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napa

Advisory Council October 2017 Meeting Presentation: Innovations to Scale

Friday, October 27, 2017

Printer Friendly Version in PDF Format (24 PDF pages)

 

Developing, Sustaining and Taking Innovations to Scale

Marie W. Schall, Senior Director Institute for Healthcare Improvement

Objectives

  • Apply key concepts and strategies for taking innovations to full scale
  • Consider a sequence of activities to plan and guide scale-up initiatives
  • Learn about and apply lessons to your context from specific case examples

Our Mission:To improve health and health care worldwide

We will improve the lives of patients, the health of communities, and the joy of the health care workforce.

IHI Strategy

  • Mission
    • Improve health and health care worldwide
  • Vision
    • Everyone has the best care and health possible
  • Strategic Approach
    • IHI applies practical improvement science and methods to improve and sustain performance in health and health systems across the world. We generate optimism, spark and harvest fresh ideas, and strengthen local capabilities.
  • What We Do
    • Safe & High Quality Care
    • Health Equity
    • Joy in Work
    • Value
    • Health of Populations
    • Improvement Science
  • How We Work
    • Convene
    • Innovate
    • Partner for Results

API's Model for Improvement

  • What are we trying to accomplish?
  • How will we know that the change is an improvement?
  • What changes can we make that will result in improvement?
    • Plan
    • Do
    • Act
    • Study

Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009. http://www.ihi.org/resources/Pages/Publications/ImprovementGuidePracticalApproachEnhancingOrganizationalPerformance.aspx

Leading the Way

  • Thought leadership and innovation
    • Triple Aim
    • 100,000 Lives Campaign
    • 5,000,000 Lives Campaign
    • WIHI
    • Breakthrough Series College
    • Global Trigger Tool
    • Bundles
    • Patient Safety Officer Training
  • Ground breaking initiatives
    • STAAR Preventing Avoidable Readmissions
    • Open School
    • Project Fives Alive!
    • Maternal and Child Health (Malawi)
    • IMPACT
    • The Conversation Project
    • 100 Million Healthier Lives

Partnering to Achieve Big Aims

  • Cincinnati Children's
  • Contra Costa Health Services
  • East London NHS Foundation Trust
  • NHS Scotland
  • Albert Einstein Sociedade Beneficente Israelita Brasileira
  • Providence St. Joseph Health
  • Bellin Health
  • Hamad Medical Corporation
  • Quiturum, Region Jönköping
  • Scottish Government Riaghaltas na h-Alba
  • Kaiser Permanente
  • Northwell Health
  • Danish Society for Patient Safety - Denmark
  • Military Health System

A Passionate Staff

 

Key Concepts and Strategies

Expanding the Scope of Change

A Path to Better Outcomes using a Learning Approach

"Some is not a number, soon is not a time...." Don Berwick

Creating a New System

  • Improvement --> Hold Gains --> Results at Scale
  • Improvement --> Hold Gains --> Design for Scale -- > Get Results at Scale

The Scale-up Framework

  • Phases of Scale-up
    • Best Practice exists
    • New Scale-up Idea
    • Set-up
    • Build Scalable Unit
    • Test Scale-Up
    • Go to Full-Scale
  • Adoption Mechanisms
    • Leadership, communication, social networks, culture of urgency and persistence
  • Support Systems
    • Learning systems, data systems, infrastructure for scale-up, human capacity for scale-up, capability for scale-up, sustainability

Barker, P. M., Reid, A., & Schall, M. W. (2016). A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa. Implementation Science, 11(1), 1.

QI: An Engine for Adaptable and Scalable Improvement

  • Model for Improvement
    • What are we trying to accomplish?
    • How will we know that a change is an improvement?
    • What change can we make that will result in improvement?
      • Act
      • Plan
      • Do
      • Study

Langley G et al. The Improvement Guide: A Practical Guide to Enhancing Organizational Performance. Josey Bass San Francisco 2009

Core elements included in the design: 1. Phased Approach

  • PDSA "ramp" testing under different conditions (API)
    • Hunches Theories
    • Very Small Scale Test (The Improvement Guide, Langley, Nolan...et.al)
    • Follow-up Tests
    • Wide-Scale Tests of Change
    • Implementation of Change
    • Changes That Result in Improvement at scale

Langley G et al. The Improvement Guide: A Practical Guide to Enhancing Organizational Performance. Josey Bass San Francisco 2009

The Scale-up Framework

  • Phases of Scale-up
    • Best Practice exists
    • New Scale-up Idea
    • Set-up
    • Build Scalable Unit
    • Test Scale-Up
    • Go to Full-Scale
  • Adoption Mechanisms
    • Leadership, communication, social networks, culture of urgency and persistence
  • Support Systems
    • Learning systems, data systems, infrastructure for scale-up, human capacity for scale-up, capability for scale-up, sustainability

Barker, P. M., Reid, A., & Schall, M. W. (2016). A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa. Implementation Science, 11(1), 1.

Challenge Question for Today!

There are five frogs on a log....five decide to jump in....how many frogs are left on the log?

Adoption Mechanisms

  • Leadership
    • Topic is a key strategic initiative
    • Goals and incentives aligned
    • Executive sponsor assigned
    • Day-to-day managers identified
  • Measurement and Feedback
  • Better Ideas
    • Develop the case
    • Describe the ideas
  • Set-up
    • Target population
    • Adopter audiences
    • Successful ties
    • Key partners
    • Initial spread strategy
  • Social System
    • Key messengers
    • Communities
    • Technical support
    • Transition Issues
  • Community Strategies (awareness & technical)
  • Knowledge Management

Nolan K, Schall M, Erb F, Nolan T. Jt Comm J Qual Saf 31(6):339-347, June 2005

Attributes of an Idea that Facilitate Adoption

  • Relative Advantage
  • Simple
  • Trialable
  • Compatible
  • Observable

The Scale-up Framework

  • Phases of Scale-up
    • Best Practice exists
    • New Scale-up Idea
    • Set-up
    • Build Scalable Unit
    • Test Scale-Up
    • Go to Full-Scale
  • Adoption Mechanisms
    • Leadership, communication, social networks, culture of urgency and persistence
  • Support Systems
    • Learning systems, data systems, infrastructure for scale-up, human capacity for scale-up, capability for scale-up, sustainability

Barker, P. M., Reid, A., & Schall, M. W. (2016). A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa. Implementation Science, 11(1), 1.

Support Systems

5x's Thinking

5X Scale-up -- Reduce cost and improve care for socially complex
Number of people System issues to address
5
  1. Form a team of volunteers
  2. Find people through referrals
25
  1. Full time team
  2. Redesign of practice
  3. Cooperation of hospitals for data
  4. Assess outcomes
125
  1. Grant funding for operations
  2. Consistent population outcomes
625
  1. ?
3125
  1. ??
15,625
  1. ???

The Scale-up Framework

  • Phases of Scale-up
    • Best Practice exists
    • New Scale-up Idea
    • Set-up
    • Build Scalable Unit
    • Test Scale-Up
    • Go to Full-Scale
  • Adoption Mechanisms
    • Leadership, communication, social networks, culture of urgency and persistence
  • Support Systems
    • Learning systems, data systems, infrastructure for scale-up, human capacity for scale-up, capability for scale-up, sustainability

Barker, P. M., Reid, A., & Schall, M. W. (2016). A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa. Implementation Science, 11(1), 1.

 

Case Examples

Methods for Getting to Full Scale

  • Breakthrough Series Collaboratives
  • Campaigns
  • Executive Mandate/Policy
  • Hybrid approach
  • Learning Networks
  • Extension Agents

Massoud MR, Donohue KL, and McCannon CJ. 2010. Options for Large-scale Spread of Simple, High impact Interventions. Technical Report. Published by the USAID Health Care Improvement Project. Bethesda, MD: University Research Co. LLC (URC).

Breakthrough Series Collaboratives

  • Consider this when:
    • Multiple sites with common aim
    • Shared learning is an advantage
    • Create or strengthen peer relationships
    • Need to demonstrates results
  • Design Challenges
  • Resource intensive
  • Build shared learning
  • Reporting and feedback to enhance learning and results

IHI Breakthrough Series(6 to 18 Months Time Frame)

Working Time Frame

The Breakthrough Series: IHI's Collaborative Model for Achieving Breakthrough Improvement. http://www.ihi.org/resources/Pages/IHIWhitePapers/TheBreakthroughSeriesIHIsCollaborativeModelforAchievingBreakthroughImprovement.aspx

Scale-up: HRSA Organ Donation Initiative

  • Set-up
    • Goal Structure Scan
    • Prep for BTS Collaborative
    • October 2002
  • Build Scalable Unit
    • OD Collaborative 1
      • 43 OPO's
      • 95 hospitals
    • September 2003
  • Test of Scale-up
    • OD Collaborative 2
      • 50 OPOs
      • 131 Hospitals
    • Trained Change Agents in each OPO to lead Scale-up
    • September 2004
  • Go to Full Scale (and Sustain)
    • Collaborative 3
      • OD plus Transplantation
    • Fall 2005
    • Formation of Alliance
    • June 2006

Shafer TJ, Wagner D, Chessare J, Zampiello FA, McBride V, Perdue J. Increasing Organ Donation Through System Redesign, CRITICALCARENURSE Vol 26, No. 2, APRIL 2006. http://ccn.aacnjournals.org

Start Small, Scale up Rapidly with Change Package

Total Pop'n:   350,000 5 million 11 million 11 million 22 million
Under 5 Pop'n:   60,000 500,000 1.7 million 1.7 million 3.3 million
Date Nov 2007 Jul 2008 Sept 2009 Oct 2009 Aug 2012 Jan 2013
Phase Start-up: months 1-8 Wave 1: months 9-22 Wave 2: months 23-63 Wave 3: months 24-89 Wave 1R: months 58-89* Wave 4: months 63-89
No of. QI Teams:   30 258 350 369 >1,046
* Referral project launch 41 Referral Teams

Campaigns

  • Consider this when:
    • Immediacy
    • Compelling aim
    • Straightforward steps
    • Aligns w/ other national initiatives
    • Connects with public
  • Design Challenges
    • Strong "command center"
    • May need to build structure
    • Fast-paced
    • Get to the field
    • Find and leverage mentors

The Campaign Approach

TOP: IHI and Campaign Leadership; MIDDLE: NOES (approx. 75) *Each Node Chairs 1 Network, Mentor Hospitals; BOTTOM: Facilities (2000-plus) *30 to 60 Facilities per Network.
  • Introduction, expert support/science, ongoing orientation, learning network development, national environment for change
  • Local recruitment and support of a smaller network through communication/collabor-atives
  • Implementation (with roles for each stakeholder in hospital and use of existing spread strategies)

http://www.ihi.org/communities/blogs/_layouts/15/ihi/community/blog/ItemView.aspx?List=7d1126ec%2D8f63%2D4a3b%2D9926%2Dc44ea3036813&ID=268&Web=1e880535%2Dd855%2D4727%2Da8c1%2D27ee672f115d

Learning and Action Network: 100 Million Healthier Lives

  • Has elements of BTS Collaboratives, Learning Networks, and Campaigns
  • Compelling aim
  • Specific time frame and numerical goals
  • Distributed leadership
  • Structure that supports dynamic and organic growth
  • Builds relationships to enhance shared learning and action
  • Develops and builds core skills and behaviors to achieve common aim at scale
  • Intention to move to full scale from the beginning

 

Overview of 100MLives

100 Million Healthier Liveshttp://www.100mlives.org

  • Identity: An unprecedented collaboration of change agents pursuing an unprecedented result:
    • 100 million people living healthier lives by 2020
  • Vision: to fundamentally transform the way we think and act to improve health, wellbeing, and equity.
  • Equity is the "price of admission."
  • Convened by the Institute for Healthcare Improvement as a partnership

100MLives Theory of Change

  • Unprecedented collaboration, plus
  • Innovative improvement, plus
  • System transformation, equals
  • 100 Million People Living Healthier Lives by 2020

Core Strategies

  1. Create healthy, equitable communities
  2. Build bridges across sectors
  3. Create a health care system that is good at health AND good at care
  4. Promote peer-to-peer approaches
  5. Create enabling conditions
  6. Develop new mindsets

Who is In Our Growing Movement:

SCALE: Spreading Community Accelerators through Learning and Evaluation

  • 24 communities nationwide (wave 1) to sustainably improve health and wellbeing, lead complex change, and advance equity together
  • Community teams composed of:
    • Institutional leaders across sectors
    • Community members with lived experience
    • local improvement advisers
  • Activities:
    • Community Health Improvement & Leadership Academies (CHILA)
    • Coaching
    • Peer-to-peer learning and support

SCALE

  • Community of Solutions skills
    • Leading from within
    • Leading together
    • Leading for outcomes
    • Leading for equity
    • Leading for sustainability
  • Community of Solutions behaviors, processes, systems
    • How people relate to themselves, one another, and to those affected by inequity
    • How the community approaches the change process
    • How the community creates abundance
  • Culture of Health outcomes
    • Health as a shared value
    • Thriving cross-sector partnerships
    • Healthy, equitable communities
    • Improved population health, wellbeing and equity outcomes

SCALE has developed through an interdisciplinary partnership of the Institute for Healthcare Improvement (IHI), Community Solutions Communities Joined in Action, and the Network for Regional Healthcare Improvement and is generously supported by the Robert Wood Johnson Foundation.

SCALE Wave 1 ("SCALE 1.0") Communitieshttp://www.100mlives.org/initiatives

  • Cheshire County, NH
  • Oklahoma City, OK
  • Summit County, OH
  • Williamson, WV
  • Algoma, WI
  • Atlanta, GA
  • Bernalillo County, NM
  • Boston, MA
  • Cattaraugus County, NY
  • Chicago (Maywood),
  • Cleveland, OH
  • Hennepin County, MN
  • Jackson, MI
  • Laramie County, WY
  • Los Angeles, CA
  • Maricopa County, AZ
  • North Colorado, CO
  • Pueblo, CO
  • Raleigh, NC
  • Salt Lake City, UT
  • San Francisco, CA
  • San Gabriel Valley, CA
  • Sitka, AK
  • Waterville, ME

 

Are You Ready for Scale-up?

Readiness

  • Will
    • (Is the Environment Receptive to the next phase of scale up)
  • Execution
    • (Can the Infrastructure/ Capability support the next phase of scale up)
  • Ideas
    • (Degree of Belief: are ideas ready for next phase of scale up)

Assessing Readiness for Scale-up

  • 20 questions across 3 core elements of Scale-up Framework.
    • Phased Approach
      • Theory of change, evidence, observability
    • Receptivity/Will
      • Complexity, relative advantage, testability, priority, urgency
    • Infrastructure/Capability
      • Data systems, learning systems, resources, knowledge, skills

Readiness For Scale-up

Alignment with Scale-Up Model Question/Prompt Strongly Disagree
to Strongly Agree
(1-5)		 Alignment with
Will, Ideas,
Execution Model
Next Phase of Scale-Up We have a set of best practices or tested change ideas that are ready test or spread to the sites of the next phase or work.   Ideas
We have a compelling theory of change.  
We can show the evidence base for our theory from previous studies.  
We have results that show how the theory has been applied to our own improvement work.  
If we are testing scale or going to full scale, improvement has been sustained in the sites where we are currently testing or implementing changs.  
We have identified test/implementation sites most likely to adopt a new approach for the next phase of the work.  
TOTAL Next Phase of Scale-up Score  
Receptivity/Will Compared to other programs and initiatives, the community that we are planning to scale-up into (adopter community) regards the improvement initiative as a top priority.   Will
The adopter community shares a sense of urgency in closing the gap in performance or outcomes around our main aim.  
The adopter community/organization recognizes the benefits of participating in this improvement initiative.  
The adopter community believes the approach we are advocating will reach our goals faster relative to other initiatives.  
The adopter community understands that the approach we are advocating is simple to understand, easy to try out and easy to measure.  
The improvement approach we are advocating aligns with the culture and values of our community/organization.  
Leaders and champions of the adopter community have been identified and have shown a willingness to advocate for the improvement initiative in their community.  
TOTAL Receiptivity/Will Score  
Infrastructure/Capability Adequate human capacity (resources, dedicated time, seniority) is available to support the scale-up of improvements across the community/organization.   Execution
Adequate improvement capability exists to support the planned work of the next phase.  
Capability exists in managers and leaders to facilitate the changes required for improvement.  
Staff and leadership across our community/organization see improvement and scale-up work as an integral part of their daily work.  
Data collection and reporting tools are available for scale up.  
Other anticipated resources are/will be available to undertake this work.  
A learning system exists to spread knowledge from improvement initiatives systematically across the organization; i.e. learning loops back into quality planning.  
TOTAL Infrastructure/Capability Score  

Thank You!

Questions Please!

October 27, 2017 -- Advisory Council Meeting #26

The meeting was held on Friday, October 27, 2017, in Washington, DC. The Advisory Council welcomed its new members and invited them to share their experiences and where they see the Council going over the length of their terms. The Advisory Council also spent some time discussing the process of developing recommendations and how those recommendations relate to the National Plan. The Council then spent much of the meeting discussing the National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers, held on October 16-17. Material available from this meeting is listed below and at https://aspe.hhs.gov/advisory-council-alzheimers-research-care-and-services-meetings#Oct2017.

Comments and questions, or alerts to broken links, should be sent to napa@hhs.gov.

 

General Information

 

Handouts

 

Presentation Slides

 

Videos

  • Welcome through Overviews -- [Video]

  • Subcommittees and Fed Workgroups and Future Meeting Discussion -- [Video]

  • Care Summit Overview and Presentation of Recommendations -- [Video]

  • Discussion through lunch -- [Video]

  • Public Comments -- [Video]

  • Marie Schall Presentation and 2017 National Plan Discussion -- [Video]

  • Federal Workgroup Updates through adjourn -- [Video]