Transcript Scaling-Up High Impact Interventions by Rashad Massoud

Scaling up high-impact
interventions
M. Rashad Massoud, MD, MPH, FACP
Director, USAID Applying Science to Strengthen and Improve Systems Project
Senior Vice President, Quality & Performance Institute
University Research Co., LLC – Center for Human Services
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What do we mean by “Spread” or “Scaleup”?
The science of taking a local
improvement (intervention, idea,
process) and actively disseminating
it across a system
…Joe McCannon
Institute for Healthcare Improvement, Cambridge, MA
USAID Applying Science to Strengthen and Improve Systems
What do we know about the spread of good
practices?
Physician compliance with evidence-based
interventions:
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•
•
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Smoking cessation counseling: 21%
Mammography screening: 27%
Warfarin for Atrial Fibrillation: 40%
ACE inhibitors for CHF: 36%
…Agency for Health Research & Quality (AHRQ)
USAID Applying Science to Strengthen and Improve Systems
Original research
Negative
results
18%
Dickerson, 1987
46%
Negative
results
Koren, 1989
Submission
0.5 year
Balas, 1995
Kumar, 1992
Acceptance
0.6 year
Publication
35%
Lack of
numbers
variable
0.3 year
Kumar, 1992
17:14
Poyer, 1982
Bibliographic databases
50%
6. 0 - 13.0 years
Expert
opinion
Antman, 1992
Poynard, 1985
Reviews, guidelines, textbook
Inconsistent
indexing
9.3 years
Implementation
It takes 17 years to turn 14 per cent of original research to the benefit of patient care.
…Agency for Health Research & Quality (AHRQ)
Diffusion of Innovations:
Attributes of an Innovation
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•
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Relative advantage
Compatibility
Complexity
Trialability
Observability
E. Rogers, Diffusion of Innovations, 1995
USAID Applying Science to Strengthen and Improve Systems
Diffusion of Innovations:
Categories of Adopters
Laggards
Innovators
Early
Adopters
2.5%
13.5%
Early
Late
Majority Majority
34%
34%
16%
E. Rogers, Diffusion of innovations,1995
USAID Applying Science to Strengthen and Improve Systems
Key Insights on Diffusion Theory
• Attributes of Innovation
• Categories of Adopters
• Spread of Idea vs. Directed Change in Systems
USAID Applying Science to Strengthen and Improve Systems
A Framework for Spread
Leadership
-Topic is a key strategic initiative
-Goals and incentives aligned
-Executive sponsor assigned
-Day-to-day managers identified
Measurement and Feedback
Social System
Better
Ideas
-Develop the case
-Describe the ideas
Set-up
-Target population
-Adopter audiences
-Successful sites
-Key partners
-Initial spread strategy
-Key messengers
-Communities
-Technical support
-Transition issues
Knowledge Management
Institute for Healthcare Improvement, Cambridge, MA
USAID Applying Science to Strengthen and Improve Systems
Three Key Questions
• What do we want to spread?
• To whom do we want to spread? By when?
• How are we going to spread?
USAID Applying Science to Strengthen and Improve Systems
How Do We Spread?
Many possible ways:
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•
•
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Natural diffusion
Extension agents
Emergency mobilization
Spread through a collaborative
Spread through a virtual collaborative
Campaign spread
Wave sequence spread
Hybrid models
Institute for Healthcare Improvement, Cambridge, MA
USAID Applying Science to Strengthen and Improve Systems
Wave Sequence Spread
USAID Applying Science to Strengthen and Improve Systems
Principles of Scale-Up
1. Begin with scale-up in mind
2. If you can reach all-at-once – you should!
3. If you cannot, then consider a phased approach:
– Look for nested systems
– Test prototypes & expand in multiples of 5-10
4. How factors change in going to scale:
– Arithmetic scale up
– Favorable scale-up
5. Information systems
6. Communication needs
7. Oversight needs with scale-up
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USAID Applying Science to Strengthen and Improve Systems
Key Lessons Learned
• Results are the key drivers
• Enabling people to make changes in their work
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–
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–
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Systems thinking
Equip with PDSA’s
Assistance to the teams in the form of site visits
Leadership Support
Role Modeling
Normative/regulatory support
• People working under constraints can be very creative
• Scale-up efforts require meticulous attention to detail
• Champions who developed the prototypes are critical
for leading the scale-up in wave sequence spread
• Leadership from within the system
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USAID Applying Science to Strengthen and Improve Systems
New Learning about
the Rate of Spread
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Uganda - Comparison of Demonstration and
Spread Sites Screening for Active TB in HIV+
Patients
% of HIV+ patients assessed for active
TB at each visit
average of 17,500 HIV+ patients per month in original sites; 5,000 in spread sites
100.0
80.0
60.0 Baseline
40.0
CQI interventions
Baseline
20.0
CQI Interventions
0.0
A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F
05 05 05 05 05 06 06 06 06 06 06 06 06 06 06 06 06 07 07 07 07 07 07 07 07 07 07 07 07 08 08
52 DEMONSTRATION SITES Month
29 FIRST WAVE SPREAD SITES
% of HIV+ patients seen in that month that were screened for active TB, based on Patient register
USAID Applying Science to Strengthen and Improve Systems
Niger - Comparison of Demonstration vs. Spread IMCI
Sites for the % Children Triaged on Arrival
Niger: Percent of children triaged on arrival
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Old sites
ov
N
ep
S
l
Ju
ay
M
ar
M
n
Ja
ec
D
O
ct
A
ug
Ju
n
pr
A
Fe
b
ec
D
O
ct
ug
A
Ju
n
A
pr
b
Fe
ec
D
O
ct
0%
New sites
USAID Applying Science to Strengthen and Improve Systems
Key Results: Maternal and Neonatal Mortality
Reduction – Basic ProCONE
Trend in Compliance with Criteria in Prenatal Care in San Marcos and 7 Additional Health Areas
during Expansion Phase
Demonstration Phase
100
95
90
90
80
Expansion Phase
94
95
94
78
85
84
85
68
60
58
50
50
40
36
30
20
0
18
Numerator
Denominator
Services reported
% Services reported
A total of 143 facilities participating
E.9
412
2310
129
90
F.9
721
2011
118
83
M.9
1230
2467
139
97
68
66
63
A.9
1373
2367
133
93
91
83
73
72
70
10
90
88
87
59
75
69
74
65
77 80 80
85
81
88
84
80
78
84
82
72
Interventions:
•Advocacy for securing
micronutrients
•Training of staff in prenatal care
needed due to high turnover rate
M.9 J.9
J.9 A.9
1421 1530 1670 1483
2402 2306 2427 2271
134 135 134 132
94
94
94
92
S.9
1485
2073
124
87
O.9
1432
1929
114
80
N.9 D.9 J.10 F.10 M.10 A.10 M.10
1485 1261 1574 1586 1459 1190 657
1924 1574 1963 2046 1737 1456 780
110 94 118 117 97
83
55
77
66
83
82
68
58
38
USAID Applying Science to Strengthen and Improve Systems
Rwanda - Comparison of Demonstration vs. Spread
site for the % Partners of Women in ANC Tested for
HIV
Rwanda: percentage of partners tested
100%
90%
80%
% of partners tested
70%
60%
50%
40%
30%
20%
10%
0%
J
F M A M J
J
A S O N D
J
F M A M J
J
A S O N D
Old Sites: % (16)
J
F M A M J
J
A S O N D
J
F M A M J
New Sites: % (20)
USAID Applying Science to Strengthen and Improve Systems
Percentage of deliveries where Active Management of Third Stage of Labor -AMTSL- was
implemented in accordance to standards. Three groups of hospitals (started 2003-2004,
n=55; 2005, n=21; 2007, n=10) . Total 86 hospitals reporting 2003-2009. Ecuador.
100
90
80
Percentage
70
60
50
40
30
20
10
0
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2003
2004
2005
2006
2007
2008
2009
% 2003-2004 0. 1514 1621 3237 3739 4142 4048 5159 5755 55 5857 6565 6168 6665 6966 6571 6463 6771 73 7681 8080 8579 7679 8679 8683 9095 9495 9795 93 8990 9495 9796 9692 9793 9391 9594 9697
% 2005
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1538 5559 4367 6277 8481 8474 7878 7984 82 8889 9389 8277 8182 8079 8487 8892 9084 8892 88 8991 8592 9592 9693 8889 9492 8891 9192
% 2007
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21 4044 5156 8879 9485 7693 90 8985 8987 8596 9795 9497 10
1010 9810
USAID Applying Science to Strengthen and Improve Systems