Getting to Scale: Spread

1
Getting to Scale Spread

• IA Graduate Seminar, May 18, 2010
• Lisa Schilling RN MPH VP, Healthcare Performance
  Improvement
• Jim Bellows, PhD Senior Director Evaluation and
  Innovation

2
Objectives for today

• Discuss models and thinking about what spread
  means and considerations for effective
  application
• Consider how to apply models in your area
• Access tools to help local sites assess readiness
  to spread and adopt practices

3
What you have already learned
The Sequence for Improvement

to here!
Dont go from here
Source Bob Lloyd, IHI 2009
4
More you already learned

• A x Q E
• A strategies to build acceptance and commitment
  (culture, accountability)
• Q quality of technical solution (both the change
  and the reliable application of change)

Source Jack Welch
5
Influencers of Implementation and Spread

• Will
• Values
• Alignment/prioritization
• Relationships
• Communication
• Goals /measures
• Ideas
• Change package
• Effective practices
• learning

• Execution
• Infrastructure and resources
• Method
• Monitoring/feedback

Source IHI 2009
6
Conceptual Models for Spread

• Psychological
• Diffusion
• Transtheoretical readiness for change
• Infrastructure
• Breakthrough Series Collaborative model
• IHI Framework for Spread
• Campaign model
• Multiplicative spread
• Other
• Hybrid models

7
Many good recipes
8
Elements Important for the Rate of Adoption

• Relative Advantage
• Compatibility
• Complexity
• Trialability
• Observability

Source Everett Rogers
9
Mental Model for Spread
Source Institute for Healthcare Improvement,
2006.
10
Applying this in Operations
Low
Test and Replicate- Diffusion
Innovate
Organizational Alignment
Test and Replicate - Collaboratives
High
Test and Replicate-Waves
Just Do It
High
Low
Transferability
Source Stacey 2002
11
Definitions

• Just Do It
• Use project management to implement
• Go fast replicate with little variation
• Test and Replicate Diffusion
• Implement in a few sites to increase level of
  agreement among stakeholders
• Encourage spread, go slow, minimal highly
  coordinated or centralized effort with
• Test and Replicate Collaboratives
• Use IHIs Breakthrough Series Collaborative model
• Focused infrastructure, accountability, learning
  and sharing to create change package

• Test and Replicate Waves
• Pilot in 1-3 sites first, then spread to 5-10
  sites, then to all the rest of the sites
• Drive spread, highly coordinated and planned
  progression of spread, testing especially in
  first two sites to implement practice to build
  will and transferability of practice
• Innovate
• Use innovation methods such as IDEO
• Go slow, prototype, replicate, refine and spread
• High failure rate to get practice

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More Tools to Apply in Operations
Readiness to Spread and Receive
1
2
Low
Test and Replicate- Diffusion
Innovate
Methods for Monitoring Spread
3
OrganizationalAlignment
Test and Replicate - Collaboratives
Supporting a Learning Culture
High
4
Test and Replicate-Waves
Just Do It
High
Low
Transferability
Source Stacey 2002
13
A Tool to Lead Spread in 9 Steps

• Determine organizational readiness for spread
• Start with the end in mind
• Determine whether linked to strategic objectives
  of organization
• Assess readiness to spread (using tool)
• Assess readiness to receive (using tool)
• Develop a plan
• Choose spread approach.
• Develop a plan for spread
• Execute on the plan
• Prepare for testing and implementation
• Gather information over time to allow adjustment
  of spread plan
• Identify sites in need of support

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Spread Tool (steps 1-4) Determine organizational
readiness for spread
2. Link to strategic objectives
3. Assess readiness to spread
4. Assess readiness to receive
1. Start with the end in mind

Step

• Determine whether linked to strategic goal, align
  incentives
• Craft a compelling message and cascade
• Charter team

• Complete readiness to spread assessment with team
• Plan for sites based on learning
• Revisit scale, scope and speed

• Complete readiness to receive assessment with
  team
• Plan for sequencing based on learning
• Create monitoring and review plan

• Determine what is being spread
• Define target population and end state
• Establish timeframe to achieve scale
• Identify system level metrics and outcome
• Define sites participating in effort

How
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Spread Tool (step 5-6)Develop a plan
5. Choose spread approach
6. Develop a plan for spread


Step

• Create full description of change package
• Create a measurement plan including impact on
  system performance
• Plan to monitor extent of spread both the change
  package and scale achieved

• Use results from steps 3 and 4 to determine
  alignment/ transferability
• Choose spread approach
• Plan resources

• Plan infrastructure and resources -elements to
  scale, new role requirements, technology
• Identify experts who will teach others re
  practice
• Determine physical and relationship
  linkages/proximity

How
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Spread Tool (steps 7-9)Execute on the Plan
8. Gather info and adjust plan
9. Identify site in need of support
7. Feedback to adopters
Step

• Manager support
• Sufficient time to test and implement
• Adopters understand methods
• Technical support

• Ensure middle management (or process owners)
  engaged throughout
• Determine sustainability metrics thresholds that
  trigger specified remedial actions
• Plan content, technical and implementation
  support

• Implement practices to share learning and
  progress
• Monitor rate of adoption and determine
  adjustments needed
• -messages
• Capable messengers
• -Transition issues

How
17
Tools to Plan and Lead Spread

• Jim Bellows

18
Topics

• Specify your goal(s) in spreading a successful
  practice
• Be clear about your role
• Assess practice readiness for export
• Assess site readiness to import

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What is your spread goal? Spread what? From
where to where?
State your Project Goal here. Remember your goal should be S.M.A.R.T. (Specific, Measurable, Agreed Upon, Realistic, Time-based)

Objectives

List measures to support the Project Goal and Objectives.
Outcome Measure(s)

Process Measure(s)

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Typical spread goals

• Bring ltpracticegt to our medical center from
  ltRegiongt
• Help other medical centers adopt our successful
  practice
• Get all the units in our medical center adopt
  ltpracticegt that has been so successful in ltpilot
  unitgt
• Bring ltpracticegt from ltRegiongt to all the units
  in our medical center, beginning with ltdemo unitgt
• Program Office says we all need to do ltpracticegt,
  so lets do it

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Your spread goal defines you role in supporting
spread
Typical goal Pattern Role
Bring ltpracticegt to our medical center from ltRegiongt External?1 Importer
Help other medical centers adopt our successful practice 1?External Exporter
Get all the units in our medical center adopt ltpracticegt that has been so successful in ltpilot unitgt 1?Many Distributor
Bring ltpracticegt from ltRegiongt to all the units in our medical center, beginning with ltdemo unitgt External?1?Many Importer-Distributor
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Tasks will depend on your role in spread
ImporterExternal?1
Confirm practice readiness for export

Assess your site readiness for import
Choose an import model
Import!


Exporter1?External
Confirm practice readiness for export
Market the practice find a distributor
Assess import site readiness for import
Choose an import model
Export!


Distributor1?Many
Confirm practice readiness for export

Assess alignment and readiness across all sites
Choose a distribution model
Distribute!


Importer-DistributorExternal?1?Many
Confirm practice readiness for export

Assess alignment and readiness across all sites
Choose a model for import and distn
Choose a demonstration site
Import! (and evaluate)
Distribute!
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Practice Readiness-for-Export Assessment
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Why assess Readiness for Export?

• Have you ever
• tried to import a practice that was successful
  for the innovator, but you just couldnt make it
  work?
• tried unsuccessfully to interest others in a
  practice that seemed great to you?
• had a senior leader ask you to
  import/distribute a practice that was
• Too complicated?
• Expensive, with little return?
• Not the best way to get the job done?
• Solution? Due diligence dont conclude too
  quickly that a practice is
• ready for export

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Readiness for Export Assessment
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Readiness for Export covers four areas
1. Impact on Primary Objective
Magnitude
Confidence
2. Impact on Other Aspects of Care
Patient Safety
Effectiveness of Care
Patient Experience
Physician/Staff Work Experience
Equity
3. Business Case
Costs
Savings
Revenue
Return on Investment
Certainty and Timing
Harvestability
4. Transferability
Observability
Simplicity
Adaptability
Cultural Fit
Goal Alignment
Sustainability
Implementation Support
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Using the Readiness for Export tool Section 1
1. Impact on Primary Objective 1. Impact on Primary Objective 1. Impact on Primary Objective 1. Impact on Primary Objective 1. Impact on Primary Objective
Element Start-Up Well-Established Start-Up Well-Established Start-Up Well-Established Start-Up Well-Established
Magnitude No impact has yet been observed, or lt5 Impact on primary performance measure(s) is 5-10 Relative impact on primary performance metric(s) is 11-20 Relative impact on primary performance measure(s) is more than 20
Confidence Impact has not been assessed Compelling anecdotes ORWeakly measured improvement in processes Robustly measured improvement in processes Robustly measured improvement in real, downstream outcomes (e.g. fewer never events, improved satisfaction, etc.)
Overall(based on all above) 1 2 3 4 5 6 7 8 9 10
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Using the Readiness for Export tool Section 2
2. Impact on Other Aspects of Care 2. Impact on Other Aspects of Care 2. Impact on Other Aspects of Care 2. Impact on Other Aspects of Care 2. Impact on Other Aspects of Care
Element Start-Up Well-Established Start-Up Well-Established Start-Up Well-Established Start-Up Well-Established
Patient Experience Potential impact has not been assessed Potential issues have been identified and mitigated Risks have been assessed by SME and are believed to be negligible Data demonstrate positive impact or no adverse impact
Physician/Staff Work Experience Potential impact has not been assessed Potential issues have been identified and mitigated Risks have been assessed by SME and are believed to be negligible Data demonstrate positive impact or no adverse impact
Overall(based on all above) 1 2 3 4 5 6 7 8 9 10
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Using the Readiness for Export tool Section 3
3. Business Case 3. Business Case 3. Business Case 3. Business Case 3. Business Case
Element Start-Up Well-Established Start-Up Well-Established Start-Up Well-Established Start-Up Well-Established
Savings No savings anticipated Modest savings are projected but not demonstrated Substantial savings have been projected but not documented Substantial savings have been documented
Certainty and Timing Costs are certain but benefits are less certain Benefits have been demonstrated as robustly, but will accrue 3 years later Benefits have been demonstrated as robustly, but will accrue 1-2 years later Benefits have been demonstrated as robustly and will occur during the same budget year
Harvest-ability Harvesting potential benefits could require painful measures Translating benefits into real dollars would require only routine efficiencies Benefits could translate directly into real dollars, but might not (i.e. contract hospitals could raise prices) Benefits would translate directly into real dollars (e.g. reduced drug costs)
30
Using the Readiness for Export tool Section 4
4. Transferability 4. Transferability 4. Transferability 4. Transferability 4. Transferability
Element Start-Up Well-Established Start-Up Well-Established Start-Up Well-Established Start-Up Well-Established
Simplicity Requires participation by 4 units or functions Requires participation by 2-3 units interactions must be tested Requires participation by 2-3 units accountabilities are clear and simple Requres no modification of current delivery system
Adaptability Adaptations have resulted in failure Adaptation has occurred at 1 pilot site with good results Adaptation has occurred, without compromising results, at 2 diverse sites that adopted the practice Key components are known acceptable variation is known
Cultural Fit Requires significant changes in work culture and roles Implementation requires some adjustment, but no fundamental changes Fits smoothly with existing work culture and norms Fits smoothly with staff hopes and desires
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Readiness for Export Assessment
32
Try using the Readiness for Export tool Scoring
Section Recommendations by Score
1. Impact on Primary Objective ? 1-4 Focus on improving performance and measurement at pilot site
Overall score ____ Weakest element(s) ? 5-7 Begin assessing impact on other aspects of care delivery while continuing to improve performance and documentation
? 8-10 Focus your energy elsewhere (but sustain the gains dont let performance slip)
2. Impact on Other Aspects of Care ? 1-4 Its time to look beyond your primary objective bring in others with responsibilities for aspects of care that might be affected
Overall score _____ Weakest element(s) ? 5-7 Strengthen documentation and/or measurement of impacts on other aspects of care
? 8-10 Focus your energy elsewhere (but keep looking for synergies)
?
4
Impact hasnt been measured well enough
?
3
Is there any impact on Patient Experience?
33
Interpreting the Readiness for Export scores

• This isnt a pass/fail test
• Low ratings in some areas are an alert to
  challenges you may face
• What you do with the scores depends on your role
• Importer Consider a different practice? Or
  proceed with your eyes wide open
• Exporter Keep developing your practice consider
  partnering with others
• Distributor Review your goals carefully if you
  proceed consider spreading slowly and embracing
  variation

34
Embrace the funnel Some innovations should
spread (some shouldnt)
Great idea
Great idea

• Be realistic about readiness for spread, and
  promote an innovation only when its value and
  transferability have been demonstrated
• Assess transferability rigorously trialability,
  simplicity, fit with KP culture, etc.
• Evaluate!

Collaborative Action Plans
True success
35
Site Readiness-to-Import Assessment

• Jim Bellows

36
Why assess Readiness to Import?

• Have you ever
• tried to import a practice that was successful
  for the innovator, but you just couldnt make it
  work at your site?
• tried unsuccessfully to interest others in a
  practice that seemed great to you?
• had a senior leader ask you to
  import/distribute a practice when
• Your organization was focused on other goals?
• Leadership was not aligned, giving conflicting
  direction?
• People were dealing with significant changes or
  disruptions?
• Solution? Due diligence dont conclude too
  quickly that your
• organization is ready to receive a practice from
  elsewhere, no matter
• how good it seems

37
Try it for your project!
38
11 Key Components of Readiness-to-Import

• Organization
• Sponsorship leadership
• Oversight Infrastructure
• Strategic Alignment with Organizations Goals
  Priorities
• Cultural Readiness
• Resources
• Staff
• Identified Project Management Championship
• Training requirements
• Space
• Technology Requirements
• Operations Infrastructure
• Measurement Monitoring

39
Sponsorship and Leadership
Key Component Definition Rating Scale (0-4, see definition column and comments below)
Sponsorship leadership Establish genuine commitment and support for changes, rather than simple compliance Get involved in the change, understand it, and promote it (Express, Model, Reinforce) Take personal responsibility and allocate sufficient time and resources to ensure the change is sustained Trustworthy, influential, respected and believable Consider the targeted sponsors for this initiative. 0 No evidence that sponsor behaviors have been exhibited no desire to sponsor this initiative 1 Limited evidence of sponsor behaviors limited desire 2 General evidence of sponsor behaviors, with inconsistent performance some desire 3 Evidence of sponsor behaviors desire to sponsor this initiative 4 Evidence of sponsor behaviors sustained over time strong desire to sponsor this initiative



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Strategic Alignment with Goals and Priorities
Key Component Definition Rating Scale (0-4, see definition column and comments below)
Strategic Alignment with Goals Priorities Change aligns with strategic priorities and the organizational goals The specifics of what is being asked are clear, the benefits (including ROI) apparent, and the impact on affected department(s)/functional units defined Consider the alignment of this initiative with goals and priorities, as well as impact on those affected 0 No alignment with priorities impact on affected unit(s) is unclear 1 Some alignment with priorities OR goals impact on the affected unit(s) is substantial given benefits 2 Some alignment with priorities AND goals impact on affected unit(s) is justifiable 3 Adequate alignment with priorities and goals 4 Complete alignment with priorities and goals impact on affected unit(s) is minimal
41
Technology Requirements
Key Component Definition Rating Scale (0-4, see definition column and comments below)
Technology Requirements There is enough technology of the right type to support the change There is a commitment to budget for long-term maintenance and sustainability of the technology Consider technology implementation and sustainability requirements 0 Requirements have not been adequately defined 1 Requirements have been adequately defined but there are significant budget gaps 2 Requirements adequately defined some budget gaps 3 Requirements adequately defined no budget gaps 4 Requirements adequately defined no budget gaps sponsor commitment to maintaining technology over time
42
Try it for your project!
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Scoring the tool provides general guidance
Use judgment in interpreting the scores and
deciding how to proceed
44
The Readiness Assessments can guide your
decisions about spread
Low
Test and Replicate- Diffusion
Innovate
Alignment
Readiness to Import
Test and Replicate - Collaboratives
Test and Replicate-Waves
High
Just Do It
High
Low
Readiness for Export
Transferability
Source Stacey 2002
45
How much variation?Adapt locally vs. copy exactly

• Adapt locally
• Theory (Paul Plsek)
• Health care is aComplex Adaptive System
• Find local Attractors
• Use only Simple Rules
• Strength
• Spread is more likely to occur if importers can
  adapt to their needs

• Copy exactly
• Theory (per Gabriel Szulanski)
• Were not as smart as we think
• Experience beats cleverness
• First import, then improve
• Strength
• Spread is more likely to get results if importers
  work with exporters to learn a proven model

46
Measurement and Feedback for Spread

• Lisa Schilling

47
Measuring Spread

• Rate of adoption
• Practice reliability map across sites
• Energy map of initiatives across sites
• Outcomes

48
Rate of Adoption Sustainability and Penetrance
49
Rate of Adoption Multiple Ideas

Source IHI, Iowa Health system 2010
50
Before Monitoring Reliable Practice Across Sites
Pink shift preparation Orange Goal
board Yellow bedside round with patient teach
back use
Source KP Hawaii NKE 2007
51
After Monitoring Reliable Practice Across Sites
Pink shift preparation Orange Goal
board Yellow bedside round with patient teach
back use
Source KP Hawaii NKE 2007
52
Energy Map Sacramento/Roseville
Source Ryan Darke 2010
53
Outcomes Adverse Drug Event Rates
Aim 50 Reduction in ADEs System-wide in 2002

Source IHI, Iowa Health System 2010
54
Outcomes Mortality Rates
55
Exercise for your portfolio

• In planning spread what variables do you need to
  monitor over time?
• Which ways would you monitor and report progress
  of your spread effort?

56
Support a Learning Culture

• Jim Bellows

57
What is the biggest part of this model?
Source Institute for Healthcare Improvement,
2006.
58
Practices spread best through personal contact
59
Who do you go to when you need information or
support?
Peoples answers define a social network map Key
nodes are not necessarily formal leaders
60
Social networks take work

• Communicate 6 times x 6 ways
• Foster relationships
• Get people together
• Send importers to meet with exporters

61
Knowledge Management Moving learnings through
social networks

• Content
• Case studies, especially patient cases
• Stories what seemed to work, what didnt
• Evaluation results
• Structure and process
• Informal exchange
• Face to face visits and meetings
• Wikis, IdeaBook, SmartBook,

62
Rapid spread of complex change A case study in
inpatient palliative care

• BMC Health Services Research 2009, 9245
• Della Penna R, Martel H, Neuwirth EB, Rice J,
  Filipski MI, Green J, Bellows J
• Results Compelling evidence of impacts on
  patient satisfaction and quality of care
  generated pull among adopters, expressed as a
  remarkably high degree of conviction about the
  value of the model. Broad leadership agreement
  gave rise to sponsorship and support that
  permeated the organization. A robust social
  network promoted knowledge exchange and built on
  an existing network with a strong interest in
  palliative care. Resource constraints,
  pre-existing programs of a different model, and
  ambiguous accountability for implementation
  impeded spread.
• Conclusions A complex, hospital-based,
  interdisciplinary intervention in a large health
  care organization spread rapidly due to a synergy
  between organizational push strategies and
  grassroots-level pull. The combination of push
  and pull may be especially important when the
  organizational context or the practice to be
  spread is complex.

63

• How can you reach your spread goal?
• Identifying social networks and communicating
  through them
• Establishing channels for knowledge management
  and creating relevant content