A trusted resource on new ideas and options in home care WHAT WORKS IN IMPLEMENTING NEW PROGRAMS WITH SPECIAL REFERENCE TO CONSUMER DIRECTED CARE (CDC) A DISCUSSION PAPER CONTENTS 1. Introduction... 2 2. Levels of implementation... 2 3. Readiness for implementation... 3 4. Framework for implementation... 3 5. Organisational factors influencing successful implementation... 4 6. Stages of implementation... 6 7. Core implementation components... 7 8. The role of staff training in implementation... 8 COTA Australia Implementation Discussion Paper December 2013 Page 1
1. INTRODUCTION Aged and community care providers face the challenge in the next few years of implementing the aged care reforms contained in the Living Longer Living Better reform package. Some of these changes require significantly different ways of delivering programs, such as the delivering the home care program using a consumer directed care approach. There is a body of literature that can help to inform the approaches taken by providers in implementing this new approach. While there is a strong emphasis in health and aged care on utilising evidence based practices, it is also important to examine the evidence on effective implementation of new programs or new approaches to delivering services. A 2005 review of the literature regarding successful implementation 1 found that co-ordinated change is required at four levels: System level Organisational level Program level Practice level Implementation appears most successful when: Carefully selected practitioners receive coordinated training, coaching and frequent performance assessment; Organisations provide the infrastructure necessary for timely training, skilful supervision and coaching, and regular process and outcome evaluations; Communities and consumers are fully involved in the selection and evaluation of programs and practices; State and federal funding avenues, policies and regulations create a hospitable environment for implementation and program operations. 2 2. LEVELS OF IMPLEMENTATION Three levels of implementation were identified: 3 2.1 Paper implementation - putting into place new policies and procedures. 2.2 Process implementation - new policies and procedures may be supplemented by training, new reporting processes, and new language adopted. 2.3 Performance implementation all the components of changes are used with good effect on the outcome for consumers. The literature across domains consistently cites the importance of stakeholder involvement and buy in throughout all stages of the implementation process. 4 1 Fixsen et al (2005) 2 Op cit p vi 3 Op cit p 6 Page 2
3. READINESS FOR IMPLEMENTATION The literature identified seven stages of community readiness for the implementation of new programs: A. No awareness B. Denial C. Vague awareness D. Pre-planning E. Preparation F. Initiation G. Stabilization. 5 4. FRAMEWORK FOR IMPLEMENTATION Figure 1 describes a conceptual framework for implementation: 6 Source the best example of the new program Destination the practitioners, teams and organisations that are to adopt the new program Communication link the purveyors of the practice or program Feedback mechanism information about performance of the new program Sphere of influence external factors that impinge directly or indirectly on the people or organisations implementing the program. 4 Fixsen et al (2005) p8 5 Op cit p 10 6 Op cit p 12 Page 3
The essential implementation outcomes are: 1. Changes in adult professional behaviour (knowledge and skills of practitioners and other key staff members within an organisation or system), 2. Changes in organisational structures and cultures, both formal and informal (values, philosophies, ethics, policies, procedures, decision making), to routinely bring about and support the changes in adult professional behaviour, and 3. Changes in relationships to consumers, stakeholders (location and nature of engagement, inclusion, satisfaction), and system partners. 7 The literature notes the importance of a consistent group of purveyors of a given program or practice to provide a repository for experiential knowledge evaluation outcomes and the wisdom accumulated over a series of implementation experiences over the years. 5. ORGANISATIONAL FACTORS INFLUENCING SUCCESSFUL IMPLEMENTATION A report for the NSW Dept. of Ageing, Disability and Home Care identified the essential elements of organisational change to bring about person-centred approaches and thinking, based on a comprehensive literature review. 8 7 Op cit p 12 8 ACU National (2009) Page 4
While the main focus of this work was on people with a disability, and there are distinctions between person-centeredness and consumer direction, many of these elements are relevant to the changes required to implement consumer directed care. Several principles were identified from surveying the definitions of person-centredness. The following are also relevant to consumer directed care: A focus on the person and who they are Future orientation concentrating on the aspirations and hopes of the person for their life A shift in power and who holds power and control A signal for the leadership and staff of organisations that there are fundamental changes to how they interact with people. Williams and Sanderson 9 identified seven key elements that they believe are foundational for person-centred organisations: Visionary leadership Shared values and beliefs Outcomes for individuals Community focus Empowered and valued staff Individual and organisational learning Partnership Another way of looking at the organisational elements involved in a change such as the move to consumer directed care and great consumer participation has been outlined by Wright et al 10. They describe the four elements as: CULTURE The ethos of an organisation, shared by all staff and service users which demonstrates a commitment to consumer participation. PRACTICE The ways of working, methods for involvement skills and knowledge which enable service users and older people to become involved. STRUCTURE The planning, development and resourcing of participation evident in an organisation s infrastructure. REVIEW The monitoring and evaluation systems which enable an organisation to evidence change affected by participants. 9 Williams & Sanderson (2005) 10 Wright P etal (2006) Page 5
6. STAGES OF IMPLEMENTATION The following stages of implementation were identified in the literature: 11 6.1 Exploration and Adoption Awareness of a need for change leads to the acquisition of information and exploration of options. The purpose of exploration is to assess the potential match between community needs, evidencebased practice and program needs, and community resources, and to make a decision to proceed or not. 12 In relation to CDC some organisations have chosen to embrace CDC while others will be required to transition in July 2015. Support for an innovation will be garnered during this phase but needs to continue through all phases. 6.2 Program Installation After a decision to implement resources are allocated to actively prepare for doing things differently. These may include structures, funding, human resources, policy development, referral mechanisms, reporting frameworks, realigning and upskilling staff, technology and liaison with stakeholders. 6.3 Initial Implementation This is a complex stage requiring change at all levels. Change is needed in skill levels, organisational capacity, organisational culture, and requires education, practice and time to mature. 13 Resistance at this stage may see the implementation go no further. 11 Fixsen et al p 15 12 Ibid p15 13 Op cit p 16. Page 6
6.4 Full Operation Full implementation occurs once the new learning becomes integrated into practitioner, organisational and community practices, policies and procedures. Over time the innovation becomes accepted practice. The destination should now be operating as effectively as the source program. 6.5 Innovation Once the program has been fully implemented as originally intended, there are opportunities to refine and expand the program. It is important to first implement the practice or program with fidelity before attempting to innovate. 6.6 Sustainability To sustain the program ongoing training will be required as new staff join the program. Adaptations will be required to adjust to a changing environment and community needs. 7. CORE IMPLEMENTATION COMPONENTS The essence of implementing new approaches such as CDC is to have practitioners interacting with consumers and other stakeholders in a way that reflects the principles underpinning CDC. The key drivers of successful implementation include: 7.1 Staff selection This includes questions such as what qualifications and competencies are required, what are the best methods of recruitment and selection, what experience and personal characteristics will best suit the CDC approach. There is also an intersection here with wider systems issues such as workforce availability, the nature of more generalised training programs and qualifications. 7.2 Pre-service and in-service training This provides background information, theory, philosophy and values; introduces the key practices and provides opportunities to practice new skills. 7.3 Consultation and Coaching Effective learning takes place on the job with additional consultation and coaching. Implementation requires behaviour change at the practitioner, supervisory and administrative support levels. 7.4 Staff Evaluation There is a need for a process to assess whether the new approaches and skills are being reflected in the daily practice of staff. 7.5 Program Evaluation At a broader level there is a need to evaluate the overall performance of the organisation in implementing the new approach. This may be achieved through quality improvement systems and measures, or a more formalised evaluation approach. Page 7
7.6 Facilitative Administration Leadership and informed decision making support the overall process, keep staff organised and focus on the desired outcomes of the implementation. 7.7 Systems Interventions Strategies are needed to work with external systems to ensure the information and resources are available to complete the implementation. 8. THE ROLE OF STAFF TRAINING IN IMPLEMENTATION 8.1 Transfer of training Recent UK social care reforms characterised by a policy of increasing personalisation and choice in adult social care have been accompanied by major reorganisation and investment in workforce training and development. There is an assumed link between training and the quality of care received. Policy makers expect that potential in-service training will contribute to the transformation in service delivery. Recent findings from the evaluation of training in social care shows that problems continue to persist in demonstrating that training results in changes in practitioner behaviour back on the job. 14 These findings mirror those found more widely and suggest that learner characteristics, intervention design, and delivery and the workplace environment combine to influence whether training transfers to use on the job. Without a focus on the transfer of training, the contribution of training to quality of care outcomes will remain illusory. 8.2 What else is needed? This view is supported in studies by Smull 15 and Williams & Sanderson. 16 Smull emphasises that training is designed to teach a skill but does not necessarily result in the use of that skill. Coaches are needed to: Demonstrate the use of the skills, Help others learn the skills and practice them, and Reinforce their use until they become habit. 17 However, through this process coaches come to learn what is working and what is not working in the organisation. Senior management need to actively listen to what the coaches have learned and then act on that learning. The degree of engagement from leadership is the strongest predictor of success. 18 14 N. Clarke, July 2013 15 Smull (2009) 16 Williams & Sanderson (2005) 17 Smull (2009) p3 18 Op cit p6 Page 8
REFERENCES ACU National (2009) Exploring and Implementing Person Centred Approaches A Guide for NSW Community Participation Program Service Providers. NSW Department of Ageing, Disability and Home Care. Clarke N (2013) Health and Social Care in the Community (July 2013) 21(1), 15 25 Fixsen DL, Naoom SF, Blase KA, Friedman RM & Wallace F (2005) Implementation Research: A Synthesis of the Literature. University of Southern Florida. Smull M, Bourne ML & Sanderson H (2009) Becoming a Person Centered System. Williams R & Sanderson H (2005) What are we learning about Person Centred Organisations? Wright P, Turner C, Clay D, Mills H (2006) The Participation of Children and Young People in Developing Social Care. London: Social Care Institute for Excellence, cited in SCIE (2007). homecaretoday contact details: Email: homecaretoday@cota.org.au Phone: 03 9909 7910 Ronda Held (mob) 0450 785 437 Page 9