1. 1 Scaling up high-impact interventions M. Rashad Massoud, MD, MPH, FACP Director, USAID Applying Science to Strengthen and Improve Systems Project Senior Vice President, Quality & Performance Institute University Research Co., LLC – Center for Human Services

2. USAID Applying Science to Strengthen and Improve Systems What do we mean by “Spread” or “Scale- up”? The science of taking a local improvement (intervention, idea, process) and actively disseminating it across a system …Joe McCannon Institute for Healthcare Improvement, Cambridge, MA

3. USAID Applying Science to Strengthen and Improve Systems What do we know about the spread of good practices? Smoking cessation counseling: 21% Mammography screening: 27% Warfarin for Atrial Fibrillation: 40% ACE inhibitors for CHF: 36% …Agency for Health Research & Quality (AHRQ) Physician compliance with evidence-based interventions:

4. Publication Bibliographic databases Submission Reviews, guidelines, textbook Negative results variable 0.3 year 6. 0 - 13.0 years 50 % 46% 18% 35% 0.6 year 0.5 year 9.3 years It takes 17 years to turn 14 per cent of original research to the benefit of patient care. …Agency for Health Research & Quality (AHRQ) Dickerson, 1987 Koren, 1989 Balas, 1995 Poynard, 1985 Kumar, 1992 Poyer, 1982 Antman, 1992 Negative results Lack of numbers Expert opinion Inconsistent indexing 17:14 Original research Acceptance Implementation

5. USAID Applying Science to Strengthen and Improve Systems Diffusion of Innovations: Attributes of an Innovation Relative advantage Compatibility Complexity Trialability Observability E. Rogers, Diffusion of Innovations, 1995

6. USAID Applying Science to Strengthen and Improve Systems Diffusion of Innovations: Categories of Adopters 2.5%13.5%34% 16% E. Rogers, Diffusion of innovations,1995 Early Adopters Innovators Early Majority Late Majority Laggards

7. USAID Applying Science to Strengthen and Improve Systems Key Insights on Diffusion Theory Attributes of Innovation Categories of Adopters Spread of Idea vs. Directed Change in Systems

8. USAID Applying Science to Strengthen and Improve Systems Set-up -Target population -Adopter audiences -Successful sites -Key partners -Initial spread strategy Social System -Key messengers -Communities -Technical support -Transition issues Communication Strategies (awareness & technical) Knowledge Management Measurement and Feedback Leadership -Topic is a key strategic initiative -Goals and incentives aligned -Executive sponsor assigned -Day-to-day managers identified Better Ideas -Develop the case -Describe the ideas A Framework for Spread Institute for Healthcare Improvement, Cambridge, MA

9. USAID Applying Science to Strengthen and Improve Systems Three Key Questions What do we want to spread? To whom do we want to spread? By when? How are we going to spread?

10. USAID Applying Science to Strengthen and Improve Systems How Do We Spread? Many possible ways: Natural diffusion Extension agents Emergency mobilization Spread through a collaborative Spread through a virtual collaborative Campaign spread Wave sequence spread Hybrid models Institute for Healthcare Improvement, Cambridge, MA

11. USAID Applying Science to Strengthen and Improve Systems Wave Sequence Spread

12. USAID Applying Science to Strengthen and Improve Systems 12 Principles of Scale-Up 1.Begin with scale-up in mind 2.If you can reach all-at-once – you should! 3.If you cannot, then consider a phased approach: –Look for nested systems –Test prototypes & expand in multiples of 5-10 4.How factors change in going to scale: –Arithmetic scale up –Favorable scale-up 5.Information systems 6.Communication needs 7.Oversight needs with scale-up

13. USAID Applying Science to Strengthen and Improve Systems 13 Key Lessons Learned Results are the key drivers Enabling people to make changes in their work –Systems thinking –Equip with PDSA’s –Assistance to the teams in the form of site visits –Leadership Support –Role Modeling –Normative/regulatory support People working under constraints can be very creative Scale-up efforts require meticulous attention to detail Champions who developed the prototypes are critical for leading the scale-up in wave sequence spread Leadership from within the system

14. 14 New Learning about the Rate of Spread

15. USAID Applying Science to Strengthen and Improve Systems Uganda - Comparison of Demonstration and Spread Sites Screening for Active TB in HIV+ Patients average of 17,500 HIV+ patients per month in original sites; 5,000 in spread sites CQI interventions Baseline CQI Interventions % of HIV+ patients seen in that month that were screened for active TB, based on Patient register

16. USAID Applying Science to Strengthen and Improve Systems Niger - Comparison of Demonstration vs. Spread IMCI Sites for the % Children Triaged on Arrival

17. USAID Applying Science to Strengthen and Improve Systems Key Results: Maternal and Neonatal Mortality Reduction – Basic ProCONE Trend in Compliance with Criteria in Prenatal Care in San Marcos and 7 Additional Health Areas during Expansion Phase A total of 143 facilities participating E.9F.9M.9A.9M.9J.9 A.9S.9O.9N.9D.9J.10F.10M.10A.10M.10 Numerator41272112301373142115301670148314851432148512611574158614591190657 Denominator2310201124672367240223062427227120731929192415741963204617371456780 Services reported12911813913313413513413212411411094118117978355 % Services reported9083979394 92878077668382685838 Interventions: Advocacy for securing micronutrients Training of staff in prenatal care needed due to high turnover rate

18. USAID Applying Science to Strengthen and Improve Systems Rwanda - Comparison of Demonstration vs. Spread site for the % Partners of Women in ANC Tested for HIV

19. USAID Applying Science to Strengthen and Improve Systems