d8/e8: spread and scale of effective practices -...
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D8/E8: Spread and Scale of Effective PracticesLisa Schilling, RN, MPH Vice President, CMI Center for Health Systems Performance
IHI Office Practice Summit
Dallas, TX
March 17, 2014
This presenter has nothing to disclose.
Common Spread Challenges
� Dealing with multiple with competing priorities
� Cultural alignment and readiness to adopt a practice
� Time, funding and resource constraints
� Understanding when a “change package” is appropriate and needed
� How to spread the culture when spreading a practice
2© 2015 Kaiser Foundation Health Plan, Inc. Reproduce by permission only.
2
Spread and Scale
� Spread and scaling of initiatives takes sponsorship, resources and a long-view of performance
� Planning based on knowing “what good looks like” in the end is necessary
� Key to success requires creating success momentum and having a good execution and learning strategy
� Assessing both the practice being spread and site readiness at all phases is important to long term success
3© 2015 Kaiser Foundation Health Plan, Inc. Reproduce by permission only.
� Spread is “… a series of planned efforts to implement a practice, product, or process broadly in an organization ...”
� Practices are more likely to spread further as/if they … [are] sustained by multiple sites …
https://wiki.kp.org/wiki/pages/viewpage.action?pageId=158794478
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3
Two Major Influences on Speed and Completeness of Spread
An assessment of the level of agreement and certainty of importance and transferability can help determine the best spread method.
#1 The degree to
which people
agree about an
issue or decision
#2 The degree to which there is certainty the practice is transferrable
and has an impact on outcomes
A more diverse or less aligned
stakeholder group and
complicated effort leads to
slower spread and less clarity of
practice
A more homogenous or
aligned stakeholder group
and simpler effort leads to
more rapid spread and
greater clarity of practice
Matrix – representation of major variables influencing spread and ease/approach for adoption focused on alignment and complexity (Stacey, 2002)
CLEAR
COMPLICATED
COMPLEX
CHAOTIC
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Examples – High Complexity Takes More Effort
Differences in the degree of alignment and certainty of transferability between these two practices had a differentiating impact on their spread.
PRACTICE TRANSFERRABILITY
LOW
OR
GA
NIZ
AT
ION
AL
AL
IGN
ME
NT
LOW
HIGH
High Alert Medication
Program
Readmission
Reduction
• Simple
• Targeted, procedural
• Measurable
• Critical to safety
• Complex
• Multiple populations
• Multiple venues of care
• Iterative
• Measurable
• Critical to quality, safety,
experience, affordability
Over time as we gain experience,
efforts are more well adopted and
transferrable
Time to impact outcome measure ≈ 3-5 yrs.
Time to impact outcome measure ≈ 1-2 yrs.
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4
Adoption
MechanismsLeadership alignment, communication, strategy, cultural engagement,
persistence, learning/knowledge management, oversight
Human resources, technology, training, project management, change
management, performance improvement, sustainability plan
Support
Infrastructure
Start with Why
• Identify strategic priorities,
measures, goals and
communications
• Define the problem and
prioritize
• Define end state, target
audience, & timeframe
• Measurement & evaluation
with PICO
• Conduct power analysis
• Identify solution and
readiness to spread
Determine What & How• Establish contextual units for
implementation—those who will
do the work (e.g., clinic or shift,
ED or ICU)
• Ask what to stop
• Identify pilot sites, adopters,
champions, assess readiness
• Pilot and PDSA
interventions/changes
• Standardize technology and
products
• Refine measurement,
evaluation, & KM plans
• Plan infrastructure
• Define approach to spread:
PM, PI, oversight, KM
• Replicate and Test scale-up in
2-5 non-pilot sites
• Develop playbook
Scale & Sustain• Refine scalable unit and
change package based on
learning from scale up
• Refine and monitor
measurement (coverage,
reliability, impact)
• Monitor stages and
milestones of adoption
• Facilitate learning and
sharing events
• Act on triggers for support
• Provide technical support &
embed operationally
• Ensure front line staff can
make the process reliable
332211
Systems
Context
PICOPopulation
Intervention
Comparison
Outcome
PDSA, TrialInterview, Case Series, Cohort Pilot Efficacy ROI, Safety Methods/Studies/Research
Retrospective Prospective Types of Data
* Measurement, Feedback,
Knowledge Management
* Measurement, Feedback,
Evaluation &
Knowledge Management
11Identify
Identify,
Prioritize, &
Scope Problem
Solution
Set
(Intervention)
33Implement
Spread
&
Scale
Sustain
Adapted from:
Barker, Reid, and Schall, 2015
Bellows, Schilling, 2013
Embargoed
Kaiser Permanente Framework To Achieve Scale, Spread, & Sustainability
Operationalize
Set-UpScalable Unit
& Change Pkg
22
Test
Scale-up
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Spread Accelerates Through Hierarchy and Networks
KP successfully spread proven sepsis care protocols throughout the program, reducing the sepsis mortality rate from 18% to 11% saving 2100 lives in 3 years.
KPNCR identifies
opportunity in
Sepsis care
Pilot Sepsis Care
@ 2 sites
All NCR hospitals:
Multi-disciplinary sepsis teams
Leaders Front-line:
ED, ICU, HBSChampions: Regional ED leads,
chiefs & manager
peer groups quality
leaders, hospital
operations leaders
2 Regional MD
Champions
Regional
Collaborative
Surviving Sepsis
website
Improvement
Advisors;
communities of
practice; peer
group collaboration
calls
2009 & 2010
National Quality
Conference
Successful Sepsis Care
at every KP hospital
NCR; SCR; HI; NW
MD & RN train
the trainer events
across the region
All KPNCR
Medical Centers
Newsletter
1
2
3
4
5
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5
Measuring Spread
Embedding measurement and expectations for spread in operations accelerates adoption.
Key variables to monitor include:
• Movement across all applicable sites (coverage-regions and facilities)
• Reliability of implementation in delivery setting (completeness of implementation)
• Quality of intervention delivered
• Speed of improvement in outcomes (performance over time)
© 2015 Kaiser Foundation Health Plan, Inc. Reproduce by permission only.9
Identify: Determine Organizational Readiness
Start with the
end in mind
Align
improvement to
strategic objects
Assess site
readiness
to receive
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Start with the
end in mind
� Determine what
is being spread
� Define target
population &
end state
� Establish
timeframe to
achieve scale
� Define
measurement
strategy
including spread
measures
Align improvement to
strategic objects
� Determine if
improvement links
with strategic goals
� Craft a
compelling
message “start
with why”
� Determine key
members of
chartered teams -
who are the key
stakeholders &
sponsorship
Assess practice
readiness to spread
� Complete
assessment of
host site
readiness to
spread
� Plan for or
identify sites
based on
learnings
� Revisit scale,
scope and speed
Assess site
readiness
to receive
� Complete
readiness to
receive
assessment
tool
� Plan for
sequencing
based on
learnings
� Create monitor
and review plan
© 2015 Kaiser Foundation Health Plan, Inc. Reproduce by permission only.
6
How Does
It Work?
� Simplicity
� Cultural Fit
� Business Case
� Tools
� Implementation Support
Identify: Practice readiness to spread
� Demonstrated Sustainability
� Demonstrated Transfer
� Adaptability
� Unintended Consequences
Does It Work?Will It Work
Elsewhere?
� Comparative Performance
� Outcome vs. Process
� Improvement Attributable to Practice
� Strength of Evidence
� Logic Model
� Key Components
� Specific Processes
� OrganizationalEnablers
� Barriers and Risks
Will It Spread?
11© 2015 Kaiser Foundation Health Plan, Inc. Reproduce by permission only.
How much variation? Adapt locally vs. copy exactly
Adapt locally
Theory (Paul Plsek)
– Health care is aComplex Adaptive System
– Find local Attractors
– Use only Simple Rules
Strength
– Spread is more likely to occur if importers can adapt to their needs
Copy exactly
Theory (Gabriel Szulanski)
– We’re not as smart as we think
– Experience beats cleverness
– First import, then improve
Strength
– Spread is more likely to get results if importers work with exporters to learn a proven model
12
© 2015 Kaiser Foundation Health Plan, Inc. Reproduce by permission only.
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