By Amanda Fixsen, Karen Blase and Dean Fixsen
| What is involved in effective scaling up of innovations in order to achieve social impact? Here are four best practices, drawn from our experience in scaling up human services innovations and programs for children and families. We also provide definitions of the key terms used.
1. Understand the target audiences Effectively scaling innovations first requires attention to defining the denominator, or population of interest for the scale-up effort, as well as the numerator, or the number of children and families who are receiving the innovation with fidelity and good outcomes. 2. Purposeful design leads to high-fidelity use Human service systems are legacy systems comprised of an accumulation of fragments of past mandates, good ideas, beliefs, and ways of work that evolved over many decades as legislators, leaders, and staff have come and gone. These legacy systems can be fragmented, siloed and inefficient. To realize social impact, organizations and systems need to be designed, or re-designed, on purpose to produce and sustain high-fidelity use of effective innovations. 3. Focus on scaling proven programs Attempts to scale ineffective or harmful programs are a waste of time, money and opportunity, so programs must reliably produce positive outcomes for the population of interest. Given that we are focused on scaling interaction-based programs that require service providers to use the program within a larger systems context, there is a great deal of complexity involved in “scaling up.” It may be difficult to assess the quality of the program for the children and families who are receiving it, as good fidelity measures for programs are not common. |
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Definitions
Fidelity: delivering the core components of the innovation as intended.
Human services: all forms of organized prevention and intervention efforts in corrections, health, education and social services.
Implementation: the supports required to purposefully and reliably produce full and effective uses of innovations in practice.
Implementation capacity: the availability of implementation teams with the knowledge, skills and abilities to develop competencies and affect change with practitioners, organizations, and systems.
Innovation: something new and previously unused by potential users or recipients.
Scaling: the extent to which an innovation is used with good effect in the entire population of interest. Delivering the innovation as intended (with fidelity) and sustaining innovations in practice are essential to achieving social impact.
Social impact: the product of effective innovations used with fidelity (the numerator) at a sufficient scale to produce noticeable benefits for the entire population of interest (the denominator).
4. Ensure adequate implementation capacity
There needs to be a focus on developing local site implementation capacity, so that each site using the program can sustain it over time.
Scaled use of an effective program depends first on scaling implementation capacity to support, sustain and improve high quality replications of the program. There is complexity inherent in maintaining and increasing the numerator, as the number of recipients of the program cannot continue to increase without attention to sustaining the quality of the program by those already providing it.
Implementation teams are one key factor in supporting programs at scale, helping to ensure sustainability of the program, and maintaining local implementation capacity. One team alone cannot support a program at scale; it would be like one teacher supporting all classrooms in a school. Given this, teams that support implementation must be present at multiple levels to support high quality use of the program over time.
It truly is a whole systems effort that is required to effectively scale programs.
Conclusions
The good news is that transformation of systems may require only small changes. It has been shown that transformed systems retain approximately 80 percent of the original system.
In sum, developing local implementation capacity and implementation teams may be the way forward if we want to ensure high quality implementation of effective programs into service delivery systems. Our experience intersects with and also differs from that reported in the recent blog post Scaling up amidst complexity, by Ann Larson.
What has your experience been with scaling up, especially in developing local implementation capacity and implementation teams at multiple levels?
To find out more:
Fixsen, D. L., Blase, K. A. and Fixsen, A. A. M. (2017). Scaling effective innovations. Criminology and Public Policy, 16, 2: 487-499.
A previous version of this blog post was published by Gary Community Investments on the Shared Knowledge website at: http://www.garycommunity.org/article/best-practices-scaling-effective-interventions
Biography: Amanda Fixsen, Ph.D. is the director of implementation at Invest in Kids in Denver, Colorado, USA. With a background in applied behavior analysis, social work research, and implementation science, she pursues her interest in how human and health services can be effectively implemented and scaled up in real-world contexts.
Biography: Karen Blase, Ph.D. is emerita senior scientist at the University of North Carolina at Chapel Hill, USA. She is co-founder of the National Implementation Research Network, co-authored ‘Implementation Research: A Synthesis of the Literature’, and led efforts to operationalize and replicate implementation and scaling methods in human services.
Biography: Dean Fixsen, Ph.D. is co-founder of the National Implementation Research Network based at the University of North Carolina at Chapel Hill, USA. He is also president of the Global Implementation Initiative. In 2005, he co-authored ‘Implementation Research: A Synthesis of the Literature’ and has been active in developing implementation science as a professional discipline.
Important messages here, as we are still seeing many scale-up efforts that play fast and loose with the core components that make them effective. This makes such an interesting read alongside the blog by Ann Larson: striking the balance between adaptations that allow innovations to become sustained but with sufficient fidelity not to lose efficacy must now be one of our biggest challenges in this field. Implementation teams could be the answer: I believe they are: but here in UK where I am based it is still hard to get funders to take this idea seriously and to invest in creating this supportive infrastructure. A false economy, as so many innovations flower and then wither without ongoing, knowledgeable support. But I agree with the first comment that these teams must also build capacity in the home system with the longer view in mind.
Thank you for the post. I agree that we have a similar view of how to scale up changes that have the potential to have large impact.
I particularly like your emphasis on coverage – paying attention to the numerator and denominator. In some cases increasing coverage means giving the new service to existing clients and in other cases it means stretching the service to reach new clients. I have found that the second is more challenging because it requires changing the terms of engagement with clients. For example, services may have relied on self-referrals or referrals from teachers or the justice system for their clients. Increasing coverage means recognising that people who could benefit are slipping through that system and a new way of engaging needs to be found, which can be disruptive in the short term because it is a significant change in how services operate.
I also like your emphasis on the implementation team, if that means an additional team to do the hard work of establishing a new practice. However there is a balance to be struck. Without the local team of service providers taking ownership and finding their own way to adopt the practice, it is unlikely the new practice will be sustained once the implementation team leaves. Nurturing the creativity of the local team to find solutions within their own context (or legacy) will be more effective than emphasising fidelity.
Ann, Thanks for the comment! I do agree with you on the balance that needs to be struck in developing an implementation team. The purpose of the implementation team is to do all the things that you state – to have the implementing site take ownership, to use their internal knowledge to drive the system changes that may need to occur for the innovation to be used with quality, etc.
In my work at Invest in Kids in Colorado, program consultants (employed by our organization) work to develop implementation teams at the site (i.e., school, preschool, district, or other community-based organization) where the program will be delivered by local providers. The goal is for our staff to drive the development of the local implementation team and to then set the team up for long-term success by establishing meeting structures, communication protocols, feedback loops, etc. The ultimate goal is to work our staff member out of the implementation team, or at least to a place where the external consultant no longer drives the meeting work of the implementation team.
I love your last statement about nurturing the local team to find solutions, and not just emphasizing fidelity.