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The Spread Problem
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  1. The Spread Problem The Challenge and Promise of Delivery System Research: A Meeting of AHRQ Grantees, Experts, and Stakeholders Joe McCannon Centers for Medicare and Medicaid Services February 17, 2011

  2. Ground to Cover • The Spread Problem • A Possible Solution (Framework) • Open Questions • Your Ideas and Advice

  3. “I think when people look back at our time, they will be amazed at one thing more than any other. It is this – that we do know more about ourselves now than people did in the past, but that very little of this knowledge has been put into effect.” – Doris Lessing 3

  4. Why Do We Fail to Take Effective Practice to Scale? • Because we lack incentives to do so

  5. Typical Explanation R&D Prototype Dissemination 5

  6. A More Accurate Representation? R&D Prototype Dissemination 6

  7. Why Do We Fail to Take Effective Practice to Scale? • Because we lack incentives to do so • Because we don’t expect to do so

  8. Why Do We Fail to Take Effective Practice to Scale? • Because we lack incentives to do so • Because we don’t expect to do so • Because we don’t appreciate how large-scale change unfolds

  9. A Sequence of Change • An innovative discovery • A demonstration in 50 hospitals • Outstanding results in 4 states • Interest from purchasers and payers • A state law in 14 states • A national mandate • A part of graduate-level training • An expectation and a standard • Confidence in ability to make change • More ambitious aims

  10. Why Do We Fail to Take Effective Practice to Scale? • Because we lack incentives to do so • Because we don’t expect to do so • Because we don’t appreciate how large-scale change unfolds • Because we don’t know how to do so (or at least we don’t approach the challenge systematically enough)

  11. A Framework 11

  12. Current Environment (Will) • Political and economic environment • Leadership engagement • Prioritization scheme • Forces for change • Incentives for change 12

  13. Levers for Change • Payment • Transparency • Regulation • Sensationalism • Guilt • Recognition • Professionalism • Affection • Personal considerations (de-zombification)

  14. Foundation (Timing) • Prior work to establish efficacy • Prior work to establish effectiveness on a smaller scale • Degree of awareness • Degree of confidence 14

  15. Framing • Problem definition • Explicit aim-setting • Tacit aim-setting • Operational image • Narrative image (predicted sequence of change over time) 15

  16. Nature of the Intervention • Evidence base • Emotional resonance • Simplicity • Trial-ability/Observability 16

  17. Structural Context • Local infrastructure • Local patterns of behavior (centers of influence) • Rules base • Financing paradigms • Geography 17

  18. Method • Technical approach to scale up OR • “Lever mix” • Data collection • Recursive evaluation • Knowledge management • Logistics/resource management 18

  19. Methods for Spread • Natural diffusion • Breakthrough Series Collaborative model • Extension agents • Emergency mobilization • Campaign model • Social movements • Wave sequence (wedge and spread) • Broad and deep • Hybrid models 19

  20. A Framework 20

  21. How Do The Best Practitioners Stimulate Change at Scale and Spread Effective Practices? They tend to address six key questions: • How do you get people to care (and care enough to take action)? • Where are you in the process of change (foundations/history)? • What is your “hard count” (explicit and implicit aims) and your story for achieving it? • What is the nature of your intervention? • What is the nature of your social system? • How will you spread your better practice (method)? 21

  22. Durable Lessons on Managing Change at Scale (What Do the Best Do?) • They attempt remarkable things (provocation and optimism) • They talk about justice • They have a shared story • They apply “many levers” • They play jazz • They keep it simple (e.g., interventions, measurement systems) • They model trust (ecosystems not hierarchies; “distributed laboratories”) • They seek affection and give recognition (recognition economy) • They break rules (avoid consensus, condense timeframes) • They go broad and deep • They revere logistics (“Amateurs discuss strategy…”) 22

  23. A Conference to Advance the State of the Science and Practice onScale-up and Spread of Effective Health Programs (July 2010) Sought to: • Review existing knowledge • Identify challenges and gaps • Set a research and practice agenda for immediate execution

  24. Major Hills to Take… • Build the field • Experiment with incentives • Experiment with new methods and technologies • Test new forms of evaluation • Create and spread practical tools

  25. Selected References • Massoud MR, Nielsen GA, Nolan K, Schall MW, Sevin C. A Framework for Spread. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006. • Simmons R, Fajans P, Ghiron L. Scaling up health service delivery. Geneva: The World Health Organization, 2007. • Victora C, Hanson K, Bryce J, Vaughan P. Achieving universal coverage with health interventions. Lancet. 2004; 364: 1541-1548. • Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC, USA: National Academies Press; 2001. • Rogers E. Diffusion of Innovations. New York: The Free Press, 1995. 25

  26. Selected References • Mangham LJ, Hanson K. “Scaling up in international health: what are the key issues?” Health Policy and Planning. 2010; 25:85-96. • Dougherty D, Conway P. The “3T’s” Road Map to Transform US Health Care. JAMA. 2008; 299 (19):2319-2321. • Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Quarterly. 2004; 82: 581-629. • Cooley L., Kohl R. Scaling Up: From Vision to Large-scale Change. Washington, DC: Management Systems International, 2006. 26

  27. Selected 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. • McCannon CJ, Berwick DM, Massoud MR. The Science of Large-Scale Change in Global Health. JAMA. October 24/31, 2007; 298: 1937 - 1939. • Berwick DM. Disseminating innovations in health care. JAMA. 2003;289(15):1969-1975. • Bradach J. Scaling Impact. Stanford Social Innovation Review. Summer 2010. 27