Phase 3: Initial Implementation

At a Glance

Each phase of the implementation process includes 4 components: activities, tools, outcomes and self-reflection. Select one below to jump directly to that component.

Activities Tools Outcomes Self-Reflection

The goal of the initial implementation phase is to begin putting the system-change effort into practice while continuing to build capacity and refine your approach. During this stage, your team will focus on starting the initial roll out, monitor early impacts or outcomes, and identify barriers or challenges as they arise.

As you work through this phase, you may feel the need to revisit previous phases before moving forward with implementation. That is okay and may be necessary for the system-change effort you are implementing.

Download Full Guide Download Phase 3 Activities

Initial Implementation phase Activities

Examples of initial implementation phase activities recently carried out by Title V CYSHCN programs include:

Example Activities from Title V CYSHCN Programs

Expanded the team to include individuals needed for the launch of the work
Identified staffing needs and wrote a Request for Proposals to hire needed contractors or new staff
Piloted the system change with one site or organization
Formalized quality improvement processes (eg, Plan-Do-Study-Act cycles in contracts, and regular ongoing feedback loops to make immediate improvements to processes)
Completed ongoing evaluations at each step of the initial implementation, including qualitative metrics (such as levels of engagement)
Engaged third-party evaluator to help assess overall success
Co-developed meeting agendas with family leaders
Addressed technological issues and integration challenges
Provided participation incentives
Created standardized referral templates

Use the list below to consider which activities might be relevant for your system-change effort at this phase, keeping in mind that the change process is not always linear, and you will likely return to this phase over time. Teams may do these activities in a different order, and/or omit activities as needed. Teams may do these activities in a different order, and/or omit activities as needed:

Activities to Consider

Convene with implementation team regularly to track progress of implementation, including reviewing data to examine and improve implementation.
Develop protocols for identifying barriers or challenges with implementation and create decision-making strategies to determine how to move forward.
Pilot the systems effort in a specific site or with a single program.
Collect data and feedback from all impacted populations (eg, CYSHCN families/caregivers, providers, insurance companies) to evaluate effectiveness and progress towards desired outcomes.
Use a process to develop and initiate improvement strategies through analysis of data and community/stakeholder feedback.
Evaluate and decide if you will make any adaptations from initial implementation, and if you will continue in the original context; you may have done one pilot, for example, and decide to do another.
Use pilot data and other decision-making criteria to determine if the innovation should be expanded to other sites or programs.

In Case Study #4 - Developmental Screening and Referral, the team piloted with one health system, developed a standardized referral template, and addressed technical application programming interface challenges while collecting continuous feedback to refine the model prior to scaling.

Tools to Consider During Initial Implementation

These tools can be useful during initial implementation, and have been successfully used by CYSHCN teams in their efforts to transform systems.

Implementation Plan Template

Guide the development of an implementation plan at any phase of implementation.

PDSA Cycles

Rapidly identify an issue and a needed change, measure the impact, and make an informed plan to improve.

Measurement Table and Logic Model

Make an explicit statement of the activities that will bring about change and the results you expect to see for the community. Keep participants moving in the same direction by providing a common language and point of reference.

Program Sustainability Assessment Tool (PSAT)

Understand and plan for the factors that influence a program’s capacity for sustainability.

CDC’s Program Evaluation Framework

Plan effective public health strategies, improve existing programs, and demonstrate the results of resource investments.

FESAT

Plan, assess, and improve family engagement.

Initial Implementation Phase Outcomes

Data and community feedback are regularly used to inform decision-making and improve implementation.
Adaptations have been identified and implemented.
There is sufficient initial evidence that the system of services for CYSHCN is experiencing improvements, warranting a scale up of the system-change effort. Improvements may include:
- Improvements in coordinated, continuous, and comprehensive care delivered through a centralized medical home
- Active youth, family, and caregiver engagement in decision-making at all levels of the system
- Increased access to public and/or private health insurance for CYSHCN and their families
- Early and ongoing screening to identify special health care needs early
- More high-quality, well-organized services that are responsive to the needs of CYSHCN and their families
- Evidence of support for successful pediatric to adult health care transition

Initial Implementation Phase Self-Reflection

Use the self-reflection questions below to prompt your thinking about the change you want to make at this phase. The reflection table can be used at any point in the system change, to process your learning and identify next steps. Begin by having each team member do individual self-reflection, then share the responses with other team members as part of a larger group discussion. The group discussion can be used during ongoing team meetings or progress check-ins. Core components are the essential parts of an intervention or innovation. You can think of them like the “active ingredients” that allow your intervention to work. Core components can be developed and refined over time but are the “what” to the system change you are hoping to make. Start by naming your core components below.

Core Components

Family or Community Partnerships

Facilitators

Barriers

Needs

Assets

Phases of Implementation

Phase 1: Exploration

In this phase, teams examine the current systems for opportunities to improve care for CYSHCN, identify core components of the system-level change, and assess feasibility of the system-level change.

Phase 2: Installation

In this phase, teams identify the key resources and infrastructure needed to implement the system-level change and build monitoring and evaluation plans to monitor if the changes are working.

Phase 4: Full Implementation

In this phase, teams have fully integrated the system change into practice, ensure the change can be sustained over time, and assess whether the change can be replicated in other settings, or scaled up