1. 𝑺 𝟑 From Spread to Scale-up to Sustainability
BRUCE D. AGINS, MD MPH
PHFS WEBINAR: 14 MARCH 2017
NEW YORK STATE DEPARTMENT OF HEALTH AIDS INSTITUTE

2. Overview Spread Scale-up: Frameworks, Factors and Processes
Sustainability: The ultimate challenge

3. S1: Spread
Spread: to (cause to) cover, reach, or have an effect on a wider or increasing area

4. What do we think about when we talk about spread in improvement work?
Spread of a collaborative: to new sites, new districts, new regions, another country
Spread of ideas, innovations, knowledge
1999: IHI focuses on “spreading change ideas within and between organizations”

5. Key Issues For Spread (IHI White Paper)
Readiness
Establishing an aim
Assess key elements for readiness
Processes involved
Methodology built upon core principles of improvement science (Deming)
Adaptation of MFI:
What are we trying to spread?
To whom do we want to spread it – and by when?
How will we spread it?
How will we know it has been spread?
Joint Commisison Jnl on Quality and Pt Safety 2005; 31:

6. Processes for Spread: Nolan’s Checklist for Spread (Organization-focused) Nolan K, et al. Using a Framework for Spread. Joint Commission Jnl on Quality and Safety :
Is improvement in this area a strategic priority for the organization?
Is there an executive responsible for spread of the improvement?
Is there a person or team in the leadership who will be involved in day-to-day spread activities?
Will leadership supply resources needed for success? (personnel; IT; tools)
Has the advantage of adopting the change been documented and communicated in an easily understood message to all potential adopters?
Is there a successful site that has implemented the change in a way that is scalable throughout the organization?
Are there credible messengers who can persuade potential adopters to implement the innovation?
Is there a clear plan to communicate the innovation throughout the organization and to assist different sites in making needed changes?

7. Approaches to Spread
Natural diffusion (adoption of idea or intervention by members of social system in absence of formal dissemination)
Executive mandates
“Extension agents” where mobile HCWs or community leaders spread ideas and best practices: “coaching and mentoring”
Emergency mobilization
Affinity group (2-3 clinics recruited to develop model)
Wave sequencing
Collaborative (structure learning around shared aims, measures & goals)
Virtual collaborative
Campaigns

10. Eight Points For Implementation in Networks: Practical Tips and Implications for HEALTHQUAL Teams
Spread has to be planned and then managed
Flexibility: adaptive response to environmental change and survives central level change [provincial and district]
Involvement of users throughout process (“consensual development”) in both prioritization and design (patients and providers)
Sharing of resources and knowledge: “communication plan”
Fostering networks between user organizations: the power of peer learning
Recognition for innovators within networks
Coaching System (“extension system”)
Close spatial contact between external agents and clients

11. S2: From Spread to Scale-Up

12. Frameworks for Scale-Up Barker, Reid, Schall 2016; Implementation Science 11:12
Four Steps to Scale-Up
Set-up
Develop the scalable unit
Test of scale-up
Full Scale

13. Fig. 3 IHI Framework for Going to Full Scale.

14. The Communication Element

15. S3: Sustainability:
Paradigms but little Proof…

16. Lori DiPrete Brown (1995): Lessons Learned in Institutionalization of Quality Assurance Programs: An International Perspective
Institutionalization: defined as “..when essential and appropriate …. activities are carried out effectively on a routine basis throughout an organization, health system or health sector”.
Sustainability occurs when “expertise, commitment and resource allocation are sufficient to apply, adapt, sustain and further develop the QA approach”.
Int J Qual Health Care (1995) 7 (4):
 DOI: 

17. http://www. healthcareimprovementscotland

18. http://www. healthcareimprovementscotland

20. Ten Domains to Guide Sustainability of Donor-Initiated Programs
Balancing flexibility/adaptability with standardization
Supportive policy, legal and regulatory environment
Ongoing focus on sustainability
Fiscal support
Political support
Building and sustaining strong organizational capacity
Community involvement, integration, buy-in and depth
Partnerships
Decentralization
Transferring ownership

21. The Policy Environment: NQPS Project (WHO)
The Policy Environment: NQPS Project (WHO) -Sheila Leatherman, WHO Lead Advisor, NQPS
Is Policy a prerequisite to sustainability?
Categories of Action:
Set policy and standards
Change clinical practice
HMIS and data systems
Regulate
Educate and inform
Use proven quality improvement methods
Payment and incentives

22. Governance: HEALTH FINANCE & GOVERNANCE PROJECT Institutional Roles & Relationships Governing the Quality of Health Care: Country Experiences, Challenges & Lessons Learned. (adapted)
Is governance a prerequisite to sustainability? Principles: -universal health coverage with quality explicitly embedded -health information system allowing real-time data for decision-making -strong technical role for MOH in relationship to the payer -both accountability and improvement need to be addressed -platform for shared learning as part of a comprehensive communication strategy -ensure that all sectors are involved -link finance to quality -political will -support research to define the critical elements of organizational architecture required for governance to ensure sustainability

23. Implementation Science: The EPIS model
Learning from
Implementation Science:
The EPIS model
Aarons, G.A., Hurlburt, M. & Horwitz, S.M. (2011). Advancing a Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors. Administration and Policy in Mental Health and Mental Health Services Research.38, 4-23.

24. What does Umar tell us? Umar 2009: The “Little Steps” Approach to Sustainability
Literature focusing on national level does not include much about actual improvement methods which are embedded in smaller projects.
All work must be contextual, building upon existing political and management systems.
Work towards incremental improvements that do not require large increases in resources: focus on what is achievable and sustainable.
Advocates for a “little steps” model

25. Umar, N et al. Toward More Sustainable Health Care Quality Improvement in Developing Countries:
The “Little Steps” approach. Q Manage Health Care. 2009; 18(4); p

26. Umar, N et al. Toward More Sustainable Health Care Quality Improvement in Developing Countries:
The “Little Steps” approach. Q Manage Health Care. 2009; 18(4); p

27. Sustainability: NHS
The NHS Modernisation Agency defines sustainability as follows:
‘Sustainability is when new ways of working and improved outcomes become the norm. Not only have the process and outcome changed, but the thinking and attitudes behind them are fundamentally altered and the systems surrounding them are transformed in support. In other words it has become an integrated or mainstream way of working rather than something ‘added on’

31. Challenges
Donor projects come and go, along with their funds and impetus
Disease or sector-specific models fail to be integrated into the healthcare delivery system
Lots of models, concepts, paradigms have been developed but few have been implemented: experience is limited
Longitudinal data are scarce, if existent at all: is any model of sustainability actually effective?
Adaptation into different environments has not been tested: context matters
Do we still need to plan spread & scale-up if we start with a sustainability paradigm?
How can a knowledge management strategy be deployed to get information to providers and consumers who need to use it?
What is the role of public health system accountability to ensure ongoing uptake?

32. How can we learn from our experiences with PHFS to inform practice, spread, scale-up and sustain the results that have been achieved?