Marie  Schall,  MA  Institute  for  Healthcare  Improvement  

The presenter has nothing to disclose

November  10,  2015      

Successful Strategies for Getting Results at SCALE

Objectives

Apply effective strategies for sustaining improvements and getting results at scale Leverage the role of the pilot teams in expanding improvements within municipalities Identify role of municipal and facility leaders in expanding improvements within municipalities

Improvement   Hold  Gains   Results  at  Scale  

Creating a New System

Design for Scale

Improvement  

Hold  Gains  

Get  Results  at  Scale  

The Sequence of Improvement

Sustaining improvements and getting results at scale

Developing a change

Implementing a change

Testing a change

Act   Plan  

Study   Do  

Theory and Prediction

Test under a variety of conditions

Make part of routine operations

Holding  the  Gains  

20  

Changes that “Stick”

Think of a time in your experience when an improvement became a standard part of daily work Are the gains from that change still there? ─ If yes, what was done that resulted in the

gains being held? ─ If no, why did the gains fail to be held? What

got in the way?

Improving Likelihood that We Will Hold Gains: During Testing

Purposefully test the changes under a wide range of conditions (robust design) –  Day shift/night shift, experienced/ inexperienced staff

Foolproof the new process/procedure –  Look for ways to use constraints, affordances, reminders,

differentiation

Use technology where appropriate –  Look for opportunities to use computers, bar coding ,etc.

Acknowledgement: Sandy Murray

To Implement . . . Cultivate leadership Assign accountability Use PDSA cycles to test implementation steps Establish buy–in, build consensus Build communication channels Create an infrastructure and support

Cycle No. Change Tested or Implemented Lead June July August September October November

24 1 8 15 22 29 5 12 19 26 2 9 16 23 30 7 14 21 28 4 11 18 25

Policies

Documentation

Hiring Procedures

Staff education/training

Job descriptions

Information Flow

Equipment Purchases

PROJECT  TEAM  WORKSHEET:    Redesign  of  Support  Processes  for  ImplementaEon  of  Change                        Change  Implemented:    ________________________  

                                                                                                             Date:            

After Implementation: Key Components of Strategy

Continue Communication –  Publicize benefits, document improvement, keep contact w/ team after initial

improvement effort Continue to Build Infrastructure

–  Job descriptions, policies, hiring, orientation, supply stream, etc. –  Assign ownership for improvement and maintenance work of the new process –  Senior leaders held responsible for efforts to sustain

Design an Effective Control System –  Use your internal QA/I resources and integrate activities into hospital-wide

control system –  Plan to standardize new process and verify conformance to the standard –  Graphically monitor data for performance/outcomes

Example of Continuing use of Run Chart to Hold the Gains from Safety Collaborative

Holding the Gains

Collaborative

John Whittington OSF Healthcare

Expanding the Scope of Change

What Does Full Scale Mean?

The Total System

A PS D

A P

S D

Small-scale tests of change

Initial System or Population of Focus

A P

S D

Ghana Case Study

h%p://www.ihi.org/Engage/Ini4a4ves/ghana/Pages/default.aspx  

The Scale-up Framework P15

AdopEon  Mechanisms  

Set-‐up   Build  Scalable  Unit  

Test    Scale-‐  Up   Go  to  Full-‐Scale  

Support  Systems  

Phases  of  Scale-‐up  

Best  PracEce  exists  

New  Scale-‐up  Idea  

Leadership,  communica4on,  social  networks,  culture  of  urgency  and  persistence  

Learning  systems,  data  systems,  infrastructure  for  scale-‐up,  human  capacity  for  scale-‐up,  capability  for  scale-‐up,  

sustainability  

How do you know you are ready to take your improvements to scale?

There is an intention to take improvements to scale

The improvement is a key initiative for the organization in the next year

A Senior Leader(s) is responsible and accountable for coordination and scale-up of the work of the improvement team

You have built and tested a “scalable unit”

Challenge Question for Today!

There are five frogs on a log….five decide to jump in….how many frogs are left on the log?

Closing the Gap!

0 10 20 30 40 50 60 70 80 90

100

Perc

ent

Time

early adopters early-late majority laggards

Rate of Awareness

Rate of Adoption

What The Improvement Team Can Do to Help with Adoption

Help to “make the case” for change Make it easier for others to do the work Develop the messengers

Help to Make the Case for Change

What are the benefits of the improvement you are making? –  To patients –  To providers and care teams

Show the results –  Evidence supporting the changes (literature,

experience) –  Two or three good annotated run charts

Promote your work: “Make it memorable” –  Patient stories –  Visual displays

Develop the Messengers

Choose the right messengers – Opinion leaders – Connectors

Educate the messengers to deliver the message

–  Include peer-to-peer communication

How Can We Foster the Adoption of Successful Change Ideas?

The traditional approaches

Policy Manual

Memo Date: Fe

bruary 2012

To: All Staff

From: Management

Starting ne

xt Monday, all staff wil

l be

expected to implement

the new

procedure we just test

ed in the 3 West

med/surg unit.

It worked th

ere so in order to save

time,

everyone will now start

doing the new

procedure like 3 West

.

Thank y

ou for your

cooperation.

People who adopt new ideas go through these five stages!

1. Awareness 2. Persuasion 3. Decision 4. Implementation 5. Confirmation

Stages of Adoption

Prochaska J, Norcross J, Diclemente C. In Search of How People Change, American Psychologist, September, 1992.

Diffusion of Innovations A theory for understanding how people respond to innovation…

Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.

…  and  how  to  use  those  responses  to  drive  needed  change  

Adoption is a SOCIAL thing!

A better idea…

…communicated through a social network…

…over time

Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.

An Early Adopter

Roger’s Adopter Categories

Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.

‘Traditionalists’

28

Rela4ve  Advantage   Simple   Trialable   Compa4ble   Observable  

Attributes of an Idea that Facilitate Adoption

Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.

Let’s Evaluate a Change…..

In pairs, rate a change from the adopters point of view. Use a 1- 5 scale and rate each of the 5 attributes:

–  1 - change is very weak relative to this attribute –  3 - change is okay relative to this attribute –  5 - change is very strong relative to this attribute

Total the evaluations for each of the attributes Attributes to Evaluate:

Relative advantage (evidence from testing) Compatibility with current system (structure, values, practices) Simplicity of the change and transition Testability of the change Ability to observe the change and its impact

Adopter Exercise With your partner create a 30-second “elevator speech” that “makes the case” to a colleague about why they should adopt your improvement

–  Try your pitch out on someone from a different pair –  Switch roles and listen to their pitch

OR - With your partner create a 30-second “elevator speech” that “makes the case” to a municipal leader about why they should support the adoption of your improvement

–  Try your pitch out on someone from a different pair –  Early adopter, early majority, late majority or traditionalist

Be prepared to discuss: –  What makes for a good “pitch” –  What challenges did you have in creating “the pitch”? –  What might you do to make a stronger case for adoption?

The WAY in Which We Communicate is Important

SHARE INFORMATION

SHAPE BEHAVIOUR

General Publications flyers newsletters videos articles posters

Personal Touch letters cards postcards

Interactive Activities telephone email visits seminars learning sets modeling

Face-to-face one-to-one mentoring shadowing

(C) 2001, Sarah W. Fraser (Adapted from Ashkenas, 1995)

Public Events Road shows Fairs Conferences Exhibitions Mass mtgs

Moving Adopters from Decision to Action

Information about the changes Mentors, coaches or experts to get answers to questions Connections with peers Feedback Accountability for results Encouragement and support from leaders

Objectives – Leaders’ Role Setting the agenda for change Assigning responsibility Providing resources and support Monitoring and guiding the effort Sustaining improvements

   

Leader’s Role

   

Creating Support Structures

Learning system –  How people will be connected to learn improvements

Data systems –  Identify data, collection methods, method for review

and accountability Infrastructure –  Staffing, resources, communication systems, etc.

Capability for scale-up –  What improvement skills and training are needed

Sustainability –  Creating reliable systems (i.e., the train tracks)

Challenge Question for Today!

There are five frogs on a log….five decide to jump in….how many frogs are left on the log?

The Scale-up Framework P37

AdopEon  Mechanisms  

Set-‐up   Build  Scalable  Unit  

Test    Scale-‐  Up   Go  to  Full-‐Scale  

Support  Systems  

Phases  of  Scale-‐up  

Best  PracEce  exists  

New  Scale-‐up  Idea  

Leadership,  communica4on,  social  networks,  culture  of  urgency  and  persistence  

Learning  systems,  data  systems,  infrastructure  for  scale-‐up,  human  capacity  for  scale-‐up,  capability  for  scale-‐up,  

sustainability  

References Attewell, P. Technology Diffusion and Organizational Learning, Organizational Science,

February, 1992 Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice

Hall, Inc. 1986. Brown J., Duguid P. The Social Life of Information. Boston: Harvard Business School

Press, 2000. Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the

Bell System, 1971 –1982, Organization Science, Vol.8, No. 5, September - October 1997.

Dixon, N. Common Knowledge. Boston: Harvard Business School Press, 2000. Fraser S. Spreading good practice; how to prepare the ground, Health Management, June

2000. Gladwell, M. The Tipping Point. Boston: Little, Brown and Company, 2000. Kreitner, R. and Kinicki, A. Organizational Behavior (2nd ed.) Homewood, Il:Irwin ,1978. Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San

Francisco: Jossey-Bass 1996. Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Implement

Practice Guidelines. JAMA, Vol. 265(17); May 1, 1991, pg. 2202-2207.

References McCannon CJ, Schall MW, Perla RJ. Planning for Scale: A Guide for Designing Large-

Scale Improvement Initiatives. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008.

Myers, DG. Social Psychology (3rd ed.) New York: McGraw-Hill, 1990. Nolan, KM; Schall, MW, ed.: Spreading Improvement across Your Health Care

Organization. Joint Commission on Accreditation of Healthcare Organizations and the Institute for Healthcare Improvement, 2007, pp. 1-24.

Nolan K., Nielsen G, Schall M: Developing Strategies to Spread Improvements. From Front Office to Front Line: Essential Issues for Health Care Leaders, Joint Commission Resources, Berman S. (ed.) 145 - 178, 2005.

Prochaska J, Norcross J, Diclemente C. In Search of How People Change, American Psychologist, September, 1992.

Rogers E. Diffusion of Innovations. New York: The Free Press, 1995. Wenger E. Communities of Practice. Cambridge, UK: Cambridge University Press,

1998.

Free Resources 100K Lives Campaign Guide on Sustainability and Spread

http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideSustainabilitySpread.aspx

White Paper on Spread http://www.ihi.org/IHI/Topics/Improvement/SpreadingChanges/