External Change Agents Research Articles

Applying the Consolidated Framework for Implementation Research to Optimize Implementation Strategies for the Friendship Bench Psychological Intervention in Zimbabwe

Scaling up an evidence-based mental health program such as the Friendship Bench (FB) Zimbabwe bares many difficulties. Guided by the Consolidated Framework for Implementation Research (CFIR), this study sought to understand the contextual determinants of FB performance and to identify and match novel implementation strategies to optimally overcome barriers. The CFIR was applied to guide twenty-five focus group discussions with n = 152 stakeholders in nine high- and four low-performing clinics across three cities in Zimbabwe to identify the constructs distinguishing clinic performance. Identified implementation barriers were included in the CFIR-Expert Recommendation for Implementation Change (ERIC) matching tool to inform strategies to optimize future FB implementation outcomes. Constructs peer pressure, goals and feedback, learning climate, planning, formally appointed leaders, and external change agents strongly distinguished between high- and low-performing clinics. Barriers to implementation were intervention complexity and organizational incentives and rewards; intervention-related constructs were identified as enablers. Strategies such as identifying and preparing champions, altering incentive structures, developing a formal implementation blueprint, and organizing regular clinician meetings were chosen to address barriers and optimize FB implementation. There was variability in the implementation performance of FB three years post-scale-up. High-performing clinics appear to be influenced positively by peer pressure, goal setting and feedback, better staff communication and integration of the program, overall learning climate, and clinic-level planning. A set of enhanced FB implementation strategies should be applied to improve implementation performance.

Export Policy Initiatives: Conceptualization of Valid Measurement Scales and Constructs for Empirical Assessment

Firms view export policies as an external change agent that stimulates international business activities. In the past decades, developing countries have witnessed significant changes in their export policies to reduce financial and infrastructural barriers to international trade. India, with an objective to double its market share at the global level by 2020, has initiated a mix of policy measures in its Foreign Trade Policy since 2009. However, to measure the effectiveness of these policy initiatives on export business, no valid measurement scales or constructs have been developed for empirical assessment. Moreover, there is very little agreement in the literature about a conceptual definition of government export assistance as well as its operational definition. Hence, the objective of this study is to identify relevant policy initiatives and develop sub-dimensional constructs with valid measurement scales. This conceptualization is explored empirically with data from 400 exporters. The data identified four sub-dimensional measurement models that can be considered for future operations. The findings also provide useful practical guidelines and recommendations to exporters, policymakers and researchers.

Barriers and Facilitators to Data Use for Decision Making: The Experience of the African Health Initiative Partnerships in Ethiopia, Ghana, and Mozambique

Three African Health Initiative (AHI) partnership projects in Ethiopia, Ghana, and Mozambique implemented strategies to improve the quality and evaluation of routinely collected data at the primary health care level and stimulate its use in evidence-based decision making. We compare how these programs designed and carried out data for decision-making (DDM) strategies, elaborate on barriers and facilitators to implementation success, and offer recommendations for future DDM programming. Researchers from each project collaboratively wrote a cross-country protocol based on these objectives. By adapting the Consolidated Framework for Implementation Research (CFIR) through a qualitative theme reduction process, they harmonized lines of inquiry on the design of the respective DDM strategies and the barriers and facilitators of effective implementation. We conducted in-depth interviews and focus group discussions with stakeholders from the primary health care systems in each country, and we carried out multistage, thematic analyses using a deductive lens. Effective implementation of DDM depended on whether implementers felt that DDM was adaptable to context, feasible to trial, and easy to introduce and maintain. The prevailing policy and political environment in the wider health system, learning climate and absorptive capacity for evidence-based change in DDM settings, engagement of external change agents and internal change leaders, and promotion of opportunities and means for team-based reflection and evaluations of what works influenced the success or failure of DDM strategies. Opportunities for team-based capacity building and individual mentorship led to effective DDM programming. External policies and associated incentives bolstered this but occasionally led to unintended consequences. Leadership engagement and availability of resources to act on recommendations; respond to capacity-building needs; and facilitate collaborations between peers, within hierarchies, and across the local health system proved crucial to DDM, as was encouraging adaptation and opportunities for iterative on-the-job learning.

Determinants of inter-organizational implementation success: A mixed-methods evaluation of Veteran Directed Care

BackgroundVeteran Directed Care (VDC) aims to keep Veterans at risk for nursing home placement in their communities. VA medical centers (VAMCs) purchase VDC from third-party organizational providers who then partner with them during implementation. Experiences with VDC implementation have varied. Objectives: We sought to identify conditions differentiating partnerships with higher enrollment (implementation success). Methods: We conducted a case-based study with: qualitative data on implementation determinants two and eight months after program start, directed content analysis to assign numerical scores (−2 strong barrier to +2 strong facilitator), and mathematical modeling using Coincidence Analysis (CNA) to identify key determinants of implementation success. Cases consisted of VAMCs and partnering non-VAMC organizations who started VDC during 2017 or 2018. The Consolidated Framework for Implementation Research (CFIR) guided analysis. Results: Eleven individual organizations within five partnerships constituted our sample. Two CFIR determinants- Networks & Communication and External Change Agent-uniquely and consistently identified implementation success. At an inter-organizational partnership level, Networks & Communications and External Change Agent +2 (i.e., present as strong facilitators) were both necessary and sufficient. At a within-organization level, Networks & Communication +2 was necessary but not sufficient for the non-VAMC providers, whereas External Change Agent +2 was necessary and sufficient for VAMCs. Conclusion: Networks & Communication and External Change Agent played difference-making roles in inter-organizational implementation success, which differ by type of organization and level of analysis. Implications: This multi-level approach identified crucial difference-making conditions for inter-organizational implementation success when putting a program into practice requires partnerships across multiple organizations.

Enablers and Constraints of STEM Programme Implementation: an External Change Agent Perspective from a National STEM Programme in Finland

An international need exists for effective programmes that will enhance learners’ interest in studies and careers related to science, technology, engineering and mathematics, i.e. STEM. When considering the impact of STEM programmes, it is important to identify what can enable or constrain effective programme implementation. As such, enablers can be systematically supported and constraints tackled to maximise a programme’s impact. This study considers a nationwide STEM programme in Finland that involved 450 teachers and their learning communities. The study followed an interpretative paradigm, collecting data through semi-structured interviews and analysed with data-driven thematic analysis. The study participants were 14 external change agents operating between participating learning communities and the national programme administration and, thus, had a valuable overview on how the programme evolved. The most important enablers of effective programme implementation were versatile support, programme flexibility and long-term vision. Two major constraints were limited resources and collaboration challenges. Considering the findings of this study can help design effective STEM programmes by providing various support mechanisms for educators, particularly scaffolding; peer and school administrator support; flexibility to enable embedding activities and adapting programme objectives to participants’ everyday work; long-term vision to support both lifelong learning and a continuum between different STEM programmes; sufficient time and economic resources to achieve a long-term impact; and collaboration and networking opportunities at the local, regional, national and international levels.

Factors affecting the willingness to accept digital transformation by small and medium enterprises in Ho Chi Minh City

Digital transformation is becoming a strategy at businesses and organizations in the 4th Industrial Revolution. The 2020 report by Cisco & IDC on digital maturity of small and medium-sized businesses in 14 countries in the Asia-Pacific region shows that: 31% of businesses are in the early stages of digital transformation, down 8% compared to 2019; 53% are in the observation period - a 3% increase compared to 2019; 13% are in the challenging stage, and 3% of the businesses have entered the mature stage, an increase of 4% and 1% respectively from 2019. Digital transformation is an irreversible trend; if a business do not keep up with it, they will inevitably fail, especially small and medium enterprises in Vietnam.The study analyzes the factors affecting the willingness to accept of Digital Transformation by small and medium enterprises (SMEs) in Ho Chi Minh City. For research, the author collects data from a direct survey of 290 SMEs in Ho Chi Minh City. The research results show that there are 8 independent factors affecting the adoption of Digital Transformation by enterprises: (1) Perceived relative advantage, (2) Perceived compatibility, (3) Perceived complexity, (4) Knowledge of digital transformation, (5) Management awareness of digital transformation, (6) External change agents, (7) Pressure from partners and opponents. From there, the author proposes implications to raise awareness of SME business owners equip, update knowledge, change awareness, see the benefits and advantages of businesses accepting to participate in digital transformation, suitable in line with social development, in line with the trend of the 4.0 technology era.

Preventing Sexual Harassment at Workplaces – the Legal and the Spiritual Perspective

Purpose: The purpose of this paper is to explore the spiritual trajectories of promoting harassment-free workspaces. The paper develops a bilateral model of individual and organizational spirituality about both the intentionality and outcomes of spiritual modes of thinking, decision-making, and performance. Design/Methodology/Approach: The paper follows the case analysis method. It draws upon the experiences of an NGO working as an external change agent for instituting the spirit of the PoSH Act, 2013 in organizations. The authors have shortlisted 10 case studies from more than 100 sexual harassment cases handled by the NGO for addressing the larger issues of spirituality in organizations. The paper is interspersed with anecdotal and ethnographical references to continually juxtapose the letter and spirit of the legislation preventing harassment in India. Findings: As evangelists of harassment-free workspaces, the authors find that realization of this goal will not be possible with only passive, mechanistic compliance with the letter of law or the rules of the organization laid down in this regard. Research Limitations: The major limitation of this paper is that it only accounts the secondary information, the empirical investigation is missing. Managerial Implications: The aim of harassment-free workspaces as a building block of a harassment-free world is a collective journey of individuals, Internal Complaint Committees, organizations, and society as a whole. That organization where the spirit is given more importance than just the letter, and the closer an organization is to the principle of equality, as expected of us by the universe, the closer it is on its spiritual path to creating harassment- free workspaces. Originality/Value: The paper draws on the first-hand experience of the NGO and is an original contribution to the further development of research in this area.

Implementation of the Meningitis Vaccine Project in Africa: lessons for vaccine implementation programs

Background The Meningitis Vaccine Project (MVP) was an international partnership that began in 2010 and focused on the development, testing, licensure, and widespread introduction of a conjugate vaccine with the promise of protecting millions of lives from group A meningococcal meningitis. To bridge gaps upstream of vaccine administration and in understanding the project’s planning, delivery and outcomes, the primary objective of this study was to delineate the barriers to and facilitators of sustainable implementation in an upstream context of the delivery of the MenAfriVac vaccine and to draw critical lessons for other vaccination programs. Methods We conducted a qualitative study with key project partners and leaders who worked on the MVP project. The interviewees were initially identified through a literature review and a search of publications and evaluations of the project. Eighteen key stakeholders were interviewed. The interviewees included individuals in the roles of implementation oversight, champion, partner, funder, and frontline implementer. The Consolidated Framework for Implementation Research (CFIR) informed the identification of a priori codes for the directed content analysis. Results There were multiple barriers and facilitators to implementing the vaccine under all five domains of the CFIR framework, including intervention characteristics, outer setting, inner setting, characteristics of individuals, and process. The most common domains mentioned by stakeholders that facilitated the success of the MVP were inner setting and process; specifically, three constructs were most representative—Tension for Change, Formally Appointed Implementation Leaders, and External Change Agents. Conclusions The tension for change—that is, the degree to which stakeholders perceive the current situation as intolerable or needing change— advocated by African leaders served as a crucial foundation for solid leadership for the MPV. The leadership came in the form of the project director and other formally appointed leaders, who could plan, engage and execute the project’s goals effectively. This leadership translated into consistent messaging, information sharing, and multiple levels of engagement with external change agents (including technical experts), which promoted a shared sense of readiness contributing to significant change investments in implementing MVP.

How do apprentices moderate the influence of organizational innovation on the technological innovation process?

This paper contributes to the literature on non-monetary benefits of Vocational Education and Training (VET) by investigating its influence on a firm’s innovation process. While an increasing number of studies finds positive effects of VET on innovation in firms, the role that apprentices play in this mechanism has largely been unexplored. To analyze this role, we use the distinction between technological and organizational innovation, two complementary forms of innovation. When investigating the initiators of organizational innovation, to date, research has primarily focused on internal and external change agents at upper echelons. We conceptualize apprentices as hybrid (a combination of internal and external) change agents at lower echelons. We examine how apprentices in the Swiss VET system are key to integrating external knowledge (through school-based education) with internal knowledge (through on-the-job training) and moderating the influence of organizational innovation on technological innovation. Drawing on a sample of 1240 firms from a representative Swiss Innovation Survey, we show that apprentices leverage the positive association between innovations in a firm’s business processes and organization of work with incremental innovations. With the description of a new mechanism that shows the significant role of apprentices on firms’ technological innovation activities and evidence for supportive associations between key variables, we contribute to the understanding of the influence of VET on innovation in firms.

A systematic review of measures of implementation players and processes: Summarizing the dearth of psychometric evidence.

Measurement is a critical component for any field. Systematic reviews are a way to locate measures and uncover gaps in current measurement practices. The present study identified measures used in behavioral health settings that assessed all constructs within the Process domain and two constructs from the Inner setting domain as defined by the Consolidated Framework for Implementation Research (CFIR). While previous conceptual work has established the importance social networks and key stakeholders play throughout the implementation process, measurement studies have not focused on investigating the quality of how these activities are being carried out. The review occurred in three phases: Phase I, data collection included (1) search string generation, (2) title and abstract screening, (3) full text review, (4) mapping to CFIR-constructs, and (5) "cited-by" searches. Phase II, data extraction, consisted of coding information relevant to the nine psychometric properties included in the Psychometric And Pragmatic Rating Scale (PAPERS). In Phase III, data analysis was completed. Measures were identified in only seven constructs: Structural characteristics (n = 13), Networks and communication (n = 29), Engaging (n = 1), Opinion leaders (n = 5), Champions (n = 5), Planning (n = 5), and Reflecting and evaluating (n = 5). No quantitative assessment measures of Formally appointed implementation leaders, External change agents, or Executing were identified. Internal consistency and norms were reported on most often, whereas no studies reported on discriminant validity or responsiveness. Not one measure in the sample reported all nine psychometric properties evaluated by the PAPERS. Scores in the identified sample of measures ranged from "-2" to "10" out of a total of "36." Overall measures demonstrated minimal to adequate evidence and available psychometric information was limited. The majority were study specific, limiting their generalizability. Future work should focus on more rigorous measure development and testing of currently existing measures, while moving away from creating new, single use measures. How we measure the processes and players involved for implementing evidence-based interventions is crucial to understanding what factors are helping or hurting the intervention's use in practice and how to take the intervention to scale. Unfortunately, measures of these factors-stakeholders, their networks and communication, and their implementation activities-have received little attention. This study sought to identify and evaluate the quality of these types of measures. Our review focused on collecting measures used for identifying influential staff members, known as opinion leaders and champions, and investigating how they plan, execute, engage, and evaluate the hard work of implementation. Upon identifying these measures, we collected all published information about their uses to evaluate the quality of their evidence with respect to their ability to produce consistent results across items within each use (i.e., reliable) and if they assess what they are intending to measure (i.e., valid). Our searches located over 40 measures deployed in behavioral health settings for evaluation. We observed a dearth of evidence for reliability and validity and when evidence existed the quality was low. These findings tell us that more measurement work is needed to better understand how to optimize players and processes for the purposes of successful implementation.

Identifying, Replicating, and Spreading Health care Innovations across a Nation‐Wide Health care System: VHA Diffusion of Excellence

Research ObjectiveLarge health care systems and organizations face the challenge of identifying, replicating, and spreading evidence‐based innovation across health care system locations. The Diffusion of Excellence (DoE) program aims to incentivize implementing and spreading innovations across the nationwide Veterans Health Administration (VHA). VHA frontline staff submit successfully implemented innovations/practices to a “Shark Tank” competition, in which VHA facility directors place bids to support further implementation. DoE designates the best submission as Gold Status Practices (GSPs), and “winning” bidders receive 6‐months of external facilitation to implement their GSP. DoE then provides national support for diffusing successful GSPs across the VHA. We present results from a mixed‐methods evaluation focused on motivations for program participation, adopting innovations, predictors of implementation, and innovation maintenance/sustainability.Study DesignThe evaluation utilizes the Consolidated Framework for Implementation Research (CFIR). Data sources include: (a) metrics on innovation adoptions linked to VHA facility characteristics; (b) tracking of project specific metrics for practices receiving intensive support for national spread (e.g., potential costs averted, individuals served); (c) 2 focus groups with bidders; (d) observations of 7 DoE events; (e) 143 participants in semi‐structured interview of facility leaders, innovation developers, teams implementing Shark Tank innovations, and implementation facilitators; and (f) 4 surveys of DoE stakeholders. Results are summarized based on the RE‐AIM (Reach‐Effectiveness‐Adoption‐Implementation‐Maintenance) evaluation framework.Population StudiedInnovations aimed at 146 VHA facilities/individual health care systems.Principal FindingsREACH—In the first four Shark Tank rounds, 1676 promising innovations/practices were submitted, with 47 designated as GSPs. EFFECTIVENESS—The impact of specific practices varied. However, impacts have been associated with greater use of evidence‐based services and improved administrative functioning. ADOPTION—Motivations for participating in the DoE process varied among individuals with key roles. Innovations frequently arose from “passion” projects to address identified issues. VA facility/medical center leaders often focus on “big picture” quality metrics and getting middle manager support. Front‐line staff varied in their motivation to implement new projects, potentially leading to a mismatch in stakeholder motivation. IMPLEMENTATION success—approximately half of facilitated‐implementation efforts were fully successful. CFIR themes of Engaging Key Stakeholders and Available Resources received ratings that varied based on level of successful implementation (i.e., fully, partially, or not successful). While sites reported some degree of concern with External Policies and Incentives (e.g., challenges quickly hiring staff), all tried to overcome these challenges with the assistance of External Change Agents (e.g., facilitators and practice developers). MAINTENANCE—At the facility‐level, 74% of facilities originating or receiving facilitated‐implementation support have maintained the practice, including facilities that may have taken longer than 6 months for initial implementation. VHA‐wide, 834 decisions to adopt GSPs have been documented.ConclusionsDoE’s innovative Shark Tank approach identified a large number of candidate practices, successfully promoted adoption of promising practices by facility directors, and supported practice implementation and diffusion across VHA.Implications for Policy or PracticeAs health systems grow in size and complexity, they face additional challenges in identifying, prioritizing, replicating, and spreading best practices. DoE offers a potential model for other health systems and can be a key strategy to move toward being a learning health system.Primary Funding SourceDepartment of Veterans Affairs.

Understanding Factors Influencing Quality Improvement Capacity Among Ambulatory Care Practices Across the MidSouth Region: An Exploratory Qualitative Study.

Success in choosing and implementing quality metrics, necessary in a value-based care model, depends on quality improvement (QI) capacity-the shared knowledge, understanding, and commitment to continuous improvement. We set out to explore factors influencing QI capacity among ambulatory care practices in the MidSouth Practice Transformation Network. As part of network participation, 82 practices submitted a plan for implementing self-selected quality metrics. This plan asked practices to identify factors that would assist or impede successful implementation of interventions to meet metric targets. We used a qualitative thematic analysis approach to explore barriers and facilitators to developing QI capacity among ambulatory care practices. Recurrent facilitators included external change agents, protected time for QI, a framework for improvement, and infrastructure including electronic health record (EHR) capabilities. Frequent barriers included lack of QI knowledge, lack of time, frequent staff turnover, inadequate EHR capabilities, lack of an internal change agent, and a belief that performance was outside of the practice's control. These findings provide insight into factors influencing the adoption and implementation of QI metrics across a diverse group of ambulatory care practices and suggest that targeting the Inner Setting of practices may be an appropriate approach for developing practice-level QI capacity, which is necessary for success in a value-based care model.

Organizational Powers: Capture of Professional Jurisdiction in the Case of U.S. Retail Clinics

Understanding inertia and change in professionalized organizational fields like health care is key to addressing inefficiencies like poor access to services, high costs, and inconsistent quality. New entrants are one source of change that may reduce the inefficiencies, but we lack a good understanding of how new entrant organizations overcome jurisdictional barriers of license and legitimacy that shelter professionalized fields. I analyze a case of emergence of retail health clinics in the U.S. primary care to theorize a strategy that allows external change agents to enter a professionalized field. Circumventing jurisdictional barriers and overcoming resistance of the incumbent profession requires jurisdictional work — cultural and market actions that effectively put forth a jurisdictional claim. Two aspects of jurisdictional work by retail clinics appear important: employing individual professionals as “front-men” who legitimize the new organizational form and finding allies among incumbent organizations that value efficiency. The problem of professional collective action allowed for the front-men strategy, in which organizations decoupled rights encoded in professional license and their use and thus turned license from a barrier into a vehicle for entry. The heterogeneity of logics and the competitive tensions among field incumbents allowed for the subsequent integration. The elaborated process model of entry generalizes the theory of professional jurisdictional competition by including organizations as actors in the division of expert labor.

Mixed methods evaluation of implementation and outcomes in a community-based cancer prevention intervention

BackgroundCommunity-based educational programs can complement clinical strategies to increase cancer screenings and encourage healthier lifestyles to reduce cancer burden. However, implementation quality can influence program outcomes and is rarely formally evaluated in community settings. This mixed-methods study aimed to characterize implementation of a community-based cancer prevention program using the Consolidated Framework for Implementation Research (CFIR), determine if implementation was related to participant outcomes, and identify barriers and facilitators to implementation that could be addressed.MethodsThis study utilized quantitative participant evaluation data (n = 115) and quantitative and qualitative data from semi-structured interviews with program instructors (N = 13). At the participant level, demographic data (age, sex, insurance status) and behavior change intention were captured. Instructor data included implementation of program components and program attendance to create a 7-point implementation score of fidelity and reach variables. Degree of program implementation (high and low) was operationalized based on these variables (low: 0–4, high: 5–7). Relationships among degree of implementation, participant demographics, and participant outcomes (e.g., intent to be physically active or limit alcohol) were assessed using linear or ordinal logistic mixed effects models as appropriate. Interview data were transcribed and coded deductively for CFIR constructs, and constructs were then rated for magnitude and valence. Patterns between ratings of high and low implementation programs were used to determine constructs that manifested as barriers or facilitators.ResultsProgram implementation varied with scores ranging from 4 to 7. High implementation was related to greater improvements in intention to be physically active (p < 0.05), achieve a healthy weight (p < 0.05), and limit alcohol (p < 0.01). Eight constructs distinguished between high and low implementation programs. Design quality and packaging, compatibility, external change agents, access to knowledge and information, and experience were facilitators of implementation and formally appointed internal implementation leaders was a barrier to implementation.ConclusionsAs higher implementation was related to improved participant outcomes, program administrators should emphasize the importance of fidelity in training for program instructors. The CFIR can be used to identify barriers and/or facilitators to implementation in community interventions, but results may be unique from clinical contexts.

Understanding the processes that Federally Qualified Health Centers use to select and implement colorectal cancer screening interventions: a qualitative study.

Colorectal cancer (CRC) screening is highly effective at reducing cancer-related morbidity and mortality, yet screening rates remain suboptimal. Evidence-based interventions can increase screening rates, particularly when they target multiple levels (e.g., patients, providers, health care systems). However, effective interventions remain underutilized. Thus, there is a pressing need to build capacity to select and implement multilevel CRC screening interventions. We report on formative research aimed at understanding how Federally Qualified Health Center (FQHC) staff select and implement CRC screening interventions, which will inform development of capacity-building strategies. We report the qualitative findings from a study that used a mixed methods design, starting with a quantitative survey followed by a qualitative study. In-depth interviews were conducted with 28 staff from 14 FQHCs in 8 states. The Consolidated Framework for Implementation Research (CFIR) guided interview questions and data analysis. Related to the CFIR process domain, few respondents described conducting formal assessments of factors contributing to low screening rates prior to planning their interventions. Many described engaging champions, implementation leaders, and external change agents. Few described a systematic approach to executing implementation plans beyond conducting plan-do-study-act cycles. Reflection and evaluation consisted primarily of reviewing Uniform Data System performance measures. Findings also include themes related to factors influencing these implementation processes. Although FQHCs are implementing CRC screening interventions, they are not actively targeting the multilevel factors influencing their CRC screening rates. Our findings on gaps in FQHCs' implementation processes will inform development of strategies to build capacity to select and implement multilevel CRC screening interventions.

A Qualitative Study Examining Stakeholder Perspectives of a Local Child Abuse Program in Community Emergency Departments

ObjectiveEmergency department (ED) providers may fail to recognize or report child abuse and/or neglect (CAN). To improve recognition and reporting, we designed the Community ED CAN Program, in which teams of local clinicians (nurses, physicians, physician assistants) received training in CAN and 1) disseminated evidence-based education; 2) provided consultation, case follow-up, and access to specialists; and 3) facilitated multidisciplinary case review. The aims of this study were to understand the Program's strengths andchallenges and to explore factors that influenced implementation. MethodsWe used a qualitative research design with semistructured, one-on-one interviews to understand key stakeholders' perspectives of the Community ED CAN Program. We interviewed 27 stakeholders at 3 community hospitals and 1 academic medical center. Researchers analyzed transcribed data using constant comparative method of grounded theory and developed themes. ResultsProgram strengths included 1) comfort in seeking help from local champions, 2) access to CAN experts, 3) increased CAN education/awareness, and 4) improved networks and communication. Facilitators of implementation included: 1) leadership support, 2) engaged local champions and external change agents (eg, CAN experts), 3) positive attributes of the champions, and 4) implementation flexibility. Program challenges/barriers to implementation included 1) variability of institutional support for the champions and 2) variability in awareness about the program. ConclusionsA Community ED CAN Program has the potential to improve recognition and reporting of CAN. Key steps to facilitate implementation include the identification of committed local champions, strong leadership support, connections to experts, program publicity, and support of the champions' time.

Building a culture of impact in an international agricultural research organization: Process and reflective learning

Most agricultural research organizations strive to address societal challenges and contribute to positive societal impacts. Fulfilling this ambition involves embedding a culture of impact in organizational culture, which, in our view, entails three main elements: understanding the role of the research community in contributing to impacts over the long term within the systems in which it operates; equipping researchers to support positive change; and implementing strategies that allow the culture of impact to percolate at various levels of the organization. To build just such a culture, in the past 8 years, Cirad, the French Agricultural Research Center for International Development, embarked on a transformational process, from which we draw key lessons. Building a culture of impact requires fostering transdisciplinary dialogue on the multiple roles of researchers, on their contribution to societal impacts, and on the relevance of this reflection. This involves adapting from pre-existing visions, interactions, and practices. Formalization in the organization's strategy and the action of leading change agents foster its institutionalization. Strengthening capacity to build shared visions of change and collective processes in research design, implementation, and evaluation while respecting the diversity of profiles and approaches in the organization favors appropriation. This requires adequate funding at the project, institutional and funding bodies level, and targeted communication to ensure buy-in by internal and external change agents. We argue that a culture of impact is a reflective culture and long-term dynamics that aims to overcome the dichotomy between research and development and bring agricultural research closer to societal needs.

IMPLEMENTATION OF EVIDENCE‐BASED PRACTICE IN HUMAN SERVICE ORGANIZATIONS: IMPLICATIONS FROM AGENT‐BASED MODELS

Much of the impact of a policy depends on how it is implemented, especially as mediated by organizations such as schools or hospitals. Here, we focus on how implementation of evidence-based practices in human service organizations (e.g., schools, hospitals)is affected by intraorganizational network dynamics. In particular, we hypothesize intraorganizational behavioral divergence and network polarization are likely to occur when actors strongly identify with their organizations. Using agent-based models, we find that when organizational identification is high, external change agents who attempt to direct organizations by introducing policy aligned messages (e.g., professional development emphasizing specific teaching practices) may unintentionally contribute to divergence in practice and polarization in networks, inhibiting full implementation of the desired practices as well as reducing organizational capacity to absorb new practices. Thus, the external change agent should consider the interaction between the type of message and the intraorganizational network dynamics driven by organizational identification.

The generation process of internal-driven management innovation in companies in transitional economies

PurposeThe purpose of this paper is to analyze how internal-driven management innovation (IDMI) takes shape, which highlights the objective-oriented and problem-oriented property of the innovation.Design/methodology/approachBased on a case study of a new practice called 11X integration strategy in Guangzhou Pharmaceutical Holdings Limited, a Chinese pharmaceutical group in Guangdong province, through applying Grounded Theory the authors get a concise systematic framework of generation process that is more practical and more understandable than the counterparts in current literature.FindingsFirst, this paper uncovers five stages and two parallel sub processes in the generation process of IDMI. The sub processes involves practical exploration process (i.e. primary activities) carried out by the internal change agents and theoretical support process (i.e. support activities) carried out by the external change agents. Second, by adopting a process perspective the authors are able to demonstrate how the different activities in both types of processes are combined over time in an intertwined way.Research limitations/implicationsFirst, the case the authors studied is embedded in the context of China’s transitional economy, and the single case study limits us to make comparisons of the generation process of management innovation between different market economies. Second, the external-driven management innovation is still a field untouched. Third, in the research the authors explore the issues of how new management innovation is generated and implemented, but the authors do not systematically research on why different companies exhibit different levels of management innovativeness.Practical implicationsFirst, the findings suggest that firms should consciously and systematically invest in IDMI to create sustainable competitive advantage. Second, the process framework provides a clear guidance to the managers in Chinese state-owned enterprises who are engaged in developing or adopting management innovation. Third, the study indicates the managers in Chinese company should be aware of the importance of external change agents to IDMI. Fourth, this study could facilitate the enterprises to develop or adopt management innovation based on their real needs rather than just “jumping on the bandwagon” when adopting certain new management skills.Originality/valueThis study offers a new generation framework by identifying possible facilitators of IDMI that does not yet exist in extant literatures, and the two sub processes – the practical exploration process and the theoretical support process – deepen the understanding of the generation mechanisms of IDMI. Furthermore, the study contributes to reaching a better understanding of management innovation in the context of transitional economy such as China.

With a little help from a stranger: The impact of external change agents on corporate sustainability investments

AbstractWe investigate the role external change agents (e.g., consultants), play in stimulating corporate sustainability investments. Using data on more than 5,300 energy efficiency investment decisions by 462 firms, we find that firms that draw more strongly on external change agents seize significantly more sustainable investment opportunities. We show that external change agents are more effective in stimulating investments if they broadly search for investment opportunities and are more strongly involved in the implementation of change initiatives. Moreover, surprisingly, we do not find that using internal change agents in parallel with external agents enhances the effectiveness of external change agents. Our findings have important implications for the literature on corporate sustainability as they point to external change agents as an important means of steering firms onto more sustainable pathways. Additionally, we shed light on the conditions under which external change agents can be used to most effectively overcome organizational path dependencies.