Effective Action Planning and Implementation

 

Introductory Paragraph

The last three steps in the SPF approach build upon the Assessment phase in which community-specific needs are identified and sufficient Capacity-Building has occurred to be able to implement solutions. The Planning, Implementation, and Evaluation phases are tightly interwoven. Since all three phases utilize the Assessment data in an integrated way, they are presented together in this single article. The Planning phase can be summarized as using the buy-in and wisdom of the coalition members to prioritize which goals can be realistically achieved and which actions should be implemented. Since the Evaluation phase will provide metrics on the effectiveness of those actions and progress towards those goals, it is important for planning priorities to be established with evaluation processes and outcomes in mind. If the Planning phase fully engages the coalition membership, there is likely to be more buy-in and accountability during the Implementation phase, as well as a deeper celebration of successful outcomes in the Evaluation phase.

Key Information

Planning

Substance misuse is a complex problem which a community can address by numerous strategies. An action plan requires the coalition to make choices about which solutions to implement. The specific approaches different communities will choose to take varies widely. The by-word for the planning process is prioritization which helps to simplify both the complexities of the task at hand and to focus on achieving results. Realizing that the Planning phases is the mid-point of the five SPF phases provides an opportunity to use two navigational points -- the data-driven and outcomes orientation of SPF. The data-driven component is based upon the Assessment phase and ensures that Implementation choices are grounded in the current needs of the community and not upon previous efforts, which may feel subjectively easier, but be less objectively effective. The outcomes component ensures that the Planning phase identifies strategies can be measured in the Evaluation phase, that they are based upon best practices, and that they align to S.M.A.R.T. goals. This acronym stands for Specific, Measurable, Achievable, Relevant, and Time-Bound. A small number of optimal SMART goals will drive the Implementation phase and can be developed by the coalition by balancing three simple criteria -- impact and capacity and timing:

• Impact. The Assessment phase will invariably identify numerous gaps and additional service needs. Since the coalition cannot provide solutions to all problems at once, it is useful to identify those outcomes which are immediately achievable. If certain coalition members are skeptical that any level of change is likely on a certain potential goal, then it may be better to shift focus to goals which will have more buy-in. Some of this may be influenced by what coalition members feel that the community-at-large will be most likely to support. Working on strategies which will have the highest impact helps the coalition to have successes which can build traction for more success.

• Capacity. When formulating an action plans, it is important that expectations are realistic and that select actions which are prioritized can be achieved by the coalition. It is important for communities to consider planning for small and early wins first, so that tangible progress will keep participants energized and motivated. Part of creating an achievable action plan is identifying and securing any financial and other resources that are necessary. There are a variety of funding sources that support planning and programs. These include local, state, or federal government grants, funding through philanthropic organizations, and support from the business community or fundraising campaigns. The action plan should identify steps to secure financial resources to meet their goals and objectives. More funding is not always feasible, so coalitions may need to consider alternate, innovative avenues in their action plans.

• Timing. Once the coalition agrees to an action plan, it is important to create timelines to complete each activity. As steps are taken to address both short- and longer-term goals, trust is built between the members working toward a common outcome. The timelines need to be reasonable and achievable. Having a range of timelines helps keep members engaged and have a sense of accomplishment. Some coalitions will have short-term goals that can be achieved in 30 or 60 days, mid-term goals that are several months out, and long-term goals that can be expected to take a year or more.

The following guidelines are useful in developing an action plan:

• Ensure that a diversity of populations within a given community are served. Due to differences in language, culture, and experiences, communities addressing any public health issue must develop action plans that can achieve desired outcomes for all people within the community.
• Include a variety of strategies to work across the continuum of care, with implementations in prevention, recovery, and access to treatment services.
• If the coalition is large enough to have a sub-committee to perform the Assessment phase and to develop a suite of possible interventions, then they should engage the full coalition in the process of prioritizing the specific strategies to implement.
• If possible include strategies which impact broad systemic and policy changes.
• Strategies should increase awareness, build education, enhance skills, build capacity, improve access, or fill gaps.
• Action plans are living documents and will need to be constantly reviewed and revised to address the new realities and lessons which are learned through the Evaluation phase. Decision makers need to be willing to experiment and constantly adjust the approaches they take. Even at the local level, aspects of the substance use epidemic change, sometimes quite rapidly. Leaders need to continually collect and analyze data in order to detect these changes and make adjustments.

Implementation

During the Implementation phase of SPF, a set of action items can be added to achieve the intended outcome of each SMART goal. Many community coalitions, especially those with a large number of members, will break into working groups or committees around each SMART goal to delineate details implementation objectives. Naturally, those members who are subject matter experts and work in specific fields can take the lead in implementing specific strategies. It is important for all participants to know what part of the action plan they are responsible for leading. This lays the groundwork of expectations between members and trust that each participant will carry out their portion of the plan. These responsibilities should be clearly spelled out in writing so there is no confusion or misunderstanding. Although one coalition member may be helping to coordinate the activities of other members, it is the responsibility of each member to be accountable and help achieve progress. For example, even coalition members who are not tasked with a specific strategy can still help to track milestones, maintain community momentum, and update key community stakeholders as progress is made. As work proceeds on implementing the plan, a process begins whereby actions are taken, effectiveness is assessed, and modifications to the plan are made. The constant evaluation of progress is an ongoing effort. Often, goals are added and changed, and sometimes changes are made in those responsible for implementing parts of the plan. It is important to have the expectation from the start that almost nothing goes exactly as planned. If focus and prioritization are the by-words for planning, the by-words for implementation are accountability and flexibility.

Evaluation

Three verbs which summarize the Evaluation phase are calibrate, celebrate, and communicate. The calibration involves evaluation of what worked well during implementation, what did not work, and what can be learned to launch a new SPF cycle of assessment, capacity-building, planning, and implementation. Celebration uses the documentation of even small wins for coalition members to share successes and to build positive momentum to achieve continued progress. The communication of evaluation results can be used to report outcomes back to funders and to advocate for the coalition mission with local and state decision-makers.

There are two types of evaluations -- process evaluations and outcome evaluations:

• Process evaluation ensures accountability and that the implementation was done with fidelity. This focus is primarily on outputs, such as number of classes offered or number of Naloxone kits distributed, and is often required for purposes of grant funding or communication with stakeholders. Did the coalition do what it said it was going to do? Were the activities within the action plan implemented? The identification of any action steps that were not implemented is likely to lead to an examination of staffing or resource issues, leadership, communication, and sustainability.
• Outcome evaluation measures effectiveness and focuses on impact. They employ change detection or pre-post measures which compare current conditions to baseline conditions. This is a process in which measurable progress towards the short-term or mid-term outcomes can be documented. Revision of long-term outcomes can be evaluated at this time as well. It should be noted that impact can also be documented through qualitative data. Often a compelling story can be told that is useful in promoting advocacy efforts. The conditions surrounding substance use are complex and documenting progress may be best served through the use of a narrative that is articulated by a variety of community members most affected by the action plan.

Solid action and evaluation plans outline a series of performance indicators which can be used to track progress towards SMART goals. Generally, the performance management process has four components:

• Identify appropriate performance indicators to determine markers of success.
• Conduct performance measurement, leveraging available data and collect new data to measure short-term and longer-term outcomes.
• Monitor and report performance management data, insights, challenges, and successes.
• Quality improvement uses evidence of limited results or setbacks as learning opportunities to be used to improve strategies and action plans.

The evaluation process guides the coalition in developing its strategies and tracks the effectiveness of each strategy over time. It will be up to each community to decide what data to collect and report, and what data should be made public. The identified lead should determine the frequency of data collection and coordinate collection efforts to regularly monitor data. The data report should educate and drive informed decision-making. For example, data used to track the number and locations of overdoses can provide the community with the knowledge of where overdoses are taking place and what hot spots exist. This allows a community to focus resources where they are needed by adding or expanding services like those related to prevention, harm reduction, and connection to services through peers or other means. Other parts of the data report may include available treatment and recovery housing beds, Naloxone distribution numbers, and the frequency of prescribed MAT in various settings. Continued communication and sharing of data is key. This will lead to greater collaboration between agencies which share data as well as other community stakeholders. Often new partnerships are forged when the data reveals what needs to be addressed.

Analysts may choose a variety of methods for sharing their data, including Geographic Information Systems (GIS), line graphs, bar charts, tables, and pie charts. Charts and graphs should be developed with the audience in mind -- easy to read, aesthetically pleasing, well-labeled, and include the totals for columns and rows. Only the most important information should be illustrated in order to keep the report simple. It is critical to use care when displaying and illustrating data in order to maintain a balance between accurately displaying data and creating an effective visualization. Communities have a variety of options for data support. Investments in off-the-shelf software systems are available for purchase and can be used to monitor data from various state and local organizations and to track system performance indicators and outcomes over time. If there is limited funding available, communities can use spreadsheet or database software, such as Microsoft Excel or Access.

Sustainability

The SPF process requires cultural competency and sustainability to be considered in all five phases. The first theme is addressed in more detail in the SAFE Solutions article titled, “Apply a Health Equity Lens.” The second is detailed in “Understand Funding and Identify Resources.” However, a few notes regarding sustainability are addressed here. Financial resources were mentioned above, regarding the Planning phase. By taking sustainability into account, planning should address the realistic capacity to maintain efforts to be implemented.

Within the Implementation context, the non-financial aspects of sustainability become apparent. Although, typically sustainability is thought of in terms of monetary resources, it also includes consideration of human capital. The training provided and the skills developed during implementation are vital to the sustained success of any coalition. Accounting for and rewarding the members of the coalition as a resource facilitates the retention of their service.

The Evaluation phase links to sustainability in two ways. First, the outcome measures create the context to document return on investment (ROI) of funds allocated during the Implementation phase. Second, the evaluation provides information on the way forward. What efforts are worthy of sustaining in the next SPF cycle?

Impactful Federal, State, and Local Policies

SAFE Solutions is an ever-growing platform.  Currently limited information is readily available for this section.  SAFE Project is dedicated to providing communities with the most relevant and innovative materials.  We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration.  Please check back soon.

Available Tools and Resources

• SAMHSA provides a summary of best practices in planning, implementation, and evaluation in its "Guide to SAMHSA’s Strategic Prevention Framework"

• SAFE Project. Coalitions can use the SAFE Solutions dashboard to help lead discussions on which strategies to implement within their community. The Community Playbook includes a template for building an action plan and for setting S.M.A.R.T. goals.

• The National Association of County and City Health Officials (NACCHO) has published a report with Joslyn Levy & Associates titled "Specifying Monitoring and Evaluation Measures for Local Overdose Prevention and Response Strategies: A Toolkit."

• The National Implementation Research Network has public health implementation as one of its four focus themes.

• The UNC Center for the Business of Health has launched the "From Settlement to Solutions" website, which is a comprehensive resource for the use of evidence-based opioid settlement funds, based on community conversations. This North Carolina case study consolidates best practices, research, policy trackers, and tools, providing a centralized hub for quick and easy reference.

• Research Meta-Analysis. Although it is dated, Durlak and DuPre (2008) is worthy of review because it provides a review of over 500 research findings on the implementation process.

Promising Practices

SAFE Solutions is an ever-growing platform.  Currently limited information is readily available for this section.  SAFE Project is dedicated to providing communities with the most relevant and innovative materials.  We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration.  Please check back soon.