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Evidence-Based Programs
The integration of best practice evidence with clinical expertise and patient value.
Institute of Medicine, 2001
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Evidence-Based Programs Leading edge of MH System ChangeRestructure therapeutic, administrative,
and financial environments to enable MH systems that are:
•More dynamic and adaptable•More accountable•More effective
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Use of “Evidence-Based” (Hoagwood & Johnson, 2003)
1900-1990 0 1990-1995 86 1995-1999 5,525
Google (10/2004): 2,320,000Google (01/2006): 16,600,000
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Consumer & Family VoiceSeveral EBPs have included the
consumer & family voice to help guide the development of their programs
ACT, Supported Employment, Teaching-Family Model, Multisystemic Therapy, Functional Family Therapy, and others
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Court Social Service ParentsSchoolsBoard Professional EvaluationYouths
T-Ps ______________________Address: __________________Evaluation Type: ___________
7=Completely Satisfied6=Satisfied5=Slightly Satisfied4= Neither Satisfied nor Dissatisfied3=Slightly Dissatisfied2=Dissatisfied1=Completely Dissatisfied
Shaded area representsacceptable rangeof performance
Current License Yes No
Certified Teaching-Parents
XXX XX X
X XXX
X XX X XX
XX X XXXX
XXXXX
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Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Effective ProgramsNurse-Family Partnership Parent Management Training Functional Family TherapyPositive Behavior SupportMulti-Systemic TherapyMultidimensional TFCTeaching-Family Model
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Effective ProgramsMedication algorithms
Family psychoeducation
Illness management
Integrated dual disorders treatment
Supported employment
Assertive Community Treatment
Fountain House Lodges
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
What does NOT Work?Non-behavioral interventions for disruptive behavior disorders and/or ADHD (Weisz et al., 1995; Pelham et al., 1998)
Group, peer-based interventions for disruptive disorders (GGI, PPC)
Instead may facilitate “deviancy training”: increases in rates of substance abuse, delinquent behaviors, and violence post-intervention (Dishion et al., 1999).
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
DARE (5th and 6th grade curriculum)Gun Buyback programs Boot Camps Peer counseling programsSummer job programs (at risk youth)Home detention with electronic monitoringWilderness / challenge programsCasework / counseling
What does NOT Work?
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
What produces negative (iatrogenic) outcomes?Waivers to adult (criminal courts)Scared StraightShock Probation / Parole
What is HARMFUL?
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
A Scale of UsefulnessEvidence-based programs have demonstrated
effectiveness through research
Promising practices have some evidence for benefits to consumers (Jim Wotring & Kay Hodges in Michigan).
Common practices have no data to support their use but over many years they have been built into a series of laws, regulations, funding mechanisms, professional and organizational accreditation standards, etc. that sustain them.
Harmful practices have evidence indicating harm to clients but often still are supported as a common practice
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Implementation
The act of accomplishing some aim or executing some orderTo put into practical effect; carry outPursue to a conclusion
– Dictionary.com
A lot of hard work!
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Implementation = Access to effective services
= Benefits to you and your family
Consumer & Family Choice
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Craft knowledgeEBP purveyors (program developers)EBP implementation site managersImplementation researchersSurvey of EBP program developers
Scientific informationCRUSK, Follow Through, Lodges, et al.Program development and replication dataSynthesis of the implementation evaluation and research literature
The NIRN
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Implementation ReviewHuman service prevention and treatment programs (e.g. substance abuse, adult / children’s MH, justice, health, education)Advanced manufacturing technologiesResearch-based clinical guidelines
Engineering: bridge maintenanceHotel service managementNational franchise operationsCancer prevention & treatment
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Implementation AttemptsHomebuilders national
implementation grants: $500 million, 5 years
Program / system change grants plus TA for systems of care, state transformation, school reform, medical clinical guidelines, etc:
$?? billion a year
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Implementation Attempts In business, change initiatives that are heavily dependent on people (reengineering, TQM, culture change) fail 80-90% of the time About 10% of what is taught in
training gets transferred to the job "Up to 70% of the failures in
business are not due to poor strategy or a lack of good ideas, but to flawed execution."
R. W. Rogers, 2002
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Lisbeth Schorr, 1993
Author of Within Our Reach
Implementation AttemptsSuccessful programs do not contain the seeds of their own replication.
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Implementation SuccessPMTO program in Norway: National
implementation of parent management program (NIDA funded research)
DOTS program in India: National implementation of TB treatment protocol, 1 million patients in 4 years
MST program in USA: National implementation of homebased interventions for juvenile offenders
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Common to SuccessGood science and technologyBaseline / decision support data
Expanding commitment & flexibilityPurposeful workforce developmentOrganizational change & supportsAlignment of system functioning
Knowledgeable purveyor, constant monitoring, feedback, intervention
Khatri & Frieden, 2002
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Good News
Knowledge of successful implementation strategies can benefit all human services
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Consumer OutcomesEffective intervention practices
+Effective implementation practices
=
Good outcomes for consumers
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Consumer Outcomes
Effective NOT Effective
Effective
NOT Effective
IMPLEMENTATION
INTE
RVE
NTI
ON Performance
ImplementationPaper / Procedure Implementation
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Paper Implementation Review of TQM adoptions in 5,492 hospitals "If organizations can minimize
evaluation and inspection of their internal operations by external constituents through adoption alone, they may neglect implementation altogether, decoupling operational routines from formally adopted programs."
Westphal, Gulati, & Shortell (1997)
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Consumer Outcomes
Effective NOT Effective
EBP
NOT Effective
IMPLEMENTATION
INTE
RVE
NTI
ON High Fidelity Low Fidelity
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Bedlington, et al., 1979
0%
10%
20%
30%
40%
50%
Homes
1.0
1.2
1.5
1.7
1.92.0
1.1
1.4
1.6
1.8
1.3
Delinquency
Teaching
rs = – .94
Per
cent
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ith Y
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s
Mean S
elf Reported
Delinquency R
atings
1 2 3 4 5 6
Teaching-Family Model
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
What you need to know
An evidence-based program is one thing
Implementation of an evidence-based program is a very different thing
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Stages of Implementation
Implementation is not an event
A mission-oriented process involving multiple decisions, actions, and corrections
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Stages of Implementation
Exploration
InstallationInitial ImplementationFull ImplementationInnovation
Sustainability
Implementation occurs in stages:
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
2 – 4 Years
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Installation
Initial Implementation
Implementation Stages:Non-Linear Processes
Practitioner
Evidence-based Practices
Purveyor
FidelityMeasure
Implementation Framework
Organizational Structures/Culture
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
EBPs: The SourceThe usability of a program has little to do with the quality or weight of the evidence regarding that program
Evidence on intervention effectiveness for specific populations helps us choose what to implement
Evidence on the effectiveness of the intervention does not help implement the program or practice successfully
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
EBPs: The SourceCore intervention components
Clearly described (what/how)
Practical measure of fidelity
Fully operationalized (do/say)
Field tested (iterative revision)
Contextualized (org./systems fit)
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Implementation Site: The Destination
Defined Need
Identified Resources
Fully informed consent re: innovation and implementation
Top level commitment to change and agreement re: access
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Implementation Site: The Destination
Practitioners impact consumers
It is the job of directors, managers, and funders to align policies and structures to facilitate effective practitioner practices
There is no such thing as an “administrative decision” – they are all treatment decisions
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
What you need to knowBe a part of the process of choosing what to implement (ask about core intervention components, match with strengths and needs, costs to consumers & families)Advocate with MH directors and legislators (what is the plural form of anecdote?)Be informed (ACMH Guide for Families, Malisa Pearson & Tiffany Leischner; www.acmh-mi.org )
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Implementation of EBPsChanging the behavior of adult human service professionals
Changing organizational structures, cultures, and climatesChanging the thinking of system directors and policy makers
Leading edge of MH System ChangeNew Freedom Commission
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Human Service Systems
“Systems trump programs.”
– Patrick McCarthy,
Annie E. Casey Foundation“
Advocate at the systems levels to enable longer lasting local impacts.
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
PurveyorExcellent experimental evidence for
what does not work
Dissemination of information by itself does not lead to successful implementation (research literature, mailings, promulgation of practice guidelines)
Having information and knowledge is helpful to decision making, but it is NOT implementation
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
PurveyorExcellent experimental evidence for
what does not workTraining alone, no matter how well
done, does not lead to successful implementation
Information dissemination and training by themselves repeatedly have been shown to be ineffective in human services, education, health, business, and manufacturing
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Active Purveyor RoleSuccessful implementation on a useful scale requires a purveyor
An individual or group of individuals representing a program or practice who actively work to implement that practice or program with fidelity and good effect
Purveyors accumulate data & experiential knowledge -- more effective and efficient over time (information economics, K. Arrow)
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Active Purveyor RoleChange the behavior of adult human service professionals
Change organizational structures, cultures, and climatesChange the thinking of system directors and policy makers
Successful and sustainable implementation of evidence-based practices and programs always requires organizational change.
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Active Purveyor Role
OrganizationManagement (leadership, policy)
Administration (HR, structure)
Supervision (nature, content)
Practitioner
State policiesSystem of care
Purv
eyor
Simultaneous, Multi-Level Interventions
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
INTEGRATED & COMPENSATORY
CONSULTATION & COACHING
STAFF PERFORMANCE EVALUATION
FACILITATIVE ADMINISTRATIVE
SUPPORTS
RECRUITMENT AND SELECTION
PRESERVICE TRAINING
SYSTEMSINTERVENTIONS
Keys to Implementation
DECISION SUPPORT DATA SYSTEMS
OUTCOMES
(% of Participants who Demonstrate Knowledge, Demonstrate new Skills in a Training Setting, and Use new Skills in the Classroom)
TRAININGCOMPONENTS
Knowledge SkillDemonstration
Use in the Classroom
Theory and Discussion
10%
5% 0%
..+Demonstration in Training
30% 20% 0%
…+ Practice & Feedback in Training
60% 60% 5%
…+ Coaching in Classroom
95% 95% 95%
Joyce and Showers, 2002
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
What you need to knowAn evidence-based program is one thing
Implementation of an evidence-based program is a very different thing
Good outcomes occur ONLY when evidence-based practices and programs are implemented well.
As a consumer of evidence-based practices and programs, you need to know how to assess the quality of implementation.
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
What you need to knowFidelity is important.
Fidelity means actually using the treatment procedures as they were tested and found to be effective.
Implementation with fidelity is required to achieve advertised outcomes
Practitioner
Evidence-based Practices
Purveyor
FidelityMeasure
Implementation Framework
Organizational Structures/Culture
Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Bedlington, et al.
0%
10%
20%
30%
40%
50%
Homes
1.0
1.2
1.5
1.7
1.92.0
1.1
1.4
1.6
1.8
1.3
Delinquency
Teaching
rs = – .94
Per
cent
Par
enta
l-Tea
chin
g W
ith Y
outh
s
Mean S
elf Reported
Delinquency R
atings
1 2 3 4 5 6
Implementation & Delinquency
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Questions you can ask What evidence do you have that the
recommended treatment is effective for me / a child like mine?
Have you been specifically trained to carry out this treatment? By someone approved by the program developers?
Have you been coached in the use of this treatment? By someone approved by the program developers?
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Questions you can ask How is your use of the treatment
evaluated? Do you typically achieve high fidelity scores?
In the past year, how many people have you treated using this program? What results have you achieved for those people?
Are consumers, family members, and others involved in carrying out and evaluating the treatment? How much time will that require?
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
SummaryConsumer and family involvement is key
to initiating and sustaining transformation efforts
Opportunities, transportation, child care, expense reimbursement
Presenting information, confident discussion, persistence
Networking and coalition building
Willing / able to take on important roles (e.g. selection, training, evaluation; community support; legislation and funding)
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
SummaryVoice and choice are important parts of the
development and evaluation of many evidence-based practices and programs.
Consumer/family voice is an important part of the selection and initiation of evidence-based practices and programs in a community.
Consumer/family choice can be enhanced by evidence-based practices and programs that are implemented and used with fidelity.
EBPs are no panacea. They are a lot of hard work to implement and maintain, but they can be helpful to you and your family.
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
Thank YouWe thank the following for their support
Annie E. Casey Foundation (EBPs and cultural competence)William T. Grant Foundation
(implementation literature review)Substance Abuse and Mental Health Services Administration
(ORC Macro sub-contract for SOC analyses of implementation; implementation strategies grants)Centers for Disease Control (implementation research contract)National Institute of Mental Health
(research and training grants)Juvenile Justice and Delinquency Prevention
(program development and evaluation grants)
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
For More InformationDean L. Fixsen
813-974-4446
Karen A. Blase813-974-4463
National Implementation Research NetworkAt the Louis de la Parte Florida Mental Health Institute
University of South Florida
http://nirn.fmhi.usf.edu
Copyright © Dean L. Fixsen and Karen A. Blase, 2006
For More InformationFixsen, 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).
E-mail us for a free copy or download all or part of the monograph at:
http://nirn.fmhi.usf.edu/resources/publications/Monograph/index.cfm