Transcript Communicating and Spreading Success, workshop Feb 1, 2007

Communicating and Spreading Success
Sponsored by: Health Quality Council of Alberta
and Western Node of Safer Healthcare Now!
February 1, 2007
Best Western Village Park Inn
1804 Crowchild Trail NW, Calgary, Alberta Foothills II Room
1 pm Welcome by Dr. John Cowell, CEO HQCA
1:15 – 2:45 pm Using Quarterly Reports Effectively!
Virginia Flintoft, Project Manager, Central Measurement Team –
Safer Healthcare Now! University of Toronto
2:45 – 3:00 pm BREAK
3:00 – 4:30 pm What Now? Sustaining and Spreading for Success
Tanis Rollefstad, Improvement Advisor, Western Node for Safer
Healthcare Now!
4:45 pm Mix and Mingle
Put title right
in
here
Communicating and Spreading Success
March 15, 2004
John W. Cowell, MD, FRCPC
Chief Executive Officer
February 1, 2007
www.hqca.ca
•HQCA has embraced and tangibly supported
SHN since its inception
•Our focus is on health system quality, safety
and performance
•We work primarily from the citizen’s point of
view
www.hqca.ca
•We collaborate and work directly with all the
health regions, professions and policy makers
•Our Template is the Alberta Quality Matrix for
Health
•We believe effective performance management
requires appropriate measurement at all levels
www.hqca.ca
What’s happening in Alberta
1. 55 teams enrolled in Alberta
2. There are teams working on each of the 6
SHN interventions
3. Alberta leads the west in providing data to the
Central Measurement Team (CMT)
www.hqca.ca
What’s happening in Alberta (cont.)
4. Over 90% of hospitals have submitted data to
CMT
5. Analysis of the data will reveal whether the
initiatives in each of the interventions result
in improved clinical outcomes
6. It is anticipated the analysis and conclusions
of this will ensure the spread of successful
change
www.hqca.ca
We have no doubt those of you working
hard on the interventions and
collaborations are making a positive
difference on the patient experience.
www.hqca.ca
What can we learn from
SHN’s Quarterly Reports?
Virginia Flintoft, RN MSc
SHN – Central Measurement Team
Objectives
•
•
•
•
•
Overview of the Quarterly Report format
Basic interpretation and caveats
Intervention-specific observations
Breakout + Quiz
Questions
Quarterly Report format
Q.R. # Date data submitted
Months reported
1
April ’06 – June ’06
Nov* ’05 – June ’06
2
April ’06 – Sept. ’06
Nov* ’05 – Sept. ’06
3
April ’06 – Dec. ’06
Nov* ’05 – Dec. ’06
* or preceding months pooled and reported in November
Quarterly Report format
AMI – 8
CLI – 3
Med Rec – 3
RRT – 3
SSI – 7
VAP – 2
Total = 26
Quarterly Report format
Quarterly Report format
Quarterly Report format
Quarterly Report format
Goals:
• Vary for each measure
• Types
 Evidence based
 Based on local performance
Quarterly Report format
o

AMI 8; CLI 1; MedRec 1 & 2;
RRT 1; VAP 1
Set by team
o
RRT 2 & 3
• Calculation method specified
at bottom of Raw Data Sheet
Data Analyzed & Presented:
• Nationally
• by Node –
 Atlantic
 Ontario
 Quebec
 Western
 Paeds
• by Implementation Stage –
 Baseline
 Early
 Full
Quarterly Report format
Quarterly Report format
Raw Data Sheet from
Measurement Workbook
Quarterly Report format
Copy values in “Final Calculation” row
on Raw Data Sheet and paste into
“Local Team” row (r7) on Quarterly
Report
Copy values in “Final Calculation” row
on Raw Data Sheet and paste into
“Local Team” row (r7) on Quarterly
Report
Basic interpretation
Definitions:
• “N (Teams)” = Number of teams reporting data for a specific month
Caveats:
• When N (Teams) <5 the data is not stable due to too small a cell size
• The number of teams reporting per month varies with
each QR
Quarterly Report format
QR #1 – data submitted April - June 2006
Comparator Group
Aspirin at Arrival
Local Team (input own data)
National
Descriptive Statistic
Goal
Final Calculation
N (Teams)
Mean
SD
Nov'05
Score
>90%
75%
17
94.06%
6.66%
Dec'05
Score
>90%
82%
11
98.10%
4.09%
Jan'06
Score
>90%
83%
6
98.15%
4.53%
Feb"06
Score
>90%
79%
6
97.22%
6.82%
Mar'06
Score
>90%
88%
10
98.89%
3.51%
Apr'06
Score
>90%
90%
3
77.77%
38.51%
May'06
Score
>90%
90%
4
95.50
5.47
QR #2 – data submitted April - Sept. 2006
Comparator Group
Aspirin at Arrival
Local Team (input own data)
National
Descriptive Statistic
Goal
Final Calculation
N (Teams)
Mean
SD
Nov'05
Score
>90%
Dec'05
Score
>90%
Jan'06
Score
>90%
Feb"06
Score
>90%
Mar'06
Score
>90%
Apr'06
Score
>90%
May'06
Score
>90%
27
92.63%
8.39%
19
93.91%
11.82%
15
89.07%
27.03%
17
92.09%
24.22%
18
98.96%
3.10%
11
93.94%
20.11%
11
98.36%
3.76%
• Data becomes more stable as sample size increases
Basic interpretation
Definitions:
• “Mean” = average score for the measure for the
hospitals reporting data for that month.
Caveat:
• The more teams reporting the more stable
the mean.
Basic interpretation
Definitions:
• “SD” = standard deviation - summary value for how widely dispersed the
scores are around the mean. In a normal distribution 95% of all scores are
within 2-SDs on either side of the mean.
Caveats:
• Very high SD indicates large variation in scores making it difficult to use
the national average to interpret your performance.
• Normal curve has no defined limits - a ‘percentage’ is limited to 0 and
100. Therefore, 2-SDs above or below the mean may be
>100 or <0.
To “Unhide” rows
• highlight 1or 2 rows above & below
node ‘section’
• right click to display menu
• select “unhide”
• Minimum – lowest score reported for a specific month
• Maximum - highest score reported for a specific month
• 25th percentile – 25% of all teams reporting data for that
month have a lower score.
• Median (50th percentile) – exactly half of the scores are
above and below this value.
• 75th Percentile - 75% of all teams reporting data for that
month have a lower score.
• It is better to be <25th percentile for some measures
• Bracketed measures (large):
o
o
Only included in National analysis
Used for calculating confidence intervals (CI)
• Bracketed measures (small):
o
Lower and Upper Bound = CI
Interpretation:
• Compare your performance (Local Team) to
National mean month-over-month
• Compare your performance to CI
o
if score falls between upper and lower bound =
statistically similar (Jan., Feb., Apr.)
No CI because
25th %ile - Max=100%
Adjust to
appropriate level
Definitions of Implementation Stages
• Baseline Stage
– Pre-intervention. Data collected for Baseline
should be collected prior to implementing
small tests of change and reflect the current
process.
Definitions of Implementation Stages
• Early (Partial) Implementation Stage
– The team has: set a clear aim(s) for this intervention
(i.e. AMI, CLI, MedRec, RRT, SSI or VAP); identified
which measures will indicate if the changes will lead
to improvement; and started to implement small
tests of change (PDSA) to identify and refine
processes, procedures and practices which will lead
to improvement and achieving the aim. When the
team is close to goal they are ready to move to Full
Implementation.
Definitions of Implementation Stages
• Full Implementation Stage
– The processes, procedures and practices are
finalized and have lead to significant improvement.
These practices on the selected unit are being
consistently applied and monitored, showing a
sustained performance at or close to goal. The team
has achieved their aim(s) and is ready to spread to
other areas.
Interpretation:
• Compare your performance (Local Team) to National monthly means–
match Implementation Stage (Baseline, Early, Full)
• Cut, Paste and Create an annotated Run Chart
Cut & Paste
Cut & Paste
Cut & Paste
• Annotated run chart
Data Submission and Performance
Nov.30.06
Intervention-specific
N Hosp Hospitals
Enrolled Reporting
24
22
37
32
22
16
1
1
9
6
1
0
94
77
94
81.9%
%
Reporting
91.7%
86.5%
72.7%
100.0%
66.7%
0.0%
81.9%
Teams Reporting by Intervention (% enrolled)
AMI
CLI
MedRec
RRT
SSI
VAP
4 (80%)
3 (75%) 16 (80%) 4 (100%) 11 (85%) 8 (89%)
12 (67%) 1 (17%) 19 (86%) 2 (20%) 15 (63%) 5 (45%)
3 (38%)
0 (of 1) 16 (70%) 0 (of 1)
4 (66%)
2 (67%)
1 (100%)
1 (50%)
0 (of 1)
6 (75%) 1 (33%) 1 (50%)
1 (33%)
0 (of 1)
20
4
57
7
32
16
33
12
72
18
47
26
61%
33%
79%
39%
68%
62%
Overall
Reporting
84%
59%
48%
100%
53%
0
136
208
65.4%
National Intervention-specific (as of Nov.’06)
• AMI
o
o
o
o
o
ASA on arrival (AMI 1) - at or >Goal
ASA @ discharge (AMI 2) - at or >Goal
Beta Blocker @ discharge (AMI 3)- at or >Goal
ACEi/ARB @ discharge (Ami 5)- at or >Goal
Thrombolysis or Primary PCI at arrival (AMI 4a & 4b)
• small cell size, ++ variation,
• mean performance since May’06 (4A)40%-65% & (4B) 35%-75%
o Smoking Cessation Counselling (AMI 6)
• mean performance 50%-75% - is documentation adequate?
National Intervention-specific (as of Nov.’06)
• AMI (cont.)
o Perfect Care (AMI 7)
• issues related to exclusion criteria – transfer in and out
o Inpatient Mortality (AMI 8) –
• poor submission (only 2 teams since Sept)
• All AMI teams should submit monthly using “retrospective”
form
National Intervention-specific (as of Nov.’06)
• CLI, RRT & VAP - ICU collaborative measures –
o CLI
• data submission improved - 8-20 teams submitting data/mo.
• Bloodstream infection rate /1000 days (CLI 1)
• CLIs now used routinely outside ICU you may choose to expand
inclusion beyond ICU
• Insertion Bundle (CLI 2)
• National mean performance 50%
• Early & Full Implementation 45%-80%
• Maintenance Bundle (CLI 3)
• Early & Full Implementation ~70%
National Intervention-specific (as of Nov.’06)
• CLI, RRT & VAP (cont.)
o RRT
• data submission improved - 11-19 teams submitting
data/mo
• Percent of codes outside of ICU (RRT 2) – 70%-90% + high SD
• Utilization Rapid Response Team (RRT 3) – 1-200 + high SD
o VAP
• better submission Nationally (21-41 teams/month)
• VAP Bundle compliance (VAP 2) between 57-83% - goal=95%
• Be sure your teams are applying revised definition (CDC)
National Intervention-specific (as of Nov.’06)
• Medication Reconciliation
o Excellent rates of submission – 27 to 69 teams/mo.
o Intentional Undocumented Discrepancies (MedRec 1)
o Median from 0.6 down to 0.26
o Unintentional Discrepancies (MedRec 2)
o Median ranges from 0.57 to 1.00
o Likely due to CCHSA requirement and Western
Collaborative
National Intervention-specific (as of Nov.’06)
• Surgical Site Infection
o Excellent rates of submission likely due to Western
Collaboration
• Timely Prophylactic Antibiotic (SSI 1)
• Appropriate prophylactic antibiotic (SSI 2)
• Appropriate Hair Removal (SSI 4)
• Appropriate selection of prophylactic antibiotic (SSI 7)
o Glucose control for Major Cardiac (SSI 5) – 3 to 5 sites / month
o Glucose control applicable beyond Major Cardiac – IMH
o Normothermia (SSI 6) – 60% to 70%
National Intervention-specific (as of Nov.’06)
• Surgical Site Infection (cont.)
o Strong move to full implementation
o Percent Clean Surg w/ Surgical Infection (SSI 3)
• Low submission rate likely due to difficulty monitoring SSI
o Appropriate selection of Prophylactic antibiotics (SSI-7) – to be
revised by SSI faculty
Sharing the Quarterly Reports
• With who do you (KOCs + Team Leaders)
share the QR info?
– Team, Sr. Mgmt, Board
• What should you tell each group?
Breakout Groups
1. Complete the quiz together
2. Determine the message(s) for your
assigned group (i.e. Team, Sr. Mgmt,
Board)
3. Report back
Questions?
Thank you for your interest in SHN!
Contact Information:
Name
Virginia Flintoft
Address
University of Toronto
Phone/email
416-946-8350
[email protected]
Sustaining and
Spreading for Success
T. Rollefstad
SIA Western Node
February 1 & 2, 2007
Safer Healthcare Now!
Western Node
Purpose
Participants will be able to:
Understand the principles of sustainability
and spreading successful initiatives
 Identify how spread elements can be
applied in a local setting
 Select strategies to enhance sustainability
and spread in their local organization

Definition of Sustainability
The Modernisation Agency’s working
definition of sustainability is:

when new ways of working and improved
outcomes become the norm.

holding the gains and evolving as
required, definitely not going back.
How to Spread Good Ideas: A systematic review of the literature on
diffusion, dissemination and sustainability of innovations in health service delivery and organisation Report for the
National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO) April 2004 prepared by
Trisha Greenhalgh, Glenn Robert, Paul Bate University College London; Olympia Kyriakidou, Fraser Macfarlane University of Surrey;
Richard PeacockUniversity College London
Definition of Spread

Spread is the extent to which learning and change
principles have been adopted in other parts of the
organisation that could benefit from them.

Improvement knowledge generated anywhere in the
healthcare system becomes common knowledge and
practice across the healthcare system.
NHS Modernization Agency 2003
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
The “Diffusion Curve”
Spread of Chronic Care Model Across Clinics
Percent of clinics implementing CCM
100
90
80
Total of 80 Clinics in
Organization
70
60
50
40
30
20
“tipping point”
10
0
Sep- Oct
98
Nov
Dec Jan- Feb
99
Mar
Apr
May
Jun
Jul
Aug Sep
Oct
Nov
Dec
Jan- Feb
00
Adopter Categories
Innovators
Early
Late
Majority Majority
Early
Adopters
2.5%
from Rogers, 1995
13.5%
Laggards
34%
34%
16%
7 Deadly Sins of Spread!
Roger Resar, MD & Carol Haraden, PhD
The things we’ve learned NOT to do:
1. Start with a large pilot area – Go Big or
Go Home
2. Find one person to do It ALL
3. Be vigilant and work harder
4. If it works in the pilot Unit, DON’T change
it for spread
5. Appoint the successful team leader as the
driver for spread to the WHOLE hospital
6. Look at the deficits on a quarterly basis
7. Early on expect marked improvement in
hospital wide outcomes
http://www.ihi.org/NR/rdonlyres/BF88C0E6-6E30-42FB-9CAF88B76B53EBE4/0/Haraden_Resar7SpreadlySins.ppt
Assessed for Risk of
Hypothermia
120%
100%
80%
60%
40%
20%
0%
Week Week Week Week Week Week Week Week Week Week
1
2
3
4
5
6
7
8
9
10
Positive Conditions
For Spread
Synthesized findings
on major
improvement
initiatives in the UK
 Describes the main
factors found to
contribute to
successful spread and
sustainability

Factors Affecting Spread














Ownership of the initiative
Effective Relationships
People who influence
Leadership
Dedicated resources
Process of implementation
Incentives
Staff Engagement
Support at senior level
Local context
Nature of initiative
Readiness for Improvement
Evidence of Improvements
Integration into practice
Where are you at?
Assessment Activity
Activity
Think of one area you will spread to next
Using the FACTOR WEB Tool:
 Take 10 minutes to rate each of the Factors
affecting spread
 0= weak
5=strong
 Place a dot on the circle which intersects the
factor line
 Join the dots and shade the inner area

“Real improvement comes
from changing systems, not
changing
within systems.”
– Berwick
Testing versus Implementation
Testing – trying and adapting alternatives
under multiple conditions
 Implementation – making a change part of
the day to day operation of the system

No implementation should fail
Creating a New System
Spread
Hold the Gains
Improvement
(test, implement)
Strategies to Hold the Gains
I. During testing

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
Hold the Gains:
II. During Implementation





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
Hold the Gains:
III. After Implementation
Old System
New System
Some Inhibitors
 “We met our goals”
 “We assumed the improvement would hold”
 Other priorities took all resources away
(not on senior management’s radar screen)
 No strategies or did not learn how to hold the
gains
 Infrastructure not in place
 Isolated project with a start and finish
Key Components to Hold the
Gains After Implementation

Communication
Regular communication
Informed with data

Infrastructure
Support processes
Leadership acountability

Effective Control System

Integrate into organization
Continue measuring
Keep Core principles but allow
customization based on real
issues
Formalize documents
Embed in orientations
Creating a New System
Spread
Hold the Gains
Improvement
(test, implement)
Readiness to Begin
Spreading Changes
There are demonstrated results from
Collaborative team
 There is will to spread the work of the
Collaborative in the organization
 Ensure strategy is a key initiative for the
organization
 A senior leader is responsible for spread of the
changes

Adoption is a DOING thing!
“BETTER
IDEAS”
COMMUNICATED
In a concrete targeted way
Happens
over time
Thru a SOCIAL system
Adapted from Rogers, 1995
(C) 2001, Sarah W. Fraser
Spread Model
Better Ideas
Information about the
Innovation and “Transfer
Materials”
Communicated
Modes
Purpose
Target
Populatio
n “To and
Through a
Social System”
Messengers
Infrastructure,
Leadership and
Measurement
Based on
materials from
IHI and
Veteran’s
Health
Administration
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
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

Spread Check List –
Better Ideas that Spread Quickly
 We
address the innovations’:
– Relative advantage (it is better than
alternative)
– Trialability (you can test it first)
– Observability (you can see it)
– Compatibility with current values (it fits)
– Simplicity (it’s simple to understand and do)
Source: Diffusion of Innovations, Everett Rogers 1995
Spread Check List –
Better Ideas
We can describe our changes (what), why the
changes were made and benefits to patients and
staff (tell the story)
 We can easily show our successes and results
(show the data)
 We have documented our story through
storyboards, presentations, newsletters, seminar
materials, reports to senior leaders, videos,
engaging stories, FAQ’s etc.
 We continually assess the value and quality of
our transfer materials

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

Spread Check List –
Communication
We have used multiple channels for
communication, focusing on interactive, peer-topeer and face-to-face methods
 We communicate early and often
 We have identified our messengers, our
connectors and “salespeople”
 We have trained our staff and provided them
with the tools to tell the story

Spread Check List –
Developing the Messengers

We have chosen the right messengers
– Trusted
– Technically competent
– Full member of local group

We have used a two – step approach
– From team to opinion leaders and connectors
– From opinion leaders and connectors to their
networks

We have adequately educated the messengers
to deliver the message
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
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?

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
Spread Check List –
Target Population & Social
System
We have identified our target population and
spread community
 We have tried to understand context of our
target population
 We have identified existing relationships, opinion
leaders, innovators and early adopters in the
target population
 We have allowed the target population to adapt
our changes to fit their environment

Leadership’s 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
Topic as a Key Strategic
Initiative
 CCHSA
– Medication Reconciliation is
a Required Organizational Practice
 CCS – Canadian Cardiovascular
Society has AMI Best Practice
Guidelines
 IHI & SHN has built momentum and
awareness of 6 strategies
Spread Check List –
Leadership
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
Additional Considerations
Developing the Communication Plan
 Strengthening the Social System
 Developing the Measurement and
Feedback System

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
Outcome Measure
Iowa Health System
% of Sampled Charts with ADEs
Targets: 2002 = 10%, 2003 = 5%, 2004 = 2%
% of Charts
50%
40%
30%
23%
20%
14%
20%
13%
12%
11%
8%
10%
0%
1 1 / 01 / 2001 N =
1 2/ 01 / 2001 N =
01 / 02/ 2002 N =
02/ 02/ 2002 N =
03/ 02/ 2002 N =
04/ 20/ 2002 N =
33/ 1 42
29/ 1 45
20/ 1 39
1 8/ 1 40
1 9/ 1 54
1 3/ 1 60
N = Number of System A DE s/ Char ts Sampl ed System-wi de
05/ 20/ 02 N = 1 2/ 1 60
Tracking the Spread of the
Changes
Outcome Measure - VHA
Average Waiting Time for Next Available Appointment (Days)
100
80
60
40
20
0
Apr
May
Jun
Jul
Aug
Prim
Sep
Eye
Oct
Nov
Dec
Audio
Jan
Feb
Cardio
Mar
Apr
May
Ortho
Jun
Uro
Jul
Aug
Sep
Measures
using Small
Multiples:
Overall System
and 4 sites
OUR SITE
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
A pr
Jun
A ug
Oct
Dec
Feb
A pr
Jun
A ug
Oct
Dec
SITE3
100
Overall Outcome
Measure
SITE2
100
Apr
Jun
Aug
Oct
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
Feb
Apr
Jun
Aug
Oct
Dec
Jun
A ug
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Spread Check List –
Infrastructure

Measures about our changes and spread plans
are reviewed by our team and our sponsor
 More balancing, upstream and downstream
 Less frequent

We have a method/process for knowledge
transfer (including improvement science),
continual learning and sharing information
Activity
Take 10 minutes to review the Spread
Checklist
 Check off the items your team has
accomplished
 What area/s still needs work?

Put it all together into a
Plan
Developing a Plan for Spread
Develop a Spread AIM
 Leadership
 Set-up/ infrastructure
 Communication
 Social System
 Measurement and Feedback

Developing a Spread Aim

Spread What:

Target Level of Performance:

Spread to Whom:

Time frame:
Developing an Initial
Spread Plan

Consider how the organization structure can be
used to facilitate spread:
– How are adoption decisions made?
– What infrastructure enhancements will assist in
achieving the Aim?
– How will the spread efforts be transitioned to
operational responsibilities?
Sample Spread Aim: Prevent
Ventilator Associated Pneumonia by
Implementing the Vent Bundle
 Spread What: Ventilator
Bundle
 Target Level of Performance: Zero Cases
of VAP
 Spread to Whom: All ICUs in our 10
hospital system
 Time Frame: By September 2007
Sample Spread Aim: Prevent
Adverse Drug Events by
Implementing BPMH and
Documentation form

Spread What: BPMH & Documentation form
 Target Level of Performance: Zero
unintentional discrepancies
 Spread to Whom: All units in our 10 hospital
system
 Time Frame: By September 2007
Levels of Spread Activities –
Level 1

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
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
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
Communication Plan
• Building Awareness
• Moving adopters from decision to
action
• Supporting and mentoring adopters
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

Feedback and adjustments may be needed for:
–
–
–
–
–
Communication plans
Materials and information
Support and mentorship
Infrastructure issues
Social system issues
Spreading the Story
Describes steps to
developing a
communication plan
 How to for “telling the
story”
 Quick read

Sarah Fraser - Health Management June
2000; 10-12
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
Acknowledgements

Strategies for Spreading Improvements in Health Care, October 14, 2004
Marie W. Schall, Institute for Healthcare Improvement

Holding the Gains and Spread, July 11, 2006
Bruce Harries, Improvement Associates

The Seven ‘Spreadly’ Sins, October 18, 2006
Roger Resar, MD & Carol Haraden, PhD

Sustainability and Spread, August 28, 2006
Diane Jacobsen, MPH, CPHQ, IHI National Director
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,
Il:Irwin ,1978.
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. 22022207.
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.