Defining Your Initiative: The WHAT, WHO and HOW
By Dr. Julia E. Moore, Executive Director, and Dr. Sobia Khan, Director of Implemention
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When implementing change, one of the foundational pieces is clearly defining what you are implementing. A full initiative involves defining WHAT is changing, WHO is making that change, and HOW they will be supported to make that change. However, in our experience, many people believe they are ready to start planning for implementation, without having defined each of these components. In this bulletin, we are revisiting the core of implementation – the full initiative.
Defining the WHAT
Often when we ask people what they’re implementing, they will name or describe an evidence-based guideline, an evidence-based practice or program, a new protocol or policy, a new technology, or some kind of clinical practice (e.g., giving a vaccine, a new therapy).
But these elements (e.g., the guidelines, the policies, and new technologies) are only part of the components that make up the full initiative. They are often referred to as being the WHAT or the “thing” (based on Geoff Curran’s paper). The WHAT describes what it is that you want people to do differently. There are multiple different types of WHATs that might be relevant for your work, and the “7 Ps” (from the second paragraph of this paper) can be a really great way to help you disentangle which WHATs are relevant for your initiative.
The 7 Ps include:
WHAT you are implementing refers to what you want people to adopt, use or to do differently, which relates to the goal of the initiative.
Programs: A set of coordinated activities to accomplish a specific goal (e.g., a pre-packaged evidence-based program)
Practices: The application of an idea or belief (e.g., guideline recommendations)
Policies: Legislative/regulatory decisions made to ensure that specific actions can be taken within a legal/regulatory framework (e.g., policies with regional policy makers and service providers to improve transitions in care)
Procedures: A set of instructions or sequential activities that help guide a specific action (e.g., a screening tool)
Principles: Beliefs/philosophies that guide action (e.g., using an equity-based approach to support underserved groups)
Pills: Refers broadly to any drugs that might be used to improve outcomes (e.g., a medication)
Products: Tools or resources that guide people in accomplishing activities/goals (e.g., an online learning platform or app).
A really important question to answer is – WHO need to do WHAT differently? Meaning, who are the people expected to be involved in the WHATs you have described. Every WHAT should be targeted to a WHO, and in some cases one WHAT might target multiple WHOs. Essentially, it should be clear early on who needs to change their behavior.
HOW you implement something consists of your implementation strategies (sometimes called integration or change strategies).
However, we know that just because you want people to do something differently, it does not mean they will change. That is why we need the HOW or the implementation strategies that we use to support the WHO to do the WHAT.
Implementation strategies are meant to help people overcome the barriers to carrying out the goal of the initiative and to make it easier for them to do the WHAT.
Defining the HOW
This is where implementation science comes in. We can use theories, models, and frameworks from implementation science to help us understand why people aren’t doing the WHAT. We first try to understand their barriers and facilitators to change, and then we can use a theory to understand potential mechanisms of change so that we can later select implementation strategies. Implementation strategies are approaches or tactics for how we can actually change people’s behavior. Examples of implementation strategies include education, reminders, champions, audit and feedback, and leadership engagement strategies.
Unfortunately, changing people’s behaviour is hard — very hard. To increase the likelihood of success, one of the reasons we use implementation science to inform implementation practice is so that we can have a systematic process to select implementation strategies. That means picking implementation strategies that directly address the underlying barriers and facilitators to doing the WHAT for each WHO. We do that by using behavior change theory to link them together.
Some simple questions you can ask yourself to define your initiative
Defining your initiative is a step that people often revisit. We think it’s because even when you have spent time defining what it is you are implementing, sometimes you lose sight of that as you get into the thick weeds of implementation. Revisiting your initiative can act as a grounding step. A few easy questions to help you get grounded again define what you are implementing include:
What do you want people to do differently? (Note: this is connected to the goal or outcome of your implementation initiative and constitutes your WHAT.)
Who needs to do WHAT differently?
How will you make it easier for people to do that thing differently? (Note: this relates to your HOW.)
What if it’s hard to define the WHAT?
You have probably noticed that having a really good grasp of your WHAT is a key step in defining your initiative. Your WHO and your HOW are all determined by how well you define your WHAT. Here are some tips we have for common cases in which it has been hard to define the WHAT.
The WHAT is a tool or product
When people are trying to implement a tool or product, the answer to the first question is often, "We want people to use the tool", which might make them uneasy about how that WHAT is defined; moreover, that WHAT can also be slotted into the HOW category as well, so there is a gray area. If you have encountered this challenge, you can think about it in more of a "layered" approach.
Let's take the example of a clinical decision support tool. The primary WHAT is that you want people to make certain clinical decisions. The secondary WHAT/primary HOW is the clinical decision support tool (it's something you want people to use in order to do something differently in their practice, so it falls in this gray zone).
Then you will still need HOWs to get people to use that tool (e.g., perhaps they need to be trained, or the use of the tool needs to be modelled, etc.). Deconstructing it this way might make the process of defining the WHATs and the HOWs a bit easier.
The WHAT is a complex initiative
When an initiative is very complex, you can still define the WHAT. Often what happens is that there are multiple WHATs at multiple levels of the system, and therefore multiple HOWs. Think about a complex initiative as a constellation of WHATs and HOWs that help you achieve your system outcome. You can use a model like the Socio-Ecological Model to help you parse out the levels of the system that your initiative targets, and then define your WHATs and HOWs for each level.
The WHAT includes principles
We have seen cases where people list the principle as a WHAT (e.g., “practicing patient-centred care”, “meeting people where they are”, “ensuring the rights and dignity of all”). Although principles are listed as one of the “Ps”, it’s hard to build an entire initiative off just the principle. If the goal is to get people to practice a principle, your WHAT then includes the actions people would take to demonstrate those principles. Once you defined these principle-based actions and who needs to do them, it becomes much easier to implement a principles-based initiative.
We hope this overview was helpful to you as you define and re-define your initiative. Happy implementing!
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