how do we ensure that we sustain the great work from each vanguard and spread it up and down the...
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How do we ensure that we sustain the
great work from each vanguard and
spread it up and down the country?
@HelenBevan#FutureNHS
@HelenBevan #FutureNHS
Our spread goals
By 31st March 2017, to have implemented eight key elements of integrated urgent care for 20%
of the national population
By 31st March 2020, to have implemented IUC across the whole of England
@HelenBevan #FutureNHS
A story
@HelenBevan #FutureNHS
What is a theory of change?
• Created at the early stages of a spread intervention
• An explicit hypothesis that links actions with goals: “if we do this, this and this we will produce that result.”
• Likely to deliver better outcomes• Builds learning• Complements “change models” and
“methodologies”Bevan, Plsek & Winstanley
“In science, a good theory reveals compelling hypotheses that subsequent experiments will validate”
Todd Zenger
@HelenBevan #FutureNHS
Task
Draw a picture of how we will achieve the spread goals for IUC vanguards
Choose the level you want to depict:• A geographical area• Between geographical areas• Across England
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The theory of change for spread needs to be strongly linked to a narrative for spread
Theory of change• Roadmap for
change• Preconditions• Underpinning
assumptions• Change process• Outcomes
Story/narrative• Connecting to
bigger purpose• Creating meaning• Commitment to
change• Engagement/
mobilising• Compelling people
to act
shar
ed v
alue
s
In trying to bring people together to take action, we get the best results if we appeal to their values, rather than intellect or facts
Ted Fickes Shared values: where theory of change meets storytelling
@HelenBevan #FutureNHS
Some definitionsDiffusion: "the process in which an innovation is communicated through
certain channels over time among the members of a social system”Rogers 1962
Spread: “deliberate efforts to increase the impact of innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and program development on a lasting basis”
Norton and colleagues 2012
Scale up: “An enterprise with annual growth in turnover > 20% per annum over a three year period, and with more than ten employees at
the beginning of the period”Coutu 2014
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From 2001 to 2005, I was responsible for the
Research into Practice team within the NHS
Modernisation Agency
The team role was to promote the spread and sustainability of service
improvement and help to build a body of
knowledge
We found that the factors of sustainability are also the factors for effective
spread
Spread and sustainability
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5 big messages from spread efforts• Ideas do not spread instantly but flow between
groups of people• An idea or change spreads because someone
chooses to adopt it• Ideas commonly go through a process of
reinvention as they spread• “Getting to scale” beyond the initial innovators
is the hardest part• The environment and context is as important as
the idea or change and its implementation
@HelenBevan #FutureNHS
@HelenBevan #FutureNHS
Globally, we see the same challenges
With alarming regularity,
many promising pilots in the
health care improvement
and implementation field
have little overall impact
when applied more broadly”
Perla & colleagues,
Health Affairs blog,
April 2015
@HelenBevan #FutureNHS
There is a tendency towards “cargo cult” improvement
Attempts are made to spread/replicate new models from
pilot projects without a proper understanding of how they work.
They end up reproducing the superficial outer appearance but not the mechanisms that produced the
outcomes in the first instance (Dixon-Woods & colleagues 2011)
Cargo cult http://www.learningsolutionsmag.com/articles/1909/nuts-and-bolts-the-cargo-cult-of-training/pageall
@HelenBevan #FutureNHS
Components of a spread model• A spread goal• Metrics to show that the goal is being achieved• A hypothesis/change theory of how it is going to
be achieved• A spread plan, covering both anatomical and
physiological components of change• A way of assessing readiness for spread (both the
robustness of the solution and the conditions for spread)
• A spread narrative
@HelenBevan #FutureNHS
@HelenBevan #FutureNHS
What do the leaders who get the best spread results do? They:
Source: McCannon
• Attempt remarkable things (provocation and optimism)• Talk about justice• Have a shared story• Apply many levers• Play jazz (adaptive, creative) • Keep it simple (e.g., interventions, measurement systems)• Model trust • Seek affection and give recognition• Break rules (avoid consensus, condense timescales)• Go broad and deep• Respect/revere logistics
@HelenBevan #FutureNHS
My favourite spread referencesBarker P, Reid A, Schall M (2016) A framework for scaling up health interventions: Lessons from large-scale improvement initiatives in Africa Implementation ScienceBuchanan D et al (2007) The sustainability and spread of organizational change: modernizing healthcare Clay-Williams R et al (2014) Do large-scale hospital- and system-wide interventions improve patient outcomes: a systematic review BMC Health Services ResearchDe Silva D (2014) Spreading improvement ideas: tips from empirical research The Health FoundationGartner (2014) The Gartner hype cycleGreenhalgh T et al (2004) Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations Milbank Quarterly Grimshaw J et al (2012), Knowledge translation of research findings Implementation Science Kastelle T (2016) We’ve hit peak innovation (hype)McClure D & Gray I (2015a) Scaling: Innovation’s Missing Middle McClure D & Gray I (2015b) Managing the journey to scale up innovation in the humanitarian and development sectorNHS Institute for Innovation and Improvement (2012) The spread and adoption toolMcCannon J (2011) The spread problemMoore G (2015) Crossing the chasm: marketing and selling products to mainstream customersNorton W et al (2012) A stakeholder-driven agenda for advancing the science and practice of scale-up and spread in healthPerla R et al (April 2015) Health Care Reform And The Trap Of The “Iron Law” Health Affairs blogRandall S (2015) Using communications approaches to spread improvement The Health FoundationSchall M & Schilling L (2014) An introduction to spreading effective practices and From sustainability to spread and scale up