The National i-THRIVE Programme team caught up with Jeni Page, Project Manager for the Scaling Up of i-THRIVE in NELFT, to talk us through each phase of the i-THRIVE Approach to Implementation starting with CAMHS and across sectors in four distinct and diverse geographical sites.
September 2018
The i-THRIVE Toolkit provides a straight forward process for implementation of the THRIVE Framework for system change (Wolpert et al., 2019) that is available for anyone to use here.
The toolkit sets out a step by step approach to implementation, and we recommend referring to it when considering any programme of implementation of the THRIVE Framework.
Why should sites use the i-THRIVE Approach to Implementation?
The i-THRIVE Approach to Implementation involves the explicit use of quality improvement methodology. This is important because it means that all changes bought in are iteratively tested, measured, and reviewed in a safe and effective way using Plan-Do-Study-Act cycles.
This technique allows innovations to be tested and measured in small numbers so that larger organisational risks are minimised. It safeguards against risk exposure and quickly stops work that has inadvertently caused unintended consequences. It ensures learning loops are built in so that if an intervention has not worked learning is shared and learnt from.
What is the i-THRIVE Approach to Implementation?
The i-THRIVE Approach to Implementation has been developed in line with a growing evidence base set out in the implementation science literature about what helps an implementation project to be successful. It has been developed to provide an approach that is locally led, co-created, pragmatic, evidence based and is designed to address local context.
The i-THRIVE Approach to Implementation is based on the Quality Implementation Framework (Meyers, Durlak and Wandersman., 2012) which outlines four phases that are considered crucial for the successful implementation of a programme:
These four phases can be undertaken sequentially, however there is usually an overlap to ensure capacity building e.g. due to staff turnover and maintain helpful processes which may be beneficial to embed in day to day work processes. For example, capacity building in Phase 2 may begin before Phase 1 has been fully completed. It might be helpful to think of Phase 1 and 2 as an on going cycle that will continue throughout the duration of the implementation process. In fact, these phases should never really stop, especially Phase 1, although the intensity with which you focus on them may vary.
So, how do I translate the theory above into implementing the THRIVE Framework in my service?
First of all, collaboratively decide on the part of the THRIVE Framework you want to focus on or enhance, e.g. Getting Advice and Signposting, or you might choose to do whole-system care planning.
Ok, so can you talk me through Phase 1?
Phase 1 guides you through all the thinking you have to do before taking action. These are important steps which will help minimise any unintended consequences of the area of focus, and also make sure you are targeting the actual problem with appropriate data, rather than what you think the problem might be.
- Set up and governance
- Who needs to be in the project team, who are the key stakeholders who need to be involved, and how will you share information with them?
- Engagement
- Who has an interest in, or will be impacted by this piece of work?
- Schedule a time to meet with them and develop a shared plan about what you are trying to do – this should include cross sector partners, referrers, and young people.
- Before ending schedule another time to meet to develop shared responsibility and accountability for ongoing progress and to maintain feedback loops. This helps orientate and structure the implementation process beyond what you may anticipate. Making use of existing meetings is also likely to lead to greater success and be more time efficient.
- Understanding your system
- What are the issues you are trying to solve, and what evidence do you have to support the need to find alternative solutions?
- To answer the questions above looking at data is essential – ask the performance or informatics team what data they have which can help you understand the problem.
- This step is essential. So even if it is frustrating do not give up. Ask for data that is broken down weekly (maximum monthly) or you won’t be able to get a true live picture of the change process.
- Don’t be shy in asking for a format that’s easy to use e.g. all the data is on one page rather than on several sheets.
Ask for help with the analysis – there will be someone in the team who is keen to help so make sure they are part of the project team. - Get advice on how to use the data you have been given. Some trusts have QI teams who hold regular drop in clinics to help anyone who needs support.
- Ensure that when there is cross-sector implementation there are similar expectations about the meaning of data e.g. what may be in a closure in one service may not be for another.
- Do this in partnership with those extracting the data.
- Once you know what the issues are you need to find out what is maintaining or contributing to it, as it might not always be what you think it is. These toolkit items might help:
- Prioritisation
- It is likely you may still have several possible areas of focus. This toolkit item might help you decide which issue are you going to tackle first:
- Now you have been able to quantify your identified area of focus, and you know what the contributing factors might be, you can further refine your target for improvement.
- So what change process are you going to enact, and what are the reasons for choosing this solution?
- Using this toolkit item will help you think of ideas, and identify the likely impact:
- Implementation planning
- Remember QI is about starting small, so decide the who, what, when, where, and why for your first test of the new initiative. MINDSet is a useful resource for more helpful tips on implementation using quality improvement.
- For example, you might run an education session for GPs about referral pathways.
- We start small to minimise the negative effect of unintended consequences, to enable us to understand which aspect of the intervention we are testing is effective.
- Remember QI is about starting small, so decide the who, what, when, where, and why for your first test of the new initiative. MINDSet is a useful resource for more helpful tips on implementation using quality improvement.
How about Phase 2?
Now you have decided what to do, Phase 2 ensures that you are in the best possible position to start your implementation:
- Developing implementation teams:
- Do the people testing out the change idea have a shared understanding of the expectations?
- If not, how will you facilitate this?
- Workforce planning
- Does the workforce have the capacity to try something new? If not, how can this be created?
- Build a local Community of Practice
- Don’t forget to talk to other people also trying to implement the THRIVE Framework to share learning and potential solutions e.g. staff engagement.
- Training
- Consider whether this would be helpful to build workforce capacity.
- For specific training on the THRIVE Framework and implementing the THRIVE Framework you can contact the National Programme Team.
- Research local QI teams that you can draw on to support you in the work
- Look into support offered by AHSNs, NHS Improvement, and Leadership Academies.
- Measurements
- This is essential so you know whether what you are testing is leading to improvements. Make sure you know what data you need, how to get it, and how to understand it, alongside whether there are different perspectives on understanding the data.
- It is difficult to keep momentum going if there is not a data feedback loop. A way around this is collecting the data yourself if accessing data from the performance or informatics team is a major barrier. However investing time in report building at this stage is crucial, as is sense checking the data you collected in phase one remains an appropriate indicator of improvements.
- Data tends to be where we get most confused, don’t be afraid to keep revisiting until you are confident you are looking at the right indicators.
What about Phase 3?
Phase 3 is where you take action.
- Making changes using QI:
- In other words start your PDSA cycles (Plan, Do, Study, Act). This means you plan what you are doing (Phase 1 and Phase 2 have already helped you do this), you implement a change process and then review the impact (this is why measurement is essential), you make any changes necessary and repeat the cycle. Remember this is the rationale for why you start small and scale up where there are positive outcomes.
- The changes might be refinements necessary to improve the detail of your test, or it might be to test it on a larger scale.
- A change might be stopping something completely if it is not working. ‘Failure’ is not a bad thing – but in QI we make sure we fail fast so the consequences are small and contained, and the learning shared. This is why it is important we don’t go too big too soon.
- This toolkit item might help:
- PDSA template
- QI resources listed here
- ‘Five Whys?’
- Technical assistance:
- Keep asking for help for example: your colleagues, the National i-THRIVE Programme team, colleagues in other service.
- If you can find some good quality QI coaching it is likely to be extremely helpful in this stage.
- Supportive feedback mechanisms:
- Talk to others who might have good ideas and can help you reflect on your progress.
- Sign up to attend the National i-THRIVE Programme team’s Community of Practice events, and newsletter to hear from sites nationally and share your learning
- Make time to meet with other colleagues who are implementing the THRIVE Framework to build a local Community of Practice.
And Phase 4?
Phase 4 is all about turning something you tested out, if successful, into business as usual.
- Learning from experience:
- What has helped keep people on board whilst you were testing out your changes? Embed sustainability of these (see below).
- What has helped other initiatives you have been involved in embed into your daily work practice? Think about systems, processes etc. and make sure these are all engaged.
- This toolkit item might help:
- Sustainability:
- Don’t assume people will keep doing something new unchecked. Make sure the new practice is a standing agenda item at a team meeting, and the data continues to be monitored. The frequency can be reduced, but it is always helpful to check in with the team every now and again so all the hard work doesn’t get forgotten.
- This toolkit item might help:
What are your top tips for a successful implementation based on the NELFT experience?
Pre-implementation
- Cultivate relationships with the performance/informatics teams
- Invest time in data report building
- Involve key stakeholders in the planning from the start
- Identify and celebrate examples of good THRIVE-like practice already developed
- Pro-active leadership is key to driving effective service improvements
To maintain or build momentum
- Ensure there are regular data driven feedback mechanisms and shared learning opportunities in place across different levels of the system
- Always schedule the next meeting with your key stakeholders before the end of meetings to maintain relationships, and try to make use of existing meeting structures
- Timetable events to share learning, and ensure these are shared across the system, e.g. Outlook invites
- Celebrate what is working well. Share your learning, and showcase good practice through i-THRIVE implementation stories, and presentations at local and national shared learning events
- Develop a leadership network to provide additional capacity, e.g., during leave arrangements
To ensure success
- Continuously review data from different cross-sector perspectives to ensure you are looking at the correct indicators, with shared understandings of data interpretation
- Start small and scale up if success is indicated
- It’s never too early to start planning for sustainability – the key is to ensure sustainability is embedded throughout “business as usual”
- Continually assess progress across the work plan and identified priorities and strategies
- Ensure learning feedback loops are embedded to shared learning across systems
If you would like to take part in a Q&A to share your experiences in relation to implementation of the THRIVE Framework and using the i-THRIVE Approach to Implementation, please get in touch with the team at ithriveinfo@tavi-port.nhs.uk.