Effective Implementation: The 'How'

The HOW refers to how effective the implementation is. It involves paying attention to the stages towards fully implementing the innovation, and creating and maintaining the infrastructure needed to ensure that the innovation is in place, is used as intended and leads to the intended outcomes.

Alongside supporting the Enabling Context and articulating the innovation (the ‘What’), it was important to consider how to effectively implement the ANEW practice changes. Guided by Active Implementation, CELCIS supported Dundee partners to understand how to change practice and drive the implementation efforts. This section provides insight into what that required.

The Implementation Stages: How the change process unfolded

Active Implementation helps us to see implementation not as a short-term event, but as a long-term process composed of four stages. We outline them below by drawing on Dundee’s example.

• Exploration – Understand and decide: In the first year of the programme, the newly established Dundee Implementation Team and CELCIS held exploration meetings and focus groups with a wide range of practitioners from front-line to senior leadership levels, from education, health, social work, community development and the third sector. We reviewed relevant policy and research evidence and supported ongoing reflection on the emerging findings. The exploration led to increased understanding of Dundee’s children, young people and families’ systems; identified needs and assets; appraised and increased readiness for change; and led to the development of Dundee’s vision for change.
• Installation – Plan and prepare: In this stage, the Dundee’s change design was further articulated, and a significant attention was placed on developing and articulating the practice changes to address the needs identified during the exploration. Dundee also started to build the infrastructure necessary to implement the changes, with a focus on local sites and building practitioner and organisational readiness and capacity.
• Initial Implementation – Test and refine: This stage included the initial efforts of staff to use the practice changes. The work focused on supporting the site implementation teams, with increased attention to using data for continuous improvement.
• Full Implementation – Maintain and grow: This final stage would see the focus shift towards scaling up and Dundee ensuring that the practice changes continue to be delivered to a high standard by the majority of the workforce, and that the innovation contributes to significant outcomes.

Whilst Exploration is the starting point of implementation, the progression from one stage to another is not necessarily linear. Challenges or setbacks can arise, leading the implementation teams to return to tasks associated with earlier stages. When implementation is sustained by a strong Enabling Context and is focused on an existing and well-defined innovation, it might take up to four or five years to reach a stage where the practice change can be considered fully implemented. It will likely take longer in complex programmes such as ANEW.

The complexity of ANEW stemmed from the multi-agency nature of the partnership needed to provide effective early support for children, young people and families, combined with the fact that there was no off-the-shelf evidence-based programme or practice available to use (see the ‘What’). It was therefore important to build commitment and buy-in from practitioners and leadership in Dundee, knowing that the design and implementation of ANEW would be a long-term process.

Pressures were felt at times because of the perceived slow pace of the work, but the ANEW programme remained committed to pursuing significant outcomes and therefore incorporated ‘quick-wins’ (small changes) only when they reinforced, not distracted from, achieving meaningful and lasting change.

The Implementation Drivers: How practice was changed within the Dundee children’s services workforce  

Practice change cannot fall solely on practitioners. Organisational change and leadership action are critical, and that is where the Implementation Drivers can provide a helpful framework for guiding the implementation efforts.

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A number of approaches were taken as part of the ANEW programme to change practice among Dundee’s health visiting, early years and school staff. The main ones included: 

Strengthening the workforce competency through training and ‘coaching to practice’:

The workforce needs to be supported to understand the practice changes and acquire new knowledge to underpin skills development. Research shows that the greatest gains occur when we go beyond training alone and also provide coaching, as practitioners begin to use the changes in their daily practice. This type of coaching may be through ongoing feedback and reflection, and is most impactful when it focuses on each practitioner’s experience, learning needs and specific practice (‘coaching to practice’).

Examples of coaching that helped to implement the effective ANEW practices identified in the ‘What’ section include:

• The Meeting Buddies were offered initial training by Children First, followed by individualised coaching to help embed the practice.
• Coaching and on-going support was offered to school and nursery staff in named person role by other members of the Dundee Implementation Team. Our learning found that educational psychologists were well placed to step into a coaching role for named persons, given their skillset and focus on improving multi-agency assessment, planning of interventions and their overall contribution to the strategic and operational delivery of GIRFEC (see also Education Scotland’s report that highlights the contribution at pages 11-13).
• The coaching in relation to the home visits carried out by health visitors was strengthened through the introduction of data tools and a more regular time for debrief and reflection within the health visiting team.
• CELCIS facilitated the changes to training and coaching by closely working with the local implementation teams, bringing learning from theory and research, and modelling key skills focused on offering and receiving positive and developmental feedback, and supporting reflective spaces.

Regular observation of practice

Active Implementation stresses that observations of practice should be carried out regularly to appraise if the practice is being delivered with high quality and as intended –with fidelity, as described in the practice profile. This enables practitioners to hear feedback on their current practice and quickly make adjustments with support from their coach. Annual or biannual observations are not sufficient.

In the ANEW work, we applied the Active Implementation learning and identified two opportunities for observing practice – the Team around the Child Meetings, and the home visits conducted by health visitors, when joined by their supervisor, practice teacher or experienced colleagues (joint visits). CELCIS supported the local implementation teams to: create readiness for observation of practice; strengthen the coaching culture; become more familiar with how to use the GIRFEC Practice Profile drafted in the ANEW programme; and develop a set of observational data tools for this purpose.

Experienced GIRFEC practitioners (e.g. health visiting team leads or educational psychologists) carried out the observations and used these as a basis to highlight high-quality practice and identify practitioners’ learning and development needs to be addressed through training and coaching.

 

Regular planning and support meetings

CELCIS and the Dundee Implementation Team met regularly with the schools, the nurseries and the health visitors involved in the programme to plan, run tests of change, discuss progress and address organisational and system barriers. Read more about the cascading model of support in the Enabling Contexts section.

Developing a Decision Support Data System (DSDS) for the innovation

CELCIS worked closely with the local teams and facilitated the development of a suite of measurements and tools that we describe as the Decision Support Data System for the ANEW programme.

In Active Implementation, the role of a Decision Support Data System is to provide timely, reliable and relevant data to support better informed decisions, including in relation to training and coaching, and removal of organisational and systemic barriers.

It helps us to understand: if practice is delivered as intended (with fidelity); the capacity for change; the scale of implementation and associated process indicators; and the outcomes of the innovation.

This approach challenges the mindsets and models that rely primarily on quantitative data, collected and analysed at large time intervals.

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The Decision Support Data System in Dundee included both qualitative and quantitative indicators, with a focus on the experiences of practitioners, children and parents or carers. The main measurements included:

• Collecting parental feedback on their Team Around the Child meeting experience via a Parent/Carer Experience Questionnaire that provides information to practitioners on how parents/carers found the Team Around the Child meeting process, from the preparation stage through to the post-meeting debrief. 
• Conducting Early Concerns Mapping exercises with each school, nursery or health visiting team involved in the programme, to better understand their specific context, the wellbeing concerns among the children they work with, and how they respond to and record those concerns.
• Practice observations tools for the Team around the Child Meetings and the home visits conducted by health visitors.

Visit our Resource section for an overview of the ANEW tools and presentations on the ANEW Decision Support Sata System. The intention behind each of the approaches that supported practice change in Dundee was to be constructive rather than critical. They were all focused on improvement and supporting individual practitioners to consistently deliver high-quality practice for children and families.    

Summary, key learning and reflections: 

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