1 Strategies to Hold the Gains and Spread ImprovementImproving Care for People Living with HIV and AIDS Strategies to Hold the Gains and Spread Long Interactive Module 2.25 hours (135 minutes) Overview of Improvement Continuum: 5 Minutes Holding the Gains: Testing and Improvement: 30 Minutes Holding the Gains: After Implementation: 20 Minutes Break: 15 Minutes Spread: Overview and Theory: 20 Minutes Spread: Framework: 35 Minutes Closing: 10 Minutes

2 Objectives Understand ways to hold the gains from your initial improvement work Identify the key components of a strategy to spread improvement Leave with ideas to help guide holding the gains and spread of the improvements made by your team(s) Objective: Overview of the session. Explanation: Review the objectives. Depending on time and situation could ask if there are any specific questions needing to be addressed. Record expectations on a flip chart. Identify which issues will be addressed in the session and which will not. Arrange a time to get back to person with expectations not being covered. Bridge to next slide: Let’s start with the relationship between improvement (often described as testing and implementation), holding the gains (for both during and after implementation) and spread.

3 Creating a New System more like … Improvement Hold Gains SpreadObjective: Describe the interconnectedness of the Improvement Continuum Explanation: Often the Improvement Continuum, the process we use to create a new system, is thought of in a linear process.(Top diagram) First, we do improvement which consists of testing changes and then implementation. Then we work on holding the gains, or making sure the changes we have implemented do not slide back to the old system ways. Then finally we work on spread, which is the process of taking a successful implementation process from a pilot unit or pilot population and replicating that change or package of changes in other parts of the organization or other organizations. Although there is some sequential nature to this continuum of improvement, the more dominant nature is one of overlapping process. (lower diagram) Bridge to next slide: Let’s look a little more closely at the overlap between Improvement and Holding the Gains. Improving or creating a new system - involves all three -Spread is the process of taking a successful implementation process from a pilot unit or pilot population and replicating that change or package of changes in other parts of the organization or other organizations. During implementation, teams learn valuable lessons necessary for successful spread, including key infrastructure issues, optimal sequencing of tasks, and working with people to help them adopt and adapt a change. Spread efforts will benefit from the use of the PDSA cycle. Units adopting the change need to plan how best to adapt the change to their unit and to determine if the change resulted in the predicted improvement. Hold Gains Spread © 2004 Institute for Healthcare Improvement

4 Holding the Gains Improvement Hold Gains During testing SpreadTest Implement During testing During implementation After implementation Objective: Emphasize the overlapping and interdependency of holding the gains (sustainability of change) Explanation: The Improvement phase of the continuum consists of testing and implementing changes (yellow part of the continuum). We use the Model for Improvement to learn and test changes in the system, usually on a pilot population. As we learn and become more confident of how to apply the change, we implement the change. The manner in which we test and implement are a critical factor to success in holding the gains. In short, the more testing we do and the better we implement, the better foundation we have for holding the gains or sustaining the change after implementation. Therefore, Holding the Gains can be looked at as overlapping with improvement and occurring during testing, during implementation and during the period after implementation. Bridge to next slide: Next we will look more closely at the overlap that occurs between improvement and holding the gains. We will start first with testing, and then discuss implementation, and then the time period after implementation. So the question is: What can we do in testing to have a more solid foundation? Spread

5 Full, Sustained ImplementationRobust Testing Full, Sustained Implementation A P S D DATA 3. Later tests designed to predict and prevent failures 2. Test over a wide variety of conditions to identify weaknesses Objective: Describe robust testing. Explanation: Robust testing allows us to learn much about the change we are making or the improved process we are trying to design. We can often learn when the change will succeed, when it is weak and when it might fail by designing test to these aims. For example, initially the early tests are simple and designed to succeed. We are testing to learn what will work in our system. Then we might design tests to identify weaknesses in the change. We will learn much about the conditions under which the change works and when it does not work as well. And finally, later tests can be designed to predict and prevent failures of the process. We might learn to identify when the process might break down. Understanding the strength, weakness and probable conditions for failure of the change prior to implementation increases potential for a successful implementation. Bridge to next slide: A couple ideas (tips) for designing robust tests. 1. Early tests are simple and designed to succeed

6 Tip #1: Planned GroupingTwo groups that have different characteristics: Group 1: Experienced MAs Group 2: inexperienced MAs Objective: Planned grouping is a method to design tests that identify weaknesses. Explanation: Planned grouping is a method of testing in which you have two groups that have different characteristics, such as different training or they work on different shifts, or work in different departments. The same test is then performed on both groups. We then compare the results of the two groups to see if there is a difference between them. This type of test is often used after some successful tests have already been performed and we are looking specifically for weakness of a change. For example, the test could be on helping patients agree on collaboratively set goals using a new patient centered inquiry process. The test could be performed by the Medical Assistants (MAs) that are working in the clinic. In this clinic there are several experienced MAs each with many years of practice, and also a few inexperienced MAs who have just graduated. This presents an opportunity to use planned grouping to test this new inquiry process. We will learn if it works with both groups. If it does, then it is a very robust process, if it does not then we need to adapt it. Bridge to next slide: Another test somewhat similar to planned grouping, but designed to find failure is the wide range test.

7 Tip #2: Wide Range Improvement for all = robust changeImprovement for few/some = further test cycles Objective: When looking for failure, use the outliers. Explanation: Wide range, or using outliers, is a method of testing in a test and is designed for the known and recognized outliers. This process would not be utilized unless much is known about the change and the aim is to look for failure. We then compare the results of this test with results of the previous tests and identify the difference between them. For example, the clinic has a very small number of hearing-impaired patients. The wide range test could be using the patient centered inquiry process we have been testing to develop collaboratively set goals with these patients. We will learn if the inquiry process is robust enough to use in this situation, or what adjustments need to be made to help it work with both groups. Or often, we find we need to develop a second or refined process for the outlier situation. Bridge to next slide: Let’s spend a little time applying this concept of robust testing.

8 Go Back Exercise (15 minutes)Think about all of the changes with which you have been involved. Choose one and think about the PDSA test(s) that were used to test the process. Now go back to that place in time and design a robust test to either identify a weakness of the process or predict a failure of the process using planned grouping or wide range. (3-4 minutes) Share redesigned tests at your table, give advice to each other for other tests. (5-6 minutes) Be prepared to share with large group. (4-5 minutes) Objective: Go Back exercise. (undo button or go back program – re-do a test)* Note to instructor: you can use the examples from the previous two slides, or design your own re-do of PDSA to use if participants need an example. Explanation: Prepare group for exercise. Go over exercise instructions from slide. Start activity and then inform group when time to move to next section of exercise. (3-4 min) Remind them of instructions. Share re-designed tests at your table, give advice to each other for other tests.(5-6min) Inform group when close to debrief time and remind them to be prepared to share with large group. Ask a couple of tables to share their re-designed PDSA tests. Ask a couple of tables to talk about experience of helping each other design tests. (2-3 min) Emphasize that designing test(s) is not always easy – and many heads make for many views - and many potential test(s) from which to learn and do robust testing. Bridge to next slide: After exercise go to next slide and use to refocus on continuum and where we are in the continuum.

9 Holding the Gains Improvement Hold Gains During implementation SpreadTest Implement During implementation During testing After implementation Objective: Refocus on the overlapping of Improvement and Holding the gains; will be discussing “during implementation” Explanation: Robust testing is an initial key to effective implementation and sustainability. However, after testing a change on a small scale, learning from each test, and refining the change through several robust PDSA cycles, the change is ready for implementation, perhaps on a broader scale, for example, for an entire pilot population or on an entire unit. How well implementation is done effects the sustainability of the change, a good implementation improves our ability to hold the gains we have made to this point. Bridge to next slide: So let’s discuss what can we do during implementation to secure the change. Spread

10 ...a permanent change to the way workImplementation ...a permanent change to the way work is done Documentation Policies and procedures Hiring Orientation Training Compensation Non-testing parts of organization Objective: Definition and structures of implementation. Explanation: First let’s define implementation. Implementation is a permanent change to the way work is done and, as such, involves building the change into the organization. It might involve documentation, written policies and procedures, hiring, orientation, training and compensation. And aspects of the organization's infrastructure that are not heavily engaged in the testing phase. Bridge to next slide: The PDSA cycle is very useful for implementation.

11 Repeated Use of the PDSA CycleChanges That Result in Improvement Learning from Data A P S D D S P A Very small scale test Follow-up tests Wide-scale tests of change Implementation of change A P S D Objective: Emphasize progression to and through implementation. Explanation: After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the change is ready for implementation on a broader scale-for example, for an entire pilot population or on an entire unit. For example, testing a change might be 3 nurses on different days using a new case management referral form; implementing a change might be all nurses on staff at the pilot clinic begin using the new case management referral form. Bridge to next slide: So tip #1 is to plan the implementation of the new process using PDSA cycles. A P S D Hunches Theories Ideas

12 Tip #1: Plan and Test Plan and test your implementationPlan and test redesign of support processes Objective: Plan the implementation; including support processes. Explanation: And include the planning and redesign of support processes. The following slide gives an example of a Project Team work sheet as a tool to help organize/manage the redesign of the support processes during the implementation phase. Bridge to next slide: Go to next slide.

13 Change Tested or ImplementedPROJECT 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 Policies Documentation Hiring Procedures Staff Education/Training Job Descriptions Information Flow Equipment Purchases Objective: Example of a tool to use/develop Explanation: The support processes are listed on the side and the dates across the top (Gantt Chart). Creating the form helps you to think through the changes needed in the support policies and develop an action plan that addresses them all. Bridge to next slide: Tip # 2

14 Tip #2: Understand VariationBaseline Begin implementation on pilot unit Testing Successful Testing Evidence of improvement during implementation Objective: Understanding variation is a key strategy to improvement. Explanation: Variation shows patterns and behavior of the system during implementation. During Implementation continue to collect data over time. Conditions during implementation might be expected to change, learning curve of those new to the process, unexpected weakness in the process not discovered during robust testing. The measures might show a bump in the improvement process before it settles down. Understanding this potential variation reduces the potential of overreacting to an expected variation. Bridge to next slide: Tip number 3 – can be remembered by it’s acronym RRAIL.

15 Tip # 3: Social Aspects RRAIL Resistance Results AppreciationInformation Learning Objective: Briefly discuss social aspects of change. Explanation: RRAIL – Sometimes people do rail against change, usually when they are being changed without understanding or by force. Sarah Fraser, an expert on sustaining improvement from the UK stated at the 4th Annual Office Practices Summit. ( Learning Lab 9 - "Sustaining Improvement in Systems”) - that “90% of failures are due to ignoring people”. Remembering these social aspects might help reduce unnecessary railing and help us support change that results in improvement. Understand and address the causes of resistance. Share and publicize the results of the testing cycles and outcome/process measures. Show appreciation for people’s efforts. Provide information on why the change is being made and how the change will affect people (address the WIFM – what’s in it for me) Continue to learn about the process - seek and use input from others, especially those affected by the change, during testing and now during implementation. Bridge to next slide: These are just a few tips – let’s see what other tips we can develop.

16 Shared Learning (10 minutes)Pick a specific change your team implemented Make a list of what was done to get the change fully implemented What would your team add to the list of tips? Objective: Shared Learning Explanation: Prepare group for exercise. Go over exercise instructions from slide: As a team first pick a specific change your team implemented. Together make a list of what was done to get the change fully implemented. Then compared to what we have already discussed what else would your team add to the list of tips? (6-7 min) Be prepared to share with larger group one tip. Inform group when close to time to debrief and remind them to be prepared to share with large group (2-3 min). Ask a couple of tables to share their tips. Bridge to next slide: Now let’s move to after implementation strategies. 4 4 4

17 Strategies to Hold the GainsImprovement Hold Gains Test Implement During testing During implementation After implementation Objective: Refocus to frame of continuum of improvement; moving to Holding the Gains: after implementation. Explanation: After solidly implementing a change we can begin to focus on holding the gains strategies, the phase labeled “after implementation”. (White bolded) Bridge to next slide: First let’s start by looking at some inhibitors to holding the gains after implementation. Spread

18 After Implementation: InhibitorsOld System New System “We met our goals” “We assumed the improvement would hold” “Other priorities took all resources away” (not on senior management’s radar screen) “Did not learn how to hold the gains” “Infrastructure not in place” Objective: Identify some inhibitors that pull the new system back to old system behaviors Explanation: In 2003 the Institute for Health Care Improvement (IHI) invited several successful teams to complete an online survey to determine how well successful teams involved in IHI’s Breakthrough Series Collaboratives (i.e. teams with gains to hold) have done at sustaining those changes. As part of the survey, comments were recorded that identified inhibitors to holding the gains and also readiness factors. The comments listed above are some of the inhibitors to successfully sustaining change identified by those teams. Bridge to next slide: The next slide shows some of the identified factors for readiness.

19 After Implementation: ReadinessOld System New System Success of collaborative team Intention to hold gains Organizational priority Leadership responsibility clear Objective: Identify some readiness factors that support sustainability. Explanation: Perhaps success breeds success, for the teams most likely to sustain improvement were those that succeeded in the goals they set for their improvement efforts. Other factors identified for readiness to hold the gains were noted as: a firm intention to hold gains; holding the gains was an organizational priority and the leadership responsibility was clear. These factors could be utilized as a check list to see if you are ready for holding the gains. Bridge to next slide: Let’s do an exercise right now to test the concept of a check list for readiness.

20 Real Work Exercise (10 minutes)Perform a brief assessment, using the aforementioned inhibitors and readiness indicators, of your organization to hold the gains of a recent improvement. Using this assessment develop a couple of strategies your team might use to help your organization prepare for holding the gains. Objective: Think of own organization and own behavior that might support holding the gains (sustainability) Explanation: We will use this time to perform a brief assessment of your organization’s potential ability to hold the gains of a recent improvement based on the readiness indicators. Then we will use the assessment to develop a couple of strategies your team/organization might use to help prepare for holding the gains. Then give these further instructions: First, pick a specific change your team/organization implemented. Now review the project in light of the readiness factors and make a few notes. Identify strengths and weaknesses related to these factors. For example, a strength might be: “We have a very successful team. They achieved more than the goal they intended.” And a weakness might be: “ the leader of the project left the organization and no one has been designated to take over the project.” Then using this assessment, together develop a couple of strategies your team might use to help your organization prepare for holding the gains. Be prepared to share with larger group. Bridge to next slide: Now let’s move on to looking at a few other methods (tips) to hold the gains.

21 Tip #1: Communication Stakeholders Teams DocumentObjective: Communication is key – again and again – over and over Explanation: Communicate clearly to all stakeholders the Aim, successes, learning, and benefits of the changes made for improvement. Keep in contact with your team and other teams. And Document! Not just the improvement effort, but the changed process and support processes; map out the process; job description changes; policies and procedures. Bridge to next slide: Another tip

22 Tip #2: Infrastructure Supports and inhibitors Establish ownershipRevise support processes Objective: Create infrastructure – hardwire and culture Explanation: Senior leaders should be held responsible for the efforts to sustain the change and remove inhibitors that might allow slippage back to the old system. Ownership for improvement and maintenance work of the new process should be assigned and established. And support processes should be revised and developed : for example address training and development of new skills and make changes to job descriptions, policies, and procedures. Bridge to next slide: And the last tip -

23 Tip #3: Control System Standardize Shewhart control chartsRun charts Outcome measures Process measures Objective: Develop a control system Explanation: Plan to standardize the new process and verify conformance to the standard. Use your internal QA resources (also accounting resources know how to develop control systems) and integrate activities into an organization-wide control system. Use Shewhart control charts (run charts) to monitor measures for performance/outcomes from the improvement: Outcome measures would be required, process measures may be desirable as early warning signals. Bridge to next slide: So before we move to spread, let’s summarize what we have covered related to holding the gains.

24 Hold the Gains --> SpreadImprovement Test Implement Hold Gains During testing During implementation After implementation Communication Infrastructure Control Awareness System Objective: Summarize holding gains as transfer to spread. Explanation: The continuum of Improvement consists of Improvement, Holding the Gains and Spread strategies. Often the improvement continuum is thought of as a linear process. Although there is some sequential nature to this continuum of improvement, the more dominant nature is one of overlapping process and interdependency. Strategies for holding the gains begin in the testing phase of improvement. Robust testing for success, weakness and failure of the process will improve potential to sustain the gains of the improvement change. During the implementation phase of improvement the PDSA cycle can be used for planning and implementing the change as well as the support processes for the change. Understanding variation during this phase will help us not overreact to implementation “bumps”. In addition, understanding and thoughtfully addressing social aspects of change are critical to sustainability. After implementation, continued communication and infrastructure support and development is necessary. Development of a control system to see unintended variation in key indicators over time is another strategy that supports sustainablity. Bridge to next slide: Now on to spread. Robust Testing Plan & Test Understand Variation Social Aspects Spread

25 Spread COMMUNICATED “BETTER IDEAS” In a certain way Happens over timeObjective: Develop a common language by defining the concept of spread. Explanation: Sarah Fraser in the United Kingdom describes spread as, “Better ideas communicated in a certain way, through a social system over time.” This is an adaptation from the work of E.M. Rogers. Think about this. There are a few important ideas here. First, there must be a good idea or set of good ideas. These ideas have to be carefully communicated. The social system becomes both an aid and a barrier in the communication process. AND, it all happens over time—sometimes later, sometimes sooner. Bridge to next slide: So let’s take this definition and work with it. Through a SOCIAL system Adapted from EM Rogers, Diffusion of Innovations (1995)

26 Reflection Think of a time in your experience when you attempted to spread an improvement. What worked? What didn’t work? Volunteer to share your story. Objective: Reflect critically on either a positive or negative experience with spread to set the stage for learning. Explanation: Read the slide. Embellish a bit. Give folks 1-2 minutes to reflect on their experiences. Then ask for 2-3 volunteers to tell their stories. Interview them if they are not giving enough detail with questions such as “Why do you think that worked/didn’t work?” Try to get one positive, and one negative spread story. Write down some of the details to make pertinent points throughout the remainder of the presentation. Bridge to next slide: Now that you have your own spread stories in mind, let’s dig a bit deeper into the concept; first readiness to spread.

27 Spread Readiness Checklist1. Is there a clear intent to spread the work of the pilot team? 2. Is HIV disease care improvement a key initiative? Objective: Determine if an idea or initiative is ready for spread. Explanation: Before beginning the spread process, it is important to understand if it all is ready for this difficult, yet rewarding work. First, is there a clear intent to move the work from the pilot group to a larger population. That is why it is so important to know even before beginning the improvement work, if there is a need/willingness/intent to eventually spread this work. The second item asks if this work is a key initiative. How big a priority is it in the organization? How does it stack up with competing priorities? Bridge to next slide: Move to next slide 1

28 Spread Readiness Checklist3. Are senior leaders responsible for, and engaged in, spreading the HIV disease care improvements? 4. Is the pilot team successful and relatively self-sufficient? Objective: Determine if an idea or initiative is ready for spread. Explanation: Let’s explore these next two items. First, are there senior leaders who are not only responsible AND accountable for spread, BUT are they also engaged in it? This is essential to spread. Somebody has to be in charge, clearing the barriers, and paving the way. The last item asks if there is actually something to spread, and if the team members can assist. Has there been success? Has the team reached their goal? Have they tested and implemented under many conditions, not only to hold their own gains, but to assure that there are some “good ideas” to spread? Is the team itself successful enough to be able to be an example to others, and even serve as teachers/resident experts? Are they self-sufficient enough to be able to move part of their focus to helping spread the work to other areas? If any of these questions receive a “no" answer, go back and do what it takes to make the answer “yes”, before attempting spread. Bridge to next slide: Assuming the answers are a resounding “yes”, let’s take a look at a bit of the theory behind spread. 1

29 Theory and Background on SpreadJust Enough… But Not Too Much Objective: Introduce the need for theoretical grounding in spread. Explanation: While there has been quite a bit of research, and quite about written about spread, let’s walk through a quick summary of the work done to date on this important topic. Bridge to next slide: Move to next slide.

30 Critical Mass and Momentum“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.M. Rogers, Diffusion of Innovations (1995) Objective: Introduce the work of E.M, Rogers. Explanation: E.M. Rogers is one of the most respected researchers on spread. He, however calls it “diffusion of innovation”. Here is a quote from his work that summarizes the good news and bad news about spread. He says that if a good idea spreads to just percent of the target population, that it is often hard to stop the diffusion—even if it turns out to be a bad idea. That is the good news. The bad news is the work it takes to get the first 10-20% to adopt the better ideas. Bridge to next slide: Move to next slide.

31 The “Tipping Point” “The name given to that one dramatic moment in an epidemic when everything can change all at once.” -- M. Gladwell, The Tipping Point (2000) Objective: Add another perspective to the mix. Explanation: Malcolm Gladwell, in his book, “The Tipping Point” says almost the same thing as E.M. Rogers. He feels that there is a moment when the balance tips, and the spread idea cannot be stopped, or when it will actually not make it and subside. Bridge to next slide: Let’s look at a picture of this concept.

32 Number of Adopters of Hybrid Seed Corn in Two Iowa Communities100 150 200 250 300 50 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 Cumulative # of Adopters Number of Farmers Objective: Introduce the diffusion curve of E.M. Rogers. Explanation: This slide is a graphic representation of what Rogers and Gladwell stated earlier. It depicts how quickly (or slowly) Iowa farmers started to use a new brand of hybrid seed corn. On the horizontal (time) axis, one can see the years 1927 through On the vertical (# of) axis, one can see the number of farmers in this test population. This shows that until the early 1930’s the going was slow. But in the early to mid-thirties, something happened, and the rate of spread took off very quickly. If one examines this graph closely, it happened when between farmers had started to use the corn. Notice that at the end of the diffusion curve, the process again slows down. We’ll discuss that later. Curves similar to this are seen over and over in spread environments. Bridge to next slide: The next slide is another example of a spread curve. Year Source: Based on Ryan and Gross (1943).

33 The “Diffusion Curve” “tipping point”Objective: Show an example closer to the medical field. Explanation: Keep in mind that the diffusion (spread) curve is rate over time. Here is a graph showing the spread of the Chronic Care Model across 80 clinics. It was slow in the beginning, then it seemed that critical mass was achieved in the 10-20% range, and the spread speeded it up. You can also see on both this and the seed corn chart, that the rate of spread slowed down near the end. That is because the last people to adopt the best idea are often traditionalists, and by definition are slow to adopt, or may never adopt the change. Bridge to next slide: Let’s take a look at another type of curve. “tipping point”

34 Adopter Categories 2.5% 13.5% 34% 34% 16% Innovators Early AdoptersObjective: Portray the adopter categories, with descriptors of each. Explanation: This curve depicts the speed at which people adopt a change. Keep in mind that the same person can be on a different end of the curve, depending on the change. First are the innovators, a very small percentage of the population (about 2.5 %). These are the ones that you often find on the bleeding edge of change. Sometimes their peers are suspicious of them as they are always “out there” with new ideas. Next are the early adopters. This is a very important section of the population as the opinion leaders are often found here. Opinion leaders are respected peers that others will go to seeking information of validation. Combined, the innovators and early adopters make up that critical 10-20% that we saw on the diffusion curve. The early majority, a very big percentage is often swayed toward adopting a new idea by the opinion leaders in the early adopter category. The late majority will probably eventually adopt the change, but they will hang on the fence, watching to see what the early majority does, and if the change is working for them. The historians, luckily only about 16% of the population, may never adopt the change. So, based on this, where should one concentrate energies in achieving spread? Answer: Concentrate efforts in the first 16% --innovators and early adopters--versus the final 16% of historians. This may seem counter-intuitive, but remember, the innovators may come along on their own, and you need the critical mass of the innovators and early adopters to reach “the tipping point”. AND, a key group—the opinion leaders-- may be lurking in that early adopter group. Let’s play with these concepts a bit: Ask for three volunteers to each take 1 minute to pitch a controversial idea. Ask for volunteers to come forward to listen to each idea, and based on the idea being pitched, decide what type of adopter they are for each of the ideas. As soon as the first “sales” person pitches their idea, ask the volunteers to label themselves, and place themselves on the continuum. (Designate one end of the room as innovators, and one as historians.). Observe what happens. How quickly did they start to move? What does the curve look like for this idea? Then have the second “sales” person pitch their idea, and ask the volunteers to label and place themselves on the continuum. Observe what happens. Did everyone stay in the same place, or did they move to a different area than for the first sales pitch? How quickly did they begin to move? Repeat with the third “sales” person. What was learned? People decide quite quickly where they “stand” on an issue. People who are innovators for one idea might be historians for another. It all depends on the idea. The curve usually distributes itself roughly in this distribution. Can anyone answer why the diffusion curve flattens out at the end (previous slide)? Answer: (the late majority and historians are slower to adopt) Bridge to next slide: Now armed with some theory, let’s move out of the theoretical, and into the more active stages, where it becomes apparent that a plan is needed for spread. Early Adopters Early Majority Late Majority Historians 2.5% 13.5% 34% 34% 16% Source: E.M. Rogers, Diffusion of Innovations (1995)

35 “Any road will do if you don’t know where you’re going.”Objective: Explain the importance of planning. Explanation: Spread is a complex and detailed process. It is necessary to have a deliberate plan, with an aim, and the steps necessary to achieve the aim. Bridge to next slide: The next slide is a framework for spread. Alice In Wonderland -- Lewis G. Carroll

36 A Framework for Spread Set-up Measurement and FeedbackLeadership -Topic is a key strategic initiative -Goals and incentives aligned -Executive sponsor assigned -Day-to-day managers identified Measurement and Feedback Set-up -Target population Successful sites Key groups that will make adoption decision -Initial strategy to reach all sites Social System -Key messengers -Communities -Transition issues -Technical support Better Ideas -Develop the case -Describe the ideas Successful Sites Objective: Explain IHI’s framework for spread. Explanation: This diagram depicts a very robust framework (beyond a plan) for spread. You will recognize some of the elements from earlier today; better ideas, communication, and social system. In addition, there is a feedback loop of measures and knowledge management between the better ideas and the social system to which they are spread. There is also a place for leadership to infuse their role as strategic leaders, and a set-up plan to move the better ideas to the social system. Bridge to next slide: On the next slides, be prepared for explanations and examples of many of the components of the Framework for Spread. Communication Strategies Knowledge Management

37 The Change: “Better Ideas”Relative Advantage: how much better is the new compared to the old? Compatibility: how consistent is this idea with values, experiences, needs? -- E.M. Rogers, Diffusion of Innovations (1995) Objective: Introduce E.M. Rogers writings on the “the change itself”. Explanation: EM Rogers looked at the change idea (the idea to be spread) as having five attributes. These attributes all can be thought of on a continuum of easy to hard to spread. For example, in terms of relative advantage, how much better is the new idea compare to the old? If it is obviously better, it will be easier to spread. How compatible is the new idea with existing values, experiences and needs. The more consistent, the easier to spread. Bridge to next slide: Move to next slide

38 The Change: “Better Ideas”Complexity: how difficult is the new idea to understand and use? Trialability: how easy is it to test the new idea? Observability: how visible are the results of the new idea? -- E.M. Rogers, Diffusion of Innovations (1995) Objective: Introduce E.M. Rogers writings on the “the change itself”. Explanation: Rogers asks how complex or how difficult is the idea to understand and use? The less complex the better. How easy is it to test or trial? Are the results visible? The easier to test, and the more visible the (good) results, the easier it will be to spread. Rogers goes on to say, however, that one can work with all these attributes of change, and try to move them to the “easier to spread” part of the continuum. Many teams actually rate the changes that they want to spread on a 1-5 scale, based on these attributes, with the high number signifying easier to spread. Then they work with the change to try to raise the numerical score of each attribute of change. Try it for yourself! Bridge to next slide: That’s enough on the change idea—the better idea. Let’s move on to leadership’s role in spread.

39 Leadership’s Role in SpreadLeadership checklist: Create a vision of the new system; build the will for this change Make the topic a key strategic initiative Assign executive sponsor AND day-to-day managers Objective: Define and explain leadership’s role in spread. Explanation: System leaders have a very clear and important role in spread. First they must have a vision for the new system, and be able to build will for this change by communicating clearly, and setting reasonable priorities. This can be done by assuring that this change being spread is indeed a strategic initiative for the organization. This means that resources will be allocated for it. Leadership also needs to assign accountability and responsibility for spread at both the executive and day-to-day levels of the organization. Bridge to next slide: Move on to next slide.

40 Leadership’s Role in SpreadLeadership checklist: Align goals and incentives Set aims, measures, and create a plan Provide ongoing review, guidance, and support Hold staff accountable Objective: Define and explain leadership’s role in spread. Explanation: In addition, it is necessary for leadership to tangibly show how spread of this change is a priority. They do this by aligning goals, and establishing suitable incentives for the work. They set aims, measure progress on these aims with data, and have a clear plan of how to get from pilot team to the entire population. In addition, they provide review, support, oversight, and they hold all accountable for both the vision and the plan. Clearly, leadership has to truly assess if the spread of a particular change is a priority before moving to all the other items on their checklist. Bridge to next slide: One of leadership’s roles is assigning the set-up (plan) for spread.

41 Set-Up for Spread Identify the target populationAssure pilot sites are successful Identify key groups to make adoption decision Create the initial strategy to reach all sites Objective: Talk about some of the steps in the set-up for spread. Explanation: First it is important to decide the target population. Is it 300 Iowa farmers to use new seed corn, or 80 clinics to use the Chronic Care Model? You have to know when you are done, before you can start. As you will remember from the spread checklist, there must be something to spread—assure that the pilot sites are successful. From there, identify some key groups or individuals to target first—to get to that critical 10-20% early in the spread plan. These may be folks who have already interested and ready to go. Or there may be an influential person in a certain group that would speed the spread later. And then, create a plan to eventually reach the entire group defined as the target population. Some groups define quarterly targets, some plan spread regionally, or by department. Bridge to next slide: In addition to this critical set-up, there are some approaches to spread that may be helpful to consider.

42 Optional Collective AuthoritarianApproaches to Spread Comp l e t ene s C o v e r a g e Optional Collective Authoritarian Objective: Explain how to use these two approaches to spread to assist in the plan for spread. Explanation: Rogers discusses some approaches to spread; completeness versus coverage AND the continuum of optional to authoritative decision-making. You can see both cover a lot of territory. When introducing a complex change with a package of many “better ideas”, completeness means each spread area adopts the entire package of better ideas. The package would march completely from one spread area to the next. Coverage means that just one (or two) at a time of those better ideas from the whole complete package would be spread over the entire population targeted for spread. It might be an idea that scored very high on the attributes rating that we talked about earlier—something less complex, more observable, easy to test, etc. Then another better idea from the package is spread. Eventually coverage meets completeness, and the work of spread is done. On the optional through authoritarian continuum, a decision made about how autocratic to be in asking for spread of change. The authoritarian end of the spectrum is a direct order, “Adopt this no change or else—and do it by xx/00.” On the other end of the continuum is the optional selection. This one sounds like, “Here are some good ideas—see if you would like to try them.” Somewhere in the middle is what is called the collective approach. It sounds like, “Here are some good ideas that we want you to adopt and use. Take a look at them, and customize them, in fact—reinvent them to work in your area. Tell us how it goes, but we need it done by xx/oo.” Bridge to next slide: After developing the set-up for spread, another of the important pieces is the communication to and within the social network.

43 Small Group DiscussionWhen would “completeness” be a good strategy? When might “coverage” work better as an initial strategy? When would the “optional” approach work better than the “authoritarian” approach? Or vice versa? Be prepared to share your ideas with the larger group. Objective: Explore in more details the concepts of completeness/coverage and optional through authoritarian approaches to spread. Explanation: Divide the large group into smaller groups of 5-7 people. Ask each group to discuss the following questions in the next 10 minutes. Give a warning around 8 minutes. Then debrief by asking a spokespersons from a few of the groups for their ideas, one idea per group. Allow about 5-7 minutes for the debrief. Bridge to next slide: Now let’s move on to another important part of the spread framework: communicatioin.

44 Develop the Communication PlanAwareness of the initiative Document benefits Show comparative data Use multiple communication channels Interpersonal approach Objective: Acquaint participants with the components of a good communication plan. Explanation: A good communication plan not only helps the social network become aware of the initiative, but it also imparts the technical knowledge needed to make the changes (adopt the better ideas). In terms of communicating awareness of the initiative, it is helpful to find and document the benefits, including comparative data. Data speaks very loudly and convincingly. Be sure to many different routes of communication, not forgetting the all important interpersonal approach. Bridge to next slide: The next slide shows some good examples of multiple routes of communication.

45 The Channels of Communication Are ImportantSHARE INFORMATION SHAPE BEHAVIOR General Publications flyers newsletters videos articles posters Personal Touch letters cards postcards Interactive Activities telephone visits seminars learning sets modeling Public Events road shows fairs conferences exhibitions mass mtgs Face-to-Face one-to-one mentoring shadowing Objective: List and explain the various modes/methods of communication. Explanation: Sarah Fraser again shares her expertise with us in showing the many modes of communication. As you can see, some are better at simply sharing information, while others are targeted at shaping behavior. Be sure to make use of many of these communication methods in your plan for spread- possibly even choose a few from each category to make sure many modes are covered. Bridge to next slide: Next let’s look at communication focused on improving technical knowledge. © 2002 Sarah W. Fraser

46 Develop the Communication PlanTechnical knowledge Explain changes succinctly Involve successful units in providing technical support Train your messengers Objective: Discuss a communication plan for dissemination of technical information. Explanation: The part of the communication plan aimed at dissemination of technical knowledge is usually the training on how to test and implement the changes or set of better ideas. Since we know simple changes “sell” better, be sure that any technical communication is succinct, clear, and actionable. It really helps to have people from the successful pilot teams either provide the technical support, or actually do the technical communication. After all, they are the experts. Sometimes, one has to to train the technical messengers, however. This may happen when a particularly influential “opinion leader” wasn’t part of the pilot team. The pilot team may need to take that person in, to experience first hand how the new system works. Then they are in a better position to communicate the technical knowledge. Bridge to next slide: Since communication takes place within a social system, let’s take a look at that next.

47 Strengthen the Social SystemContent, context, and community Understand the relevant circumstances affecting peoples’ ability/willingness to adopt the changes: transition issues and technical support Take advantage of the existing relationships within the system Objective: Discuss how the concepts of content, context, and community can strengthen a social system AND be useful for spread of new ideas. Explanation: The main idea on this and the next slide is that the content (the knowledge being communicated) is best shared within a context that is both understood and leveraged for maximum benefit. Knowledge shared within a community is constantly refreshed, renewed, and valued. So one of the first areas to address is to really understand the circumstances and the culture in which the spread of change is being attempted. There may be important transition issues or the need for technical support. An example of this was a doctor, who was fairly flexible in most circumstances refused to use the electronic medical record (EMR). This usually mild-mannered individual even threatened to quit instead of using the EMR. Upon exploration of the issue, it turned out that he needed glasses or a large screen, and was too embarrassed to admit it. When a large screen was procured, the resistance quickly went away. Another important idea is to leverage the existing relationships within the social system. For example, if the pediatric chief plays golf with the chief of surgery, spread from pediatrics to surgery. Bridge to next slide: Move to next slide.

48 Strengthen the Social SystemContent, context, and community Develop “communities of practice” among those with similar roles Develop key messengers: opinion leaders and connectors Objective: Discuss how the concepts of content, context, and community can strengthen a social system AND be useful for spread of new ideas. Explanation: Another way to strengthen the social system is to encourage and develop communities of practice among those with similar roles or similar interests. This can be a powerful way to get things started, keep them moving, and get them anchored in the culture. These communities may be formal and meet at prescribed times, or more informal and meet ad hoc or by . Last, within any social system, it is important to note that there are key messengers. These roles and people need to be developed. For example, identify the person that everyone goes to when a something new has come down the pike—the opinion leader. This is usually someone who is respected clinically, and is the hub of both clinical and social opinion. These people, once identified and supported, can be powerful allies in the world of spread. Why do you think pharmaceutical companies are so careful to also identify these people? A connector is very important. These are the people who have huge clinical and social networks. Just send them a message for either formal or informal distribution, and it is OUT within minutes. Bridge to next slide: So, a strong social system can be a powerful ally to communicate and spread better ideas. Let’s now take a look at the role of measurement and feedback in spread.

49 Develop the Measurement and Feedback SystemData collected on: Outcome measures Spread measures Reporting to provide feedback Link to follow-up, guidance, and action Objective: Explain the role and importance of the measurement and feedback system within the framework for spread. Explanation: When better ideas are being spread, it is important that the social system being spread to informs the original pilots about new knowledge gained, so that it can be fed back into the social system for maximum gain. It then becomes a dynamic system, changing, and adding new knowledge. But it is essential that there also be a measurement system to be sure that the changes being made continue to be an improvement, and that spread is actually occurring. For that reason, data continues to be collected on the original outcome measures, and a new set of measure, spread measures are added to the measurement system. Spread measures are similar to the Roger’s diffusion of innovation curve, and track the rate at which spread is occurring. The measures system also informs another feedback loop, that of follow-up, guidance, and action. If the new spread area is not achieving the outcomes that the pilot team did, then follow-up, guidance, and action are required. If the rate of spread is not moving as fast as the spread plan dictates, again follow-up, guidance, and action are required. Bridge to next slide: Move to next slide.

50 Develop the Measurement and Feedback SystemData/reporting at different levels within the organization Both leadership and frontline Objective: Explain the role and importance of the measurement and feedback system within the framework for spread. Explanation: Last, the data must be reported at, and relevant to many different levels of the organization. Rate of spread may be most important to the leadership whereas outcomes are important to the spread and pilot teams, with leadership monitoring these important measures. Bridge to next slide: The next slides display examples of outcome and spread data.

51 Outcome Measure Objective: Show examples of outcome data.Explanation: This slide shows viral load data from two teams. This data was very important to them, whereas an aggregate of all team data, might be most helpful for leadership. Bridge to next slide: Move to next slide.

52 Tracking the Spread of the ChangesObjective: Show example of spread data. Explanation: This run-chart show the percent of physicians involved in strategies to improve their practice. In this example, the spread goal was 33% of the MDs within 18 months. Bridge to next slide: Next slide

53 What the Collaborative Team Can Do To Help with SpreadHelp to make the case for change Make it easier for others to do the work Develop the messengers Objective: Give the original pilot team a sense of their role in spread. Explanation: Because of their experience in the improvement trenches, the pilot team has a large role to play in spread. They are among the best candidates to actually make the case for change, to tell stories of the benefits, and display their data. They can make it easier for others to start the work and do the work. And, then can be a training ground for the connectors and opinion leaders that may not have been on the pilot team. Bridge to next slide: Let’s look at the next slides for more detail.

54 Help to Make the Case for ChangeIdentify and communicate benefits Demonstrate success and positive outcomes Showcase their work Objective: The pilot teams understands their role in making the case for change. Explanation: The pilot team is in an excellent position to both identify, and credibly relate the benefits of the better ideas. They can demonstrate their successes through their outcomes and process data, and can tell stories about their work. They can create public story-boards or data walls for all to see, as well as lead “grand round” type events in their organizations. Bridge to next slide: Next they can pave the way for new spread teams.

55 Pave the Way Give new teams specifics about: Tell management about:Successful sequencing of changes Details of changes How to get started Tell management about: Transition issues Support needs Objective: The pilot teams understands their role in paving the way for new spread teams. Explanation: The pilot team, through their experience are the ideal people to talk about how to get started, the details of all the better ideas, and what to do first, and next, and last, and maybe not at all. They are the seasoned veterans who can tell management how to support the new teams, what kind of issues the new teams may encounter as they transition from the old way of doing things to the new. They are now the experts and the teachers. Bridge to next slide: Last, the pilot teams can help develop the messengers.

56 Develop the MessengersChoose the right messengers Opinion leaders Connectors Educate the messengers to deliver the message Include peer-to-peer communication Objective: The pilot teams understands their role in developing the messengers. Explanation: The pilot team may already have some opinion leaders or connectors on the team. If not, they may be able to help identify them. Then, the pilot team can mentor the messengers and communicators. They can provide them with lessons learned, best practices, touching stories of success. They can also be part of that all-important peer-to-peer communication. Bridge to next slide: Let’s tie it all together by taking a last look at IHI’s Framework for Spread.

57 A Framework for Spread Measurement and Feedback Knowledge ManagementLeadership Measurement and Feedback Better Ideas Set-up Social System Success-ful Sites Objective: Review and summary Explanation: The framework for spread is a powerful tool to manage the difficult of spread. Spread truly is “Better ideas communicated (in a special way) through a social system over time.” Add in leadership, a set-up (plan) for spread, and a knowledge management and measurement/feedback loop, and you have a tool to diffuse innovation. Bridge to next slide: Following are resources sited in the presentation, and others that may prove helpful. Knowledge Management Communication Strategies

58 Summary of the Day Strategies to Holding the Gains and Spread Improvement Understand ways to hold the gains from your initial improvement work Identify the key components of a strategy to spread improvement Leave with ideas to help guide holding the gains and spread of the improvements made by your team(s) Objective: Review objectives for Holding the Gains and Spread Explanation: Review objectives Bridge to next slide: In closing

59 References Attewell P. Technology diffusion and organizational learning. Organizational Science. February 1992. Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, New Jersey: Prentice Hall, Inc.; 1986. Brown J, Duguid P. The Social Life of Information. Cambridge, Massachusetts: Harvard Business School Press; 2000. Cool et al. Diffusion of information within organizations: Electronic switching in the Bell System, 1971 –1982. Organization Science. September-October 1997;8(5). Objective: Additional reading and knowledge-building 10 17 10

60 References Dixon N. Common Knowledge. Cambridge, Massachusetts: 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, Massachusetts: Little, Brown and Company; 2000. Kreitner R, Kinicki A. Organizational Behavior (2nd ed.) Homewood, Illinois: Irwin; 1978. Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco, California: Jossey-Bass; 1996. Objective: Additional reading and knowledge-building 10 17 10

61 References Lomas J, Enkin M, Anderson G. Opinion leaders vs. audit and feedback to implement practice guidelines. JAMA. 1 May 1991;265(17): Myers DG. Social Psychology (3rd ed.). New York, New York: McGraw-Hill; 1990. Prochaska J, Norcross J, DiClemente C. In search of how people change. American Psychologist. September 1992. Rogers EM. Diffusion of Innovations (4th ed.). New York, New York: The Free Press; 1995. Wheeler DJ. Understanding Variation. Knoxville, Tennessee: SPC Press; 1993. Objective: Additional reading and knowledge-building 10 17 10

62 Web Resources ImprovementMethods provides information on improvement methods, strategies, and changes Changes provides a framework and changes for spreading improvements system-wide