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M 6Practical Tools to Spread

Improvements and Achieve Results at Scale

December 5, 2011

Orlando, FL

Session Objectives

• Describe different spread models and how

to apply them

• Acknowledge the unique needs of the

culture in each local department or setting

• Assess both site readiness and an

improvement’s readiness to spread

• Apply lessons to your own practice and

care delivery situation

Agenda - AM

• Overview of Spread and Scale-up

─Concepts and Strategies

─ Introduction to Case Studies

• Readiness

─Start with the End in Mind (Step 1)

─Link to Strategic Objectives (Step 2)

─Assess Readiness (Steps 3 and 4)

• Lunch

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Agenda - PM

• Recap/Reflections from AM Session

• Develop a Spread/Scale-up Plan

─Choose a Spread Approach (Step 5)

─Key Elements of a Plan (Step 6)

• Execute the Plan

─Prepare for Testing and Implementation (Step 7)

─Gather Information; Make Adjustments (Step 8)

─ Identify Sites in Need of Support (Step 9)

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Faculty

• Marie Schall, MA, Institute for Healthcare Improvement

• Gail Nielsen, BSHCA, Iowa Health System

• Jim Bellows, PhD, KP Care Management

Institute

• Lisa Schilling, RN, MPH, Kaiser Permanente

• Kristene Cristobal, MS, Kaiser Permanente

• Denise Myers, RN, MPH, Kaiser Permanente

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Meet Your Colleagues

• At your tables – in 5 minutes:

1. Introduce yourselves

2. Examples of successful spread?

3. Current/planned spread effort? What topic?

4. Challenges and/or questions you have for today?

• Be prepared to share the experience from

your table

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Overview of Spread and

Scale-up

Marie W. Schall, MA, IHI

Lisa Schilling, RN, MPH, Kaiser

Permanente

The Sequence for Improvement

and Spread

Spreading a change to other

locations

Developing a change

Implementing a change

Testing a change

Act Plan

Study Do

Theory and Prediction

Test under a variety of conditions

Make part of routine operations

Robert Lloyd, PhD

Testing/Implementation/Spread

• Testing: Trying and adapting existing knowledge on small scale. Learning what works in your system.

• Implementing: Making this change a part of the day-to-day operation of the system in your pilot population. Holding the gains.

• Spreading: adapting change to areas or populations other than your pilot populations

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Implementation: Key Components of Strategy

• Communication

─ Publicize benefits, document improvement, keep contact w/

team

• Infrastructure

─ Job descriptions, policies, hiring, orientation, supply stream, etc.

─ Assign ownership for improvement and maintenance work of the new process

─ Senior leaders held responsible for efforts to sustain

• Design Effective Control System

─ Use your internal quality assurance or improvement resources

─ Plan to standardize new process and verify conformance to the

standard

─ Graphically monitor measures for performance/outcomes from

the collaborative.

Spreading Improvements

IHI Breakthrough Series(6 to 18 Months Time Frame)

Select Topic

(Develop Mission)

Planning

Group

Develop

Framework & Changes

Participants (10-100 Teams)

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports

Email (listserv) Phone Conferences

Visits Assessments

Monthly Team Reports

Dissemination

Publications,

Congress. etc.A D

P

SExpert

Meeting

AP1 AP2 AP3*

LS – Learning Session

AP – Action Period

*AP3 –continue

reporting data as

needed to

document success

Holding

the Gains

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Set-up-Target population

-Adopter audiences

-Successful sites

-Key partners

-Initial spread strategy

A Framework for Spread

Social System-Key messengers

-Communities

-Technical support

-Transition issues

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

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

Scale up vs. Spread

• Scale-up: The progressive design of a system of interrelated parts;

moving from one setting to a larger setting and then an even larger setting within an interrelated system.

─ Expect new learning and structural changes to achieve results at scale.

─ Ex: A pilot unit at MGH successfully implements electronic medical records (EMR). The hospital decides to implement EMR in all units in the hospital.

• Spread: Taking a system or intervention and replicating it in an

independent site.

─ Active adaptation and replication by adopter sites but without significant new learning (about the system or intervention) or structural changes.

─ Ex: A pilot unit at MGH successfully implements EMR. A hospital in an unrelated setting, such as Chicago or St. Louis, is interested in their work and decides to

implement EMR in a pilot unit in this new, unrelated hospital.

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Scale-up of New System for Improving

Transitions in Care

Entire Hospital

All Surgical Units

All Medical Units

Pilot Unit(s)

….redesigning care processes to improve transitions for all patients (e.g., enhanced assessment, handover communications between settings, etc.)

From Pilot Units to Clinical Departments (multiple units) to Entire Hospital….

Spread: Pilot Sites to Similar Sites in other Systems

P

S

S

P

P

S

S

S

S S

P

S

Spreading Effective Practices

December 5, 2011

Lisa Schilling RN MPH

VP, Healthcare Performance Improvement

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KP/IHI CFO Dialog

• Practices are hard to transfer

• We don’t know the best infrastructure to spread

• We don’t have the will to spread

• We don’t make great decisions about what to spread (few return what’s promised)

20Source: Institute for Healthcare Improvement, 2006.

Mental Model for Spread

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What you need to know about effectiveness…

A x Q = E

A= strategies to build acceptance and commitment (culture, accountability)

Q= quality of technical solution (both the

change and the reliable application of change)

Source: Jack Welch

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Applying this in Operations

Org

an

iza

tio

na

l A

lig

nm

en

t

High

TransferabilityHigh Low

Low

Source: Stacey 2002

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A Tool to Lead Spread in 9 Steps

Determine organizational readiness for spread1. Start with the end in mind2. Determine whether linked to strategic objectives of

organization3. Assess readiness to spread (using tool)4. Assess readiness to receive (using tool)

Develop a plan:5. Choose spread approach. 6. Develop a plan for spread

Execute on the plan:7. Prepare for testing and implementation8. Gather information over time to allow adjustment of

spread plan9. Identify sites in need of support

Case Studies: Overview

• Iowa Health System

─ Gail Nielsen, BSHCA

• Kaiser Permanente

─ Kristene Cristobal, MS

─ Denise Myers, RN MPH

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Spread Project

• What: Medication Safety

• Where: 10 IHS hospitals

• AIM: Reduce Adverse Drug Events

50% in two consecutive years

• Time Frame: 2 years (2002-2003)

Iowa Health System

Medication Safety Components

─Culture of Safety

�Unit Briefings

�Executive WalkRounds ©

─FMEA

─Medication Reconciliation

─Hazard Drugs

Iowa Health Spread Project

Iowa Health Spread Project

• Full Scale Plan at Outset:

─ System Strategic Aim

─ System-wide Patient Safety Implementation Team

─Hospitals’ VPMAs, Pharmacy Directors, Quality Leaders, Educators, and front-line representation

• Prototypes

─ Pilots 1 and 2 then

─ System-wide collaborative for 10 hospitals

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Iowa Health System

Aim: 50% Reduction in ADEs System-wide in 2002 & 2003

Iowa Health System Adverse Drug Events: % of Sampled Charts with Harm Levels ADEs E-I

Targets: 2002 = 10%, 2003 = 4%

20%

14%

9% 9%10%

6%

4%

6%5% 5%

3%

6% 6%

10%11%

2%

10%

6%

3%4%

0%

10%

20%

30%

N-01 D-01 J-02 F-02 M -02 A-02 M -02 J-02 J-02 A-02 S-02 O-02 N-02 D-02 J-03 F-03 M -03 A-03 M -03 J-04

% o

f C

ha

rts

'03 Target 4%

Reduced Sample Size

Sepsis Case study

Spreading Effective Practices

Why Sepsis ?

205,000 Adult Hospital Admissions

5,500 Sepsis Admissions

200,000 Other Admissions

1,400 Deaths from Sepsis

4,300 Deaths from Everything Else

24% of All Deaths

2.7% of All Admissions

Mortality Rate 2.2%Mortality Rate 25%

2007 KPNC Adult Hospital Stays, includes OB

1 in 4 deaths11 times the mortality rate

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Step 1.

Start with the End in Mind

Marie Schall, MA, IHI

Start with the End in Mind

• Determine what is being spread

• Define target population and end

state

• Establish timeframe to achieve scale

• Identify system level metrics and

outcome

• Define “sites” participating in effort

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Why it Matters

• Because WHAT you are trying to do

is going to effect HOW you will do it─What methods you will use, i.e., spread

versus scale up

─ If spread, then which spread methods

─ If scale-up, then what structures to pay attention to

─ If both, how to develop an integrated plan

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Things to Consider in Selecting a Spread Approach

• Nature of the Intervention(s)

• Organizational Structure

• Social System

• Ability to reach target sites all at once

• Constraints

Scale-up Planning

• Define targeted scale at project setup

• Use the system issues in discussions with executives of the participating organizations. What structures need to change to accommodate scale-up?─ Administration structures ─Responsibility, accountability control structures ─ Physical structures─Human resource requirements─ Information systems

• Being aware of constraint changes as you expand

Case Studies and Exercises

• Iowa Health System

─ Gail Nielsen, BSHCA

• Kaiser Permanente

─ Kristene Cristobal, MS

─ Denise Myers, RN MPH

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Step 2.

Link to Strategic Objectives

Gail Nielsen, BSHCA, Iowa Health

System

Link to Strategic Objectives

• Determine whether linking to a strategic

goal aligns with initiatives

• Craft a compelling message and cascade

• Charter the team

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Strategic Alignment

• System AIM adopted by all 10 hospitals:

─ Reduce Adverse Drug Events 50% in two consecutive years 2002-2003

• A compelling message cascaded system-wide

─ 1 in 5 patients are experiencing serious medication events in our hospitals, and we

now know how to improve. We need help from everyone!

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Cascade Compelling Message

• Provide visible senior leader commitment to communities being engaged

• Coach Senior Leaders to show up at meetings and ask questions about progress

• Focus on possibilities rather than always on barriers

Iowa Health System

Cascade Compelling Message

• Help Senior Leaders keep the initiative

alive through “sense-making”

─explaining the criticality, relating it to everyone’s role

• Coach Senior Leaders to ask illustrative

questions and coach during WalkRounds©

─signaling priority of the work

Iowa Health System

Establishing the Charter

• AIM, boundaries, scope, measures, timeline

• Recommended changes

• Team members:

- Vice Presidents of Medical Affairs

- Pharmacy Directors

- Quality Improvement Directors

- Educators

- Front-line representation

- Improvement coaches

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Iowa Health System

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KP Case Study and Exercise

• Kaiser Permanente

─ Kristene Cristobal, MS

─ Denise Myers, RN MPH

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Step 3.

Assess Practice and Readiness

Jim Bellows, PhD, KP Care

Management Institute

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IHI Minicourse:

Practical Tools to Spread Improvements and Achieve Results at Scale

Readiness for Spread

Jim Bellows, PhD December 5, 2011Senior DirectorKP Care Management Institute

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In this segment

� Understand what makes a practice ready for successful spread

� Understand what makes a site ready to import a practice

� Know how to use readiness assessment tools

� Apply the readiness tools to your project

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Why assess Readiness?

Have you ever…

… tried to import a practice that was successful for the

innovator, but you just couldn’t make it work?

… tried unsuccessfully to interest others in a practice that

seemed great to you?

… had a senior leader ask you to spread a practice that was too complicated? Gave little return?

The solution? Due diligence

• Don’t assume every promising pilot produces a ready-to-

spread practice

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Is the site

ready to receive?

Yes

Site frustration –

Practice may be imported, but without

anticipated value

Success!

NoDon’t even try it

:-(

Leadership frustration –

The practice won’t take root

No Yes

Is the practice ready for spread?

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Assess Readiness to Spread

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Sources for Readiness tools in KP’s Spreading Effective Practices Toolkit

Sources

� Diffusion of Innovations, E Rogers. 1962.

� Diffusion of Innovations in Service Organizations: Systematic

Review and Recommendations. Greenhalgh T, et al. 2004.

� Sustainability – Ensuring Continuity in Improvement. UK NHS Institute for Innovation and Improvement. 2006.

� Options for Large-scale Spread of Simple, High-impact

Interventions. Massoud R et al. 2010.

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Some innovations are destined to spread

� Trialability

� Advantage

� Compatibility

� Observability

� Simplicityper Everett Rogers

Plus…

� Task relevance

� Task usefulness

� Feasibility

� Implementation complexity

� Divisibility

� Explicit knowledge base

per Trisha Greenhalgh 2004

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Impact on Other

Aspects of Care

� Implementation Sustainability and Reliability

� Implementation Support

� Observability

� Simplicity

� Adaptability

� Cultural Fit

� Goal Alignment

Dimensions of practice readiness

� Cost

� Savings

� Revenue

� Return on Investment

� Certainty and Timing

� Harvestability

Impact on

Primary ObjectiveBusiness Case

� Magnitude

� Confidence

� Patient Safety

� Effectiveness

� Patient Experience

� Physician & Staff Work Experience

Maturity &

Transferability

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Effectiveness –

Primary Objective

Other Impacts(Unintended Consequences)

Business Case

Maturity &

Transferability

Readiness Bingo –Is the practice ready for spread?

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How ready for spread was the sepsis bundle?

� Early pilot reduced sepsis mortality to 13% compared with a 34% among sepsis patients in whom the protocol was not completed (p = 0.008).

� Some physicians felt that early central line placement created unneeded risk of complications, and discounted their ability to make accurate, timely diagnoses.

� Length of stay averaged 8 days compared with 12 days for patients in whom the bundle was not completed, so the return on investment must have been excellent.

� Results had been replicated or exceeded at other hospitals, and training materials and protocols were available to smooth implementation.

This scenario is provided for discussion only.

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Effectiveness –

Primary Objective �

Other Impacts(Unintended Consequences) �

Business Case �

Maturity &

Transferability �

Could readiness for spread be improved by refinement or better data?

This scenario is provided for discussion only.

Step 4.

Assess Site Readiness

Jim Bellows, PhD, KP Care

Management Institute

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Assess site readiness to receive

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Organizational

Culture

� Project Management & Championship

� Training

� Measurement and Monitoring

Dimensions of site readiness

� Staff Capacity & Competency

� Space

� Technology

Leadership

Alignment

Operational

Resources

� Strategic Alignment with Goals and Priorities

� Sponsorship & Leadership

� Oversight Infrastructure

� Cultural Readiness for Change

� Operational Infrastructure (# of units involved, relationships)

Implementation

Infrastructure

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Leadership

Alignment

Organizational

Culture

Operational

Resources

Spread

Infrastructure

Readiness Bingo –Is the site ready to receive?

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How ready is Blossomville?

� Blossomville Medical Center serves 150,000 KP members, with

a 300 bed hospital + primary and specialty care facilities.

� Senior leadership didn’t expect ROI, but want to improve

hospital mortality so the initiative was well aligned with goals.

� The leadership and staff often felt stretched by having many

initiatives underway.

� The Improvement Director reports to the COO, and gets 3-5

minutes at monthly executive meetings to report on initiatives.

� Blossomville’s top leadership supported the initial launch by sending three emails to the ED staff.

� Blossomville had participated in IHI’s Transforming Care at the Bedside, which built a culture of openness to trying new things.

� The initiative required the ED physicians and nurses to

coordinate closely with the lab, Admissions process, and others.

This scenario is provided for discussion only.

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How ready is Blossomville? Part 2

� The Blossomville ED found that the intervention was causing

operational wrinkles that had not been reported at pilot sites.

� The PI director heard that central line placement often didn’t

happen on time because the supply kits were in short supply.

� The PI Director had secured a capable project manager for the

spread effort. Her “day job” as administrative services director

allowed her to spend 30% of her time for 2 months.

� Because the intervention was a collection of many separate

practices, the project manager wasn’t sure what the real priorities were.

� The initiative promised to decrease hospital mortality, but

physicians and nurses couldn’t see any gains after several weeks of effort.

This scenario is provided for discussion only.

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Leadership

Alignment �

Organizational

Culture �

Operational

Resources �

Spread

Infrastructure �

Where should effort be devoted to increase site readiness?

This scenario is provided for discussion only.

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Using the Readiness tools

Invest the time

• How much time will you spend trying to drive spread?

Be a hard grader

• Be realistic about challenges – recognition will help you prepare for resistance

• A low Readiness score is just information, not a sign of failure

Complete the tools as a team

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Summary: The Readiness tools can help address…

� Is this spread project positioned for success?What’s missing?

� How could gaps be addressed in the spread plan?

� Do sponsors and other key stakeholders have a shared understanding of strengths and barriers?

Iowa Health System

• Revisiting scale, scope, and speed

─Reducing Readmissions, Year 1

�Most team leads were novice improvers – doing most of the testing work

�Senior leaders partially engaged – some new to sponsoring improvement

�Changed scope and speed mid year to help teams dig deeper, learn implementation and reliability skills and build larger teams

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Scale, Scope, and Speed

• Create monitoring

and review plan

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STAAR Recommended Changes

for Transitioning Patients from

Hospital to Home

# of Teams currently

testing, implementing,

or spreading

recommended changes

Enhanced Assessment

•Include Patients, Families and Community

•Reconcile Medications

•Identify Initial Risk

•Customize Discharge Plan

624

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Teaching and Learning

•Customize Education and Print Materials

•Identifying Learners and Teaching Them

•Teach Back

546

Follow up

•Identify Risk for Readmission

•Schedule Follow up Appointments

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Handover

•Medication Reconciliation at Discharge

•Critical Information to Next Site of Care

•Patient Friendly Discharge Plan

•Clinician-to-Clinician Handover

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2

Iowa Health System

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Hospital 30-Day All-Cause Readmissions for HF Patients

0%

10%

20%

30%

40%

50%

60%

Pe

rce

nt

Re

ad

mis

sio

ns

% readmissions Median

Iowa Health System

Reflections on AM Session

• What if anything surprised you?

• What if anything confused you?

• What did you find the most helpful in planning your spread/scale-up efforts?

• What additional questions do you have?

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