1. Sustaining and Spreading Changes Robert A. Gabbay, MD, PhD Connie Sixta, PhD, RN, MBA

2. Improvement Hold Gains Spread Creating an Improved Clinical System Improvement Hold Gains Spread NON-LINEAR MODEL BETTER API Lloyd Provost

3. We’ve talked a lot about improvement Model for Improvement: Aim Measurement Rapid testing of changes (PDSA cycles) Test lots of ideas! Expect some will “fail” Most will need refinement (PDSA cycles)

4. Sustaining Improvement Drop off in measures is common but preventable! Initial excitement, urgency wear off. Possible change fatigue. Pay particular attention to yearly measures (foot exams, eye exams, LDL tests, etc.) as you approach end of initial 12 months. If strong system of population management is in place should not see these decline. Staff/Provider turnover, particularly among change leaders.

5. Strategies to Hold the Gains Establish and document standard processes Make changes to job descriptions Use measurement and audits Pay attention to orientation and training Assign ownership Address the social aspects of change (who are the peer leaders, who talks to whom)

6. Your Sustainability Experience How are you checking to make sure changes are sticking? What kind of shared ownership exists in your practice for your improvement data? How have you been documenting revised processes and revised job duties?

7. Test --> Implement --> Spread Testing : Trying and adapting existing knowledge on small scale. Learning what works. Change is not permanent. Lot of experimentation and revisions. Failure very useful here, even expected. Few people impacted (limited staff, few patients). Need to build improvement documentation for permanent implementation and spread of successful changes.

8. Test --> Implement --> Spread Implementing : Making this change a part of the routine day-to-day operation of your practice. More people impacted than during testing. Increased resistance compared to testing. Generally requires more time than testing. Some additional revisions may be needed. But don’t expect failure here because you have documented success of changes.

9. Test --> Implement --> Spread Spreading: Adapting change to additional areas (other practices) or other patient populations beyond diabetes. Useful for multi-site practices, systems. Good population management processes work across chronic diseases and prevention. Application to other conditions is important for NCQA recognition and Meaningful Use.

10. Degree of belief that the changes will result in improvement High Developing the Change Testing and Adapting the Change Implementing Then Spreading the Change Successful changes Beginning to implement and spread. Changes still need further testing. There is a risk of moving to implementation and spread. Unsuccessful proposed changes Low Moderate What’s the status of each of your changes? Change 1 Change 3 Change 2 API –Lloyd Provost

11. Innovators Early Adopters Early Majority Late Majority Laggards 2.5% 13.5%34% 16% from Rogers, 1995 Adopter Categories

12. The “Tipping Point” “The name given to that one dramatic moment in an epidemic when everything can change all at once.” - M. Gladwell “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. Rogers

13. The “Diffusion Curve”

14. Diffusion Depends on 6 Factors 1.Relative advantage over current practice 2.Compatibility with current culture and practice 3.Simplicity 4.Observability 5.Trial ability 6.Timing of return on investment Everett Rogers, The Diffusion of Innovation

15. Developing a Spread Plan Is improvement a key strategic initiative? Is there a budget for spread? Has time been allocated for spread? Are goals and incentives aligned? Identify and develop your spread champions. Leverage your improvement data—tell your improvement story! Document your ROI.

16. Rest of Practice or Across System AP SD AP SD (Tests to adapt changes, then implementation) Population of Focus for the initial improvement (pilot population) AP SD Target Population for Spread

17. The Communication Plan Document benefits Show comparative data Use multiple communication channels Explain changes succinctly Involve successful units in providing technical support Measure and provide feedback

18. The Social System Understand the relevant circumstances affecting peoples’ ability/willingness to adopt changes. Take advantage of the existing relationships within the system. Develop “communities of practice” among those with similar roles (peer-to-peer support and learning).

19. Your Thoughts What changes have you already spread? How has the spread gone? Any resistance to overcome? What barriers are keeping you from spreading?

20. References Attewell, P. Technology Diffusion and Organizational Learning, Organizational Science, February, 1992 Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986. Brown J., Duguid P. The Social Life of Information. Boston: Harvard Business School Press, 2000. Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the Bell System, 1971 – 1982, Organization Science, Vol.8, No. 5, September - October 1997. Dixon, N. Common Knowledge. Boston: Harvard Business School Press, 2000. Fraser S. Spreading good practice; how to prepare the ground, Health Management, June 2000. Gladwell, M. The Tipping Point. Boston: Little, Brown and Company, 2000. Kreitner, R. and Kinicki, A. Organizational Behavior (2 nd ed.) Homewood, Il:Irwin,1978.

21. References Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco: Jossey-Bass 1996. Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Implement Practice Guidelines. JAMA, Vol. 265(17); May 1, 1991, pg. 2202-2207. Myers, D.G. Social Psychology (3 rd ed.) New York: McGraw-Hill, 1990. Prochaska J., Norcross J., Diclemente C. In Search of How People Change, American Psychologist, September, 1992. Rogers E. Diffusion of Innovations. New York: The Free Press, 1995. Wenger E. Communities of Practice. Cambridge, UK: Cambridge University Press, 1998.

22. Questions?