Strategies for Spreading Improvements in Health Care

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Strategies for Spreading Improvements in Health
Care
Marie W. Schall Institute for Healthcare
Improvement
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Creating a New System

• Make improvements
• Hold the gains
• Spread the improvements to others

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Creating a New System


Improvement
Spread
Hold Gains

BETTER
Improvement
Hold Gains
Spread
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Adoption is a DOING thing!
BETTER IDEAS
COMMUNICATED
In a certain way
Happens over time
Thru a SOCIAL system
Adapted from Rogers, 1995
(C) 2001, Sarah W. Fraser
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Some Theory on Spread

• Everett Rogers Adopter categories Attributes of
  an innovation Different aspects of communication
  
• John Seely Brown Content, context, community
• Malcolm Gladwell Tipping point Stickiness
  factor Law of the few Power of context
• Nancy Dixon Explicit and tacit knowledge
• James Prochaska Stages of Change Model
• Albert Bandura Preconditions for change
  Motivation Modeling and guided enactment
  

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The Tipping Point

• The name given to that one dramatic moment in an
  epidemic when everything can change all at once.
  
• - M. Gladwell
• The part of the diffusion curve from about 10
  percent to 20 percent adoption is the heart of
  the diffusion process. After that point, it is
  often impossible to stop the further diffusion of
  a new idea, even if one wished to do so.
• - E. Rogers

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The Diffusion Curve
tipping point
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Adopter Categories
Innovators
Early Majority
Late Majority
Early Adopters
Laggards
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2.5
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13.5
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from Rogers, 1995
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A Framework for Spread
Leadership -Topic is a key strategic
initiative -Goals and incentives
aligned -Executive sponsor assigned -Day-to-day
managers identified
Social System -Key messengers -Communities
-Technical support -Transition issues
Set-up -Target population
-Adopter audiences -Successful sites
-Key partners -Initial spread
strategy
Better Ideas -Develop the case -Describe the
ideas

Communication Strategies (awareness technical)
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What the Improvement Team Can Do to Help with
Spread

• Help to make the case for change
• Make it easier for others to do the work
• Develop the messengers

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Leaderships Role in Spread

• Leadership
• Topic is a key strategic initiative
• Executive sponsor assigned
• Day-to-day managers identified
• Goals and incentives are aligned
• Set-up for Spread
• Target population
• Are pilot sites successful?
• Identify key groups who make adoption decision
• Initial strategy to reach all sites

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Topic as a Key Strategic Initiative

• VHA Access pressure from veterans and
  Congressional offices
• BPHC national goal to reduce health disparities
  
• NHS/Primary Care Collaborative national
  Modernisation initiative

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Plan to Reach all Units in Target Population

• Identify who will make the adoption decision
  (individuals, practice group, department,
  facility, etc)
• Consider the following in planning the sequence
  for spread
• Coverage versus completeness
• How best to optimize the learning with the
  addition of new units
• Relationship of the units to the pilot sites
• Champions exist or can be developed
• Availability of resources

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A Framework for Spread
Leadership -Topic is a key strategic
initiative -Goals and incentives
aligned -Executive sponsor assigned -Day-to-day
managers identified
Social System -Key messengers -Communities
-Technical support -Transition issues
Set-up -Target population
-Adopter audiences -Successful sites
-Key partners -Initial spread
strategy
Better Ideas -Develop the case -Describe the
ideas

Communication Strategies (awareness technical)
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Additional Considerations

• Developing the Communication Plan
• Strengthening the Social System
• Developing the Measurement and Feedback System

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Communication Plan

• Awareness of the initiative
• Document benefits
• Show comparative data
• Use multiple communication channels
• Technical knowledge
• Explain changes succinctly
• Involve successful units in providing technical
  support
• Train your messengers

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Attributes of the Change that Affect the Rate of
Adoption

• Relative advantage
• Compatibility with current system
  
• Simplicity of the change and transition
• Testability of the change
• Ability to observe the change and its impact

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Social System

• Content, context, and community
• Understand the relevant circumstances affecting
  peoples ability/willingness to adopt the changes
• Take advantage of the existing relationships
  within the system
• Develop communities of practice among those
  with similar roles

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Some Things to Consider about the Social System

• Behavior change is not just about action
  (Prochaska)
• What is the plan to integrate adopters willing
  to get involved?
• What are the peer-to-peer opportunities?

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Measurement and Feedback

• Data collected on
• Outcome measures
• Measures to track spread of specific changes
• Reporting to provide feedback
• Link to follow up guidance and action
• Data and reporting at different levels within the
  organization
• Both leadership and front line
  

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Outcome Measure
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Tracking the Spread of the Changes
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Outcome Measure - VHA
Average Waiting Time for Next Available
Appointment (Days)
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Small Multiples Overall System and 22 Regions
Average Waiting Times All Primary Care Clinics
in VHA System
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Developing a Plan for Spread

• Leadership
• Set-up
• Communication
• Social System
• Measurement and Feedback

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Levels of Spread Activities Level 1

• Set-up
• Establishing steering committees
• Orienting leadership groups
• Organizing data collection
• Developing materials
• Identifying successful sites
• General Communication
• Wide spread dissemination of information about
  the initiative
• Sending out comparative data
• Holding meetings with a broad range of potential
  adopters

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Level 2 Spread Activities

• Identification of Early Adopters
• The push of general communication from Level 1
  results in pulling adopters to the project
• The number and different categories of adopters
  identified are good measures for LEVEL 1
  activities
• The key activity here is identification of the
  early adopters and a plan for how they will be
  integrated into the work

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Level 3 Spread Activities

• Strategies to Get Adopters to Action
• Organizing purposeful peer-to-peer interaction
  that integrate adopters identified in your LEVEL
  2 activities (e.g. mentoring, visiting, meetings
  with specific invitation lists, and group
  discussions around materials on the website)
• Champions for successful sites identified in
  Level 1 can help to provide the technical support
  needed although each early adopter should be able
  to add to the knowledge exchange  

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Level 4 Spread Activities

• Feedback loops for LEVEL 3 activities
• Collecting and reviewing data on the adoption of
  the key changes and the outcome measures
• The aim is to understand how LEVEL 3 activities
  might be refined to improve upon results and how
  this might be best communicated with adopters

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References

• Attewell, P. Technology Diffusion and
  Organizational Learning, Organizational Science,
  February, 1992
• Bandura A. Social Foundations of Thought and
  Action. Englewood Cliffs, N.J. Prentice Hall,
  Inc. 1986.
• Brown J., Duguid P. The Social Life of
  Information. Boston Harvard Business School
  Press, 2000.
• Cool et al. Diffusion of Information Within
  Organizations Electronic Switching in the Bell
  System, 1971 1982, Organization Science, Vol.8,
  No. 5, September - October 1997.
• Dixon, N. Common Knowledge. Boston Harvard
  Business School Press, 2000.
• Fraser S. Spreading good practice how to prepare
  the ground, Health Management, June 2000.
• Gladwell, M. The Tipping Point. Boston Little,
  Brown and Company, 2000.
• Kreitner, R. and Kinicki, A. Organizational
  Behavior (2nd ed.) Homewood, IlIrwin ,1978.

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References

• Langley J, Nolan K, Nolan T, Norman, C, Provost
  L. The Improvement Guide. San Francisco
  Jossey-Bass 1996.
• Lomas J, Enkin M, Anderson G. Opinion Leaders vs
  Audit and Feedback to Implement Practice
  Guidelines. JAMA, Vol. 265(17) May 1, 1991, pg.
  2202-2207.
• Myers, D.G. Social Psychology (3rd ed.) New York
  McGraw-Hill, 1990.
• Prochaska J., Norcross J., Diclemente C. In
  Search of How People Change, American
  Psychologist, September, 1992.
• Rogers E. Diffusion of Innovations. New York The
  Free Press, 1995.
• Wenger E. Communities of Practice. Cambridge, UK
  Cambridge University Press, 1998.
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