Stages of Implementation, created by the National Implementation Research Network at the University of North Carolina, Chapel Hill, is a 4-stage framework that policymakers and directors of provider organizations can use to get the most out of the evidence-based interventions they wish to implement in new environments. The 4 stages are exploration, installation, initial implementation, and full implementation.
An implementation team stays engaged in the process through all four stages, and assesses the process at each stage. During the exploration stage, for example, the team could ask: “What should we do to further strengthen readiness and leadership commitment? Are there others who should be included in this process?”
Critical to the Stages of Implementation strategic framework are preparation, data collection, reporting, and improvement.
The NIRN Framework focuses on the following 4 phases of implementation activities: exploration, installation, initial implementation, and full implementation.
To begin, you must select an implementation team of 3 or more fulltime professionals who understand interventions, implementation science, and organization change. If you have such people on your staff already, wonderful. If not, you will need to hire from the outside.
The implementation team will do a needs assessment and decide which areas of need to target. Next, your team will review which evidence-based programs fit your needs. There are several things to consider here:
- What is the need for improved outcomes?
- What interventions are available that match the need?
- How strong is the evidence of each program?
- How well does the program apply to your environment?
- Are you ready to take a program proven to work elsewhere and replicate it in your environment?
- Do you have the resources to do so?
- Do you have the implementation capacity to support the program?
After the appropriate level of exploration, the team will select a program.
From the beginning of the exploration process, the implementation team organizes communication among the appropriate stakeholders (such as funders and partners) regarding the need for exploration. At the end of the process, the group will make its recommendation to those authorized to green-light the program.
The implementation team will also identify the structural and functional changes required for the program to be installed. These changes likely will consist of shifting schedules and materials and reallocating roles and responsibilities—including possibly making new hires. The organization should then make those changes.
At the installation stage, your team will select the first implementers—those people at the provider organization and any collaborators involved in implementing the program. Those implementers must be trained at the installation stage.
The implementation team must evaluate the readiness and sustainability of your data systems, including your fidelity data system. You must establish a communication structure for reporting what is working and what is holding up progress at the next stage—initial implementation.
Clear, accurate reporting (sharing of information) is essential at each stage of implementation. At initial implementation, you should have a communication plan to inform stakeholders of launch dates and activities. You also need to have communication protocols in place to identify challenges to success and to solve problems.
Leadership in your organization should have a support plan in place to promote persistence.
You will also need a coaching plan—in writing—and a coaching system for assessing fidelity to ensure that best practices are followed.
With an eye toward sustaining your new program, you should review
- Your recruitment and hiring process
- Your training procedures
- Your coaching processes
- Your data measures and reporting process
- Your fidelity measures and reporting process
- Your administrative policies and practices
You’re ready to launch with the first cohort of implementers. Leadership in your organization should be prepared to make changes to support the full and effective use of the intervention. You should also have a support plan in place to promote persistence of the intervention.
At full implementation, you need to have your monitoring and support systems in place and functional. The following feedback processes must also be in place:
- From your implementers to your administrators
- From your implementers to your implementation team support
- From agencies (such as schools, clinics, or care settings) to the next levels of administration
Your implementation and leadership teams should be using data during full implementation to make decisions regarding outcomes, behavior, and fidelity. And they should be asking: “What could we do to further strengthen and maintain implementation? What are the next ‘right steps’ to take?”
The National Implementation Research Network has a checklist of the steps that are necessary in all four stages—with columns for In Place, Initiated or Partially in Place, and Not Yet Initiated—in its publication Stages of Implementation Analysis: Where Are We?
Research about implementation stages is rare when it comes to evaluating the relative contributions of implementation factors across stages. However, a well-designed study by McCormick, Steckler, and McLeroy (1995) randomly assigned school districts to experimental or control conditions and provided all districts with a choice of middle school tobacco prevention curricula. The study found that smaller school districts were more likely to adopt a curriculum at the end of the exploration stage, whereas larger school districts (with more resources and greater flexibility) were more likely to implement more of the curriculum during the initial implementation stage.
Romney and colleagues (2014) also found that skipping the exploration process is expensive. Agencies that were required to use an evidence-based program did not produce the level of desired outcomes compared with agencies that had experienced the exploration process—and, therefore, the cost per successful case was much higher.
Other research includes case examples of statewide implementation and recommendations for psychologists across multiple roles to assist in advancing the implementation of EBPs in clinical practice.
Stages of Implementation can be used by policymakers, practitioners, staff, administrators, leaders, organizations, and communities. The stages are dynamic within organizations such as schools and clinics, moving back and forth among the stages as personnel and circumstances change. It is important to understand the stages so that the work of Implementation teams can be matched to the stage of the provider organization.
Gotham, H. J. (2006). Advancing the implementation of evidence-based practices into clinical practice: How do we get there from here? Professional Psychology: Research and Practice, 37(6), 606.
Romney, S., Israel, N., & Zlatevski, D. (2014). Effect of exploration-stage implementation variation on the cost-effectiveness of an evidence-based parenting program. Zeitschrift für Psychologie, 222(1), 37–48. doi:10.1027/2151-2604/a000164