The AHRQ Health Care Innovations Exchange: Moving to Scale

Veronica F. Nieva, PhD

Westat

Rockville, MD

AHRQ 2011 Annual Conference

Leading Through Innovation & Collaboration

September 19, 2011

Bethesda, MD

After Innovation– Scale up and Spread

• Over 600 evidence-based Innovations

• How to bridge the gap between these innovations and potential adopters?

• How to accelerate the rate of spread?

Innovation Scaling

“Deliberate efforts to increase the impact of health service innovations locally tested in pilot or experimental projects, so as to benefit more people and to foster policy and program development on a lasting basis.”

Simmons R, Fajans P, Ghiron L (2007)

Dissemination: the targeted

distribution of information and

intervention materials to specific audiences

Implementation: the use of strategies to adopt and implement interventions within

specific settings+

Scaling

Key Concepts

• Types of Scaling• Factors Affecting Scaling

Types of ScalingBottom – up• Led by inspired

individuals

Relational• Network based• Participatory

• Top – down• Hierarchical• Centralized

Types of Scaling

Functional Scaling

Vertical Scaling

Horizontal Scaling

Factors Affecting Scale Up

SCALE UP

The Innovator

Stakeholder Organizations

The Innovation

Scaling Organizations

Policy and Market Environments

Adopting Organizations

Methods for Scaling

Is the Innovation Ready for Scaling?

• Credibility• Relevance and Compatibility• “Trialability” /Testable• Evidence• Clear benefits for each stakeholder group• Well- defined core components• Cost efficiency• Return on investment (ROI)

The Innovation

Is the Adopting Organization Ready for

the Innovation?• Internal Change Champions • “Learning Organization”• Innovation-specific capacity

• Space?• Professional role changes?• Technology?• Work flow impact? Patient role changes?

• Beware of innovation fatigue!

Adopting Organizations

Is the Innovator Ready to Scale?

• Innovator and Spread roles differ• Innovators vs. Entrepreneurs

• Many innovators are not interested in spread• Academic research• Specific problem solving

• Interested innovators need to learn spread skills • “Marketing” is not a dirty word”

The Innovator

What Roles Might Scaling Organizations

Have?

• Visioning and planning• Stakeholder assessment• Coalition and partnership building• Process documentation • Project evaluation• Fundraising

Scaling Organizations

What Methods can be Used to Scale?

• “Campaigns” • Top-down• National, state or community levels• Public or private initiatives• Often with supportive regulations• Across sectors and involving many organizations

Methods for Scaling

Methods for Scaling

• More “Top-Down” Methods

• Executive Mandates – top down, within system

• Wave sequence – unfolding within system

• Extension Agents – agricultural model

•

Methods for Scaling • Technical Assistance

• Consulting

• Collaborative Learning

• Licensing/Franchising

• Credentialing

How can Stakeholder Organizations be Engaged?

Media

Insurers

ProfessionalAssociations

States

Foundations

Regulators

Federal Agencies

KnowledgeBrokers Universities

Scaling requires developing relationships and aligning incentives among stakeholders

Does the Policy Environment Support the

Innovation?• Supportive legislation and regulations

• Affordable Care Act• Medicare Shared Savings Program (ACOs)

• Policy barriers• E.g. Volume based reimbursement

policies

Policy and Market

Environments

Is the Market Environment Supportive?

• Competitive advantage of the innovation, vis-à-vis comparables

• Readiness of the potential adopter “markets”— organizations, providers, patients

Policy and Market

Environments

Some Questions

• WHO should lead Scale Up and Spread efforts?

• WHAT would an effective Scale Up and Spread infrastructure look like?

• HOW should individual behaviors change to support spread?

References• Cooley L, Kohl R. Scaling Up: From Vision to Large Scale Change --A Management

Framework for Practitioners. Management Science International. Washington DC, March 2006.

• Going to Scale: Can we bring more benefits to more people more quickly? Workshop Highlights (draft) presented by the CGIAR-NGO Committee and The Global Forum for Agricultural Research (with other organizations), April 2000.

• Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Quarterly, 82(4), 581-629

• Hartmann A, Linn JF. Scaling Up: A Framework and Lessons for Development Effectiveness from Literature and Practice. Brookings Institute (Wolfensohn Center for Development) Working Paper 5, Oct 2008.

• Massoud MR, Donohue KL, McCannon CJ. Options for Large-scale Spread of Simple, High-impact Interventions. Technical Report, Sept 2010 for USAID.

References• McCannon CJ, Berwick D, Massoud MR. The Science of Large Scale Change. JAMA.

2007; 298(16):1937-1939.

• Norton WE, Mittman BS. Scaling Up Health Promotion/Disease Prevention Programs in Community Settings: Barriers, Facilitators, and Initial Recommendations. Jan 2010, Report submitted to Patrick and Catherine Weldon Donaghue Medical Research Foundation (available on http://sss.donaghue.org).

• Rogers, E. M. (2003). Diffusions of Innovations. New York: Free Press. Fifth Edition

• Simmons R, Shiffman, J. Scaling-up health service innovations: A framework for action. In Simmons R, Fajans P, Ghiron L (Eds.), Scaling-up health delivery: From pilot innovations to policies and programmes. Geneva, Switzerland: World Heath Organization, 2007. 

• Uvin, P (1995). “Fighting Hunger at the Grassroots: Paths to Scaling Up,” World Development, 23(6): 927-939.

• Yuan CT, Nembhard IM, Stern AF, Brush JE, Krumholz HM, Bradley EH. Blueprint for the Dissemination of Evidence-Based Practices in Health Care. The Commonwealth Fund. Issue Brief, May 2010.