Western Node Spread Call #2Feb 5th, 2009

1. Understand when you are ready for spread◦ Reliable design◦ Support systems for sustainability◦ NHS sustainability model

2. Identifying the scale, scope and social context of your spread plan

◦ Spread AIM◦ What, Who and How

3. Introduce some planning tools

The science of taking a local improvement(intervention, idea, process) and activelydisseminating it across a system

There are many possible definitions for “asystem” (e.g. a hospital, a group ofhospitals, a region, a country)

“New Generation of Ideas on Spread”, Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad IHI National Forum Dec 2008

“BETTERIDEAS”

Happens over time

COMMUNICATED

Thru a SOCIAL systemAdapted from Rogers, 1995

In a concrete targeted ways

(C) 2001, Sarah W. Fraser

Diffusion of Innovation Theory

Sustainability◦ New process, thinking, attitudes and support systems for

the change become the norm & improve with time

Spread◦ Spread is the result of the "process of adoption" - success

is dependent on the willingness of others to adopt the ideas.

Adapting◦ Customizing the change to culture, need or environment

for the purposes of adoption

Adopting◦ A conscious decision to implement a change; each

individual must decide

Spread Adoption

Push ideas out towards others Pull ideas to myself

My agenda at the center of a larger organization

My agenda at the sharp end of delivering care

Use of organizational structure and hierarchy to communicate the change

Use of social systems to communicate about change

Focus on tools, techniques and processes

Focus on relationships and facilitation

NHS Institute for Innovation & Improvement Source: Fraser & Plesk, 2003

“New Generation of Ideas on Spread”, Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad IHI National Forum Dec 2008

“New Generation of Ideas on Spread”, Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad IHI National Forum Dec 2008

From Improvement to Spread

Spreading a change to other

locations

Developing a change

Implementing a change

Testing a change

Act Plan

Study Do

Theory and Prediction

Test under a variety of conditions

Make part of routine operations

Robert Lloyd

“A few observations and much reasoning lead to error;

many observations and a little reasoning lead to truth.”

(1873-1944) born on Jun 28 US "surgeon, biologist". "He invented, with C. Lindbergh,

the perfusion pump called artificial heart, 1936; Nobelist, 1912."

B. Harries, Improvement Associates, Holding the Gains and Spread presentation SHN WN Teleconference 11/07/06

Replicate gains under a variety of conditions◦ Test the changes under a wide range of

conditions (robust design)◦ Judgment samplings◦ Planned groupings

Foolproof the new process/procedure◦ Reduce likelihood of mistake/error◦ Use short feedback loops◦ Use technology where appropriate

B. Harries, Improvement Associates, Holding the Gains and Spread presentation SHN WN Teleconference 11/07/06

Seek and use input from others Use multiple PDSA cycles to implement

the change Collect data over time when conditions are

expected to change Redesign support processes for new

process Address the social aspects of change

Integrate into organization

Continue measuring Rely on others Provide

communication and education

Recognize hard work

PROJECT TEAM WORKSHEET: Redesign of Support Processes for Implementation of Change Change Implemented:

Date: Cycle No.

Change Tested or Implemented Lead June July August September October November 24 1 8 15 22 29 5 12 19 26 2 9 16 23 30 7 14 21 28 4 11 18 25

Policies

Documentation

Hiring Procedures

Staff education/training

Job descriptions

Information Flow

Equipment Purchases

Spring Learning Session June 18-19, 2003 IHI BTS Collaborative Holding the gains

www.institute.nhs.uk/sustainability

Ask: How well are the new processes being

used? Is the outcome data holding at/near target

or improving Have the structures been put in place to

support the new process? Do new staff know and do the new process? Is the new process fully implemented in the

pilot area?

Set realistic spread timelines Understand specifics of external pressures Develop and maintain regular

communication with leaders Regularly communicate progress and key

lessons

HowBy When

What To Whom

Set-up-Target population -Adopter audiences -Successful sites -Key partners-Initial spread strategy

A Framework for Spread

Social System-Key messengers -Communities -Technical support-Transition issues

Communication Strategies (awareness & technical)

Knowledge Management

Measurement and Feedback

Leadership-Topic is a key strategic initiative

-Goals and incentives aligned-Executive sponsor assigned

-Day-to-day managers identified

Better Ideas-Develop the case -Describe the ideas

Nolan K, Schall M, Erb F, Nolan T. Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety. 2005 Jun:31 (6):339-347.

Infrastructure,Leadership and Measurement

Better IdeasInformation about the

Innovation and “Transfer Materials”

Target Population “To and Through a Social System”

Communicated

Modes

Purpose

MessengersBased on

materials from IHI and

Veteran’s Health

Administration

Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration.

Joint Commission Journal on Quality and Patient Safety. 2005 Jun;31(6):339-347.

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Develop a Spread AIM Leadership Set-up/ infrastructure Communication Social System Measurement and Feedback

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Spread What:

Target Level of Performance:

Spread to Whom:

Time frame:

Developing a Spread Aim

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Spread What: All measures in the SSI Bundle

Target Level of Performance: Zero Cases of SSI

Spread to Whom: All surgical populations in our 10 hospital system

Time Frame: By September 2010

Sample Spread Aim: Prevent Surgical Site Infections by Implementing the SSI

Bundle

We have an overall spread plan Our spread activities are included in strategic and

business plans of our organization We have visible and active support from our senior

leader to spread our changes Roles and responsibilities for spread are clearly defined

Senior leader assures success, remove barriers, make case for change

Day to day leaders communicate, develop messengers, educate, make it easy for others to do the work

‣ An honest ‘warts and all’ account of their journey

‣ Clear improvement goals

‣ Measures and results

‣ The challenges the team can’t unblock without senior leadership input

‣ Evidence of learning and sharing – will you help the chief executive to spread

‣ To be asked for money – results first is a good tactic !Regina Shakespeare Department of Health , UK, Building Momentum for the Future: Taking the Next Step in Patient

Safety, Improvement Team and Leader: In Perfect Harmony? Improvement Team and Leader: In Perfect Harmony? Winnipeg April 1st & 2nd 2008

‣ The pride and determination of professionals to improve the care they give

‣ Results

‣ Stories of how improvement has benefited patients and carers – sometimes they don’t get out much!

‣ Results

‣ Linking the improvement goals and measures to the organisation’s stay in business goals

Regina Shakespeare Department of Health , UK, Building Momentum for the Future: Taking the Next Step in Patient Safety, Improvement Team and Leader: In Perfect Harmony? Improvement Team and Leader: In Perfect Harmony? Winnipeg April 1st & 2nd 2008

‣ Game playing, such as - using the access to pursue other agendas between professions, departments or business units

‣ Having to referee the team conflicts!

‣ Keeping your work an organisational secret

‣ Disregard for the organisation’s corporate agenda

Regina Shakespeare Department of Health , UK, Building Momentum for the Future: Taking the Next Step in Patient Safety, Improvement Team and Leader: In Perfect Harmony? Improvement Team and Leader: In Perfect Harmony? Winnipeg April 1st & 2nd 2008

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Set-up/Infrastructure◦ 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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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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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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‣Building Awareness‣Moving adopters from decision to action

‣Supporting and mentoring adopters

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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

Feedback and adjustments may be needed for:◦ Communication plans◦ Materials and information◦ Support and mentorship◦ Infrastructure issues◦ Social system issues

‣ You DON’T have to know it all before you start

‣You learn as you go

‣Spend 20 % on the Plan and 80% on the DOING

‣supporting and adapting

‣Keep the work VISIBLE‣ to Staff and Leaders

New Generation of Ideas on Spread, Dec 8, 2008 Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad, IHI National Forum

Strategies for Spreading Improvements in Health Care, October 14, 2004 Marie W. Schall, Institute for Healthcare Improvement

Holding the Gains and Spread, July 11, 2006Bruce Harries, Improvement Associates

The Seven ‘Spreadly’ Sins, October 18, 2006 Roger Resar, MD & Carol Haraden, PhD IHI

Sustainability and Spread, August 28, 2006Diane Jacobsen, MPH, CPHQ, IHI National Director

Continuing the Conversation Holding the Gains and Spreading Good Ideas: From Local Improvement to System-wide Change October 4, 2007 Marie Schall, MA Institute for Healthcare Improvement

National Health Services (NHS) Modernization Agency Improvement - Sustainability and its relationship with spread and adoption. www.institute.nhs.uk/improvementleadersguides

Hinchey Judge KA. Et al., Factors Contributing to Sustaining and Spreading learning Collaborative Improvements, Qualitative Research Study Findings by the Primary Care Development Corporation, Dec 2007.

Nolan K, Schall M, Erb F, Nolan T. Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety. 2005 Jun:31 (6):339-347.

Paul Plsek, Spreading Good Ideas for Better Health Care - A Practical Toolkit Volume 2 - Veterans Health Administration 2000 Research Series. VHA, 2000.

Paul E. Plsek,  Charles M. Kilo From resistance to attraction: a different approach to change - Positively Influencing Physicians Physician Executive,  Nov-Dec, 1999.

Dr. Lynne Maher, Emerging themes for improvement and innovation, presentation QHN Fall Forum, November 21, 2007.

Developing your initial spread plan, IHI Boston Spread Workshop Feb. 2007

Barb Saunders, Spread of Improvement Efforts – Guideline for Fraser Health, March 10, 2005

Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety. 2005 Jun;31(6):339-347

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,

Il:Irwin ,1978.

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.

References