Research That Matters (January 17 - 20, 2008)

Understanding how one can change policies, programs and practices is arguably as important as understanding why one should change them. Because desired changes generated in research and administrative settings are often not easily applied in everyday practice, increasing attention is being focused on implementation. The National Institute of Health developed implementation workgroups and called for research on “interrelated structures and processes” during implementations (NIMH, 2002, 2005). Lennon and Corbett (2003) identified a need to “study process issues at every level of implementation”. The aims of this qualitative study are twofold: (1) to describe how frontline clinicians attempt to implement a state-mandated mental health policy; and, (2) to articulate the interrelated processes between the written mandate, related expectations, and clinicians' actual implementation attempts.

Methods:

This is a case study of the processes through which frontline clinicians implement a state mental health policy mandating completion and clinical utilization of a 67-question outcomes survey with adult mental health consumers. Data was collected through participant-observation of 17 consumer-clinician dyads (n= 17 consumers and 9 clinicians recruited from 4 mental health centers) completing and/or discussing the survey. To trace processes embedded in clinical experiences, a bottom-up, snowball sampling interview strategy was used to collect data from supervisors and administrators (n =22). Atlas.ti was used to manage and analyze data. First, quotations referencing consumer/clinician experiences, understandings, and uses of the surveys were coded and sorted by shared themes. Second, themes were grouped under mandated policy expectations and actual practice expectations. Third, mandated themes were compared with clinician/consumer themes. Last, administrator/supervisor data were used to elucidate intermediary processes between actual frontline attempts and mandated expectations.

Results:

Analysis provided descriptive information about the processes through which clinicians negotiated procedural and billing constraints conflicting with the policy. Significant aspects of the interrelated processes between the written mandate, related expectations, and clinicians' actual implementation attempts included: (1) most consumers expressed a strong preference for completing the survey interactively with clinicians; (2) survey results were often not received by clinicians, or received months later, or received in formats deemed “hard to understand”; (3) clinical discussion generated by consumer survey responses most occurred during interactive survey completion, not when reviewing results ; (4) Medicaid – a primary funding source – didn't routinely pay for survey completion time; and, (5) routine outcomes completion didn't count toward clinicians' billable hour quotas. How frontline clinicians negotiated between consumer preferences, existing constraints and policy requirements was similar across agency settings.

Conclusions and Implications:

Grounded in experiences of clinician-client dyads, this study offers a detailed description of an implementation endeavor in which interrelated and conflicting system processes converge, manifest and are negotiated in individual frontline experiences. Through taking up frontline perspectives in naturalistic settings, problematic confluences of system processes where the ‘rubber meets the road' can be explicated and intervened upon, rather than remaining the unarticulated barriers to implementation. Findings underscore the importance of excavating the socially organized processes embedded in individual frontline implementation experiences. Acknowledgment: Grant funded by the Ohio Department of Mental Health.