Upload
jonathan-beeman
View
222
Download
0
Tags:
Embed Size (px)
Citation preview
1
Scaling up high-impact interventions
M. Rashad Massoud, MD, MPH, FACP
Director, USAID Applying Science to Strengthen and Improve Systems Project
Senior Vice President, Quality & Performance Institute
University Research Co., LLC – Center for Human Services
USAID Applying Science to Strengthen and Improve Systems
What do we mean by “Spread” or “Scale-up”?
The science of taking a local improvement (intervention, idea, process) and actively disseminating it across a system
……Joe McCannonJoe McCannon
Institute for Healthcare Improvement, Cambridge, MA
USAID Applying Science to Strengthen and Improve Systems
What do we know about the spread of good practices?
• Smoking cessation counseling: 21%• Mammography screening: 27%• Warfarin for Atrial Fibrillation: 40%• ACE inhibitors for CHF: 36%
……Agency for Health Research & Quality (AHRQ)Agency for Health Research & Quality (AHRQ)
Physician compliance with evidence-based interventions:
Publication
Bibliographic databases
Submission
Reviews, guidelines, textbook
Negative
results
variable
0.3 year
6. 0 - 13.0 years50%
46%
18%
35%
0.6 year
0.5 year
9.3 years
It takes 17 years to turn 14 per cent of original research to the benefit of patient care.It takes 17 years to turn 14 per cent of original research to the benefit of patient care.……Agency for Health Research & Quality (AHRQ)Agency for Health Research & Quality (AHRQ)
Dickerson, 1987
Koren, 1989
Balas, 1995
Poynard, 1985
Kumar, 1992
Kumar, 1992
Poyer, 1982
Antman, 1992
Negative results
Lack of numbers
Expertopinion
Inconsistentindexing
17:14
Original research
Acceptance
Implementation
USAID Applying Science to Strengthen and Improve Systems
Diffusion of Innovations: Attributes of an Innovation
• Relative advantage• Compatibility• Complexity• Trialability• Observability
E. Rogers, Diffusion of Innovations, 1995E. Rogers, Diffusion of Innovations, 1995
USAID Applying Science to Strengthen and Improve Systems
Diffusion of Innovations:Categories of Adopters
2.5% 13.5% 34% 34% 16%
E. Rogers, Diffusion of innovations,1995
EarlyAdopters
Innovators
EarlyMajority
LateMajority
Laggards
USAID Applying Science to Strengthen and Improve Systems
Key Insights on Diffusion Theory
• Attributes of Innovation
• Categories of Adopters
• Spread of Idea vs. Directed Change in Systems
USAID Applying Science to Strengthen and Improve Systems
Set-up-Target population -Adopter audiences -Successful sites -Key partners-Initial spread strategy
Social System-Key messengers -Communities -Technical support-Transition issues
Communication Strategies (awareness & technical)
Knowledge Management
Measurement and Feedback
Leadership-Topic is a key strategic initiative
-Goals and incentives aligned-Executive sponsor assigned
-Day-to-day managers identified
Better Ideas-Develop the case -Describe the ideas
A Framework for Spread
Institute for Healthcare Improvement, Cambridge, MA
USAID Applying Science to Strengthen and Improve Systems
Three Key Questions
• What do we want to spread?
• To whom do we want to spread? By when?
• How are we going to spread?
USAID Applying Science to Strengthen and Improve Systems
How Do We Spread?
Many possible ways:
• Natural diffusion • Extension agents• Emergency mobilization• Spread through a collaborative• Spread through a virtual collaborative • Campaign spread• Wave sequence spread• Hybrid models
Institute for Healthcare Improvement, Cambridge, MA
USAID Applying Science to Strengthen and Improve Systems
Wave Sequence Spread
USAID Applying Science to Strengthen and Improve Systems12
Principles of Scale-Up
1. Begin with scale-up in mind
2. If you can reach all-at-once – you should!
3. If you cannot, then consider a phased approach:– Look for nested systems– Test prototypes & expand in multiples of 5-10
4. How factors change in going to scale:– Arithmetic scale up– Favorable scale-up
5. Information systems
6. Communication needs
7. Oversight needs with scale-up
USAID Applying Science to Strengthen and Improve Systems13
Key Lessons Learned
• Results are the key drivers• Enabling people to make changes in their work
– Systems thinking– Equip with PDSA’s– Assistance to the teams in the form of site visits – Leadership Support– Role Modeling– Normative/regulatory support
• People working under constraints can be very creative • Scale-up efforts require meticulous attention to detail• Champions who developed the prototypes are critical
for leading the scale-up in wave sequence spread• Leadership from within the system
14
New Learning about the Rate of Spread
USAID Applying Science to Strengthen and Improve Systems
0.0
20.0
40.0
60.0
80.0
100.0
A05
S05
O05
N05
D05
J06
F06
M06
A06
M06
J06
J06
A06
S06
O06
N06
D06
J07
F07
M07
A07
M07
J07
J07
A07
S07
O07
N07
D07
J08
F08
Month
% o
f HIV
+ pa
tient
s a
sses
sed
for a
ctiv
e TB
at e
ach
visi
t
52 DEMONSTRATION SITES 29 FIRST WAVE SPREAD SITES
Uganda - Comparison of Demonstration and Spread Sites Screening for Active TB in HIV+ Patientsaverage of 17,500 HIV+ patients per month in original sites; 5,000 in spread sites
CQI interventions
Baseline
Baseline
CQI Interventions
% of HIV+ patients seen in that month that were screened for active TB, based on Patient register
USAID Applying Science to Strengthen and Improve Systems
Niger: Percent of children triaged on arrival
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Old sites New sites
Niger - Comparison of Demonstration vs. Spread IMCI Sites for the % Children Triaged on Arrival
USAID Applying Science to Strengthen and Improve Systems
Key Results: Maternal and Neonatal Mortality Reduction – Basic ProCONE
Trend in Compliance with Criteria in Prenatal Care in San Marcos and 7 Additional Health Areas during Expansion Phase
A total of 143 facilities participating
78
90
85 8587
94 95
9594
68
72
63
84
7368 75
8883
90 91
80
85 81 8884
18
36
50
58 5966 69 65 72
74 77 80 80 78 84 8284
0
10
20
30
40
50
60
70
80
90
100
Demonstration Phase Expansion Phase
E.9 F.9 M.9 A.9 M.9 J.9 J.9 A.9 S.9 O.9 N.9 D.9 J.10 F.10 M.10 A.10 M.10Numerator 412 721 1230 1373 1421 1530 1670 1483 1485 1432 1485 1261 1574 1586 1459 1190 657Denominator 2310 2011 2467 2367 2402 2306 2427 2271 2073 1929 1924 1574 1963 2046 1737 1456 780Services reported 129 118 139 133 134 135 134 132 124 114 110 94 118 117 97 83 55% Services reported 90 83 97 93 94 94 94 92 87 80 77 66 83 82 68 58 38
Interventions:•Advocacy for securing micronutrients•Training of staff in prenatal care needed due to high turnover rate
USAID Applying Science to Strengthen and Improve Systems
Rwanda - Comparison of Demonstration vs. Spread site for the % Partners of Women in ANC Tested for HIV
Rwanda: percentage of partners tested
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J
% o
f p
art
ners
teste
d
Old Sites: % (16) New Sites: % (20)
USAID Applying Science to Strengthen and Improve Systems
Percentage of deliveries where Active Management of Third Stage of Labor -AMTSL- was implemented in accordance to standards. Three groups of hospitals (started 2003-2004,
n=55; 2005, n=21; 2007, n=10) . Total 86 hospitals reporting 2003-2009. Ecuador.
0
10
20
30
40
50
60
70
80
90
100
Per
cen
tag
e
% 2003-2004 0. 1514 1621 3237 3739 4142 4048 5159 5755 55 5857 6565 6168 6665 6966 6571 6463 6771 73 7681 8080 8579 7679 8679 8683 9095 9495 9795 93 8990 9495 9796 9692 9793 9391 9594 9697
% 2005 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1538 5559 4367 6277 8481 8474 7878 7984 82 8889 9389 8277 8182 8079 8487 8892 9084 8892 88 8991 8592 9592 9693 8889 9492 8891 9192
% 2007 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21 4044 5156 8879 9485 7693 90 8985 8987 8596 9795 9497 10 1010 9810
Jl-03AgSpOt Nv DcEn FbMr ABMyJn Jl AgSpOcNv Dc EnFb MrAbMyJn Jl AgSpOcNvDc EnFb MrAbMyJn Jl AgSpOcNv DcEn FbMr AbMyJn Jl AgSpOcNv Dc EnFb MrAbMyJn Jl AgSpOcNvDc EnFb MrAb
2003 2004 2005 2006 2007 2008 2009