From Ghost Systems to Host Systems via Transformation Zones

Over the past two centuries social reformers and educators have worked hard to include children from disadvantaged families, girls, racial and ethnic minorities, children with special needs, and young adults into an education system open to all. This was a struggle, and now a free and appropriate public education (FAPE) is available for all children from birth through high school graduation and beyond. As a result of these struggles to include all children, current education systems are legacy systems. They are the fragmented remains of different times and a wide variety of approaches to reforming education. There is no ill will implied in this statement. Systems often have their beginnings in this piecemeal manner. The goals were inclusion and equality, and the effectiveness of the overall system was anticipated but was not the main focus of the reform efforts. In the new millennium, the focus is shifting. Given the lack of improvement in education outcomes in the United States over the past decades, the emphasis now is on a free, appropriate, and effective public education system. The purpose of this Brief is to outline the convergence of advances in implementation, organization change, and system reinvention science and practice. The confluence of these fields is lighting the way for effective and efficient changes in large education and human service systems

Specifying and reporting complex behaviour change interventions: the need for a scientific method

Abstract Complex behaviour change interventions are not well described; when they are described, the terminology used is inconsistent. This constrains scientific replication, and limits the subsequent introduction of successful interventions. Implementation Science is introducing a policy of initially encouraging and subsequently requiring the scientific reporting of complex behaviour change interventions

Translating clinical training into practice in complex mental health systems: Toward opening the 'Black Box' of implementation

<p>Abstract</p> <p>Background</p> <p>Implementing clinical training in a complex health care system is challenging. This report describes two successive trainings programs in one Veterans Affairs healthcare network and the lessons we drew from their success and failures. The first training experience led us to appreciate the value of careful implementation planning while the second suggested that use of an external facilitator might be an especially effective implementation component. We also describe a third training intervention in which we expect to more rigorously test our hypothesis regarding the value of external facilitation.</p> <p>Results</p> <p>Our experiences appear to be consonant with the implementation model proposed by Fixsen. In this paper we offer a modified version of the Fixsen model with separate components related to training and implementation.</p> <p>Conclusion</p> <p>This report further reinforces what others have noted, namely that educational interventions intended to change clinical practice should employ a multilevel approach if patients are to truly benefit from new skills gained by clinicians. We utilize an implementation research model to illustrate how the aims of the second intervention were realized and sustained over the 12-month follow-up period, and to suggest directions for future implementation research. The present report attests to the validity of, and contributes to, the emerging literature on implementation research.</p

Employing external facilitation to implement cognitive behavioral therapy in VA clinics: a pilot study

<p>Abstract</p> <p>Background</p> <p>Although for more than a decade healthcare systems have attempted to provide evidence-based mental health treatments, the availability and use of psychotherapies remains low. A significant need exists to identify simple but effective implementation strategies to adopt complex practices within complex systems of care. Emerging evidence suggests that facilitation may be an effective integrative implementation strategy for adoption of complex practices. The current pilot examined the use of external facilitation for adoption of cognitive behavioral therapy (CBT) in 20 Department of Veteran Affairs (VA) clinics.</p> <p>Methods</p> <p>The 20 clinics were paired on facility characteristics, and 23 clinicians from these were trained in CBT. A clinic in each pair was randomly selected to receive external facilitation. Quantitative methods were used to examine the extent of CBT implementation in 10 clinics that received external facilitation compared with 10 clinics that did not, and to better understand the relationship between individual providers' characteristics and attitudes and their CBT use. Costs of external facilitation were assessed by tracking the time spent by the facilitator and therapists in activities related to implementing CBT. Qualitative methods were used to explore contextual and other factors thought to influence implementation.</p> <p>Results</p> <p>Examination of change scores showed that facilitated therapists averaged an increase of 19% [95% CI: (2, 36)] in self-reported CBT use from baseline, while control therapists averaged a 4% [95% CI: (-14, 21)] increase. Therapists in the facilitated condition who were not providing CBT at baseline showed the greatest increase (35%) compared to a control therapist who was not providing CBT at baseline (10%) or to therapists in either condition who were providing CBT at baseline (average 3%). Increased CBT use was unrelated to prior CBT training. Barriers to CBT implementation were therapists' lack of control over their clinic schedule and poor communication with clinical leaders.</p> <p>Conclusions</p> <p>These findings suggest that facilitation may help clinicians make complex practice changes such as implementing an evidence-based psychotherapy. Furthermore, the substantial increase in CBT usage among the facilitation group was achieved at a modest cost.</p

Membrane vesicles, current state-of-the-art: emerging role of extracellular vesicles

Release of membrane vesicles, a process conserved in both prokaryotes and eukaryotes, represents an evolutionary link, and suggests essential functions of a dynamic extracellular vesicular compartment (including exosomes, microparticles or microvesicles and apoptotic bodies). Compelling evidence supports the significance of this compartment in a broad range of physiological and pathological processes. However, classification of membrane vesicles, protocols of their isolation and detection, molecular details of vesicular release, clearance and biological functions are still under intense investigation. Here, we give a comprehensive overview of extracellular vesicles. After discussing the technical pitfalls and potential artifacts of the rapidly emerging field, we compare results from meta-analyses of published proteomic studies on membrane vesicles. We also summarize clinical implications of membrane vesicles. Lessons from this compartment challenge current paradigms concerning the mechanisms of intercellular communication and immune regulation. Furthermore, its clinical implementation may open new perspectives in translational medicine both in diagnostics and therapy

Achievement Place: experiments in self-government with pre-delinquents

One of the goals of many treatment programs for pre-delinquent youths is the development of the skills involved in the democratic decision-making process. At Achievement Place, one aspect of the treatment program is a semi-self-government system whereby the seven pre-delinquent youths can democratically establish many of their own rules of behavior, monitor their peers' behavior to detect violations of their rules, and conduct a “trial” to determine a rule violator's guilt or innocence, and to determine the consequences for a youth who violates a rule. Two experiments were carried out to determine the role of some of the procedures in the boys' participation in the self-government system. Experiment I showed that more boys participated in the discussion of consequences for a rule violation when they had complete responsibility for setting the consequence during the trials than when the teaching-parents set the consequence for each rule violation before the trial. An analysis of the rule violations in this experiment indicated that the boys in Achievement Place reported more of the rule violations that resulted in trials than reported by the teaching-parents or school personnel. The boys reported rule violations that occurred in the community and school as well as at Achievement Place, including most of the serious rule violations that came to the attention of the teaching-parents. In Experiment II, the results indicated that more trials were called when the teaching-parents were responsible for calling trials on rule violations reported by the peers than when the boys were responsible for calling trials. When the youths earned points for calling trials the average number of trials per day increased, but more trivial rule violations were reported. These results suggest that aspects of the democratic decision-making process in a small group of pre-delinquents can be studied and variables that affect participation can be identified and evaluated

Achievement Place: the reliability of self-reporting and peer-reporting and their effects on behavior

The reliability of the boys reporting their own behavior of their peers was measured in two experiments at Achievement Place, a community based, family style, behavior modification program for delinquents based on a token (point) economy. The results of these experiments indicated that; (a) the boys were not “naturally” reliable observers, (b) the reliability of peer-reporting could be improved by providing training on the behavioral definitions and by making points contingent on agreement between each boy's peer-report and an independent adult observers' report, (c) the reliability of self-reporting could be improved by making points contingent on agreement between the self-report and the trained peer's report, and (d) giving self-reports and peer-reports did not produce a systematic effect on the boys' room-cleaning behavior as measured by an independent observer

Specifying and reporting complex behaviour change interventions: the need for a scientific method

Abstract Complex behaviour change interventions are not well described; when they are described, the terminology used is inconsistent. This constrains scientific replication, and limits the subsequent introduction of successful interventions. Implementation Science is introducing a policy of initially encouraging and subsequently requiring the scientific reporting of complex behaviour change interventions.</p