Framework for Getting Results at Scale

Why we need context-sensitive implementation and scale-up designs Large scale efficacy Study Reliable “real-life” implement-ation Basic science Proof of concept Scale-up to populations

Mechanisms to adapt to different contexts and environments Improvement Guide. 2nd Edition, 2009

Mechanisms to adapt to different contexts and environments

Is your idea/program ready to go to full scale?

Core elements included in the design: 1. Phased Approach Prototype development and test of scalable units (Massoud, 2004)

Core elements included in the design: 2. Adoption mechanisms IHI’s framework for spread (Nolan, Schall et al. 2005)

Core elements included in the design: 3. Support Mechanisms 5x Scale up thinking

What does the New Framework attempt to provide? Guidance on multifaceted approach on how to take improvement to full scale Integrates IHI’s existing models and thinking on achieving results at scale Clarifies terminology - describes what happens in clear, simple terms. Describes 3 basic components: Road map or sequence of activities to reach full scale Adoption mechanisms Infrastructure for scale up. Describes different methods that can be used at different stages of the journey to full scale.

The Framework Phases of getting to Full Scale Fostering Adoption assembling knowledge, set up, building the scalable unit, testing scale-up, going to full-scale and sustaining improvement Fostering Adoption leadership, communication, social networks Support Systems Learning systems, data systems, infrastructure for scale-up, human capacity for scale-up, capability for scale up.

The Framework Adoption Mechanisms Set-up Build Scalable Unit Test Scale- Up Go to Full-Scale Support Systems Phases of Scale-up Best Practice exists New Scale-up Idea Leadership, communication, 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

Framework: Integration of Phases, Adoption and Support Systems The framework can apply to efforts to introduce and scale-up new interventions from “scratch” efforts to spread existing innovations or “best practices” Phases of scale up should link closely to adoption mechanisms and support systems from the outset

Core elements included in the design: 4 Core elements included in the design: 4. Existing concepts of “spread” and “scale up” “scale-up” - overcoming the system/infrastructure issues that arise during efforts to scale-up implementation “spread” – the leadership, social, and environmental factors that promote adoption and replication, with little modification, of an intervention within a health system (Kurapati, Laderman, et al., 2011). The framework may or may not include these terms – yet to be decided whether these are useful or confusing – but the framework uses these concepts as core elements of the design.

Review of other scale up models Sequence of Scale-up Adoption Support Structures   Set-up Build Scalable Unit Test Scale-up Full-scale and Sustain Adoption Mechanisms (including leadership) Develop Learning Systems Build Human Capacity & Capability Strengthen Infrastructure Implementing Best Practices X ExpandNet/WHO Management Systems International Consolidated Framework for Implementation Research Yamey WHO (Massoud)

Phases of Scale Up Best Practice exists Build Scalable Unit Test Scale- Up Set-up Go to Full-Scale New Scale-up Idea Introduction of a new evidence based intervention for system-wide scale-up OR Adaptation and Scale up of a successful innovation in one part of the system to the rest of the system

Phases of Scale Up Best Practice exists Build Scalable Unit Test Scale- Up Set-up Go to Full-Scale New Scale-up Idea analysis of the existing programming strategies and protocols, and assemble best practices (expert group) baseline data collection understand the roles and contributions of stakeholders. engage & build will with leadership identify prototype test sites, early adopters, and potential “champions” Build prototype design (“5 elements”)

Phases of Scale Up Best Practice exists Build Scalable Unit Test Scale- Up Set-up Go to Full-Scale New Scale-up Idea Administrative unit includes core activities and support systems that need to be replicated in the larger health system. Intensively test local ideas, Generate a set of context-sensitive interventions for scale up “change package” Build will, seed adoption Build infrastructure Start testing sustainability

Phases of Scale Up Best Practice exists Build Scalable Unit Test Scale- Up Set-up Go to Full-Scale New Scale-up Idea Test and further develop preliminary change package in a broader range of contexts representing the predicted full-scale environment Build adoption strategies Build infrastructure Develop sustainability change package

Phases of Scale Up Best Practice exists Build Scalable Unit Test Scale- Up Set-up Go to Full-Scale New Scale-up Idea Rapid deployment phase - well-tested set of interventions are deployed at large scale, adopted by frontline staff. Focus on replication Ensure sustainability

Adoption Mechanisms Included in all phases but most emphasis is in rapid deployment phase - well-tested set of interventions are deployed at large scale, adopted with minimal further adaptation by frontline staff. Includes core elements… Leadership of change Communication and networks Attributes of the intervention (IHI’s Spread Framework) Culture of urgency and persistence

Support Systems Build human capability for scale-up . Leadership team to guide the process Reference to 5x thinking framework – phased training from volunteers to trained, dedicated improvement specialists QI-based programs for those who need additional training. (start before scale-up begins). QI teams Build infrastructure for scale-up: Balance targeted resource addition vs system redesign. reconfiguration of existing resources (e.g., examination room design, lab needs, data system infrastructure) additional tools (e.g., checklists, data capture systems), communication tools, and key personnel (e.g., data capturers, quality improvement mentors) Build reliable data collection and reporting systems track and provide feedback on the performance of key processes Data systems for improvement vs monitoring Develop learning systems: Mechanisms for collecting, vetting, and rapidly sharing change ideas or interventions.

Sustainability Standard work processes for high-reliability of the new processes Data systems that support, track and feedback key indicators Inspection systems to ensure desired results are being achieved, Resources/support for structural elements, Ongoing learning systems Leadership

Methods deployed at each phase Set-up Build Prototype Test Scale-up Go to Full-scale Methods Model for Improvement Surveys Brainstorms Expert meetings Scans Site visits Interviews Idealized Design  Collaborative learning (e.g., adaption of Breakthrough Series (BTS) Collaboratives)   Deployment and refinement of change package Site redesign Collaborative learning Change agents Extension agents Affinity groups BTS Collaboratives Wave sequence Campaigns Hybrid approaches