Implementation drivers

The implementation drivers/components are the elements that positively influence the success of the implementation and replication of a programme. These drivers refer to the capacities, infrastructure, and functioning of organizations and are grouped in three categories (as shown in figure 46):

1. Competency drivers: are activities to develop, improve, and sustain ability to put programs and innovations into practice in order to benefit to the patient or the community. The three competency drivers include: (a) selection of staff, (b) training, (c) coaching/feedback from performance assessment. Mentioned less often, but equally important, is the integration of these components. Too often practitioners leave training and find their new knowledge and skills are not supported by their supervisor. In an integrated approach, supervisors are prepared to support and expand the knowledge and skills introduced in training.

2. Organization drivers: are mechanisms set-up and maintained to ensure the enabling conditions and environment for the programme or innovation to be implemented and therefore to obtain results. The three organization drivers include: (e) system interventions meaning the importance to ensure commitment and support for change at all levels of the system/organization and to rely on champions and persons with influence to work together to build and sustain the culture, policies, regulatory practices, and funding mechanisms necessary for both the implementation drivers and the intervention practices to thrive, (f) facilitative administrative supports including internal policy analyses and decisions, procedural changes, funding allocations and a culture that is focused on what it takes to implement with good outcomes and reduces barriers for implementation, for example by minimizing paperwork and ensuring that issues such as practitioner workload, safety, remuneration, communication, and feedback are proactively addressed by the administration to the satisfaction of the practitioners, and (g) decision supported by data and evidence as a critical component for continuous quality improvement. Implementation support teams help organizations establish and evolve their data systems so information is immediately accessible and useful to practitioners, trainers, coaches, and managers for short-term and long-term planning and improvement at clinical and organizational levels.

3. Leadership drivers: are the leadership strategies to set-up for supporting the implementation of the programme or the innovation. Competent leaders are needed throughout an organization for supporting implementation. It is rare to find a description of change that does not point to leadership as an important contributor to success or failure.

Both (h) technical and (i) adaptive leadership are needed. Technical leadership might be thought of as good management. The leader is engaged, quick to recognize and respond to issues that arise, organizes groups to solve problems, and regularly produces desired results.

Technical leaders work in the zone where there is substantial agreement about what needs to be done and reasonable certainty about how to do it. Adaptive leadership is required in the zone of complexity where there is little agreement and less certainty. The concept of adaptive leadership resonates with leaders who recognize the layers of complexity involved

in any large-scale systems reform. For example, adaptive leaders understand the difference between “authority” (i.e., a formal position of power) and “leadership” (i.e., the act of helping people through to achieve meaningful change). Heifetz & Linsky⁴⁰ note that “authority” is organized to provide “direction, protection, and order” and maintain a stable system. When systems undergo change, the natural tendency of those in the system is to look to those in authority to minimize the tension of change and regain stability. However, when change is the goal, formal authority can get in the way of leadership because it is designed to maintain systems, not to help people overcome their natural tendencies to maintain the status quo.

When organizations and systems are being changed on purpose, adaptive leadership is needed to manage the change process. Implementation support teams can help leaders and their management teams explore the nature of adaptive challenges and make good use of adaptive leadership methods to resolve issues, particularly in the case of quality improvement cycles that require continuous review of practices.

FIGURE 45: DRIVERS FOR IMPLEMENTING CHANGES AND INNOVATIONS

RELIABLE BENEFITS

CONSISTENT USE OF INNOVATION BY PRACTITIONERS

INTEGRATED &

COMPENSATORY

Performance review

Coaching Systems

intervention

Facilitative administration

Decision support data system Training

Selection

Technical Adaptive

Leadership drivers Compet

ency driv

ers Or

ganiz ation driv

ers

Source: Fixsen D.L, Karen A. Blase K.A, Naoom S.F, Duda M.A, Implementation Drivers: Assessing Best Practices,

This framework aligns well with lessons from the maternal health literature. For example, as for competency drivers, it has long been clear that in-service training (short term - knowledge base) alone is not sufficient for maintaining skills. This also requires an appropriate selection of candidates for training³⁷, as well as ongoing coaching, supervision and mentoring^41,42. As shown on table 9, the capacity of health professionals to apply a practice in their own work environment can increase from 5% to 95% when in service training (theory+practical demonstration during the training+practice off-site) is complemented by on-site mentorship/coaching.⁶¹.

TABLE 9: EFFECTIVENESS OF IN-SERVICE TRAINING APPROACHES FOR THE IMPLE-MENTATION OF NEW SKILLS

OUTCOMES

% of Participants who Demonstrate Knowledge, Demonstrate New Skills in Training Setting, and Use new Skills in the work environment

TRAINING COMPONENTS KNOWLEDGE SKILL

DEMONSTRATION USE IN THE WORK ENVIRONMENT

Theory and Discussion 10% 5% 0%

...+Demonstration

in Training 30% 20% 0%

...+Practice & Feedback

in Training 60% 60% 5%

...+Coaching in the work

environment 95% 95% 95%

The maternal health literature also supports the applicability of the organization and leadership drivers. It demonstrates that the right management practices can facilitate change and make a demonstrable difference in the ability of a facility to provide respectful and quality maternal care⁴³. But individual facilities ultimately need to be supported by strengthening the entire health system⁴⁴. The experience of Cambodia, which has achieved MDG 5, is particularly instructive in this regard⁴⁵. The effort to improve referral for EmONC by systematically working to forge personal relationships and organizational ties within a referral network, profoundly changed how the system performed when a life-threatening

obstetric complication occurs. Such new practices are supported by strengthening health information systems so that they inform ongoing problem-solving and decision making at policy level and for improving service-delivery⁴⁶. An additional example from Zimbabwe demonstrates the potential positive impact of a strengthened decision support data system. Program implementers created a monthly clinical data dashboard in a hospital and staff (both management and midwives) were committed to the program, which allowed the identification of negative trends in clinical outcomes and the formulation and implementation of remedial actions⁴⁷.