1. Spread the Word! We’re Talking About Spreading Improvement Ideas
Ben Ridout

2. Outline Context 7 “Spreadly Sins” Theory and Framework
Practical Tips and Tool

3. Context
“Islands of improvement” Limited resources and time Rediscovering the same ideas?
Examples of lack of spread – Islands of improvement
Decreasing resources and time availability, increasing public pressure for improvement in health care
Wasted effort rediscovering same ideas
Project reports or storyboards being displayed at QF or Accreditation in the past – ideas spread to other areas?
How many unique issues being addressed? Learn from others?
Percentage of efforts going to relearning
A key factor in closing the gap between best practice and common practice is the ability…to rapidly spread innovations and new ideas

4. Mentioned in abstract viral videos
If only it was this easy to spread health care ideas
The dream

5. Spread
“when best practice is disseminated consistently and reliably across a whole system, and involves the implementation of proven interventions”
* Jeffcott, S. The spread and sustainability of quality improvement in healthcare. NHSScotland Quality Improvement Hub.

6. Disseminate Information
Change
Technical Aspects
Social Aspects
Disseminate Information
Overcome Barriers
Every change has both a technical aspect (the nature of the change itself) and a social aspect (how people feel about doing it). In order for an idea to spread, people need first to find out about it, and then to get beyond emotional, structural, or resource thresholds that might be barriers to its implementation. These two aspects (technical and social) and two activities (disseminating information and overcoming thresholds for change) are interrelated in complex ways.

7. No silver bullet solution or single way to ensure spread

8. 7 Deadly…“Spreadly Sins”
While not one solution to spread, there are some common missteps
Flip mindset and think about how to overcome common errors when spreading improvement
Everyone here assuming because spread is a challenge, haven’t figured it out
Give us a chance to reflect on experiences and harness the power and knowledge in this room

9. 7 “Spreadly Sins” Don’t bother testing – just do a large pilot
Give one person the responsibility to do it all
Rely solely on vigilance and hard work
Spread the success unchanged; don’t bother adapting
Require the person and team responsible for initial improvements to lead spread
Check progress/data just once every quarter
Expect huge improvements quickly then spread right away

10. Table Discussion What’s your experience been with the “Spreadly Sins”?
How can we avoid committing the “Spreadly Sins” in our work?

11. - IHI resource available for your team with practical tips for avoiding the spreadly sins

12. Some Theory
Diffusion of Innovation Psychology of Change Complexity Theory

13. Diffusion of Innovation
Advantageous
Compatible
Simple
Testable
Observable
These two aspects (technical and social) and two activities (disseminating information and overcoming thresholds for change) are interrelated in complex ways.
Technical and social aspects both important
Diffusion of innovation – Everett Rogers
Note how the technical aspects of the change such as advantage, compatibility with the current system and simplicity are intertwined with the social aspects of compatibility with values, commitment, and observation of others. Both are critical. Technically rational ideas for improvement can fail if the social aspects of change are not well handled.
Reinvention - Advocates do best by promoting the basic concepts behind the change, while allowing the details to be re-invented as the idea spreads.
Change is emotional and social, threshold for change lowered when latitude to adapt

14. Stages of Change Precontemplation Contemplation Action Maintenance
Different stages of change models – DiClemente and Prochaska – Four Stages of Personal Change
Pre – not ready to even discuss or consider a change
Cont – willing to listen and consider a change
Action – ready to do something concrete
Maintenance – having made a change and striving not to slip back into old behaviours
Ex) Pre – capture emotional attention of person and move to contemplation – provide data on performance to peers or dramatic story of bad patient experience, instead of case study of change in other unit
key is the realization that the leader needs different messages for different audiences
Knowing the audience and thoughtfully tailoring the message are required actions for successful spread of ideas
Prochaska - diclimente
Can’t overcommunicate

15. Complexity Theory Spread of change somewhat messy process
Degree of exploration and experimentation
Chantelle “stop putting simple solutions on complex problems”
Health care complex adaptive system – can’t apply simple solutions to complex problems
For this talk, more about all individuals have freedom to make up own minds about a change
spread of change is naturally a somewhat messy process, we must expect some degree of exploration and experimentation in the spread of improvement ideas within organizations
change occurs more naturally when there is flexibility on the details of the change. At the same time, we cannot expect constructive change and the spread of good ideas to occur in an infinitely flexible setting. CAS theory suggests that we should be inflexible on the basic concepts of the change, yet flexible on the details needed to implement that change in a specific setting.
For example, the flocking behavior of birds seems to follow three simple rules: avoid collisions, match speed with others, and try to go generally where others are going. There is wide latitude for detailed flying behavior within these “min specs”, but if a bird violates any of these rules the result does not satisfy the aim of flocking.
- Health care example: ?

16. Not prescriptive nor specific intervention
Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety.2005Jun;31(6):
Founded on Everett Roger’s definition of diffusion and draws from the literature and experiences of organizations
Not prescriptive nor specific intervention
Suggest general areas to consider when large spread undertaken
Source: Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety.2005Jun;31(6):
* The Improvement Guide 2nd Edition – p. 196

17. Leadership Strong leadership essential to success
Support innovation as key strategic initiative
Spread process needs to be managed
Day-to-day leadership
Align incentives with work and allocate appropriate resources
Leadership role to give work priority – executive sponsor
Assign executive sponsor
Responsible for improved performance
improvement a strategic initiaive in org?
Is executives responsible for spread?
How will this executive be involved ongoing?
Is there a person or team who will manage the day-to-day spread activities?
What are positions of key people who will make adoption decision?

18. Better Ideas Clear advantage Compatibility Simplicity of change
Ease of testing
Observability
Succinct description of ideas to spread
Ideas that spread more rapidly have 5 core qualities
Evidence shows…
- Rate of spread influenced by benefit to all adopters of idea relative to other ideas
Has the relative advantage of changes been communicated to adopter audiences?

19. Setup for Spread Develop spread plan early Initial plan for spread
Identify ways to attract early adopters
Changes packaged for easy comprehension and testing
Find successful site(s) to promote
Once better ideas are documented and successful sites identified
- Leadership initiates process by identifying target population
Leadership oversees initial plan for spread
- Identify ways to attract early adopters
Communication about advantages
Identify persons influential with peers
Share comparative data with adopters
Are changes packaged so that they can be easily understood and tested by adopters?
Is there a successful site that has implemented the new system?
Has an initial plan for spread been developed?
Consider:
Ways to attracts early adopters
Potential infrastructure changes needed

20. Social System Communication at the heart of spread
Over-communicate by factor of 10
Communication twofold
Raising awareness – attract adopters
Sharing technical content
Social system is founded on communication
Communication at the heart of spread
Communication campaign throughout initiative
Best messengers:
Influencers or opinion leaders in system
Twofold communication
Use different channels of communication to raise awareness and share knowledge
Other examples from group?
How will awareness of initiative by communicated?
Have benefits for different audiences been documented?
Have comparative data been shared?
What channels will be used to raise awareness in target population?
How will technical knowledge be communicated?
Are peer to peer interactions planned?
Are potential adopters influential in social system willing to be involved?
How will successful units be involved to provide support?

21. Feedback Loops Measurement Knowledge Management
Demonstrate extent of spread
Demonstrate outcome of changes implemented
Knowledge Management
Capture and share knowledge generated during spread process
integral part of improvement - Used to continuously monitor the spread work
Need to consider practical side – who will be doing this?
How will otucomes be measured?
How will the rate of spread be monitored?
Used to make it easier for others to adopt the changes
Capture knowledge – have a system in place
What information/reports will be used as feedback to site and to monitor and refine the spread strategy?
What systems will be used or developed to capture and share the new knowledge generated during the spread initiative?
Ex) Communication tool:
Share tips
Share tools
Success stories
Other info to assist adoption

22. Not prescriptive nor specific intervention
Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety.2005Jun;31(6):
Founded on Everett Roger’s definition of diffusion and draws from the literature and experiences of organizations
Not prescriptive nor specific intervention
Suggest general areas to consider when large spread undertaken
Source: Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety.2005Jun;31(6):
* The Improvement Guide 2nd Edition – p. 196

23. Experience in Practice
No simple answer Different approaches for different contexts Training alone unlikely to be successful Best strategies incorporate variety of approaches
Reinvention - Advocates do best by promoting the basic concepts behind the change, while allowing the details to be re-invented as the idea spreads.
Change is emotional and social, threshold for change lowered when latitude to adapt

24. Experience in Practice
Extent of spread affected by factors in 3 domains:
Intentional activities to introduce spread
Attitudes and capabilities of clinical staff
Context of site/facility being targeted
Intentional activities to introduce spread and support innovation
Attitudes and capabilities of clinical staff responsible for implementing innovation

25. Top Tips from Evidence
Involve range of people in implementation & dissemination
View people as active change agents not passive
Emphasize alignment with people’s priorities
Target messages differently to different audiences
Support and train people to understand and implement change
Plan dissemination strategies from outset
Dedicate time for dissemination
Make use of wide range of approaches
Evaluate success of innovations and improvements
- Based on review of 477 studies
The Health Foundation (2014). Spreading improvement ideas: Tips from empirical research

26. NHS Spread Tool

27. Questions?

28. Contact Information
Ben Ridout Director, Patient & Public Engagement T: