Identifying and ranking implicit leadership strategies to promote evidence-based practice implementation in addiction health services

Guerrero et al. Implementation Science (2016) 11:69 DOI 10.1186/s13012-016-0438-y RESEARCH Open Access Identifying and ranking implicit leadership strategies to promote evidence-based practice implementation in addiction health services Erick G. Guerrero1*, Howard Padwa2, Karissa Fenwick1, Lesley M. Harris3 and Gregory A. Aarons4 Abstract Background: Despite a solid research base supporting evidence-based practices (EBPs) for addiction treatment such as contingency management and medication-assisted treatment, these services are rarely implemented and delivered in community-based addiction treatment programs in the USA. As a result, many clients do not benefit from the most current and efficacious treatments, resulting in reduced quality of care and compromised treatment outcomes. Previous research indicates that addiction program leaders play a key role in supporting EBP adoption and use. The present study expanded on this previous work to identify strategies that addiction treatment program leaders report using to implement new practices. Methods: We relied on a staged and iterative mixed-methods approach to achieve the following four goals: (a) collect data using focus groups and semistructured interviews and conduct analyses to identify implicit managerial strategies for implementation, (b) use surveys to quantitatively rank strategy effectiveness, (c) determine how strategies fit with existing theories of organizational management and change, and (d) use a consensus group to corroborate and expand on the results of the previous three stages. Each goal corresponded to a methodological phase, which included data collection and analytic approaches to identify and evaluate leadership interventions that facilitate EBP implementation in community-based addiction treatment programs. Results: Findings show that the top-ranked strategies involved the recruitment and selection of staff members receptive to change, offering support and requesting feedback during the implementation process, and offering in vivo and hands-on training. Most strategies corresponded to emergent implementation leadership approaches that also utilize principles of transformational and transactional leadership styles. Leadership behaviors represented orientations such as being proactive to respond to implementation needs, supportive to assist staff members during the uptake of new practices, knowledgeable to properly guide the implementation process, and perseverant to address ongoing barriers that are likely to stall implementation efforts. Conclusions: These findings emphasize how leadership approaches are leveraged to facilitate the implementation and delivery of EBPs in publicly funded addiction treatment programs. Findings have implications for the content and structure of leadership interventions needed in community-based addiction treatment programs and the development of leadership interventions in these and other service settings. Keywords: Leadership strategies, Implementation, Organization, Management, Evidence-based practice, Managers, Addiction, Substance use disorder * Correspondence: ; 1 School of Social Work, University of Southern California, 655 West 34th Street, Los Angeles CA 90089, USA Full list of author information is available at the end of the article © 2016 Guerrero et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Guerrero et al. Implementation Science (2016) 11:69 Background According to the 2013 National Survey on Drug Use and Health, 21.6 million individuals older than 12 years old in the USA meet diagnostic criteria for a substance use disorder (SUD) [1]. In the past few decades, evidence-based practices (EBPs) have been developed and proven effective in the treatment of SUDs. Two of the most effective EBPs in SUD treatment are contingency management treatment (CMT) and medication-assisted treatment (MAT). CMT uses positive reinforcement to facilitate behavior change and has been shown to substantially improve SUD treatment adherence and reduce substance use [2–4]. A strong evidence base also supports MAT—the use of pharmacotherapies such as acamprosate for alcohol dependence, buprenorphine for opioid dependence, and naltrexone for alcohol or opioid dependence—in conjunction with psychosocial interventions [5–9]. However, despite their proven efficacy and effectiveness, neither CMT nor MAT is widely used in SUD treatment, also referred here as addiction health services [10–12]. This implementation gap is likely the result of several factors including insufficient training [13], lack of time [13], and limited program resources [13, 14]. Similarly, competing clinical priorities [15] and treatment ideologies that conflict with EBPs also inhibit implementation efforts [11, 14, 16, 17]. For the SUD treatment workforce, lack of graduate education, high provider turnover, passive leadership, and unstable funding make it difficult for publicly funded SUD programs to implement and sustain major changes to service delivery [18–20]. Given that publicly funded programs deliver the vast majority of specialty SUD treatment services in the USA [21, 22], devising and testing strategies to facilitate EBP implementation in these programs is critical to ensure that the SUD treatment population receives evidence-based care. Conceptual framework Leadership behaviors are emerging as a focus of implementation science because leaders’ attitudes, priorities, and behavior [23] are increasingly being recognized as major contributors to employee and organizational outcomes [24, 25]. Leadership approaches focusing on both upper and middle managers can inform implementation strategies to help publicly funded behavioral health organizations (including SUD treatment providers) overcome barriers that inhibit EBP implementation and sustainment [26–31]. Yet most SUD program leaders are unprepared for their roles as implementers and ill equipped to effectively facilitate EBP implementation [28]. Furthermore, when SUD program leaders do successfully facilitate implementation, they are often unaware of the specific leadership approaches or strategies that they used. Rather than using formally articulated or reasoned implementation strategies, SUD program leaders use implicit leadership Page 2 of 13 theories—personal cognitive constructs that guide their behaviors and interactions with staff members—to implement change [32, 33]. This is consistent with the over (...truncated)