The AHRQ Health Care Innovations Exchange: Moving to Scale

1. The AHRQ Health Care Innovations Exchange: Moving to Scale Veronica F. Nieva, PhD Westat Rockville, MD AHRQ 2011 Annual Conference Leading Through Innovation & Collaboration September 19, 2011 Bethesda, MD

2. After Innovation– Scale up and Spread • Over 600 evidence-based Innovations • How to bridge the gap between these innovations and potential adopters? • How to accelerate the rate of spread?

3. Innovation Scaling “Deliberate efforts to increase the impact of health service innovations locally tested in pilot or experimental projects, so as to benefit more people and to foster policy and program development on a lasting basis.” Simmons R, Fajans P, Ghiron L (2007)

4. Dissemination: the targeted distribution of information and intervention materials to specific audiences Implementation: the use of strategies to adopt and implement interventions within specific settings + Scaling

5. Key Concepts • Types of Scaling • Factors Affecting Scaling

6. Types of Scaling • Top – down • Hierarchical • Centralized • Bottom – up • Led by inspired individuals • Relational • Network based • Participatory

7. Types of Scaling Vertical Scaling Horizontal Scaling Functional Scaling

8. Factors Affecting Scale Up The Innovation The Innovator Adopting Organizations SCALE UP Scaling Organizations Methods for Scaling Policy and Market Environments Stakeholder Organizations

9. Is the InnovationReady for Scaling? The Innovation • Credibility • Relevance and Compatibility • “Trialability” /Testable • Evidence • Clear benefits for each stakeholder group • Well- defined core components • Cost efficiency • Return on investment (ROI)

10. Is the Adopting OrganizationReady for the Innovation? Adopting Organizations • Internal Change Champions • “Learning Organization” • Innovation-specific capacity • Space? • Professional role changes? • Technology? • Work flow impact? Patient role changes? • Beware of innovation fatigue!

11. Is the InnovatorReady to Scale? The Innovator • Innovator and Spread roles differ • Innovators vs. Entrepreneurs • Many innovators are not interested in spread • Academic research • Specific problem solving • Interested innovators need to learn spread skills • “Marketing” is not a dirty word”

12. What Roles Might Scaling Organizations Have? Scaling Organizations • Visioning and planning • Stakeholder assessment • Coalition and partnership building • Process documentation • Project evaluation • Fundraising

13. What Methodscan be Used to Scale? Methods for Scaling • “Campaigns” • Top-down • National, state or community levels • Public or private initiatives • Often with supportive regulations • Across sectors and involving many organizations

14. Methods for Scaling • More “Top-Down” Methods • Executive Mandates – top down, within system • Wave sequence – unfolding within system • Extension Agents – agricultural model

15. Methods for Scaling • Technical Assistance • Consulting • Collaborative Learning • Licensing/Franchising • Credentialing

16. How can Stakeholder Organizations be Engaged? Insurers Media Professional Associations Regulators States Federal Agencies Knowledge Brokers Universities Foundations Scaling requires developing relationships and aligning incentives among stakeholders

17. Does thePolicy Environment Support the Innovation? Policy and Market Environments • Supportive legislation and regulations • Affordable Care Act • Medicare Shared Savings Program (ACOs) • Policy barriers • E.g. Volume based reimbursement policies

18. Is theMarket EnvironmentSupportive? Policy and Market Environments • Competitive advantage of the innovation, vis-à-vis comparables • Readiness of the potential adopter “markets”— organizations, providers, patients

19. Some Questions • WHO should lead Scale Up and Spread efforts? • WHAT would an effective Scale Up and Spread infrastructure look like? • HOW should individual behaviors change to support spread?

20. References • Cooley L, Kohl R. Scaling Up: From Vision to Large Scale Change --A Management Framework for Practitioners. Management Science International. Washington DC, March 2006. • Going to Scale: Can we bring more benefits to more people more quickly? Workshop Highlights (draft) presented by the CGIAR-NGO Committee and The Global Forum for Agricultural Research (with other organizations), April 2000. • Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Quarterly, 82(4), 581-629 • Hartmann A, Linn JF. Scaling Up: A Framework and Lessons for Development Effectiveness from Literature and Practice. Brookings Institute (Wolfensohn Center for Development) Working Paper 5, Oct 2008. • Massoud MR, Donohue KL, McCannon CJ. Options for Large-scale Spread of Simple, High-impact Interventions. Technical Report, Sept 2010 for USAID.

21. References • McCannon CJ, Berwick D, Massoud MR. The Science of Large Scale Change. JAMA. 2007; 298(16):1937-1939. • Norton WE, Mittman BS. Scaling Up Health Promotion/Disease Prevention Programs in Community Settings: Barriers, Facilitators, and Initial Recommendations. Jan 2010, Report submitted to Patrick and Catherine Weldon Donaghue Medical Research Foundation (available on http://sss.donaghue.org). • Rogers, E. M. (2003). Diffusions of Innovations. New York: Free Press. Fifth Edition • Simmons R, Shiffman, J. Scaling-up health service innovations: A framework for action. In Simmons R, Fajans P, Ghiron L (Eds.), Scaling-up health delivery: From pilot innovations to policies and programmes. Geneva, Switzerland: World Heath Organization, 2007.  • Uvin, P (1995). “Fighting Hunger at the Grassroots: Paths to Scaling Up,” World Development, 23(6): 927-939. • Yuan CT, Nembhard IM, Stern AF, Brush JE, Krumholz HM, Bradley EH. Blueprint for the Dissemination of Evidence-Based Practices in Health Care. The Commonwealth Fund. Issue Brief, May 2010.