1. Spreading Improvements Heidi Johns, Quality Leader, BCPSQC July, 2013

2. Objectives To better understand: How is spread defined? What are the difficulties with spreading and improvement? How do you evaluate when it is opportune to spread an improvement? Understand and use tools designed to evaluate spread of improvements

3. What is Spread? What has been your experience with spread?

4. “disseminate and implement successful interventions across a system or systems” Lanham et al, How complexity science can inform scale-up and spread in health care: Understanding the role of self organization in variation across local contexts, Social Science and Medicine.

5. Recent research Scale – up and Spread recent shift in thinking Complexity Science influences how we think about the complex social behaviors of spread.

6. Complexity Science Complexity science will see the patterns, anticipate and influence them. System Environment Boundry Plexus Institute: Complexity Lens http://www.plexusinstitute.org /

7. Complexity Science SimpleComplicated

8. Complexity Science Complex

9. Complex systems What are the compositions of complex systems? Complexity and interrelationship is problematic.

10. Self – organization Interdependencies Sense making

11. Self-Organization Variation Patterns Contextual Influential

12. “Deliberately attending to patterns of self- organization can be a powerful strategy for improving diffusion of effective health care practices across diverse settings” Lanham et al, How complexity science can inform scale-up and spread in health care: Understanding the role of self organization in variation across local contexts, Social Science and Medicine.

13. Interdependencies Relationship Infrastructure and Technology Patterns

14. Sensemaking “…is the process through which people assign meaning to experience.” (Lanham, 2012)

15. Key Themes Human dimension Diffusion of knowledge Infrastructure

16. What do you want to spread? Who is the spread intended for? How are we going to spread?

17. Spread Checklist Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety.2005Jun;31(6):339-347. Infrastructure, Leadership and Measurement Better Ideas Information about the Innovation and “Transfer Materials” Target Population “To and Through a Social System” Communicated Modes Purpose Messengers

18. This is the visibility – Document the story: storyboards, presentations – Tell the story – Share the data Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety.2005Jun;31(6):339-347. Better Ideas Information about the Innovation and “Transfer Materials”

19. Communicate often Communicate in different ways People all know and can tell the story Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety.2005Jun;31(6):339-347. Communication

20. Identify existing relationship, leaders, innovators Change leaders can adapt changes to fit environment Develop the messengers from the team – educate and support them with the messaging Target Population Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety.2005Jun;31(6):339-347.

21. Roles and responsibilities are planned Spread plan is developed and fits Methods for knowledge transfer Measures are in place Nolan K, Schall M, Erb F, Nolan T.; Using a framework for spread: The case of patient access in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety.2005Jun;31(6):339-347. Infrastructure

22. Common “Spread” Problems Keeping the Engine Running: Sharing Directions for Successful Spread & Sustainability Dr. Lynne Maher Head of Innovation Practice, NHS UK

23. Exercise At your table you have some of the Myths and Don’ts with respect to the spread of improvements. With your table discuss how you would turn those Myths and Don’ts into Reality and Do’s 20 minutes

24. Reality and Do’s Local Small Scale Testing, Local Implementation under multiple conditions, Spread  Small scale testing is crucial to learning how to neutralise or overcome barriers  Front line staff opinions generated from small scale testing are essential in creating a clearly defined process  Most processes can be “firmed up” in 3 or 4 cycles of testing and in the long run will be faster and have more chance of success than larger scale implementation

25. Spread is a TEAM effort  A process dependent on a single individual is basically not a sustainable process  When key individuals are absent, the reliability of the process will deteriorate within days

26. Expecting vigilance and hard work to solve problems  Hold the gains with infrastructure support  Hard work and vigilance cannot be maintained over the long term  A process that succeeds using hard work and vigilance is hard to teach to new employees  A process dependent on hard work is difficult to test for competency

27. Choose the Non-negotiables but allow local customization  Without allowing some key elements of customization, successful spread will be very unlikely.  Customization should be allowed, but controlled.  Customization should be based on understanding defects. Study small samples and customize based on the learning.

28. Choose the Spread Team based on the scope of the spread  Using the successful leader in one unit to be responsible for spread will burn out this person unless they have been specifically given the job of champion  Allowing others to assume the responsibility helps builds the infrastructure to sustain the process  Spread requires local leaders with a common goal set by leadership

29. Frequently look at the spread measures to “tailor” the work of spread  Look at defects as they occur both when initially testing and when spreading  Use the “10 Chart Strategy”  Look at small samples on a daily or every other day basis

30. Outcome improvement needs widespread reliable processes & implementation  Outcomes can not be expected to change unless processes change. Staff can be responsible for process improvement.  If processes becomes highly reliable the outcome will follow as long as it is connected to science.  Outcomes will change on the pilot unit only after processes become more reliable.

31. NHS Spread tool Questions which will help you prepare and frame your improvements Three categories: People Innovation Context

32. http://www.institute.nhs.uk/innovation/spre ad_and_adoption/spread_and_adoption.html Take the remainder of the time and complete the spread tool developed by the NHS.

33. Questions?