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.

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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


� 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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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

© 2015 Kaiser Foundation Health Plan, Inc. Reproduce by permission only.5

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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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

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Test

Scale-up


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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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)


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.

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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?


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

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Key components ≈ Minimum specifications

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“The Greatest glory in living lies not in never falling,

but in rising every time we fall.”- Nelson Mandela

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