National Collaborating Centre for Methods and Tools

Relevance for Public Health

Description

Implementing new initiatives in large organizations is a complex and challenging process. This method outlines four stages in the implementation of innovative programs, including the planning and evaluating of knowledge application activities.

Organizational processes are critical issues to consider when addressing the gap between evidence and practice. Decision-making behaviours and practice may be shaped more by workplace policies, values, norms and resources than by scientific evidence alone. Some suggest that individuals exercise a 'bounded rationality' that is influenced by estimates, standard protocols, common beliefs and values and group identification, rather than solely relying on a logical evaluation of alternatives for decision-making. 

Furthermore, the organizational context influences decision-making through a number of factors, including: multiple and often competing goals and priorities; choosing among partially-effective innovations; and leadership turnover resulting in inconsistent attention to and participation in decision-making and program implementation.

This approach highlights four primary strategies to facilitate the implementation of research findings into complex organizations:

1. Develop a decision-making coalition to support adopting the innovation.
2. Align the innovation to existing organizational goals and values.
3. Monitor implementation and outcome measures of the innovation.
4. Nurture communities of practice to sustain the innovation.

These strategies are applied within the following stages of implementing an innovation:

• deciding to implement the innovation
• initial implementation
• sustained implementation
• termination or transformation of the innovation

Several roles would help ensure successful program implementation within complex organizations, including epidemiologists, program managers, communications officers, policy analysts, evaluation specialists, clinical educators, program directors and frontline staff. Frontline staff and management are the primary participants in this method.

This approach identifies four stages in knowledge application. 

Stage A: Deciding to Adopt the Innovation
Organizations choose to disseminate and implement innovations due to a number of factors, including the following:

1. The strength of a decision-making coalition. By forming a coalition, individuals collectively advocate for the initiative, exerting their influence through formal and informal channels. The political power of coalition members and the resources they garner in support of a program, often determine the successful implementation of an innovation. 

2. How the innovation is aligned with broader organizational objectives or with external values. When the anticipated program outcomes are consistent with larger organizational goals or with external opinions or values, the innovation will more likely be adopted.

3. Being able to frame external crises as windows of opportunity. The innovation can be positioned as resolving an external crisis, which can help in gathering timely support for a new program.

4. Uncertainty and unpredictability in organizational circumstances. When the organizational context is unpredictable, and quite different from the settings in which research was conducted, this may decrease the likelihood of an innovation being implemented.

Stage B: Initial Implementation
When initially implementing a program, it is critical that the coalition builds and maintains support for the innovation. To do this, the coalition must focus on clearly articulated initiatives. The following steps can affect the initial implementation phase:

1. Define a clear, specific implementation decision with a commitment of appropriate resources. There is a tension between symbolic action (using decisions to communicate values within organizations and to stakeholders) and actionable implementation (where decisions result in action and resource allocation sufficient for effective implementation). In large organizations, symbolic action often results from multiple levels being involved in the decision-making process.

2. Create an implementation plan with subsequent program evaluation. Developing an implementation plan that clearly articulates how all aspects of the program will be implemented is critical for successful program adoption. Creating an evaluation plan and using tools to assess the program ensures the program is being implemented as intended.

3. Disseminate evaluation results. Sharing evaluation results establishes accountability where local program performance can be compared against wider program standards and objectives.

4. Manage weakly-implemented innovations. Poorly-implemented, ineffective innovations use the same resources as strongly-implemented programs, but diminish staff morale with little benefit for target groups. It is critical to take steps to ensure proper adherence to program design through monitoring and evaluation.

Stage C: Sustained Implementation

This stage highlights maintaining, adapting or revitalizing innovations over the long term. Sustained implementation is influenced by a number of factors that work at multiple levels (program and system levels), such as:

• lack of access to evaluation data
• lack of ability to enforce program adherence
• reduced staffing
• emerging and competing priorities
• uncertainty and partial effectiveness of interventions, which can affect staff morale and implementation
• changes in leadership
• changes in and unpredictable external context

Two approaches to sustain program implementation over long periods of time include:

1. Outcome evaluation and enforcement of standards. The purpose of sustained implementation is maintaining program effectiveness, which requires monitoring and adhering to program standards. This approach involves engaging in quantitative performance monitoring and having the political will and capacity to enforce adherence to program performance standards.

2. Nurturing communities of practice and the learning organization. Developing a self-sustaining subculture among staff is critical for maintaining implementation over the long-term. Fostering communities of practice requires frequent interaction and sharing experiences among frontline staff. This interaction allows practitioners to make sense of and learn from their collective experiences, stories and knowledge. As communities of practice evolve, they may adapt, reconfigure or replace specific program elements to meet the changing needs of the target population or organization.

Stage D: Termination or transformation of the innovation

Very little research has been conducted on terminating ineffective programs. Programs often end when there is loss of coalition members or the program is no longer connected with wider organizational priorities or values. Programs can be eliminated or transformed in these ways:
1. Subordination to other emerging organizational goals.
2. Transformation through the gradual expansion of specific program elements and phasing out ineffective elements.
3. Lack of cost-effectiveness and poor performance (often due to lack of support for the program, which hinders maintaining program fidelty).

Title of Primary Resource

File Attachment

Web-link

Reference

Type of Material

Format

Cost to Access

Language

Conditions for Use

Title of Supplementary Resource

File Attachment

Web-link

Reference

Type of Material

Format

Cost to Access

Language

Conditions for Use