Harnessing Implementation Science Methods to Embed Organizational Climates for Change

Background and Purpose: Implementation strategies are needed to improve equitable access to care that is evidence-informed and anti-oppressive in order to address disparities in the quality and outcomes of behavioral health services. Significant evidence suggests organizational social context is a critical entry point to shape providers’ behavior and clinical health outcomes. However, from a systems theory perspective, multiple potential pathways exist within a given organizational that lead to a positive outcome and little is known about how organizations accomplish the critical task of embedding strategic climates that support clinical innovations. This multiple case study examined two organizations’ pathways towards embedding climates that supported a new clinical innovation within the context of participation in a large-scale implementation effort.

Methods: Using a mixed methods multiple case study approach and guided by the Exploration, Preparation, Implementation and Sustainment model, multiple sources of data were integrated to understand the pathways through which leaders embedded organizational climates. Quantitative implementation outcome data (observed fidelity) and staff ratings of organizational climate for implementation at 4 time points across 21 agencies informed sampling of two organizations that succeeded in embedding new climates but varied on organizational characteristics (e.g., size). Case study reports were generated from key stakeholder interviews, recorded regular coaching sessions, participant observation, and documents. Data were independently co-coded followed by an iterative consensus process. Individual case study reports, implementation maps, and conceptual matrices aided in both within and across case analysis. Both quantitative and qualitative data (quant > QUAL) were converged to facilitate depth and breadth of understanding of the phenomena over time.

Results: Two pathways emerged to successfully embed an implementation climate that supports a new clinical innovation. In the first case, previous (failed) experiences with similar innovations and consistency of innovation-organization values fit informed the decision to adopt and dedicate administrative capacity within the organization to support the implementation effort. Dedicating capacity supported other embedding strategies (e.g., selling the innovation to stakeholders, integrating it into policies and procedures, and providing rewards and recognition for its use). In the second case, innovation-organization values fit was also high and the organization made changes to highlight the innovation (e.g., to their mission). However, the approach to embedding climate was more top-down (e.g., less meaningful engagement of provider feedback) and the primary objective was using the innovation to improve the financial bottom line. The first case study also made the business case across stakeholders, but the innovation also sparked conversations in which clinicians were excited about the clinical impact of the new tool, which reinforced and motivated the work necessary to integrate the innovation into already taxed workflows.

Conclusions and Implications: Findings highlight two organizational pathways to embedding new climates that support innovation implementation and illuminate how leaders in human service organizations can create climates that support practices changes that are consistent with existing evidence and ethical mandates. Implications for organizational implementation practice and research will be discussed.