communicating and spreading success sponsored by: health quality council of alberta

Communicating and Spreading SuccessSponsored by: Health Quality Council of Alberta

and Western Node of Safer Healthcare Now!

February 1, 2007 Best Western Village Park Inn

1804 Crowchild Trail NW, Calgary, Alberta Foothills II Room

1 pm Welcome by Dr. John Cowell, CEO HQCA

1:15 – 2:45 pm Using Quarterly Reports Effectively!Virginia Flintoft, Project Manager, Central Measurement Team –

Safer Healthcare Now! University of Toronto

2:45 – 3:00 pm BREAK

3:00 – 4:30 pm What Now? Sustaining and Spreading for SuccessTanis Rollefstad, Improvement Advisor, Western Node for Safer

Healthcare Now!

4:45 pm Mix and Mingle

www.hqca.ca

Put title right in here

March 15, 2004

Communicating and Spreading Success

John W. Cowell, MD, FRCPCChief Executive Officer

February 1, 2007

www.hqca.ca

•HQCA has embraced and tangibly supported SHN since its inception

•Our focus is on health system quality, safety and performance

•We work primarily from the citizen’s point of view

www.hqca.ca

•We collaborate and work directly with all the health regions, professions and policy makers

•Our Template is the Alberta Quality Matrix for Health

•We believe effective performance management requires appropriate measurement at all levels

www.hqca.ca

1. 55 teams enrolled in Alberta

2. There are teams working on each of the 6 SHN interventions

3. Alberta leads the west in providing data to the Central Measurement Team (CMT)

What’s happening in Alberta

www.hqca.ca

4. Over 90% of hospitals have submitted data to CMT

5. Analysis of the data will reveal whether the initiatives in each of the interventions result in improved clinical outcomes

6. It is anticipated the analysis and conclusions of this will ensure the spread of successful change

What’s happening in Alberta (cont.)

www.hqca.ca

We have no doubt those of you working hard on the interventions and collaborations are making a positive difference on the patient experience.

What can we learn from SHN’s Quarterly Reports?

Virginia Flintoft, RN MScSHN – Central Measurement Team

Objectives• Overview of the Quarterly Report format• Basic interpretation and caveats• Intervention-specific observations• Breakout + Quiz• Questions

Quarterly Report formatQ.R.

#Date data submitted

Months reported

1 April ’06 – June ’06 Nov* ’05 – June ’06

2 April ’06 – Sept. ’06

Nov* ’05 – Sept. ’06

3 April ’06 – Dec. ’06 Nov* ’05 – Dec. ’06

* or preceding months pooled and reported in November

Quarterly Report format


AMI – 8CLI – 3Med Rec – 3RRT – 3SSI – 7VAP – 2Total = 26


Goals:• Vary for each measure• Types

Evidence based Based on local performance

o AMI 8; CLI 1; MedRec 1 & 2; RRT 1; VAP 1

Set by teamo RRT 2 & 3

• Calculation method specified at bottom of Raw Data Sheet


Data Analyzed & Presented:• Nationally• by Node –

Atlantic Ontario Quebec Western Paeds

• by Implementation Stage – Baseline Early Full

Quarterly Report formatYour Job!!

Quarterly Report formatCopy values in “Final Calculation” rowon Raw Data Sheet and paste into “Local Team” row (r7) on Quarterly Report

Raw Data Sheet from Measurement Workbook

Copy values in “Final Calculation” rowon Raw Data Sheet and paste into “Local Team” row (r7) on Quarterly Report

Definitions:• “N (Teams)” = Number of teams reporting data for a specific month

Caveats:• When N (Teams) <5 the data is not stable due to too small a cell size • The number of teams reporting per month varies with each QR

Basic interpretation

Comparator Group Descriptive Statistic Nov'05 Dec'05 Jan'06 Feb"06 Mar'06 Apr'06 May'06Score Score Score Score Score Score Score

Aspirin at Arrival Goal >90% >90% >90% >90% >90% >90% >90%Local Team (input own data) Final Calculation 75% 82% 83% 79% 88% 90% 90%

National N (Teams) 17 11 6 6 10 3 4Mean 94.06% 98.10% 98.15% 97.22% 98.89% 77.77% 95.50%SD 6.66% 4.09% 4.53% 6.82% 3.51% 38.51% 5.47%


Comparator Group Descriptive Statistic Nov'05 Dec'05 Jan'06 Feb"06 Mar'06 Apr'06 May'06 Jun'06Score Score Score Score Score Score Score Score

Aspirin at Arrival Goal >90% >90% >90% >90% >90% >90% >90% >90%Local Team (input own data) Final CalculationNational N (Teams) 27 19 15 17 18 11 11 10

Mean 92.63% 93.91% 89.07% 92.09% 98.96% 93.94% 98.36% 97.90%SD 8.39% 11.82% 27.03% 24.22% 3.10% 20.11% 3.76% 4.99%

QR #1 – data submitted April - June 2006

QR #2 – data submitted April - Sept. 2006

• Data becomes more stable as sample size increases


Definitions:• “Mean” = average score for the measure for the

hospitals reporting data for that month.Caveat:• The more teams reporting the more stable the mean.


Definitions:• “SD” = standard deviation - summary value for how widely

dispersed the scores are around the mean. In a normal distribution 95% of all scores are within 2-SDs on either side of the mean.

Caveats:• Very high SD indicates large variation in scores making it difficult to

use the national average to interpret your performance.• Normal curve has no defined limits - a ‘percentage’ is limited to 0

and 100. Therefore, 2-SDs above or below the mean may be >100 or <0.

To “Unhide” rows • highlight 1or 2 rows above & below node ‘section’• right click to display menu• select “unhide”

• Minimum – lowest score reported for a specific month• Maximum - highest score reported for a specific month• 25th percentile – 25% of all teams reporting data for

that month have a lower score.• Median (50th percentile) – exactly half of the scores are

above and below this value.• 75th Percentile - 75% of all teams reporting data for

that month have a lower score.• It is better to be <25th percentile for some measures

• Bracketed measures (large):o Only included in National analysiso Used for calculating confidence intervals

(CI)• Bracketed measures (small):

o Lower and Upper Bound = CI

Interpretation:• Compare your performance (Local Team)

to National mean month-over-month• Compare your performance to CI

o if score falls between upper and lower bound = statistically similar (Jan., Feb., Apr.)

No CI because25th %ile - Max=100%

Adjust to appropriate level

Definitions of Implementation Stages• Baseline Stage

– Pre-intervention. Data collected for Baseline should be collected prior to implementing small tests of change and reflect the current process.

Definitions of Implementation Stages• Early (Partial) Implementation Stage

– The team has: set a clear aim(s) for this intervention (i.e. AMI, CLI, MedRec, RRT, SSI or VAP); identified which measures will indicate if the changes will lead to improvement; and started to implement small tests of change (PDSA) to identify and refine processes, procedures and practices which will lead to improvement and achieving the aim. When the team is close to goal they are ready to move to Full Implementation.

Definitions of Implementation Stages• Full Implementation Stage

– The processes, procedures and practices are finalized and have lead to significant improvement. These practices on the selected unit are being consistently applied and monitored, showing a sustained performance at or close to goal. The team has achieved their aim(s) and is ready to spread to other areas.

Interpretation:• Compare your performance (Local Team) to National monthly

means– match Implementation Stage (Baseline, Early, Full)• Cut, Paste and Create an annotated Run Chart

Cut &

Paste

Cut &

Paste

Cut &

Paste

• Annotated run chart

Data Submission and PerformanceNov.30.06

Intervention-specificN Hosp Hospitals % Overall

Enrolled Reporting Reporting AMI CLI MedRec RRT SSI VAP Reporting24 22 91.7% 4 (80%) 3 (75%) 16 (80%) 4 (100%) 11 (85%) 8 (89%) 84%37 32 86.5% 12 (67%) 1 (17%) 19 (86%) 2 (20%) 15 (63%) 5 (45%) 59%22 16 72.7% 3 (38%) 0 (of 1) 16 (70%) 0 (of 1) 4 (66%) 2 (67%) 48%1 1 100.0% 1 (100%) 100%9 6 66.7% 1 (50%) 0 (of 1) 6 (75%) 1 (33%) 1 (50%) 1 (33%) 53%1 0 0.0% 0 (of 1) 0

94 77 81.9% 20 4 57 7 32 16 13694 33 12 72 18 47 26 208

81.9% 61% 33% 79% 39% 68% 62% 65.4%

Teams Reporting by Intervention (% enrolled)

National Intervention-specific (as of Nov.’06)• AMI

o ASA on arrival (AMI 1) - at or >Goalo ASA @ discharge (AMI 2) - at or >Goal o Beta Blocker @ discharge (AMI 3)- at or >Goal o ACEi/ARB @ discharge (Ami 5)- at or >Goal o Thrombolysis or Primary PCI at arrival (AMI 4a & 4b)

• small cell size, ++ variation, • mean performance since May’06 (4A)40%-65% & (4B) 35%-

75% o Smoking Cessation Counselling (AMI 6)

• mean performance 50%-75% - is documentation adequate?

National Intervention-specific (as of Nov.’06)

• AMI (cont.)o Perfect Care (AMI 7)

• issues related to exclusion criteria – transfer in and out

o Inpatient Mortality (AMI 8) – • poor submission (only 2 teams since Sept)• All AMI teams should submit monthly using

“retrospective” form

National Intervention-specific (as of Nov.’06)• CLI, RRT & VAP - ICU collaborative measures –

o CLI • data submission improved - 8-20 teams submitting

data/mo.• Bloodstream infection rate /1000 days (CLI 1)

• CLIs now used routinely outside ICU you may choose to expand inclusion beyond ICU

• Insertion Bundle (CLI 2) • National mean performance 50%• Early & Full Implementation 45%-80%

• Maintenance Bundle (CLI 3) • Early & Full Implementation ~70%

National Intervention-specific (as of Nov.’06)• CLI, RRT & VAP (cont.)

o RRT • data submission improved - 11-19 teams submitting

data/mo• Percent of codes outside of ICU (RRT 2) – 70%-90% + high

SD • Utilization Rapid Response Team (RRT 3) – 1-200 + high SD

o VAP • better submission Nationally (21-41 teams/month)• VAP Bundle compliance (VAP 2) between 57-83% -

goal=95%• Be sure your teams are applying revised definition (CDC)

National Intervention-specific (as of Nov.’06)• Medication Reconciliation

o Excellent rates of submission – 27 to 69 teams/mo. o Intentional Undocumented Discrepancies (MedRec

1)o Median from 0.6 down to 0.26

o Unintentional Discrepancies (MedRec 2)o Median ranges from 0.57 to 1.00

o Likely due to CCHSA requirement and Western Collaborative

National Intervention-specific (as of Nov.’06)• Surgical Site Infection

o Excellent rates of submission likely due to Western Collaboration

• Timely Prophylactic Antibiotic (SSI 1) • Appropriate prophylactic antibiotic (SSI 2)• Appropriate Hair Removal (SSI 4) • Appropriate selection of prophylactic antibiotic (SSI 7)

o Glucose control for Major Cardiac (SSI 5) – 3 to 5 sites / month

o Glucose control applicable beyond Major Cardiac – IMH

o Normothermia (SSI 6) – 60% to 70%

National Intervention-specific (as of Nov.’06)• Surgical Site Infection (cont.)

o Strong move to full implementation

o Percent Clean Surg w/ Surgical Infection (SSI 3)• Low submission rate likely due to difficulty monitoring

SSI

o Appropriate selection of Prophylactic antibiotics (SSI-7) – to be revised by SSI faculty

Sharing the Quarterly Reports• With who do you (KOCs + Team

Leaders) share the QR info?– Team, Sr. Mgmt, Board

• What should you tell each group?

Breakout Groups1. Complete the quiz together2. Determine the message(s) for your

assigned group (i.e. Team, Sr. Mgmt, Board)

3. Report back

Questions?Thank you for your interest in SHN!Contact Information:Name Virginia FlintoftAddress University of TorontoPhone/email 416-946-8350

[email protected]

Safer Healthcare Now! Western Node

Sustaining and Sustaining and Spreading for Spreading for

SuccessSuccess

T. RollefstadT. RollefstadSIA Western NodeSIA Western Node

February 1 & 2, 2007February 1 & 2, 2007

http://www.saferhealthcarenow.ca/en/default.aspx

PurposePurposeParticipants will be able to:Participants will be able to: Understand the principles of Understand the principles of

sustainability and spreading sustainability and spreading successful initiativessuccessful initiatives

Identify how spread elements can be Identify how spread elements can be applied in a local settingapplied in a local setting

Select strategies to enhance Select strategies to enhance sustainability and spread in their sustainability and spread in their local organizationlocal organization

Definition of SustainabilityDefinition of SustainabilityThe Modernisation Agency’s working The Modernisation Agency’s working

definition of sustainability is:definition of sustainability is: when new ways of working and when new ways of working and

improved outcomes become the norm.improved outcomes become the norm.

holding the gains and evolving as holding the gains and evolving as required, definitely not going back.required, definitely not going back.

How to Spread Good Ideas: A systematic review of the literature ondiffusion, dissemination and sustainability of innovations in health service delivery and organisation Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO) April 2004 prepared byTrisha Greenhalgh, Glenn Robert, Paul Bate University College London; Olympia Kyriakidou, Fraser Macfarlane University of Surrey; Richard PeacockUniversity College London

Definition of SpreadDefinition of Spread

Spread is the extent to which learning and Spread is the extent to which learning and change principles have been adopted in other change principles have been adopted in other parts of the organisation that could benefit from parts of the organisation that could benefit from them.them.

Improvement knowledge generated anywhere in Improvement knowledge generated anywhere in the healthcare system becomes common the healthcare system becomes common knowledge and practice across the healthcare knowledge and practice across the healthcare system.system.

NHS Modernization Agency 2003NHS Modernization Agency 2003

The “Tipping Point”The “Tipping Point” ““The name given to that one dramatic moment in The name given to that one dramatic moment in

an epidemic when everything can change all at an epidemic when everything can change all at onceonce.” .”

- M. Gladwell- M. Gladwell

““The part of the diffusion curve from about 10 The part of the diffusion curve from about 10 percent to 20 percent adoption is the heart of percent to 20 percent adoption is the heart of the diffusion process. After that point, it is often the diffusion process. After that point, it is often impossible to stop the further diffusion of a new impossible to stop the further diffusion of a new idea, even if one wished to do so.” idea, even if one wished to do so.”

- E. Rogers- E. Rogers

Spread of Chronic Care Model Across Clinics

0

10

20

30

40

50

60

70

80

90

100

Sep-98

Oct Nov Dec Jan-99

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan-00

Feb

Perc

ent o

f clin

ics

impl

emen

ting

CCM

Total of 80 Clinics in Organization

The “Diffusion Curve”

“tipping point”

Innovators

EarlyAdopters

EarlyMajority

LateMajority

Laggards

2.5% 13.5% 34% 34% 16%

from Rogers, 1995

Adopter Categories

7 Deadly Sins of Spread!7 Deadly Sins of Spread!

The things we’ve learned NOT to do:The things we’ve learned NOT to do:1.1. Start with a large pilot area – Go Big Start with a large pilot area – Go Big

or Go Homeor Go Home

2. Find one person to do It ALL2. Find one person to do It ALL

3. Be vigilant and work harder3. Be vigilant and work harder

Roger Resar, MD & Carol Haraden, PhDRoger Resar, MD & Carol Haraden, PhD

4. If it works in the pilot Unit, DON’T 4. If it works in the pilot Unit, DON’T change it for spreadchange it for spread

5. Appoint the successful team leader as 5. Appoint the successful team leader as the driver for spread to the WHOLE the driver for spread to the WHOLE hospitalhospital

6. Look at the deficits on a quarterly 6. Look at the deficits on a quarterly basisbasis

7. Early on expect marked improvement 7. Early on expect marked improvement in hospital wide outcomesin hospital wide outcomes

http://www.ihi.org/NR/rdonlyres/BF88C0E6-6E30-42FB-9CAF-http://www.ihi.org/NR/rdonlyres/BF88C0E6-6E30-42FB-9CAF-88B76B53EBE4/0/Haraden_Resar7SpreadlySins.ppt88B76B53EBE4/0/Haraden_Resar7SpreadlySins.ppt

http://www.ihi.org/NR/rdonlyres/BF88C0E6-6E30-42FB-9CAF-88B76B53EBE4/0/Haraden_Resar7SpreadlySins.ppt

http://www.ihi.org/NR/rdonlyres/BF88C0E6-6E30-42FB-9CAF-88B76B53EBE4/0/Haraden_Resar7SpreadlySins.ppt

Assessed for Risk of Assessed for Risk of HypothermiaHypothermia

0%

20%

40%

60%

80%

100%

120%

Week1

Week2

Week3

Week4

Week5

Week6

Week7

Week8

Week9

Week10

Positive Conditions Positive Conditions For Spread For Spread

Synthesized Synthesized findings on major findings on major improvement improvement initiatives in the UKinitiatives in the UK

Describes the main Describes the main factors found to factors found to contribute to contribute to successful spread successful spread and sustainabilityand sustainability

Factors Affecting SpreadFactors Affecting Spread Ownership of the initiativeOwnership of the initiative Effective RelationshipsEffective Relationships People who influencePeople who influence LeadershipLeadership Dedicated resourcesDedicated resources Process of implementationProcess of implementation IncentivesIncentives Staff EngagementStaff Engagement Support at senior levelSupport at senior level Local contextLocal context Nature of initiativeNature of initiative Readiness for ImprovementReadiness for Improvement Evidence of ImprovementsEvidence of Improvements Integration into practiceIntegration into practice

Where are you at?Where are you at?Assessment ActivityAssessment Activity

ActivityActivity Think of one area you will spread to nextThink of one area you will spread to nextUsing the FACTOR WEB Tool:Using the FACTOR WEB Tool: Take 10 minutes to rate each of the Take 10 minutes to rate each of the

Factors affecting spread Factors affecting spread 0= weak 5=strong0= weak 5=strong Place a dot on the circle which intersects Place a dot on the circle which intersects

the factor linethe factor line Join the dots and shade the inner areaJoin the dots and shade the inner area

““Real improvement Real improvement comes from changing comes from changing

systems, not changing systems, not changing within systemswithin systems.”.”

– – BerwickBerwick

Testing versus Testing versus Implementation Implementation

Testing – trying and adapting Testing – trying and adapting alternatives under multiple alternatives under multiple conditionsconditions

Implementation – making a change Implementation – making a change part of the day to day operation of part of the day to day operation of the system the system

No implementation should failNo implementation should fail

Creating a New SystemCreating a New System

Hold the Gains

Spread

Improvement (test, implement)

Strategies to Hold the GainsStrategies to Hold the GainsI. During testingI. During testing

Replicate gains under a variety of Replicate gains under a variety of conditionsconditions– Test the changes under a wide range of Test the changes under a wide range of

conditions (robust design)conditions (robust design)– Judgment samplingsJudgment samplings– Planned groupingsPlanned groupings

Foolproof the new process/procedureFoolproof the new process/procedure– Reduce likelihood of mistake/errorReduce likelihood of mistake/error– Use short feedback loopsUse short feedback loops– Use technology where appropriateUse technology where appropriate

Hold the Gains:Hold the Gains:II. During ImplementationII. During Implementation

Seek and use input from othersSeek and use input from others Use multiple PDSA cycles to implement Use multiple PDSA cycles to implement

the changethe change Collect data over time when conditions are Collect data over time when conditions are

expected to changeexpected to change Redesign support processes for new Redesign support processes for new

processprocess Address the social aspects of changeAddress the social aspects of change

Hold the Gains:Hold the Gains:III. After ImplementationIII. After Implementation

Old System Old System New SystemNew SystemSome InhibitorsSome Inhibitors ““We met our goals”We met our goals” ““We assumed the improvement would hold”We assumed the improvement would hold” Other priorities took all resources away Other priorities took all resources away (not on senior management’s radar screen)(not on senior management’s radar screen) No strategies or did not learn how to hold the No strategies or did not learn how to hold the

gainsgains Infrastructure not in placeInfrastructure not in place Isolated project with a start and finishIsolated project with a start and finish

Key Components to Hold the Key Components to Hold the Gains After ImplementationGains After Implementation

CommunicationCommunication

InfrastructureInfrastructure

Effective Control SystemEffective Control System

Integrate into organizationIntegrate into organization

Regular communicationRegular communicationInformed with dataInformed with data

Support processes Support processes Leadership acountabilityLeadership acountability

Continue measuringContinue measuringKeep Core principles but allow Keep Core principles but allow

customization based on customization based on real issuesreal issues

Formalize documentsFormalize documentsEmbed in orientationsEmbed in orientations

Creating a New SystemCreating a New System

Hold the Gains

Spread

Improvement (test, implement)

Readiness to Begin Readiness to Begin Spreading ChangesSpreading Changes

There are demonstrated There are demonstrated resultsresults from from Collaborative teamCollaborative team

There is There is willwill to spread the work of the to spread the work of the Collaborative in the organizationCollaborative in the organization

Ensure strategy is a Ensure strategy is a key initiativekey initiative for the for the organizationorganization

A A senior leadersenior leader is responsible for spread is responsible for spread of the changesof the changes

Adoption is a DOING Adoption is a DOING thing!thing!

“BETTERIDEAS”

Happens over time

COMMUNICATED

Thru a SOCIAL system

Adapted from Rogers, 1995

In a concrete targeted way

(C) 2001, Sarah W. Fraser

Spread ModelSpread Model

Infrastructure,Leadership and Measurement

Better IdeasInformation about the

Innovation and “Transfer Materials”

Target Population “To and Through a

Social System”

CommunicatedModes

Purpose

Messengers

Based on materials from

IHI and Veteran’s

Health Administration

What the Improvement What the Improvement Team Can Do to Help with Team Can Do to Help with

SpreadSpread Help to make the case for Help to make the case for

change change Make it easier for others to do Make it easier for others to do

the workthe work Develop the messengersDevelop the messengers

Attributes of the Change that Attributes of the Change that Affect the Rate of AdoptionAffect the Rate of Adoption

Relative advantage Relative advantage Compatibility with current system Compatibility with current system

Simplicity of the change and transitionSimplicity of the change and transition Testability of the changeTestability of the change Ability to observe the change and its Ability to observe the change and its

impactimpact

Spread Check List –Spread Check List –Better Ideas that Spread Better Ideas that Spread

QuicklyQuickly We address the innovations’:We address the innovations’:

– Relative advantage (Relative advantage (it isit is better than better than alternativealternative))

– Trialability (Trialability (you canyou can test it firsttest it first))– Observability (Observability (you can see ityou can see it))– Compatibility with current values (Compatibility with current values (itit fitsfits))– Simplicity (Simplicity (it’s simple to understand and it’s simple to understand and

dodo))

Source: Diffusion of Innovations, Everett Rogers 1995

Spread Check List – Spread Check List – Better IdeasBetter Ideas

We can describe our changes (what), why We can describe our changes (what), why the changes were made and benefits to the changes were made and benefits to patients and staff (tell the story)patients and staff (tell the story)

We can easily show our successes and We can easily show our successes and results (show the data)results (show the data)

We have documented our story through We have documented our story through storyboards, presentations, newsletters, storyboards, presentations, newsletters, seminar materials, reports to senior leaders, seminar materials, reports to senior leaders, videos, engaging stories, FAQ’s etc. videos, engaging stories, FAQ’s etc.

We continually assess the value and quality We continually assess the value and quality of our transfer materialsof our transfer materials

Communication PlanCommunication Plan Awareness of the initiative Awareness of the initiative

– Document benefits Document benefits – Show comparative dataShow comparative data– Use multiple communication channels Use multiple communication channels

Technical knowledge Technical knowledge – Explain changes succinctlyExplain changes succinctly– Involve successful units in providing Involve successful units in providing

technical supporttechnical support– Train your messengersTrain your messengers

Spread Check List – Spread Check List – CommunicationCommunication

We have used multiple channels for We have used multiple channels for communication, focusing on interactive, communication, focusing on interactive, peer-to-peer and face-to-face methodspeer-to-peer and face-to-face methods

We communicate early and oftenWe communicate early and often We have identified our messengers, our We have identified our messengers, our

connectors and “salespeople”connectors and “salespeople” We have trained our staff and provided We have trained our staff and provided

them with the tools to tell the story them with the tools to tell the story

Spread Check List – Spread Check List – Developing the MessengersDeveloping the Messengers

We have chosen the right messengers We have chosen the right messengers – TrustedTrusted– Technically competentTechnically competent– Full member of local groupFull member of local group

We have used a two – step approachWe have used a two – step approach– From team to opinion leaders and connectorsFrom team to opinion leaders and connectors– From opinion leaders and connectors to their From opinion leaders and connectors to their

networksnetworks We have adequately educated the We have adequately educated the

messengers to deliver the message messengers to deliver the message

Social SystemSocial System Content, context, and communityContent, context, and community

– Understand the relevant Understand the relevant circumstances affecting peoples’ circumstances affecting peoples’ ability/willingness to adopt the ability/willingness to adopt the changeschanges

– Take advantage of the existing Take advantage of the existing relationships within the system relationships within the system

– Develop “communities of practice” Develop “communities of practice” among those with similar rolesamong those with similar roles

Some Things to Consider Some Things to Consider about the Social Systemabout the Social System

““Behavior change is not just about Behavior change is not just about action” (Prochaska)action” (Prochaska)

What is the plan to integrate What is the plan to integrate adopters willing to get involved?adopters willing to get involved?

What are the peer-to-peer What are the peer-to-peer opportunities?opportunities?

Plan to Reach all Units in Plan to Reach all Units in Target PopulationTarget Population

Identify who will make the adoption decision Identify who will make the adoption decision (individuals, practice group, department, facility, (individuals, practice group, department, facility, etc)etc)

Consider the following in planning the sequence Consider the following in planning the sequence for spreadfor spread– Coverage versus completenessCoverage versus completeness– How best to optimize the learning with the How best to optimize the learning with the

addition of new units addition of new units – Relationship of the units to the pilot sitesRelationship of the units to the pilot sites– Champions exist or can be developedChampions exist or can be developed– Availability of resourcesAvailability of resources

Spread Check List – Spread Check List – Target Population & Social Target Population & Social

SystemSystem We have identified our target population We have identified our target population

and spread communityand spread community We have tried to understand context of our We have tried to understand context of our

target populationtarget population We have identified existing relationships, We have identified existing relationships,

opinion leaders, innovators and early opinion leaders, innovators and early adopters in the target populationadopters in the target population

We have allowed the target population to We have allowed the target population to adapt our changes to fit their environment adapt our changes to fit their environment

Leadership’s Role in Leadership’s Role in SpreadSpread

LeadershipLeadership– Topic is a key strategic initiativeTopic is a key strategic initiative– Executive sponsor assignedExecutive sponsor assigned– Day-to-day managers identifiedDay-to-day managers identified– Goals and incentives are alignedGoals and incentives are aligned

Set-up for spreadSet-up for spread– Target populationTarget population– Are pilot sites successful? Are pilot sites successful? – Identify key groups who make adoption Identify key groups who make adoption

decisiondecision– Initial strategy to reach all sitesInitial strategy to reach all sites

Topic as a Key Strategic Topic as a Key Strategic Initiative Initiative

CCHSA – Medication Reconciliation CCHSA – Medication Reconciliation is a Required Organizational is a Required Organizational PracticePractice

CCS – Canadian Cardiovascular CCS – Canadian Cardiovascular Society has AMI Best Practice Society has AMI Best Practice Guidelines Guidelines

IHI & SHN has built momentum IHI & SHN has built momentum and awareness of 6 strategiesand awareness of 6 strategies

Spread Check List – Spread Check List – LeadershipLeadership

We have an overall spread planWe have an overall spread plan Our spread activities are included in strategic Our spread activities are included in strategic

and business plans of our organizationand business plans of our organization We have visible and active support from our We have visible and active support from our

senior leader to spread our changessenior leader to spread our changes Roles and responsibilities for spread are clearly Roles and responsibilities for spread are clearly

defineddefined Senior leader assures success, remove barriers, Senior leader assures success, remove barriers,

make case for changemake case for change Day to day leaders communicate, develop Day to day leaders communicate, develop

messengers, educate, make it easy for others to do messengers, educate, make it easy for others to do the workthe work

Additional ConsiderationsAdditional Considerations Developing the Communication Plan Developing the Communication Plan Strengthening the Social SystemStrengthening the Social System Developing the Measurement and Developing the Measurement and

Feedback System Feedback System

Measurement and Measurement and FeedbackFeedback

Data collected on: Data collected on: – Outcome measuresOutcome measures– Measures to track spread of specific Measures to track spread of specific

changeschanges Reporting to provide feedbackReporting to provide feedback

– Link to follow up guidance and action Link to follow up guidance and action Data and reporting at different Data and reporting at different

levels within the organizationlevels within the organization – Both leadership and front line Both leadership and front line

Outcome MeasureOutcome MeasureIowa Health System

% of Sampled Charts with ADEsTargets: 2002 = 10%, 2003 = 5%, 2004 = 2%

23% 20%14% 13% 12% 11% 8%

0%

10%

20%

30%

40%

50%

11/ 01/ 2001 N =33/ 142

12/ 01/ 2001 N =29/ 145

01/ 02/ 2002 N =20/ 139

02/ 02/ 2002 N =18/ 140

03/ 02/ 2002 N =19/ 154

04/ 20/ 2002 N =13/160

05/ 20/ 02 N = 12/ 160

N = Number of System ADEs/Charts Sampled System-wide

% o

f Cha

rts

Tracking the Spread of Tracking the Spread of the Changesthe Changes

Iowa Health System System-wide Diffusion - Medication FMEA

01

23

456

78

910

J un-01

J ul-01 Aug-01

Sep-01

Oct-01

Nov-01 LS1

Dec-01

J an-02

Feb-02 LS2

Mar-02

Apr-02

May-02

J un-02

J ul-02 Aug-02

Setp02

Oct-02

Nov-02

Average Waiting Time for Next Available Appointment (Days)

0

20

40

60

80

100

Apr May J un J ul Aug Sep Oct Nov Dec J an Feb Mar Apr May J un J ul Aug SepPrim Eye Audio Cardio Ortho Uro

Outcome Measure - VHA

Average Waiting Times: All Primary Care Clinics in VHA System

0

20

40

60

80

100

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May June Jul Aug Sep Oct Nov Dec Jan

2 0

0 0

2 0

0 1

2

0

Overall Outcome Measure

Measures using Small Multiples:

Overall System and 4 sites

OUR SITE

0

102030405060708090

100

Apr J un Aug Oct Dec Feb Apr J un Aug Oct Dec

SITE2

0

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20

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40

5060

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100


SITE3

0102030405060708090

100


SITE4

0102030405060708090

100


These graphs re called small multiples. They are designed for a quick visual comparisons of the data from each site The graphs are all presented on the same scale (both x and y axis)

The graphs for each site are called small multiples. They are designed for a quick visual comparisons of the data from each Site. The graphs are all presented on the same waiting time scale (0 to 100 days) and time scale (4/00 - 12/01).

Spread Check List – Spread Check List – InfrastructureInfrastructure

Measures about our changes and spread Measures about our changes and spread plans are reviewed by our team and our plans are reviewed by our team and our sponsorsponsor More balancing, upstream and downstreamMore balancing, upstream and downstream Less frequentLess frequent

We have a method/process for knowledge We have a method/process for knowledge transfer (including improvement science), transfer (including improvement science), continual learning and sharing informationcontinual learning and sharing information

ActivityActivity Take 10 minutes to review the Spread Take 10 minutes to review the Spread

ChecklistChecklist Check off the items your team has Check off the items your team has

accomplishedaccomplished What area/s still needs work?What area/s still needs work?

Put it all together into Put it all together into a Plana Plan

Developing a Plan for Developing a Plan for SpreadSpread

Develop a Spread AIMDevelop a Spread AIM Leadership Leadership Set-up/ infrastructureSet-up/ infrastructure CommunicationCommunication Social SystemSocial System Measurement and FeedbackMeasurement and Feedback

Spread What: Spread What:

Target Level of Performance:Target Level of Performance:

Spread to Whom: Spread to Whom:

Time frame:Time frame:

Developing a Spread Aim

Developing an Initial Developing an Initial Spread PlanSpread Plan

Consider how the organization structure Consider how the organization structure can be used to facilitate spread:can be used to facilitate spread:– How are adoption decisions made?How are adoption decisions made?– What infrastructure enhancements will assist in What infrastructure enhancements will assist in

achieving the Aim?achieving the Aim?– How will the spread efforts be transitioned to How will the spread efforts be transitioned to

operational responsibilities?operational responsibilities?

Spread WhatSpread What: Ventilator Bundle: Ventilator Bundle Target Level of PerformanceTarget Level of Performance: Zero Cases : Zero Cases

of VAP of VAP Spread to WhomSpread to Whom: All ICUs in our 10 : All ICUs in our 10

hospital systemhospital system Time FrameTime Frame: By September 2007: By September 2007

Sample Spread Aim: Prevent Ventilator Associated Pneumonia by

Implementing the Vent Bundle

Spread WhatSpread What: BPMH & Documentation form: BPMH & Documentation form Target Level of PerformanceTarget Level of Performance: Zero : Zero

unintentional discrepanciesunintentional discrepancies Spread to WhomSpread to Whom: All units in our 10 hospital : All units in our 10 hospital

systemsystem Time FrameTime Frame: By September 2007: By September 2007

Sample Spread Aim: Prevent Adverse Drug Events by

Implementing BPMH and Documentation form

Levels of Spread Activities – Levels of Spread Activities – Level 1Level 1

Set-up/InfrastructureSet-up/Infrastructure– Establishing steering committeesEstablishing steering committees– Orienting leadership groupsOrienting leadership groups– Organizing data collectionOrganizing data collection– Developing materialsDeveloping materials– Identifying successful sitesIdentifying successful sites

General CommunicationGeneral Communication– Wide spread dissemination of information about Wide spread dissemination of information about

the initiativethe initiative– Sending out comparative dataSending out comparative data– Holding meetings with a broad range of potential Holding meetings with a broad range of potential

adoptersadopters

Level 2 Spread ActivitiesLevel 2 Spread Activities Identification of Early AdoptersIdentification of Early Adopters

– The push of general communication from The push of general communication from Level 1 results in pulling adopters to the Level 1 results in pulling adopters to the projectproject

– The number and different categories of The number and different categories of adopters identified are good measures for adopters identified are good measures for LEVEL 1 activitiesLEVEL 1 activities

– The key activity here is identification of the The key activity here is identification of the early adopters and a plan for how they will be early adopters and a plan for how they will be integrated into the workintegrated into the work

Level 3 Spread ActivitiesLevel 3 Spread Activities Strategies to Get Adopters to ActionStrategies to Get Adopters to Action

– Organizing purposeful peer-to-peer interaction Organizing purposeful peer-to-peer interaction that integrate adopters identified in your that integrate adopters identified in your LEVEL 2 activities (e.g. mentoring, visiting, LEVEL 2 activities (e.g. mentoring, visiting, meetings with specific invitation lists, and meetings with specific invitation lists, and group discussions around materials on the group discussions around materials on the website)website)

– Champions for successful sites identified in Champions for successful sites identified in Level 1 can help to provide the technical Level 1 can help to provide the technical support needed although each early adopter support needed although each early adopter should be able to add to the knowledge should be able to add to the knowledge exchange exchange

Communication PlanCommunication Plan

•Building AwarenessBuilding Awareness•Moving adopters from decision Moving adopters from decision

to actionto action•Supporting and mentoring Supporting and mentoring

adoptersadopters

Level 4 Spread ActivitiesLevel 4 Spread Activities Feedback loops for LEVEL 3 activitiesFeedback loops for LEVEL 3 activities

– Collecting and reviewing data on the adoption of the Collecting and reviewing data on the adoption of the key changes and the outcome measureskey changes and the outcome measures

– The aim is to understand how LEVEL 3 activities The aim is to understand how LEVEL 3 activities might be refined to improve upon results and how might be refined to improve upon results and how this might be best communicated with adoptersthis might be best communicated with adopters

Feedback and adjustments may be needed for:Feedback and adjustments may be needed for:– Communication plansCommunication plans– Materials and informationMaterials and information– Support and mentorshipSupport and mentorship– Infrastructure issuesInfrastructure issues– Social system issuesSocial system issues

Spreading the StorySpreading the Story Describes steps to Describes steps to

developing a developing a communication communication planplan

How to for “telling How to for “telling the story”the story”

Quick readQuick read

Sarah Fraser - Health Management June 2000; 10-12

Some Theory on SpreadSome Theory on Spread Everett Rogers: Everett Rogers: Adopter categories; Attributes Adopter categories; Attributes

of an innovation; Different aspects of of an innovation; Different aspects of communication communication

John Seely Brown: John Seely Brown: Content, context, communityContent, context, community Malcolm GladwellMalcolm Gladwell: Tipping point; Stickiness : Tipping point; Stickiness

factor; Law of the few; Power of contextfactor; Law of the few; Power of context Nancy Dixon:Nancy Dixon: Explicit and tacit knowledge Explicit and tacit knowledge James Prochaska: James Prochaska: Stages of Change ModelStages of Change Model Albert BanduraAlbert Bandura: Preconditions for change; : Preconditions for change;

Motivation; Modeling and guided enactmentMotivation; Modeling and guided enactment

AcknowledgementsAcknowledgements Strategies for Spreading Improvements in Health Care, October Strategies for Spreading Improvements in Health Care, October

14, 200414, 2004 Marie W. Schall, Institute for Healthcare Marie W. Schall, Institute for Healthcare ImprovementImprovement

Holding the Gains and Spread, July 11, 2006Holding the Gains and Spread, July 11, 2006Bruce Harries, Improvement AssociatesBruce Harries, Improvement Associates

The Seven ‘Spreadly’ Sins, October 18, 2006 The Seven ‘Spreadly’ Sins, October 18, 2006 Roger Resar, MD & Carol Haraden, PhDRoger Resar, MD & Carol Haraden, PhD

Sustainability and Spread, August 28, 2006Sustainability and Spread, August 28, 2006Diane Jacobsen, MPH, CPHQ, IHI National DirectorDiane Jacobsen, MPH, CPHQ, IHI National Director

ReferencesReferences

Attewell, P. Technology Diffusion and Organizational Learning, Attewell, P. Technology Diffusion and Organizational Learning, Organizational Organizational ScienceScience, February, 1992, February, 1992

Bandura A. Bandura A. Social Foundations of Thought and ActionSocial Foundations of Thought and Action. Englewood Cliffs, N.J.: . Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986.Prentice Hall, Inc. 1986.

Brown J., Duguid P. Brown J., Duguid P. The Social Life of InformationThe Social Life of Information. Boston: Harvard Business . Boston: Harvard Business School Press, 2000.School Press, 2000.

Cool et al. Diffusion of Information Within Organizations: Electronic Switching Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the Bell System, 1971 –1982, in the Bell System, 1971 –1982, Organization ScienceOrganization Science, Vol.8, No. 5, , Vol.8, No. 5, September - October 1997.September - October 1997.

Dixon, N. Dixon, N. Common KnowledgeCommon Knowledge. Boston: Harvard Business School Press, 2000.. Boston: Harvard Business School Press, 2000.Fraser S. Spreading good practice; how to prepare the ground, Fraser S. Spreading good practice; how to prepare the ground, Health Health

ManagementManagement, June 2000., June 2000.Gladwell, M. Gladwell, M. The Tipping Point. The Tipping Point. Boston: Little, Brown and Company, 2000.Boston: Little, Brown and Company, 2000.Kreitner, R. and Kinicki, A. Kreitner, R. and Kinicki, A. Organizational Behavior (2Organizational Behavior (2ndnd ed.) Homewood, ed.) Homewood,

Il:Irwin ,1978.Il:Irwin ,1978.

ReferencesReferences

Langley J, Nolan K, Nolan T, Norman, C, Provost L. Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement GuideThe Improvement Guide. . San Francisco: Jossey-Bass 1996.San Francisco: Jossey-Bass 1996.

Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Implement Practice Guidelines. Implement Practice Guidelines. JAMAJAMA, Vol. 265(17); May 1, 1991, pg. 2202-, Vol. 265(17); May 1, 1991, pg. 2202-2207. 2207.

Myers, D.G. Social Psychology (3Myers, D.G. Social Psychology (3rdrd ed.) New York: McGraw-Hill, 1990. ed.) New York: McGraw-Hill, 1990.Prochaska J., Norcross J., Diclemente C. In Search of How People Change, Prochaska J., Norcross J., Diclemente C. In Search of How People Change,

American Psychologist, American Psychologist, September, 1992.September, 1992.Rogers E. Rogers E. Diffusion of InnovationsDiffusion of Innovations. New York: The Free Press, 1995. . New York: The Free Press, 1995. Wenger E. Wenger E. Communities of Practice. Communities of Practice. Cambridge, UK: Cambridge University Cambridge, UK: Cambridge University

Press, 1998.Press, 1998.

communicating and spreading success sponsored by: health quality council of alberta

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