Implementation in action
5. Stage 2: Plan and prepare
During Stage 2, the implementation team (or other decision makers) will plan and prepare for implementation. During this stage, you'll need to:
- choose implementation strategies
- develop and start using your implementation plan
- identify your implementation outcomes
- decide how to monitor the implementation process.
5.1 Choose implementation strategies
Implementation strategies are the 'how to' of implementation. You'll use these strategies to overcome barriers, build readiness and drive the implementation process. Choose the best strategies for your context, and the program or practice you're implementing. Some interventions, such as manualised programs, come packaged with specific implementation strategies; for example, training requirements and quality monitoring. However, even these usually have scope to add other implementation strategies at the local level if you need them. Other programs or practices will not suggest which implementation strategies to use, so you'll need to choose them yourself.
If you're able to choose your own implementation strategies, one useful technique is to match the strategies to the implementation barriers you've identified or experienced. The Expert Recommendations for Implementing Change (ERIC) project identified more than 70 commonly used implementation support strategies that can be used to drive the implementation process (Powell et al., 2015; Waltz et al., 2015). See Table 3 for some examples. These strategies have been matched with common implementation barriers (defined using the CFIR) to create a decision aid - the CFIR-ERIC Matching Tool.
Source: Powell et al., 2015
You can use the CFIR-ERIC Matching Tool to help you decide which implementation strategies to use. Input the implementation barriers you've identified into the tool and it will generate a list of implementation strategies that experts think will best address these barriers.
Sometimes the CFIR-ERIC Matching Tool will generate a long list of potential strategies for addressing the inputted barriers, and these won't all be feasible in your context. While helpful, the Matching Tool can't replace careful thought and decision making based on your specific context. We've identified some guiding principles to help you select the best implementation strategies for your context:
- Select implementation strategies that best describe the change in behaviour you require to overcome the barriers you identified in Stage 1.
- Engage stakeholders (practitioners, leadership, clients, referrers and the community) to help you select the best implementation strategies and develop actions for these strategies. Consider asking stakeholders to rate the importance and feasibility for proposed implementation strategies to help you make the decision.
- Remember that implementation strategies can be one discrete action, or a collection of actions that are interwoven, packaged up and aimed at addressing multiple barriers (Powell et al., 2012).
Once you've chosen your implementation strategies, develop specific actions to bring them to life. Table 4 provides examples of common barriers to implementation, and relevant strategies and actions that can be used in the child and family services context to overcome each of the barriers.
5.2 Develop an implementation plan
It's important to plan your implementation carefully. Planning will help you identify and address many of the common barriers before they start to cause issues. It will also help you to establish the right implementation strategies to overcome or minimise the barriers. The implementation plan is best developed collaboratively by those on your implementation team (or other key decision makers if you have not set up a team). You can amend and adapt the plan over time. You may need to reconsider your priorities as conditions change and new barriers emerge. The implementation plan can also be used to record implementation enablers, ensuring there is a plan in place for maintaining them throughout implementation.
Your implementation plan should include:
- the implementation barriers (identified in Stage 1)
- the implementation strategies and specific actions you will take to overcome each of the barriers (chosen in Stage 2)
- who will deliver on each action
- timeframes, milestones and due dates for each action.
Depending on your needs, your implementation plan may also include:
- a record of implementation enablers, and strategies and actions for how to maintain them
- a register of all the risks you've identified during implementation
- an implementation quality monitoring plan (described in Chapter 5.3)
- an activity tracker (to track the progress of your implementation strategies and actions)
- any other information that can help guide your process.
You can use the Implementation Plan Template (Appendix E) to help the implementation team or other decision makers to map out their plan. For another example, see this template developed by the National Clinical Effectiveness Committee.
The only way to know if your implementation is going well is to monitor its progress. This needn't be an onerous task. Firstly, you'll need to decide which data will be most useful. Choose data that will show when you need to adjust and improve the implementation process, or your new program or practice. You'll also need to ensure you collect and review data regularly. The best implementation monitoring plans use continuous quality improvement cycles during Stage 3 - once you've started the new practice or program (see Chapter 6.3). Ideally, they should also help you identify any unintended consequences (both positive and negative), which can inform future implementation efforts, such as scaling-up to other teams or sites (see Chapter 7.2).
Your implementation monitoring plan should track your key implementation outcomes (i.e. is the program being implemented and how well?). These are different to your program outcomes, which describe the desired changes for children, parents, carers, families and caregivers (i.e. is the program making a difference for people using the service?). Implementation outcomes indicate the quality of your implementation. An evidence-informed program or practice that's implemented well (i.e. has good implementation outcomes) has the best chance of delivering benefits for children and families (see Figure 2 in Chapter 2).
Your implementation team or other decision makers should select which outcomes to monitor, ideally before the new program or practice has started. However, if the program or practice has already started, it's not too late to put monitoring measures in place. You can do this any time.
Table 5 includes some key implementation outcomes, alongside some simple, good-quality measurement methods and tools. We also encourage you to consider additional outcomes and measures that are appropriate for your context.
It's important to consider the quality of your measurement tools. This includes psychometric considerations such as reliability, validity and sensitivity, as well as practical considerations such as length, language and ease of use.
|Implementation outcome||Definition||How to measure|
|Acceptability||The perception among stakeholders that a program or practice is agreeable, palatable or satisfactory||
|Feasibility||The extent to which the program or practice can be successfully used or carried out within your setting||
|Appropriateness||The perceived fit, relevance or compatibility of a program or practice||
|Fidelity||The extent to which a program or practice is being delivered as intended||
|Reach||The degree to which a program or practice is integrated into an agency or service provider setting, including the degree it effectively reached the target population.||
Your fidelity measures should be tailored to the program or practice you're implementing. The EPIS Centre website (www.episcenter.psu.edu/fidelity) provides examples of existing fidelity measures for a range of programs in the child and family service sector. The best fidelity measures or checklists allow for assessment of how often the program or practice is used, and how extensive its reach is. They also track the competence and quality of program or practice use.
The Society for Implementation Research Collaboration (SIRC) is currently developing a repository of tools (see societyforimplementationresearchcollaboration.org/sirc-instrument-project/) that measure implementation outcomes. The repository includes information on the psychometric properties (e.g. reliability, validity) and pragmatic qualities of each tool. The repository is a work in progress and available to paid members of SIRC.
Table 5 includes three short, simple and freely accessible implementation outcome measures with good psychometric properties: AIM (to measure acceptability), FIM (to measure feasibility) and IAM (to measure appropriateness). All three have been developed and validated by Weiner and colleagues (2017) and are available as a free download.
5.4 Build readiness to use the program or practice
Now it's time to build your organisation's readiness to implement the program or practice. Start using the implementation strategies and activities in your implementation plan that are relevant at this early stage. Some strategies, such as ongoing and skills-based training and identifying and preparing champions, will need to be used during Stage 2 so you can start to build readiness before you start the program or practice. You may also need to use other strategies in your implementation plan later in the implementation process (e.g. follow-on coaching, which would only start after the program or practice has been initiated in Stage 3).