Module 21 - Day 3 11:45 - 12:30 pm (45 min) Improvement Alert!  Generating and Maintaining Organizational Support/Enthusiasm for Quality Improvement.

Module 21 - Day 3 11:45 - 12:30 pm (45 min)
Improvement Alert!  Generating and Maintaining Organizational Support/Enthusiasm for Quality Improvement “What’s wrong with having a little fun?” 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

At your tables think of a fun way to
Warm-up! At your tables think of a fun way to Generating and Maintaining Organizational Support/Enthusiasm for Quality Improvement! 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

Why do we need to be enthused?

Hamilton Consulting, LLC & Performance Management Group
What is motivation? ..what words come to mind? Hamilton Consulting, LLC & Performance Management Group

We don’t need to motivate people…
…we need to stop demotivating people Hamilton Consulting, LLC & Performance Management Group

What is demotivation? Hamilton Consulting, LLC & Performance Management Group

People are born with intrinsic motivation, self-esteem, dignity, curiosity to learn, joy in learning. W. Edwards Deming ( ) @learningandimproving.com

Forces of destructions(p.122) Merit system. Judge people, Put them into slots. Competition Between people, groups, divisions Forced distribution of grades In schools. Gold stars. Pay for performance Incentive pay. Numerical goals without a method Explanation of variance Suboptimiztion. Every group, every division, a profit center Life begins Life ends These forces cause humiliation, fear, self-defense, competition for gold star., high grade, high rating on the job. They lead anyone to play to win, not for fun. They crush out joy in learning, joy on the job, innovation. Extrinsic motivation (complete resignation to external pressure) gradually replaces intrinsic motivation, self-esteem, dignity. One is born with intrinsic motivation, self esteem, dignity, cooperation, curiosity, joy in learning. These attributes are high at the beginning of life, but are gradually crushed by the forces of destruction. Hamilton Consulting, LLC & Performance Management Group

Herzberg: How do you motivate employees? Harvard Business Review (reprint Jan, 2003) Hamilton Consulting, LLC & Performance Management Group 10

Alphie Kohn Alfie Kohn writes and speaks widely on human behavior, education, and parenting. The author of twelve books and scores of articles, he lectures at education conferences and universities as well as to parent groups and corporations. Kohn's criticisms of competition and rewards have been widely discussed and debated, and he has been described in Time magazine as "perhaps the country's most outspoken critic of education's fixation on grades [and] test scores." Hamilton Consulting, LLC & Performance Management Group

Punished by rewards Alphie Kohn
Our society is caught in a whopping paradox. We complain loudly about sagging productivity, the crisis of our schools and the warped values of our children. But the very strategy we use to solve those problems—dangling rewards like incentive plans and grades and candy bars in front of people—is responsible for the fix we’re in. We are a society of loyal Skinnerians, unable to think our way out of the box we have reinforced ourselves into. (pg.xii) Punished by rewards Alphie Kohn Hamilton Consulting, LLC & Performance Management Group 12

Burrhus Frederic Skinner (1904-1990) Operant Conditioning
Hamilton Consulting, LLC & Performance Management Group 13

Alphie Kohn Pay is not a motivator Rewards punish Rewards rupture relationships Rewards ignore reasons Rewards discourage risk-taking Rewards undermine interest Hamilton Consulting, LLC & Performance Management Group

@learningandimproving.com

about what motivates us
TIL Book Club Virtual Book: Process and Questions Drive: The surprising truth about what motivates us 11 minute you tube Process: Choose a leader Ground Rule: all voices heard Questions: To what did you most respond ? And Why? What surprised you? What puzzled you? How might this knowledge influence your management? Your improvement efforts? Debrief: Large group Closing thoughts Hamilton Consulting, LLC & Performance Management Group

When to Use Rewards: A Simple Flow Chart (Pink p. 69)
Use rewards, even “if-then” rewards, but be sure to Can you increase the task’s challenge or variety, make it less routine, or connect it to a larger purpose? Sure I can do that 2. Acknowledge that the task is boring 3. Allow people to complete the t ask their own way 1. Offer a rationale for why the task is necessary That is pretty hard YES Is this task mostly routine? Start Here No Concentrate on building a healthy, long-term motivational environment that pays people fairly and that fosters autonomy, mastery, and purpose. Avoid “if-then” rewards in almost all circumstances. Consider unexpected, noncontingent “now that” rewards. And remember that those rewards will be more effective if: 1. They offer praise and feedback rather than things people can touch or spend 2. They provide useful information rather than an attempt to control When to Use Rewards: A Simple Flow Chart (Pink p. 69) Hamilton Consulting, LLC & Performance Management Group

..a couple tools to help us choose
What can we do to support intrinsic motivation and decrease de-motivation? ..a couple tools to help us choose Hamilton Consulting, LLC & Performance Management Group

Gallop 12 Questions (Gallup Survey 1 million employees over 35,000 organizations) Do I know what is expected of me at work? Do I have the materials and equipment I need to do my work right? At work, do I have the opportunity to do what I do best every day ? In the last seven days, have I received recognition or praise for doing good work? Does my supervisor, or someone at work, seem to care about me as a person? Is there someone at work who encourages my development? At work, do my opinions seem to count? Does the mission/purpose of my company make me feel my job is important? Are my co-workers committed to doing quality work? Do I have a best friend at work? In the last six months, has someone at work talked to me about my progress? This last year, have I had opportunities at work to learn and grown? Buckingham, M. and Coffman, C. First Break All the Rules 1999 Hamilton Consulting, LLC & Performance Management Group

Decision Making Tools Multi Voting Structured Discussion Agree on the criteria for selecting ideas Identify each idea in the list with a letter of the alphabet Agree on the number of ideas for which each member will vote Vote individually on paper, listing the letter of each selected idea Take turns calling out the letters of selected ideas Record and add the votes on a flip chart Decide which ideas would receive further consideration Agree on the criteria for the decision Take turns expressing points of view without interactive debate Summarize points of agreement after all members have had an opportunity to speak uninterrupted Debate and discuss conflicting ideas Continue to discuss and debate the ideas until a decision is reached Hamilton Consulting, LLC & Performance Management Group

If you remember nothing else....
We don’t need to motivate people; we need to stop demotivating people Hamilton Consulting, LLC & Performance Management Group

Module 20 – Day 3 11:15– 12:30 pm (75 min)
Spreading and Holding the Gains of Improvements The National Quality Center is pleased to bring you the Quality Academy, an online learning opportunity on key quality management concepts. The NQC provides no-cost, state-of the-art technical assistance for all Ryan White CARE Act grantees to improve the quality of HIV care nationwide. The Center is funded through a cooperative agreement with the HRSA HIV/AIDS Bureau and managed by the New York State Department of Health AIDS Institute. This Tutorial is titled: Spreading Good Ideas for Change

Learning Objectives: You will learn about…
Explore ways how to sustain improvements over time in your HIV program Learn how innovation works Understand the theories behind innovation and the spread of innovation Explore ways to spread improvements

What’s the Sequence? ??? more like … Improvement Hold Gains Spread
Objective: 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. Spread Source: Institute for Healthcare Improvement (IHI)

Discussion Think about a recent time when you have just finished a successful QI project, with proven data to document the improvements. How did you sustain the gains? OR Why did you slide backwards?

Holding the Gains After Implementation: Inhibitors
Old System New System “We met our goals” “We assume improvements will hold” “We can only focus on one QI project at the time “It takes too many resources to maintain the improvements” “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.

Holding the Gains After Implementation: Readiness
Old System New System “We need to plan for holding gains” “During the project cycle, we have start planning” “Holding gains is an expectations” “Integration into existing data systems is routine” “I know simple steps how to hold gains” “I can work on the next project” 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. 29

What’s the Sequence? Improvement Hold Gains Spread Test Implement
During testing During implementation After implementation Objective: Emphasize the overlapping and interdependency of holding the gains (sustainability of change): Be sure to emphasize that our main focus will be on maintaining the gains after implementation. However, sustaining the gains during testing and implementation should be considered. Holding the gains during testing: robust testing in a variety of circumstances and conditions HTG during implementation: 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. Be sure to plan and test the implementation, paying attention to what support services are needed. Attention to social aspects: Explanation of 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. 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 Source: Institute for Healthcare Improvement (IHI)

Holding the Gains After Implementation
Communication Documentation Measurement Education and Training Leadership How can you make sure that your improvement effort, in “show business” terms, “has legs and can be maintained after implementation?” Essentially, the improvements have to be institutionalized in order to “stick”. They have to be written down, tracked and integrated into standard policies and procedures. Here are some ideas to help you facilitate institutionalization of your improvements—details on next slides Pay attention to the social aspects of change •Continue to measure performance indicators. You may be able to collect less data, or collect it less frequently, but develop a way to keep track of whether the improvement you’ve made continues to have the result you want •Revise job descriptions so they reflect the new ways of doing work you have developed •Make sure to train, train, train. It’s critical that staff know what to do •The role of leadership cannot be understated…

Communication Fully understand the improvements
Understand the benefits for patients and staff Gather data points over time Realize the affects of sliding back to old ways Communicate throughout the organization Share project results, measures and improvements Present successes during staff meetings Inform senior leadership within the organization Objective: 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.

Channels of Communication
SHARE 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

Documentation Write or Update: Storyboards Job descriptions
Orientations Policies and procedures Flow charts ……to reflect the new way of doing things…..

Measurement Routinely measure and analyze the data to ensure gains are sustained over time Integrate routine performance measurement into existing data collection efforts Review data routinely, and follow-up, if indicated Develop a threshold-to-revisit indicator

Education and Training
Routinely educate and train staff to support improvements—both the “what” and the “why” Update staff on additional changes Provide competency training as necessary Provide cross-training as needed

Engage the leadership in their role to sustain changes
Support the newly implemented improvement Remove inhibitors or barriers Assign ownership to maintain the gains Maintain the priority of the new improvements in the context of multiple and competing priorities 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 leadership to maintain the priority of this change, even in the face of new, changing, or multiple priorities. Have someone be appointed to direct the “holding the gains” phase and oversee all these steps. The organization’s leadership should assign the responsibility

Creating a New Order “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 Perhaps you are familiar with the writing of the Renaissance political theorist Machiavelli. He has some not-very-inspiring words for people who would “create a new order of things.” Luckily, we now know more about what is involved in creating a new order than Machiavelli did, and this information can reduce some of the “danger” involved.

Getting Improvement to “Spread”
Initial test/clinic/ sub-population The rest of the system: - All patients - Other providers - Other units Other clinics - Other hospitals Once you’ve tackled the challenges of sustaining an improvement, it’s time to start thinking about how to approach the larger task of taking a proven change and spreading it to the other parts of the HIV care program, that is, the other parts of your system. These are some important things to keep in mind about “spread.” • Spread can be challenging because the “rest of the system” doesn’t have the knowledge or background that the initial test site has about why and how the change was developed • An organization’s senior leadership has the responsibility for spread, as they are the part of the organization that can manage the relation of the parts of the organization to the whole of the organization • We know a lot about how people react to innovation, and senior leaders need to learn this information to be able to guide the spread of improvements successfully 39

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) The good news on spread: Malcolm Gladwell’s The Tipping Point has stayed on best-seller lists for years. In this highly readable story, Gladwell examines several cases where a new idea or approach has seemingly “caught fire” overnight, and explores the specific conditions and actions behind each case. We highly recommend reading this valuable resource if you would like to gain even further knowledge on this topic.

Diffusion of Innovations
Everett M. Rogers The Free Press, New York, 1995 Gladwell’s work builds on, and popularizes, the theoretical work of Everett M. Rogers, probably the leading thinker in the field of innovation. Roger’s book, Diffusion of Innovations, is a thought-provoking resource about how new ideas get adopted and used. We will refer to Roger’s work throughout this presentation.

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) Here is a quote from Roger’s work that further explains Gladwell’s tipping point. Rogers talks about the importance of the “10 percent to 20 percent” part of the diffusion curve, that most of the work involved in spreading an innovation comes at this point. Getting to or past this point on the diffusion curve is, however, more complicated than that small percentage would suggest.

The “Diffusion Curve”: Reaching the Tipping Point
300 250 200 Number of Farmers 150 100 Tipping Point 50 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. 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 Year Number of Adopters of Hybrid Seed Corn in Two Iowa Communities Source: Based on Ryan and Gross (1943)

“Diffusion Curve” in Health Care
Here’s some evidence that this theory applies in health care, not just in fashion or in agriculture. This graph shows the actual 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 accelerated. You can also see on both this and the seed corn chart on the following slide, 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. “tipping point” “tipping point” Source: Institute for Healthcare Improvement

Innovators - Venturesome Early Adopters - Respected
Types of Innovators Innovators - Venturesome Early Adopters - Respected Early Majority - Deliberate Late Majority - Skeptical Laggards - Traditional Let’s examine the five ways that people respond to innovation. • First, we have the Innovators, the venturesome among us. These are the people who bring new ideas into the system, those who tolerate risk and are willing to accept the possibility of losses in seeking potential gain. Sometimes their very innovativeness causes them to be viewed as “outsiders” by the rest of the system in which they live or work. • Next along the curve come the Early Adopters. Less “cosmopolitan” than innovators, their dominant characteristic is that they are respected by others in their system. They are well integrated into the local social system, are seen as opinion leaders and advisors of others. Because they serve as role models, their adoption of an innovation decreases uncertainty about the innovation for others, making it more likely that others will try it out. • The next group is the Early Majority, deliberate in their decision making, relying on, but also trusting, the early adopters. They can be convinced by the logic of the benefit of the change. • The Late Majority then follows. This group is, in general, skeptical about the innovation (and also is less able to handle a financial risk). They tend to adopt the innovation only in the face of economic necessity or when they face intense peer pressure, and they need to know they will be in the majority if they adopt the innovation. • Finally, there are the laggards, tied to tradition, connected with the past. They will learn about innovation later than others, and their peer group will be those with similar traditional ideas.

‘Diffusion of Innovation’
Why can diffusion be difficult? Because of the different ways people in the population feel about new ideas. Think about the people you know: probably someone was the first person you knew to get an i-Pod, and probably someone else is still listening to cassette tapes – or even record albums! This graph is from a study in 1940 that measured how quickly farmers in Iowa accepted a new kind of corn seed. Rogers’ work has shown that this graph applies pretty much no matter what the specific innovation is: corn seed, i-Pods or new processes in health care. It’s basically a bell curve, with a small number of people who will take up a new idea quickly, most people in the middle, and a few people who lag behind. Take a minute and see where the 20% tipping point lies on this graph, and then we’ll talk more about each of these categories. Source: Ryan and Gross, “Hybrid Seed Among Iowa Farmers,” 1940

Human Diffusion Curve Exercise
2-3 Volunteers to sell Volunteers to buy Let’s see what we learn….

Rogers’s Five Attributes of Change
Relative Advantage - how much better is the new compared to the old? Compatibility - how consistent is this idea with current values, experiences, and needs? 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) Rogers also identified five attributes of change: Relative Advantage: how much better is the new compared to the old? Compatibility: how consistent is this idea with values, experiences, and needs? 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? Each attribute is on a continuum, and the more of the attribute the change has, the easier it will be to spread. For example, a change with a high degree of compatibility will be easier to spread than one without. A change with visible results will be easier to disseminate that one where the results are subtle.

What the Improvement Teams Can Do to Help
Make the case for change Clarify the benefits Demonstrate that your changes provide these benefits Share the evidence supporting the changes (literature and experience) Data – especially annotated run charts Make it easier for others to do the work Describe the change Coach how to start doing improvement work Highlight where management needs to help Identify the messengers Choose the right messengers (opinion leaders, connectors) Educate the messengers to deliver the message Include peer-to-peer communication Now let’s talk about some very specific things that improvement teams, those who developed the original change for improvement, can do to help spread the improvement through your HIV care program. Here are three concrete tips: •Help make the case for change. Remember how important this is to convince the early majority – and you need their help to get to the “tipping point.” •Make the change easy, and make “making the change” easy too. Remember the importance of “complexity” and “trialability.” People will be more willing to accept a change if they understand it and can easily try it out. •Identify who the messengers will be. Don’t rely on innovators for this; they don’t command the attention of the organization. You need the trusted early adopters as your messengers. The following slides will detail these 3 points.

Small Table Exercise Review at your small tables the provided scenario and strategize how to employ key diffusion/spread principles Use the Spread Worksheet as a guide Be prepared to share their ideas and strategies with the larger group

Scenario ‘A small rural clinic has developed a reminder system that utilizes text messaging to alert clients about their upcoming appointments. In collaboration with a local community college, a free software application has been developed which links the clinic appointment system, client contact information and online text messaging. All clients with cell phones receive a 1-week and 1-day reminder about their upcoming appointments. This innovation has led to significantly higher retention rates among those patients with cell phones.’ Develop strategies to implement this innovation across all HIV programs in the entire state.

“We are what we repeatedly do; excellence is not an act, but a habit.”
Closing Thoughts “We are what we repeatedly do; excellence is not an act, but a habit.” -Aristotle We hope that what you have learned in this session on sustain and spread will help your HIV care program in its pursuit of excellence. As Aristotle reminds us, excellence comes from habit. Make quality a habit in the HIV care and services that you provide.

Resources 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, Malcolm, The Tipping Point, Boston and New York: Little, Brown, 2002 Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco, California: Jossey-Bass; 1996. Rogers, Everett M., Diffusion of Innovation, New York: Free Press, 1995. For more information about the IHI’s Framework for Spread, see or download their white paper on this topic at The IHI’s: Improving HIV Care: A Modular Quality Improvement Curriculum, available on the Institute for Healthcare Improvement’s web site at also has valuable information on spread. Several of the slides in this Tutorial come from the Modular QI Curriculum, and we are grateful. Many sources of information contributed to the creation of this Tutorial. If you would like to learn more, you can check out these valuable resources and don’t forget, you can also contact the National Quality Center for more help, at

National Quality Center (NQC)
NationalQualityCenter.org

Working Shortened Lunch...

Module 22 - Day 3 1:30 - 2:00 pm (30 min)
Next Steps “Putting Theory Into Action” 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

Module Objectives Create an opportunity for participants to covert topics and ideas covered in the session to action items they want to bring back to their organizations for consideration and implementation Have participants share their action plans with colleagues as well as NQC Increase the participant’s confidence that they can effectively support quality improvement activities 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.

Individual Reflection, Analysis, Opportunity Identification
Individually, spend the next 20 minutes identifying potential action items you would like to bring back to your organization based on the learning of the last 3 days Use the form handed out by faculty to record your ideas Be prepared to share your items

Sharing of Aha! Moments & Day 3 Evaluation
Module 23 – Day 3 2:00 – 3:00 pm (60 min) Sharing of Aha! Moments & Day 3 Evaluation

Highlights & Aha! Moments
What have been some of your Aha! Moments throughout the last 3 days?

The way the 3-day training was delivered was an effective way for me to learn.
Strongly Disagree Agree Strongly Agree

I had sufficient opportunity to participate over the last 3 days.

The agenda and content over the last 3 days was logically organized.

Overall, I was satisfied with the session facilitator(s).

Materials were useful during each day.

My knowledge and/or skills increased as a result of the last 3 days.

How ready are you to facilitate a quality management committee and/or quality improvement team?
Not Ready Mostly Ready Very Ready

How ready are you to conduct an organizational assessment of the QM program?

How ready are you to actively lead a quality effort in your organization?

Thank you and we look forward to continuing to work with you National Quality Center (NQC) NationalQualityCenter.org

NationalQualityCenter.org

Module 21 - Day 3 11:45 - 12:30 pm (45 min) Improvement Alert!  Generating and Maintaining Organizational Support/Enthusiasm for Quality Improvement.

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Module 21 - Day 3 11:45 - 12:30 pm (45 min) Improvement Alert!  Generating and Maintaining Organizational Support/Enthusiasm for Quality Improvement.

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