1. The Spread Problem The Challenge and Promise of Delivery System Research: A Meeting of AHRQ Grantees, Experts, and Stakeholders Joe McCannon Centers for Medicare and Medicaid Services February 17, 2011

2. Ground to Cover The Spread Problem A Possible Solution (Framework) Open Questions Your Ideas and Advice 2

3. “I think when people look back at our time, they will be amazed at one thing more than any other. It is this – that we do know more about ourselves now than people did in the past, but that very little of this knowledge has been put into effect.” – Doris Lessing 3

4. Why Do We Fail to Take Effective Practice to Scale? Because we lack incentives to do so 4

5. Typical Explanation Prototype Dissemination R&D 5

6. A More Accurate Representation? Prototype Dissemination R&D 6

7. Why Do We Fail to Take Effective Practice to Scale? Because we lack incentives to do so Because we don’t expect to do so 7

8. Why Do We Fail to Take Effective Practice to Scale? Because we lack incentives to do so Because we don’t expect to do so Because we don’t appreciate how large-scale change unfolds 8

9. A Sequence of Change 1. An innovative discovery 2. A demonstration in 50 hospitals 3. Outstanding results in 4 states 4. Interest from purchasers and payers 5. A state law in 14 states 6. A national mandate 7. A part of graduate-level training 8. An expectation and a standard 9. Confidence in ability to make change 10. More ambitious aims

10. Why Do We Fail to Take Effective Practice to Scale? Because we lack incentives to do so Because we don’t expect to do so Because we don’t appreciate how large-scale change unfolds Because we don’t know how to do so (or at least we don’t approach the challenge systematically enough) 10

11. A Framework 11

12. Current Environment (Will) Political and economic environment Leadership engagement Prioritization scheme Forces for change Incentives for change 12

13. Levers for Change Payment Transparency Regulation Sensationalism Guilt Recognition Professionalism Affection Personal considerations (de-zombification) 13

14. Foundation (Timing) Prior work to establish efficacy Prior work to establish effectiveness on a smaller scale Degree of awareness Degree of confidence 14

15. Framing Problem definition Explicit aim-setting Tacit aim-setting Operational image Narrative image (predicted sequence of change over time) 15

16. Nature of the Intervention Evidence base Emotional resonance Simplicity Trial-ability/Observability 16

17. Structural Context Local infrastructure Local patterns of behavior (centers of influence) Rules base Financing paradigms Geography 17

18. Method Technical approach to scale up OR “Lever mix” Data collection Recursive evaluation Knowledge management Logistics/resource management 18

19. Methods for Spread Natural diffusion Breakthrough Series Collaborative model Extension agents Emergency mobilization Campaign model Social movements Wave sequence (wedge and spread) Broad and deep Hybrid models 19

20. A Framework 20

21. How Do The Best Practitioners Stimulate Change at Scale and Spread Effective Practices? They tend to address six key questions: 1.How do you get people to care (and care enough to take action)? 2.Where are you in the process of change (foundations/history)? 3.What is your “hard count” (explicit and implicit aims) and your story for achieving it? 4.What is the nature of your intervention? 5.What is the nature of your social system? 6.How will you spread your better practice (method)? 21

22. Durable Lessons on Managing Change at Scale (What Do the Best Do?) They attempt remarkable things (provocation and optimism) They talk about justice They have a shared story They apply “many levers” They play jazz They keep it simple (e.g., interventions, measurement systems) They model trust (ecosystems not hierarchies; “distributed laboratories”) They seek affection and give recognition (recognition economy) They break rules (avoid consensus, condense timeframes) They go broad and deep They revere logistics (“Amateurs discuss strategy…”) 22

23. A Conference to Advance the State of the Science and Practice on Scale-up and Spread of Effective Health Programs (July 2010) Sought to: Review existing knowledge Identify challenges and gaps Set a research and practice agenda for immediate execution 23

24. Major Hills to Take… Build the field Experiment with incentives Experiment with new methods and technologies Test new forms of evaluation Create and spread practical tools 24

25. Selected References Massoud MR, Nielsen GA, Nolan K, Schall MW, Sevin C. A Framework for Spread. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006. Simmons R, Fajans P, Ghiron L. Scaling up health service delivery. Geneva: The World Health Organization, 2007. Victora C, Hanson K, Bryce J, Vaughan P. Achieving universal coverage with health interventions. Lancet. 2004; 364: 1541-1548. Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC, USA: National Academies Press; 2001. Rogers E. Diffusion of Innovations. New York: The Free Press, 1995. 25

26. Selected References Mangham LJ, Hanson K. “Scaling up in international health: what are the key issues?” Health Policy and Planning. 2010; 25:85-96. Dougherty D, Conway P. The “3T’s” Road Map to Transform US Health Care. JAMA. 2008; 299 (19):2319-2321. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Quarterly. 2004; 82: 581- 629. Cooley L., Kohl R. Scaling Up: From Vision to Large-scale Change. Washington, DC: Management Systems International, 2006. 26

27. Selected References McCannon CJ, Schall MW, Perla RJ. Planning for Scale: A Guide for Designing Large-Scale Improvement Initiatives. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008. McCannon CJ, Berwick DM, Massoud MR. The Science of Large- Scale Change in Global Health. JAMA. October 24/31, 2007; 298: 1937 - 1939. Berwick DM. Disseminating innovations in health care. JAMA. 2003;289(15):1969-1975. Bradach J. Scaling Impact. Stanford Social Innovation Review. Summer 2010. 27