𝑺 𝟑 From Spread to Scale-up to Sustainability BRUCE D. AGINS, MD MPH PHFS WEBINAR: 14 MARCH 2017 NEW YORK STATE DEPARTMENT OF HEALTH AIDS INSTITUTE

Overview Spread Scale-up: Frameworks, Factors and Processes Sustainability: The ultimate challenge

S1: Spread Spread: to (cause to) cover, reach, or have an effect on a wider or increasing area

What do we think about when we talk about spread in improvement work? Spread of a collaborative: to new sites, new districts, new regions, another country Spread of ideas, innovations, knowledge 1999: IHI focuses on “spreading change ideas within and between organizations”

Key Issues For Spread (IHI White Paper) Readiness Establishing an aim Assess key elements for readiness Processes involved Methodology built upon core principles of improvement science (Deming) Adaptation of MFI: What are we trying to spread? To whom do we want to spread it – and by when? How will we spread it? How will we know it has been spread? Joint Commisison Jnl on Quality and Pt Safety 2005; 31: 339-46

Processes for Spread: Nolan’s Checklist for Spread (Organization-focused) Nolan K, et al. Using a Framework for Spread. Joint Commission Jnl on Quality and Safety 2005. 31: 339-349. Is improvement in this area a strategic priority for the organization? Is there an executive responsible for spread of the improvement? Is there a person or team in the leadership who will be involved in day-to-day spread activities? Will leadership supply resources needed for success? (personnel; IT; tools) Has the advantage of adopting the change been documented and communicated in an easily understood message to all potential adopters? Is there a successful site that has implemented the change in a way that is scalable throughout the organization? Are there credible messengers who can persuade potential adopters to implement the innovation? Is there a clear plan to communicate the innovation throughout the organization and to assist different sites in making needed changes?

Approaches to Spread Natural diffusion (adoption of idea or intervention by members of social system in absence of formal dissemination) Executive mandates “Extension agents” where mobile HCWs or community leaders spread ideas and best practices: “coaching and mentoring” Emergency mobilization Affinity group (2-3 clinics recruited to develop model) Wave sequencing Collaborative (structure learning around shared aims, measures & goals) Virtual collaborative Campaigns

Eight Points For Implementation in Networks: Practical Tips and Implications for HEALTHQUAL Teams Spread has to be planned and then managed Flexibility: adaptive response to environmental change and survives central level change [provincial and district] Involvement of users throughout process (“consensual development”) in both prioritization and design (patients and providers) Sharing of resources and knowledge: “communication plan” Fostering networks between user organizations: the power of peer learning Recognition for innovators within networks Coaching System (“extension system”) Close spatial contact between external agents and clients

S2: From Spread to Scale-Up

Frameworks for Scale-Up Barker, Reid, Schall 2016; Implementation Science 11:12 Four Steps to Scale-Up Set-up Develop the scalable unit Test of scale-up Full Scale

Fig. 3 IHI Framework for Going to Full Scale.

The Communication Element

S3: Sustainability: Paradigms but little Proof…

Lori DiPrete Brown (1995): Lessons Learned in Institutionalization of Quality Assurance Programs: An International Perspective Institutionalization: defined as “..when essential and appropriate …. activities are carried out effectively on a routine basis throughout an organization, health system or health sector”. Sustainability occurs when “expertise, commitment and resource allocation are sufficient to apply, adapt, sustain and further develop the QA approach”. Int J Qual Health Care (1995) 7 (4): 419-425.  DOI: https://doi.org/10.1093/intqhc/7.4.419

http://www. healthcareimprovementscotland http://www.healthcareimprovementscotland.org/about_us/what_we_do/knowledge_management/knowledge_management_resources/spread_and_sustainability.aspx

http://www. healthcareimprovementscotland http://www.healthcareimprovementscotland.org/about_us/what_we_do/knowledge_management/knowledge_management_resources/spread_and_sustainability.aspx

Ten Domains to Guide Sustainability of Donor-Initiated Programs Balancing flexibility/adaptability with standardization Supportive policy, legal and regulatory environment Ongoing focus on sustainability Fiscal support Political support Building and sustaining strong organizational capacity Community involvement, integration, buy-in and depth Partnerships Decentralization Transferring ownership

The Policy Environment: NQPS Project (WHO) The Policy Environment: NQPS Project (WHO) -Sheila Leatherman, WHO Lead Advisor, NQPS Is Policy a prerequisite to sustainability? Categories of Action: Set policy and standards Change clinical practice HMIS and data systems Regulate Educate and inform Use proven quality improvement methods Payment and incentives

Governance: HEALTH FINANCE & GOVERNANCE PROJECT Institutional Roles & Relationships Governing the Quality of Health Care: Country Experiences, Challenges & Lessons Learned. (adapted) Is governance a prerequisite to sustainability? Principles: -universal health coverage with quality explicitly embedded -health information system allowing real-time data for decision-making -strong technical role for MOH in relationship to the payer -both accountability and improvement need to be addressed -platform for shared learning as part of a comprehensive communication strategy -ensure that all sectors are involved -link finance to quality -political will -support research to define the critical elements of organizational architecture required for governance to ensure sustainability

Implementation Science: The EPIS model Learning from Implementation Science: The EPIS model Aarons, G.A., Hurlburt, M. & Horwitz, S.M. (2011). Advancing a Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors. Administration and Policy in Mental Health and Mental Health Services Research.38, 4-23.

What does Umar tell us? Umar 2009: The “Little Steps” Approach to Sustainability Literature focusing on national level does not include much about actual improvement methods which are embedded in smaller projects. All work must be contextual, building upon existing political and management systems. Work towards incremental improvements that do not require large increases in resources: focus on what is achievable and sustainable. Advocates for a “little steps” model

Umar, N et al. Toward More Sustainable Health Care Quality Improvement in Developing Countries: The “Little Steps” approach. Q Manage Health Care. 2009; 18(4); p.295-304

Umar, N et al. Toward More Sustainable Health Care Quality Improvement in Developing Countries: The “Little Steps” approach. Q Manage Health Care. 2009; 18(4); p.295-304

Sustainability: NHS The NHS Modernisation Agency defines sustainability as follows: ‘Sustainability is when new ways of working and improved outcomes become the norm. Not only have the process and outcome changed, but the thinking and attitudes behind them are fundamentally altered and the systems surrounding them are transformed in support. In other words it has become an integrated or mainstream way of working rather than something ‘added on’

Challenges Donor projects come and go, along with their funds and impetus Disease or sector-specific models fail to be integrated into the healthcare delivery system Lots of models, concepts, paradigms have been developed but few have been implemented: experience is limited Longitudinal data are scarce, if existent at all: is any model of sustainability actually effective? Adaptation into different environments has not been tested: context matters Do we still need to plan spread & scale-up if we start with a sustainability paradigm? How can a knowledge management strategy be deployed to get information to providers and consumers who need to use it? What is the role of public health system accountability to ensure ongoing uptake?

How can we learn from our experiences with PHFS to inform practice, spread, scale-up and sustain the results that have been achieved?