Holding the Gains and Spread California Chronic Care Learning Communities Initiative Collaborative Learning Session 3 June 8, 2005 Angela Hovis Improvement Advisor

“There is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new order of things….” -Nicolo Machiavelli, The Prince

Objectives Enable you to apply current knowledge about holding and spreading improvements to your setting – so that you can sustain and spread the improvements in this project and – so that you have skills to sustain and spread other improvements in future activities.

Collaborative Time Frame 12 months Select Topic Planning Group Develop Framework & Changes Participants Prework LS 1 P S AD P S AD LS 3 LS 2 Expert Meeting Strategy: -test -implement -hold the gain -spread Beyond LS 3 How well do successful teams “hold the gains” and spread after LS3?

© 2005 Institute for Healthcare Improvement Improvement Hold Gains Spread Creating a New System Improvement Hold Gains Spread BETTER

© 2005 Institute for Healthcare Improvement 2003 IHI Survey on Holding the Gains Brief History-surveyed 33 successful teams from different collaboratives. Objective: To determine if successful teams involved in IHI Collaboratives sustained their progress after the end of the final learning session.

© 2005 Institute for Healthcare Improvement Question: What is your current level of performance compared to the end of the final learning session for the key outcome measure? BTS Successful Teams Much Better BetterSameWorse 13 initial responders follow-up responders Total Teams 10 (30.3%) 12 (36.4%) 10 (30.3%) 1 (3.0%) Summary 97% of teams at least “held the gains” from the BTS 67% of teams are now performing better than at end of BTS

© 2005 Institute for Healthcare Improvement Additional Survey Findings Question% Yes Are you still tracking your performance? 85% Is there periodic reporting to leadership regarding performance? 88% Were other residual benefits gained in the improvement process that took hold? 91% Do you and your colleagues continue to use improvement methodology in your work? 91%

© 2005 Institute for Healthcare Improvement General impressions The power of internal publicity Commitment to real sustainability versus “quick hits” (leadership, resources, ambition) Understanding that the end of the formal collaborative is only the beginning (and that success is only a step in the right direction)

© 2005 Institute for Healthcare Improvement Old 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 After Implementation Some Inhibitors:

“We are what we repeatedly do; excellence is not an act, but a habit.” -Aristotle

© 2005 Institute for Healthcare Improvement Plan to Hold the Gains: Three Key Components Infrastructure Effective Control System Social Aspects of Change

© 2005 Institute for Healthcare Improvement  Address training and development of new skills  Make changes to job descriptions, policies, and procedures  Assign ownership for improvement and maintenance work of the new process  Senior leaders held responsible for the efforts to sustain the change and remove inhibitors that might allow slippage back to the old system Plan to Hold the Gains: Infrastructure

© 2005 Institute for Healthcare Improvement  Plan to standardize new process, link to other processes whenever possible  Continue to monitor measures for performance and outcomes  Outcome measures required  Process measures may be desirable as early warning signals Plan to Hold the Gains: Design Effective Control System

Run Chart Class referral Goal setting Class referral Goal Setting

Not holding gain; Things getting worse Act to correct Old system New system Using Shewhart Control Limits to Detect Important Changes in SC System Class referral Goal Setting

© 2005 Institute for Healthcare Improvement Provide information on why the change is being made and how the change will effect people (WIFM) Show appreciation for people’s efforts Understand and address the causes of resistance Publicize the results and learning Address the Social Aspects of Change

While Holding Gains, Spread Begins Spread: Adoption of an Innovation Population for Spread Target Population in your Aim Statement - Reach more patients - Other clinicians - Other clinics - Other chronic conditions

Spreading Innovations to Patients: brown Rice instead of white rice - Contra Costa/Richmond Health Center Spontaneous Spread – Yoga classes at Silver Avenue Family Health Sharing collaborative info with SB and presentations - San Francisco Gen. Hosp. and San Mateo Medical Center Getting Started with Influential Partners - Santa Clara Valley Medical Center Local champions share knowledge to small groups of providers - Contra Costa/Richmond Health Center Understanding Spread: Learning from Examples

© 2005 Institute for Healthcare Improvement Adoption is a DOING thing! “BETTER IDEAS” Happens over time COMMUNICATED Thru a SOCIAL system Adapted from Rogers, 1995 In a certain way (C) 2001, Sarah W. Fraser

© 2005 Institute for Healthcare Improvement Adoption Curve Time Percent Adopting

© 2005 Institute for Healthcare Improvement Leadership’s Role in Spread Leadership –Topic is a key strategic initiative –Executive sponsor assigned –Day-to-day managers identified –Goals and incentives are aligned Set-up for Spread –Target population –Are pilot sites successful? –Identify key groups who make adoption decision –Initial strategy to reach all sites

© 2005 Institute for Healthcare Improvement What the Improvement Team Can Do to Help with Spread Help to make the case for change Provide examples of PDSAs Make it easier for others to do the work –Provide examples of PDSAs –Share tools –Host a site visit to show new process (tacit knowledge) Be a messenger to a new site

KnowledgePersuasionDecisionImplementationConfirmation Steps to Adoption

Innovators Early Adopters Early Majority Late Majority Laggards 2.5% 13.5%34% 16% from Rogers, 1995 Adopter Categories

How “Spreadable” are your Improvements? (1=not at all, 5=absolutely) Rogers’ Attributes of Change” FactorsScore Relative advantage - is this idea better? Compatibility with current system Complexity - How difficult or simple is it to understand and use? Testability - How easy is it to try out before adopting? Observability - How visible are the results - ability to observe the change and its impact

© 2005 Institute for Healthcare Improvement Spread: The messages we communicate are important To build will: –Highlight need for change –Highlight potential for change Good ideas (concepts) –Pragmatic guidance for implementation Which one works best? –Both messages needed –Different receivers respond differently

Table Exercise 5 minutes: Imagine that you have only 2 minutes with a colleague to create interest in your improvement work. Plan a 2 minute (or less) talk to “pitch” or sell a change or group of changes your team has implemented. Consider addressing the factors that influence the adoption of an innovation. Will pitch to the group.

Bibliography Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, Inc Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the Bell System, 1971 –1982, Organization Science, Vol.8, No. 5, September - October Gladwell, M. The Tipping Point. Boston: Little, Brown and Company, Lomas J, Enkin M, Anderson G. etc. Opinion Leaders vs Audit and Feedback to Implement Practice Guidelines. JAMA, Vol. 265(17); May 1, 1991, pg Rodgers E. Diffusion of Innovations. New York: The Free Press, 1995.