Transcript Sustaining and Spreading Changes Robert A. Gabbay, MD, PhD Connie Sixta, PhD, RN, MBA.

Sustaining and
Spreading Changes
Robert A. Gabbay, MD, PhD
Connie Sixta, PhD, RN, MBA
Creating an Improved Clinical System
Improvement
Hold Gains
Spread
NON-LINEAR MODEL BETTER
Improvement
Hold Gains
Spread
API Lloyd Provost
We’ve talked a lot about
improvement
• Model for Improvement:
• Aim
• Measurement
• Rapid testing of changes
(PDSA cycles)
• Test lots of ideas!
• Expect some will “fail”
• Most will need refinement
(PDSA cycles)
Sustaining Improvement
Drop off in measures is common but
preventable!
• Initial excitement, urgency wear off.
• Possible change fatigue.
• Pay particular attention to yearly measures (foot
exams, eye exams, LDL tests, etc.) as you
approach end of initial 12 months.
• If strong system of population management is in place
should not see these decline.
• Staff/Provider turnover, particularly among
change leaders.
Strategies to Hold the Gains
• Establish and document standard processes
• Make changes to job descriptions
• Use measurement and audits
• Pay attention to orientation and training
• Assign ownership
• Address the social aspects of change (who
are the peer leaders, who talks to whom)
Your Sustainability Experience
• How are you checking to make sure
changes are sticking?
• What kind of shared ownership exists in
your practice for your improvement data?
• How have you been documenting revised
processes and revised job duties?
Test --> Implement --> Spread
• Testing: Trying and adapting existing
knowledge on small scale. Learning what
works.
• Change is not permanent.
• Lot of experimentation and revisions.
• Failure very useful here, even expected.
• Few people impacted (limited staff, few patients).
• Need to build improvement documentation for
permanent implementation and spread of
successful changes.
Test --> Implement --> Spread
• Implementing: Making this change a
part of the routine day-to-day operation of
your practice.
• More people impacted than during testing.
• Increased resistance compared to testing.
• Generally requires more time than testing.
• Some additional revisions may be needed.
• But don’t expect failure here because you have
documented success of changes.
Test --> Implement --> Spread
• Spreading: Adapting change to additional
areas (other practices) or other patient
populations beyond diabetes.
• Useful for multi-site practices, systems.
• Good population management processes work
across chronic diseases and prevention.
• Application to other conditions is important
for NCQA recognition and Meaningful Use.
Degree of belief that the changes will
result in improvement
What’s the status of each of your changes?
Successful changes
Beginning to implement
and spread.
High
Changes still need
further testing. There
is a risk of moving to
implementation and
spread.
Moderate
Change 1
Unsuccessful
proposed changes
Change 2
Change 3
Low
Developing
the Change
API –Lloyd Provost
Testing and
Adapting the
Change
Implementing Then
Spreading the Change
Adopter Categories
Innovators
Early
Adopters
2.5%
13.5%
from Rogers, 1995
Early
Late
Majority Majority
34%
34%
Laggards
16%
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
10
0
Sep- Oct
98
Nov
Dec Jan- Feb
99
Mar
Apr
May
Jun
Jul
Aug Sep
Oct
Nov
Dec
Jan- Feb
00
Diffusion Depends on 6 Factors
1. Relative advantage over current practice
2. Compatibility with current culture and
practice
3. Simplicity
4. Observability
5. Trial ability
6. Timing of return on investment
Everett Rogers, The Diffusion of Innovation
Developing a Spread Plan
• Is improvement a key strategic initiative?
• Is there a budget for spread?
• Has time been allocated for spread?
• Are goals and incentives aligned?
• Identify and develop your spread champions.
• Leverage your improvement data—tell your
improvement story!
• Document your ROI.
Target Population for Spread
A P
S D
Population of Focus
for the initial
A P improvement
S D (pilot population)
A P (Tests to adapt
S D changes, then
implementation)
Rest of Practice
or Across System
The Communication Plan
• Document benefits
• Show comparative data
• Use multiple communication channels
• Explain changes succinctly
• Involve successful units in providing technical
support
• Measure and provide feedback
The Social System
• Understand the relevant circumstances
affecting peoples’ ability/willingness to
adopt changes.
• Take advantage of the existing relationships
within the system.
• Develop “communities of practice” among
those with similar roles (peer-to-peer
support and learning).
Your Thoughts
• What changes have you already spread?
• How has the spread gone?
• Any resistance to overcome?
• What barriers are keeping you from
spreading?
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. 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.
Questions?