When a Plan Is Not Being Implemented: Warning Signs and Fixes

When it comes to the behaviour support process there is one moment when a practitioner's point of diagnostic attention is almost always misplaced. Briefly, the data is flat or worsening, the review is near, and the professional question becomes: What about some other strategies, what about wrong function, what about wrong reinforcement, what about something different, and in the darker scenario, what about more restrictive responses? But as in every other field, a cause prevails over all the clinical ones when a flat plan is considered thoroughly, namely this: that as a rule the so-called plan is not being carried out, and not for some time now, as it is set forth in writing. Implementation drift by practitioners, like every quality system, is invisible, silent and cumulative and without a set of definite warning signs, checked on a regular basis, practitioners are not going to reach any conclusions regarding the strategies.

The warning signs, in the order they appear

The language shifts.  Pay attention to the team's verbal communication. When the conversation starts to return to folk level, the plan is usually replaced by folk plan names, early warning signs and the framing of the function has a folk form. The words go first.

Data is reshaped before it is levelled.  These are implementation indicators dressed up as data, usually recorded as patchier or drifting vague entries, PRN or incident-related forms that are increasing in volume, behaviour that remains the same, or a few that drop off, and typically warn of visible behaviour change weeks before.

The team census is not in line with the briefing record.  The most diagnostic question that exists: how many people supported the person this month, as opposed to how many people have an on-going briefing on the plan. A widening gap is a drift in its purest form, and widening fastest where incidents tend to occur: weekends, nights, fill shifts.

The strategies turn into sensible-sounding variations.  Abandonment doesn't usually show up as abandonment. The waiting strategy is reduced as he appears prepared; the low demand approach gains encouragement as encouragement is a friendly thing; the visual schedule moves to a drawer as he now knows the routine. Each variant has its own sense of local irony and its own deadly consequence, as this series has already been arguing in the course of its development: The plan's mechanism is predictability itself.

The setting slips back into its quiet state.  The physical and routine aspects of the plan that it said would erode, the calm corner, the transition warnings, the choice points all erode and nobody notes the erosion because no day removes anything.

Diagnose before redesigning

The answer to signs is investigation, not accusation; a common shift or two, not a show; a genuine curiosity, talking with workers; what does happen when “X” starts; what of the plan doesn't work in the real world; checking in on the briefing gate and the currency of the summary; walk the environment against the plan's specs. Clinically, it matters: teams that are asked to take responsibility for the blame, they comply, they cover up the drift, they perform it; teams that are invited to report the friction, they discover the intelligence a redesign needs.

Fix the machinery, then re-baseline

The process for repairing is the same as the series: summary refreshed, gate re-established with the provider, core team re-rehearsed on the mutated strategies, environment restored, data system returned to collectable, and finally, a re-baselined evaluation window, because judging strategies on data collected during drift is like judging a medication on data collected while the patient wasn't taking it. The clinical question, are these the right strategies? only comes once the strategies are defined and verified to be implemented after a certain period of time. But sometimes it will be no, and the redesign will go ahead, and this time on a solid basis. The path the functional analysis forecasted, unfortunately, often just continues.

How this plays out in practice

Here is the opening scenario of this article, but now with flat data, an upcoming review, and a provider asking for more robust interventions for a man with a fast-building escalation. The language has been replaced, the briefing is 11 workers short, the visual schedule is in the kitchen drawer, and the waiting strategy has become “waiting for forty seconds”. The machinery is rebuilt in over a month, the evaluation window is re-baselined, and by review the original strategies are on course as per design. The more stringent measures that were on the verge of being enacted would have limited a man whose only clinical issue is an unimplemented plan, which is the silent stake this entire discipline guards.

Next steps

Create your own five-sign checklist from this article and use it on all plans at the halfway point between the reviews, not only when things worry you about the data. When it is detected early, a fortnight's repair. Drift that occurs during review is a year's deflection.