Based on both concepts from implementation science and our experience providing technical assistance to states to improve system components, we describe how implementing system change can be different from implementing practices.
The desired system improvement will most often need to be developed or adapted, not adopted.
State Part C and 619 systems are structured quite differently from state to state. A state team will usually need to develop a system improvement (innovation) that fits the unique needs, capacity and existing service system components. A state team will need to review available literature and quality indicators and study other state examples to develop or adapt an improvement that will work for their state. The design of the improvement must include an operational description of how it is intended to work and what impacts and benefits are expected. During implementation, continuous evaluation of all aspects of process and impacts is necessary. The initial design of the improvement must be adjusted and refined until it operates efficiently and yields the desired results.
The concept of fidelity is different in system improvement.
Unlike using existing fidelity measures while implementing evidence-based practices, fidelity measures in system improvement must be designed and tested to fit the particular improvement. As the improvement is adjusted and refined, it will function more like the developers intended. Appropriate measures and quality indicators can be articulated to describe efficiency and effectiveness of procedures. Concepts of fidelity develop through an iterative process, based on continuous evaluation during the development and refinement of the improvement itself.
Conducting field tests or pilots may not always be possible.
Given equity, legal and/or efficiency considerations, states may not able to pilot a system change, but must implement statewide all at once. When initial implementation is statewide the implementation focus must be on continuous improvement rather than fidelity and scale up.