Western Node Spread Call #1 Jan 22, 2009

1. Understand some of the pre-work for spread ◦ Motivation ◦ History ◦ Leadership 2. Seven deadly sins for spread 3. Characteristics for successful initiatives

 The science of taking a local improvement (intervention, idea, process) and actively disseminating it across a system  There are many possible definitions for “a system” (e.g. a hospital, a group of hospitals, a region, a country) “New Generation of Ideas on Spread”, Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad IHI National Forum Dec 2008

Adoption is a DOING thing! “BETTER IDEAS” Happens over time COMMUNICATED Thru a SOCIAL system Adapted from Rogers, 1995 In a concrete targeted ways (C) 2001, Sarah W. Fraser Diffusion of Innovation Theory

 What do we want to spread?  To whom do we want to spread?  How are we going to spread?

 Build will ◦ Communication, motivation, history  Develop the reliable idea ◦ The “ what” is scalable, relevant, doable  Execute en mass ◦ Logistics of spread/full implementation to scale “New Generation of Ideas on Spread”, Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad IHI National Forum Dec 2008

From Improvement to Spread Spreading a change to other locations Developing a change Implementing a change Testing a change ActPlan StudyDo Theory and Prediction Test under a variety of conditions Make part of routine operations Robert Lloyd

Identifying Core Elements of the Improvement  Few in number  Absence of any substantially changes the nature of the improvement or the outcome result  Usually are of the “what” type “New Generation of Ideas on Spread”, Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad IHI National Forum Dec 2008

Keeping the Engine Running: Sharing Directions for Successful Spread & Sustainability Dr. Lynne Maher Head of Innovation Practice, NHS UK

 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 Attributes of the Change that Affect the Rate of Adoption

“New Generation of Ideas on Spread”, Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad IHI National Forum Dec 2008

Author: Sarah Fraser  Simple steps to telling the story  Short and simple read  Practical ideas

 There are demonstrated results  There is will to spread the idea within the organization  The strategy is a key initiative for the organization  A senior leader is responsible for spread of the changes  There is an agreed upon Plan documented

 Motivation ◦ Looking outward ◦ Level or urgency  History ◦ Narrative placement ◦ Prior success ◦ Leadership engagement “New Generation of Ideas on Spread”, Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad IHI National Forum Dec 2008

 Explicit aim (finite period)  Tacit aims – the silent or understood aims “New Generation of Ideas on Spread”, Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad IHI National Forum Dec 2008

James Reinertsen, MD  Leaders must make quality a core strategy of the organization. That's probably the most important barrier that must be addressed — a mindset change from "quality is the job of the quality department" to "quality is a core operational responsibility for every executive, every person." /

 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

Myths – Don’tsReality – DO’s 1. Start with Large Pilots vs Testing  Gives font line staff, who do not necessarily know the science, too much opportunity for input to a process  All this testing just takes too long  Getting too many other opinions just confuses the team since most of the time they already know what to do 1. Local Small Scale Testing, Local Implementation under multiple conditions, Spread  Small scale testing is crucial to learning how to neutralise or overcome barriers  Front line staff opinions generated from small scale testing are essential in creating a clearly defined process  Most processes can be “firmed up” in 3 or 4 cycles of testing and in the long run will be faster and have more chance of success than larger scale implementation

Myths – Don’tsReality – DO’s 2. Find one person willing to do it all  A willing team member able to take the entire burden makes it easier on all other team members  One person can then be held responsible for the process  Commonly, we can make a lot of progress using the enthusiasm and charisma of one person 2. Spread is a TEAM effort  A process dependent on a single individual is basically not a sustainable process  When key individuals are absent, the reliability of the process will deteriorate within days

Myths – Don’tsReality – DO’s 3. Vigilance & Hard Work  Just being more careful and working harder will accomplish the task. This is what I do in my clinical work.  If only every one else worked as diligently as I do there would be no problem 3. Hold the Gains with infrastructure support  Hard work and vigilance cannot be maintained over the long term  A process that succeeds using hard work and vigilance is difficult to teach to new employees  A process dependent on hard work is difficult to test for competency

Myths – Don’tsReality – DO’s 4. If the pilot works then spread the idea unchanged  Any customization will ruin the hard work we put into the design.  If it works well in one area all other units should be able to do the same.  We were taught that variation is not desirable so why should we allow it in our designs? 4. Choose the Non-negotiables but allow local customization  Without allowing some key elements of customization, successful spread will be very unlikely.  Customization should be allowed, but controlled.  Customization should be based on understanding defects. Study small samples and customize based on the learning.

Myths – Don’tsReality – DO’s 5. Require The Person and Team Who Drove the Pilot to be Responsible for Hospital Wide Spread  Since the leader of the pilot was successful who better to spread the process through the hospital  A different leader might change the process  The team is a multidisciplinary team already and represents the whole hospital 5. Choose the Spread Team based on the scope of the spread  Using the successful leader in one unit to be responsible for spread will burn out this person unless they have been specifically given the job of champion  Allowing others to assume the responsibility helps builds the infrastructure to sustain the process  Spread requires local leaders with a common goal set by leadership

Myths – Don’tsReality – DO’s 6. Look at Defects on a Quarterly Basis  Prioritizing the defects will allow us to fix any problems as spread occurs, but we need a lot of data  Do not get too wrapped up in the details of the defects, but rather the general themes 6. Frequently look at the spread measures to “tailor” the work of spread  Look at defects as they occur both when initially testing and when spreading  Use the “10 Chart Strategy”  Look at small samples on a daily or every other day basis

Myths – Don’tsReality – DO’s 7. Early on Expect Marked Improvement in Outcomes Without Attention to Process Reliability  Outcomes are the real focus of our work, correct?  Even when we are still piloting on only one unit, we should monitor hospital-wide outcomes and expect improved outcomes. 6. Outcome improvement needs widespread reliable processes & implementation  Outcomes can not be expected to change unless processes change. Staff can be responsible for process improvement.  If processes becomes highly reliable the outcome will follow as long as it is connected to science.  Outcomes will change on the pilot unit only after processes become more reliable.

 Identify some successful or unsuccessful spread efforts in your experience  What were some factors affecting the outcome?

 Crisp aims (and priorities)  Shared optimism (opportunity to do something remarkable)  Creativity and opportunism  Simplicity  Profound respect for logistics ◦ “Amateurs discuss strategy… professionals discuss logistics” “New Generation of Ideas on Spread”, Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad IHI National Forum Dec 2008

 Total openness as the price of admission (take everything people bring)  Focus on value (tacit, practical knowledge)  Constantly seeking and tapping energy (what exhilarates participants?)  Creating a shared sense of system (a shared map and shared narrative)  Letting go of need to control – an ecosystem, not a hierarchy (trust)

 The group that asks versus the group that shares  Knowledge management (at high speed) ◦ Harvesting ◦ Distilling ◦ Redistributing  Recognition management (“recognition economy”) and affection-seeking  Celebration

1. Clearly define the core elements of the spread behaviour (the action you want to spread)  Be able to explain, communicate and make the change easy for the next user 2. Discuss and engage Senior Leaders in the spread plan 3. Choose the spread team  local, middle and senior leaders are active members 4. Understand the Motivation and History of the people you will spread to 5. Define the spread AIM

Q: How do I know where to spread first? ◦ A: Go where there is interest, look at the motivation, history and leadership goals Q: What do you do with those who jump the gun and start before we have done the “steps” ◦ A: Consult, provide a platform for discussion and sharing, learn from them, share your learning, discuss the CORE elements(the what). Allow customization of the how. Q: How far back in the process does the testing go? IE: Do we want the next unit retesting the idea? ◦ A: testing for customization is about the HOW, as far as possible, keep the core elements of the WHAT standard. The main issue is making sure that the what is truly relevant in their context.

Infrastructure, Leadership and Measurement Better Ideas Information about the Innovation and “Transfer Materials” Target Population “To and Through a Social System” Communicated Modes Purpose Messengers Based on materials from IHI and Veteran’s Health Administration

1.Reading Cain, M. & Mittman, R. Diffusion of Innovation in Healthcare, Institute for the Future, May Bodenheimer, T. The Science of Spread: How Innovations in Care Become the Norm, September, Woodard, F. How to Achieve Effective Clinical Engagement and Leadership when Working Across Organisational Boundaries, Practical Recommendations, Modernisation Initiative, April Checklist Review the Spread Checklist and Identify areas to begin a spread plan 3.Team Thinking Reflect on the Motivation and History portions of pre-work to identify what your team needs to do to prepare for spread Mission Possible: Your Assignment (should you decide to accept it!)

 New Generation of Ideas on Spread, Dec 8, 2008 Joe McCannon, Marie Schall, Lynn Maher, Rashad Moussad, IHI National Forum  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 IHI  Sustainability and Spread, August 28, 2006 Diane Jacobsen, MPH, CPHQ, IHI National Director  Continuing the Conversation Holding the Gains and Spreading Good Ideas: From Local Improvement to System-wide Change October 4, 2007 Marie Schall, MA Institute for Healthcare Improvement

 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  Brown J., Duguid P. The Social Life of Information. Boston: Harvard Business School Press,  Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the Bell System, 1971 –1982, Organization Science, Vol.8, No. 5, September - October  Dixon, N. Common Knowledge. Boston: Harvard Business School Press,  Fraser S. Spreading good practice; how to prepare the ground, Health Management, June  Gladwell, M. The Tipping Point. Boston: Little, Brown and Company,  Kreitner, R. and Kinicki, A. Organizational Behavior (2 nd ed.) Homewood, Il:Irwin,1978.

 Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco: Jossey-Bass  Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Implement Practice Guidelines. JAMA, Vol. 265(17); May 1, 1991, pg  Myers, D.G. Social Psychology (3 rd ed.) New York: McGraw-Hill,  Prochaska J., Norcross J., Diclemente C. In Search of How People Change, American Psychologist, September,  Rogers E. Diffusion of Innovations. New York: The Free Press,  Wenger E. Communities of Practice. Cambridge, UK: Cambridge University Press, References