The impact of inter-organizational alignment (IOA) on implementation outcomes: evaluating unique and shared organizational influences in education sector mental health

Abstract

BackgroundIntegrated healthcare delivered by work groups in nontraditional service settings is increasingly common, yet contemporary implementation frameworks typically assume a single organization—or organizational unit—within which system-level processes influence service quality and implementation success. Recent implementation frameworks predict that inter-organizational alignment (i.e., similarity in values, characteristics, activities related to implementation across organizations) may facilitate the implementation of evidence-based practices (EBP), but few studies have evaluated this premise. This study’s aims examine the impact of overlapping organizational contexts by evaluating the implementation contexts of externally employed mental health clinicians working in schools—the most common integrated service delivery setting for children and adolescents. Aim 1 is to estimate the effects of unique intra-organizational implementation contexts and combined inter-organizational alignment on implementation outcomes. Aim 2 is to examine the underlying mechanisms through which inter-organizational alignment facilitates or hinders EBP implementation.Methods/designThis study will conduct sequential, exploratory mixed-methods research to evaluate the intra- and inter-organizational implementation contexts of schools and the external community-based organizations that most often employ school-based mental health clinicians, as they relate to mental health EBP implementation. Aim 1 will involve quantitative surveys with school-based, externally-employed mental health clinicians, their supervisors, and proximal school-employed staff (total n = 120 participants) to estimate the effects of each organization’s general and implementation-specific organizational factors (e.g., climate, leadership) on implementation outcomes (fidelity, acceptability, appropriateness) and assess the moderating role of the degree of clinician embeddedness in the school setting. Aim 2 will explore the mechanisms through which inter-organizational alignment influences implementation outcomes by presenting the results of Aim 1 surveys to school-based clinicians (n = 30) and conducting semi-structured qualitative interviews. Qualitative data will be evaluated using an integrative inductive and deductive approach.DiscussionThe study aims are expected to identify intra- and inter-organizational constructs that are most instrumental to EBP implementation success in school-based integrated care settings and illuminate mechanisms that may account for the influence of inter-organizational alignment. In addition to improving school-based mental health, these findings will spur future implementation science that considers the relationships across organizations and optimize the capacity of implementation science to guide practice in increasingly complex systems of care.

Implementation Determinants and Outcomes of a Technology-Enabled Service Targeting Suicide Risk in High Schools: Mixed Methods Study

“…The codebook template was used to understand the multilevel determinants of implementation. Determinants include aspects of the innovation (eg, evidence strength and relative advantage), outer context (eg, external policies and incentives), the inner organizational context (eg, implementation climate and tension for change ), characteristics of the individuals operating within target settings (eg, attitudes and efficacy), and process of change in the organization (eg, engagement strategies and change agents) [ 47 - 51 ]. School personnel interviews were audio recorded, transcribed, and coded with directed content analysis.…”

Protocol for a hybrid type 2 cluster randomized trial of trauma-focused cognitive behavioral therapy and a pragmatic individual-level implementation strategy

“…Indeed, some studies have found that individual factors (especially attitudes) may be significantly more predictive of the use of EBT than organizational factors (e.g., organizational culture, implementation climate) [23,24]. Although individual attitudes and behaviors are embedded within larger contexts [25], individual barriers This study will be the first to test a pragmatic, theory-driven, and generalizable implementation strategy in the context of improving clinician use of an evidence-based trauma intervention in the education sector, the most common setting for youth mental health service delivery.…”

“…Indeed, some studies have found that individual factors (especially attitudes) may be significantly more predictive of the use of EBT than organizational factors (e.g., organizational culture, implementation climate) [ 23 , 24 ]. Although individual attitudes and behaviors are embedded within larger contexts [ 25 ], individual barriers may be more malleable and proximal to EBT implementation.…”

Enhancing Evidence-Based Practice Through University–Practitioner Partnerships

“…Hoover and colleagues (2018) offered a separate four-stage process for implementing an EBP program, Cognitive Behavioral Intervention for Trauma in Schools, which included (a) planning, (b) community buy-in, (c) training, and (d) implementation and support. Other studies have illustrated the intra- and interorganizational process required within schools to successfully implement EBP in mental health, calling for additional interorganizational alignment between schools and outside organizations to guide implementation efforts (e.g., Lyon et al, 2018).…”

“…Bauman et al (2002) found that practitioners cite time constraints and a general dislike for research as reasons for not using literature to guide practice. Further, research in related fields suggests that implementing EBP in school settings is complicated and is best accomplished using intentional frameworks for implementation (Hoover et al, 2018;Lyon et al, 2018;Novins, Green, Legha, & Aarons, 2013). As a result, practitioners' attitudes toward research and evidence, and the lack of intentional frameworks for implementation of evidence-based school counseling, place one of the fields' top priorities (implementing effective school counseling models) in a precarious position.…”