Objectives
j
• Extrude common attributes of successful
dissemination efforts at any
y level
• Describe common impediments to largescale change
• Suggest possible action from donors,
researchers, practitioners and other
influential stakeholders
Typical
yp
Explanation
p
R&D
Prototype
Dissemination
A More Accurate
R
Representation?
t ti ?
R&D
Prototype
Dissemination
How Do You Stimulate Change at Scale and
Spread Effective Practice?
The best tend to six key questions:
1. How do you get people to care (and care enough to
take action)? (Will)
2. Where you are in the process of change?
(
(Foundations/timing)
g)
3. What, exactly, are you seeking to accomplish?
(Framing/aims)
4. What is the nature of your intervention?
5. What is the nature of y
your social system?
y
((Structural
Context)
6. How will you spread your better practice? (Method)
Levers for Change
g
•
•
•
•
•
•
•
•
•
Information/transparency
Pay for performance
Regulations
Sensationalism
Guilt
Alignment (making sense of multiple initiatives)
Joint support/technical support
Leadership
Shared infrastructure ((e.g.,
g , videoconference))
Levers for Change
g
•
•
•
•
•
•
•
•
•
Recognition
Collaboration/networks
Professionalism
Affection
Devolving control to the field
PR/media
Innovation
Changing the rules base (e.g., condense timeframes)
Personal considerations (de
(de-zombification)
ombification)
How Do You Stimulate Change at Scale and
Spread Effective Practice?
The best tend to six key questions:
1. How do you get people to care (and care enough to
take action)? (Will)
2. Where you are in the process of change?
(
(Foundations/timing)
g)
3. What, exactly, are you seeking to accomplish?
(Framing/aims)
4. What is the nature of your intervention?
5. What is the nature of y
your social system?
y
((Structural
Context)
6. How will you spread your better practice? (Method)
A Sequence
q
of Change
g
1. An innovative discovery
1
2. A demonstration in 50 hospitals
3. Outstanding results in 4 states
4. Interest from p
purchasers and p
payers
y
5. A state law in 14 states
6 A national mandate
6.
7. A part of graduate-level training
8. An expectation and a standard
9. Confidence in abilityy to make change
g
10. More ambitious aims
How Do You Stimulate Change at Scale and
Spread Effective Practice?
The best tend to six key questions:
1. How do you get people to care (and care enough to
take action)? (Will)
2. Where you are in the process of change?
(
(Foundations/timing)
g)
3. What, exactly, are you seeking to accomplish?
(Framing/aims)
4. What is the nature of your intervention?
5. What is the nature of y
your social system?
y
((Structural
Context)
6. How will you spread your better practice? (Method)
Worksheet to Assess an Idea for Spread
Key idea for spread:
Attributes
Relative to the attribute, the idea is
Very Weak
1
OK
2
3
Relative
advantage
Compatibility
Simplicity
Trialability
Observability
The Improvement Guide, p. 201
Very Strong
4
5
Comments
How Do You Stimulate Change at Scale and
Spread Effective Practice?
The best tend to six key questions:
1. How do you get people to care (and care enough to
take action)? (Will)
2. Where you are in the process of change?
(
(Foundations/timing)
g)
3. What, exactly, are you seeking to accomplish?
(Framing/aims)
4. What is the nature of your intervention?
5. What is the nature of y
your social system?
y
((Structural
Context)
6. How will you spread your better practice? (Method)
Adopter
p Categories
g
Innovators
Early
Majority
Late
Majority
Early
Adopters
2.5%
13.5%
from E. Rogers, 1995
Laggards
34%
34%
16%
Crucial Differences in Context
•
•
•
•
•
Scale
Pace
Resources
Local skill
Behavior patterns of media,
media policymakers,
policymakers
payers, researchers, etc.
• Dominant theory of change
Another Way to Think About This
• Who will oppose us?
• Who will tolerate us?
• Who will support us?
How Do You Stimulate Change at Scale and
Spread Effective Practice?
The best tend to six key questions:
1. How do you get people to care (and care enough to
take action)? (Will)
2. Where you are in the process of change?
(
(Foundations/timing)
g)
3. What, exactly, are you seeking to accomplish?
(Framing/aims)
4. What is the nature of your intervention?
5. What is the nature of y
your social system?
y
((Structural
Context)
6. How will you spread your better practice? (Method)
Methods for Spread
•
•
•
•
•
•
•
•
•
Natural diffusion
Breakthrough Series Collaborative model
Extension agents
Emergency mobilization
Campaign model
Social movements
Wave sequence (wedge and spread)
Broad and deep
Hybrid models
Step-wise Approach to Spread within a District (“The
Wedge )
Wedge”)
3o care
2o care
Community
Subsequent, Rapid Scale Up
3o care
2o/ District
H
Hospital/
it l/ CHC
2o/ District
Hospital/ CHC
Community
2o/ District
Hospital/ CHC
Community
Durable Lessons on Managing Change
at Scale
• The power of trying something remarkable (provocation
and optimism)
• The value of a shared storyy and image
g
• The value of simplicity (e.g., interventions, measurement
systems)
• The value of trust (ecosystems not hierarchies;
“distributed laboratories”)
• The value of affection and recognition (recognition
economy))
• The value of breaking rules (avoid consensus, condense
timeframes)
• Profound respect for practical value, logistics (“Amateurs
discuss strategy…”)
Recurrent Challenges in
M
Managing
i Ch
Change att S
Scale
l
• Proper aim-setting (electrification versus electrocution)
• Poor prioritization (where is acuity and volume?)
• Lack of systems thinking and integration (spreading
widgets versus solving social problems)
• “Plays well with levers”
• Un-scalable design
• Poor method selection
• Poor logistics
• Rigidity (classical versus jazz)
Dissemination Science
• Networking science
• Logistics
• Communications and knowledge
managementt
• Benchmarking
e c a
g sp
spread
ead app
approaches
oac es (e
(e.g.,
g,
emergency management)
“I think when people look back at our time,
they
y will be amazed at one thing
g more
than any other. It is this – that we do know
more about ourselves now than people did
in the past, but that very little of this
knowledge has been put into effect
effect.”” –
Doris Lessing
g
McCannon CJ, Schall MW, Perla RJ.
Planning
g for Scale: A Guide for Designing
g g
Large-Scale Improvement Initiatives. IHI
Innovation Series white paper
paper. Cambridge
Cambridge,
Massachusetts: Institute for Healthcare
Improvement; 2008.
2008
Spread References
Attewell, P. Technology Diffusion and Organizational Learning, Organizational Science, February, 1992
B d
Bandura
A
A. Social
S i lF
Foundations
d ti
off Th
Thought
ht and
dA
Action.
ti
E l
Englewood
d Cliff
Cliffs, N.J.:
N J Prentice
P ti Hall,
H ll Inc.
I
1986.
1986
Barabasi AL. Linked: How Everything is Connected to Everything Else and What It Means. New York, NY:
Plume Books; 2003.
Berwick DM. Disseminating innovations in health care. Journal of the American Medical Association.
2003;289(15):1969 1975.
2003;289(15):1969-1975
Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 Lives Campaign: Setting a goal and
a deadline for improving health care quality. Journal of the American Medical Association.
Jan 2006;295(3):324-327.
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.
Gl d ll M
Gladwell,
M. The
Th Tipping
Ti i Point.
P i t Boston:
B t
Little,
Littl Brown
B
and
d Company,
C
2000.
2000
Granovetter M. Strength of weak ties. Am J Social. 1973; 78:1360-1380.
Improvement leader's guide to sustainability and spread. NHS Modernisation Agency. Ipswich, England:
Ancient House Printing Group; 2002.
Kreitner R.
Kreitner,
R and Kinicki,
Kinicki A.
A Organizational Behavior (2nd ed.)
ed ) Homewood
Homewood, Il:Irwin ,1978.
1978
Spread References
Langley J,
J Nolan K,
K Nolan T,
T Norman,
Norman C,
C Provost L
L. The Improvement Guide.
Guide San Francisco: JosseyJossey
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.
Massoud MR, Nielsen GA, Nolan K, Schall MW, Sevin C. A Framework for Spread.
p
Cambridge,
g
Massachusetts: Institute for Healthcare Improvement; 2006
McCannon CJ, Schall MW, Calkins DR, Nazem AG. Saving 100,000 lives in US hospitals. BMJ. 2006 Jun
3; 332 (7553):1328-30. Myers, D.G. Social Psychology (3rd ed.) New York: McGraw-Hill, 1990.
McCannon CJ, Berwick DM, Massoud MR. The Science of Large-Scale Change in Global Health.
JAMA October 24/31,
JAMA,
24/31 2007; 298: 1937 - 1939.
1939
McCannon CJ, Schall MW, Perla RJ. Planning for Scale: A Guide for Designing Large-Scale Improvement
Initiatives. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare
Improvement; 2008.
McCannon CJ, Perla RJ. Learning
g networks for sustainable, large-scale
g
improvement.
p
Joint Commission
Journal on Quality and Patient Safety. 2009 May;35(5):286-291.
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
E. Communities of Practice.
Practice Cambridge,
Cambridge UK: Cambridge University Press
Press, 1998
1998.
World Health Organization (HTM/EIP) and Institute for Healthcare Improvement. An Approach to Rapid
Scale-up Using HIV/ADS Treatment and Care As An Example. Geneva: WHO; 2004.