1. Framework for Getting Results at Scale

2. Why we need context-sensitive implementation and scale-up designs
Large scale efficacy Study
Reliable “real-life” implement-ation
Basic science
Proof of concept
Scale-up to populations

3. Mechanisms to adapt to different contexts and environments
Improvement Guide. 2nd Edition, 2009

4. Mechanisms to adapt to different contexts and environments

5. Is your idea/program ready to go to full scale?

6. Core elements included in the design: 1. Phased Approach
Prototype development and test of scalable units (Massoud, 2004)

7. Core elements included in the design: 2. Adoption mechanisms
IHI’s framework for spread (Nolan, Schall et al. 2005)

8. Core elements included in the design: 3. Support Mechanisms
5x Scale up thinking

9. What does the New Framework attempt to provide?
Guidance on multifaceted approach on how to take improvement to full scale
Integrates IHI’s existing models and thinking on achieving results at scale
Clarifies terminology - describes what happens in clear, simple terms.
Describes 3 basic components:
Road map or sequence of activities to reach full scale
Adoption mechanisms
Infrastructure for scale up.
Describes different methods that can be used at different stages of the journey to full scale.

10. The Framework Phases of getting to Full Scale Fostering Adoption
assembling knowledge, set up, building the scalable unit, testing scale-up, going to full-scale and sustaining improvement
Fostering Adoption
leadership, communication, social networks
Support Systems
Learning systems, data systems, infrastructure for scale-up, human capacity for scale-up, capability for scale up.

11. The Framework
Adoption Mechanisms
Set-up
Build Scalable Unit
Test Scale- Up
Go to Full-Scale
Support Systems
Phases of Scale-up
Best Practice exists
New Scale-up Idea
Leadership, communication, social networks, culture of urgency and persistence
Learning systems, data systems, infrastructure for scale-up, human capacity for scale-up, capability for scale-up, sustainability

12. Framework: Integration of Phases, Adoption and Support Systems
The framework can apply to
efforts to introduce and scale-up new interventions from “scratch”
efforts to spread existing innovations or “best practices”
Phases of scale up should link closely to adoption mechanisms and support systems from the outset

13. Core elements included in the design: 4
Core elements included in the design: 4. Existing concepts of “spread” and “scale up”
“scale-up” - overcoming the system/infrastructure issues that arise during efforts to scale-up implementation
“spread” – the leadership, social, and environmental factors that promote adoption and replication, with little modification, of an intervention within a health system
(Kurapati, Laderman, et al., 2011).
The framework may or may not include these terms – yet to be decided whether these are useful or confusing – but the framework uses these concepts as core elements of the design.

14. Review of other scale up models
Sequence of Scale-up
Adoption
Support Structures
Set-up
Build Scalable Unit
Test Scale-up
Full-scale and Sustain
Adoption Mechanisms (including leadership)
Develop Learning Systems
Build Human Capacity & Capability
Strengthen Infrastructure
Implementing Best Practices X
ExpandNet/WHO
Management Systems International
Consolidated Framework for Implementation Research
Yamey
WHO (Massoud)

15. Phases of Scale Up
Best Practice exists
Build Scalable Unit
Test Scale- Up
Set-up
Go to Full-Scale
New Scale-up Idea
Introduction of a new evidence based intervention for system-wide scale-up OR
Adaptation and Scale up of a successful innovation in one part of the system to the rest of the system

16. Phases of Scale Up
Best Practice exists
Build Scalable Unit
Test Scale- Up
Set-up
Go to Full-Scale
New Scale-up Idea
analysis of the existing programming strategies and protocols, and assemble best practices (expert group)
baseline data collection
understand the roles and contributions of stakeholders.
engage & build will with leadership
identify prototype test sites, early adopters, and potential “champions”
Build prototype design (“5 elements”)

17. Phases of Scale Up
Best Practice exists
Build Scalable Unit
Test Scale- Up
Set-up
Go to Full-Scale
New Scale-up Idea
Administrative unit includes core activities and support systems that need to be replicated in the larger health system.
Intensively test local ideas,
Generate a set of context-sensitive interventions for scale up “change package”
Build will, seed adoption
Build infrastructure
Start testing sustainability

18. Phases of Scale Up
Best Practice exists
Build Scalable Unit
Test Scale- Up
Set-up
Go to Full-Scale
New Scale-up Idea
Test and further develop preliminary change package in a broader range of contexts representing the predicted full-scale environment
Build adoption strategies
Build infrastructure
Develop sustainability change package

19. Phases of Scale Up
Best Practice exists
Build Scalable Unit
Test Scale- Up
Set-up
Go to Full-Scale
New Scale-up Idea
Rapid deployment phase - well-tested set of interventions are deployed at large scale, adopted by frontline staff.
Focus on replication
Ensure sustainability

20. Adoption Mechanisms
Included in all phases but most emphasis is in rapid deployment phase - well-tested set of interventions are deployed at large scale, adopted with minimal further adaptation by frontline staff. Includes core elements…
Leadership of change
Communication and networks
Attributes of the intervention (IHI’s Spread Framework)
Culture of urgency and persistence

21. Support Systems Build human capability for scale-up .
Leadership team to guide the process
Reference to 5x thinking framework – phased training from volunteers to trained, dedicated improvement specialists
QI-based programs for those who need additional training. (start before scale-up begins).
QI teams
Build infrastructure for scale-up:
Balance targeted resource addition vs system redesign.
reconfiguration of existing resources (e.g., examination room design, lab needs, data system infrastructure)
additional tools (e.g., checklists, data capture systems),
communication tools, and
key personnel (e.g., data capturers, quality improvement mentors)
Build reliable data collection and reporting systems
track and provide feedback on the performance of key processes
Data systems for improvement vs monitoring
Develop learning systems:
Mechanisms for collecting, vetting, and rapidly sharing change ideas or interventions.

22. Sustainability
Standard work processes for high-reliability of the new processes
Data systems that support, track and feedback key indicators
Inspection systems to ensure desired results are being achieved,
Resources/support for structural elements,
Ongoing learning systems
Leadership

23. Methods deployed at each phase
Set-up
Build Prototype
Test Scale-up
Go to Full-scale
Methods
Model for Improvement
Surveys
Brainstorms
Expert meetings
Scans
Site visits
Interviews
Idealized Design 
Collaborative learning (e.g., adaption of Breakthrough Series (BTS) Collaboratives)
Deployment and refinement of change package
Site redesign
Collaborative learning
Change agents
Extension agents
Affinity groups
BTS Collaboratives
Wave sequence
Campaigns
Hybrid approaches