Spreading Improvements

Heidi Johns, Quality Leader, BCPSQCJuly, 2013

Objectives

To better understand:

•How is spread defined?•What are the difficulties with spreading and improvement?•How do you evaluate when it is opportune to spread an improvement?•Understand and use tools designed to evaluate spread of improvements

What is Spread?What has been your experience with spread?

“disseminate and implement successful interventions across a system or systems”

Lanham et al, How complexity science can inform scale-up and spread in health care: Understanding the role of self organization in variation across local contexts, Social Science and Medicine.

Recent research• Scale – up and Spread recent shift in

thinking • Complexity Science influences how we

think about the complex social behaviors of spread.

Complexity Science

• Complexity science will see the patterns, anticipate and influence them.

System Environment

Boundry

Plexus Institute:Complexity Lens

http://www.plexusinstitute.org/

Complexity Science

Simple Complicated

Complexity Science

Complex

Complex systems • What are the compositions of complex

systems?

• Complexity and interrelationship is problematic.

• Self – organization

• Interdependencies

• Sense making

Self-Organization

• Variation• Patterns• Contextual• Influential

“Deliberately attending to patterns of self-organization can be a powerful strategy for improving diffusion of effective health care

practices across diverse settings”

Lanham et al, How complexity science can inform scale-up and spread in health care: Understanding the role of self organization in variation across local contexts, Social Science and Medicine.

Interdependencies

•Relationship•Infrastructure and Technology•Patterns

Sensemaking

“…is the process through which people assign meaning to experience.” (Lanham, 2012)

Key Themes

•Human dimension•Diffusion of knowledge•Infrastructure

• What do you want to spread?• Who is the spread intended for?• How are we going to spread?

Spread Checklist

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):339-347.

Infrastructure,Leadership and Measurement

Better IdeasInformation about the

Innovation and “Transfer Materials”

Target Population

“To and Through a

Social System”

CommunicatedModes

PurposeMessengers

• This is the visibility– Document the story: storyboards,

presentations– Tell the story– Share the data

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):339-347.

Better IdeasInformation about the

Innovation and “Transfer Materials”

• Communicate often• Communicate in different ways• People all know and can tell the story

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):339-347.

Communication

•Identify existing relationship, leaders, innovators•Change leaders can adapt changes to fit environment•Develop the messengers from the team – educate and support them with the messaging

Target Population

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):339-347.

• Roles and responsibilities are planned• Spread plan is developed and fits• Methods for knowledge transfer• Measures are in placeNolan 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):339-347.

Infrastructure

Common “Spread” Problems

Keeping the Engine Running:Sharing Directions for Successful Spread & Sustainability

Dr. Lynne MaherHead of Innovation Practice, NHS UK

Exercise• At your table you have some of the Myths and

Don’ts with respect to the spread of improvements.

• With your table discuss how you would turn those Myths and Don’ts into Reality and Do’s

20 minutes

Reality and Do’sLocal Small Scale Testing, Local Implementation under

multiple conditions, Spread Small scale testing is crucial to learning how to neutralise or

overcome barriers

Front line staff opinions generated from small scale testing are essential in creating a clearly defined process

Most processes can be “firmed up” in 3 or 4 cycles of testing and in the long run will be faster and have more chance of success than larger scale implementation

Spread is a TEAM effort

A process dependent on a single individual is basically not a sustainable process

When key individuals are absent, the reliability of the process will deteriorate within days

Expecting vigilance and hard work to solve problems

Hold the gains with infrastructure support Hard work and vigilance cannot be maintained over the

long term A process that succeeds using hard work and vigilance is

hard to teach to new employees A process dependent on hard work is difficult to test for

competency

Choose the Non-negotiables but allow local customization

Without allowing some key elements of customization, successful spread will be very unlikely.

Customization should be allowed, but controlled.

Customization should be based on understanding defects. Study small samples and customize based on the learning.

Choose the Spread Team based on the scope of the spread

Using the successful leader in one unit to be responsible for spread will burn out this person unless they have been specifically given the job of champion

Allowing others to assume the responsibility helps builds the infrastructure to sustain the process

Spread requires local leaders with a common goal set by leadership

Frequently look at the spread measures to “tailor” the work of spread

Look at defects as they occur both when initially testing and when spreading

Use the “10 Chart Strategy”

Look at small samples on a daily or every other day basis

Outcome improvement needs widespread reliable processes & implementation

Outcomes can not be expected to change unless processes change. Staff can be responsible for process improvement.

If processes becomes highly reliable the outcome will follow as long as it is connected to science.

Outcomes will change on the pilot unit only after processes become more reliable.

NHS Spread tool• Questions which will help you prepare and

frame your improvements• Three categories:

• People• Innovation • Context

http://www.institute.nhs.uk/innovation/spread_and_adoption/spread_and_adoption.html

Take the remainder of the time and complete the spread tool developed by the NHS.

Questions?