Translating Evidence Into Practice: System-Centered Implementation Strategies Week 2 POLICY IMPLEMENTATION: Why Even the Best Laid Plans Often Fail

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Translating Evidence Into Practice
System-Centered Implementation Strategies Week
2POLICY IMPLEMENTATIONWhy Even the Best Laid
Plans Often Fail

• Laura Schmidt, PhD, MSW, MPH
• Jim Kahn, MD, MPH
• Philip R. Lee Institute for Health Policy Studies
  
• Clinical and Translational Institute
• Training in Clinical Research Program

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• 90 of policymaking
• is implementation
• And 90 of implementation is shoring up
• unintended consequences

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Why Are Implementation FailuresSo Common?

• There are many ways to fail
• Each case is unique
• Complexity frustrates efforts at control
• The path things will take is hard to predict
• Efforts to prevent normal accidents increase
  the risk of catastrophic failures

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Why Are Implementation FailuresSo Common?

• There are many ways to fail

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IMPLEMENTATION STUDIES

• Lots of Monday morning quarterbacking
• Many descriptive case studies
• but few prescriptive analyses
• Analysts tend to focus on unintended
  consequences, but there are many
• other ways to fail

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MANY WAYS TO FAIL
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Why Are Implementation FailuresSo Common?

• Each case is unique

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EACH CASE IS UNIQUEmaking it hard to predict
outcomes

• Unique initial conditions shape the course of
  implementation (institutions)
• Chance events shape the course of implementation
  (historical contingencies)
• Most policy prescriptions assume top-down control
  when this is virtually never the case (forward
  mapping)

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Why Are Implementation FailuresSo Common?

• Complexity frustrates
• efforts at control

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Compare this
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To this
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SOURCES OF COMPLEXITY

• Marble cake federalism
• Most policies are carried out by street-level
  bureaucrats who are far removed from policymakers
• -Health policies often target behaviors over
  which policymakers have little control
• -Ironically, efforts to establish top-down
  control tend to increase organizational
  complexity

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Why Are Implementation FailuresSo Common?

• Implementation is a path dependence process but
  the path is hard to predict

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PATH DEPENDENCE

• SELF-REINFORCING FEEDBACK LOOPS
• Policies create their own political
  constituencies
• Policies create institutions and organizations
  that become hard to change
• Policies teach people how to make policy
• (political learning)
• DYNAMIC OF INCREASING RETURNS

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WHY WE CANT PREDICT WHAT PATH A POLICY WILL TAKE

• PUNCTUATED EQUILIBRIUM
• There is a status quo bias
• but chance events can put the whole
  system on a new path.

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Why Are Implementation FailuresSo Common?

• Efforts to prevent normal accidents increase
  the risk of catastrophic failures

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Preventing Normal Accidents

• The bread and butter of policy analysis
• Usually an exercise in forward mapping
  -GOALS increase top-down controls, checks and
  balances, redundancies, fail safes and
  interdependent units within the system

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Producing Catastrophic FailuresAnatomy of a
System Crisis
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Prescription for Preventing Implementation
Failures

• Devolution of authority to street-level
  bureaucrats
• Top-down controls less is more
• Coalition building at lowest levels of the system
• Quality circles and teams