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Sustaining and Spreading Changes. Robert A. Gabbay , MD, PhD Connie Sixta, PhD, RN, MBA. Creating an Improved Clinical System. Improvement. Hold Gains. Spread. NON-LINEAR MODEL BETTER. Improvement. Hold Gains. Spread. API Lloyd Provost. We’ve talked a lot about improvement. - PowerPoint PPT Presentation
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Sustaining and Spreading ChangesRobert A. Gabbay, MD, PhDConnie Sixta, PhD, RN, MBA
Improvement
Hold Gains
Spread
Creating an Improved Clinical System
Improvement Hold Gains Spread
NON-LINEAR MODEL BETTER
API Lloyd Provost
We’ve talked a lot about improvement• Model for Improvement:
• Aim• Measurement• Rapid testing of changes
(PDSA cycles)• Test lots of ideas!
• Expect some will “fail”• Most will need refinement
(PDSA cycles)
Sustaining ImprovementDrop off in measures is common but preventable!• Initial excitement, urgency wear off.• Possible change fatigue.• Pay particular attention to yearly measures (foot
exams, eye exams, LDL tests, etc.) as you approach end of initial 12 months.• If strong system of population management is in place
should not see these decline.• Staff/Provider turnover, particularly among
change leaders.
Strategies to Hold the Gains• Establish and document standard processes• Make changes to job descriptions• Use measurement and audits• Pay attention to orientation and training• Assign ownership• Address the social aspects of change (who
are the peer leaders, who talks to whom)
Your Sustainability Experience• How are you checking to make sure
changes are sticking?• What kind of shared ownership exists in
your practice for your improvement data?• How have you been documenting revised
processes and revised job duties?
Test --> Implement --> Spread• Testing: Trying and adapting existing
knowledge on small scale. Learning what works.• Change is not permanent.• Lot of experimentation and revisions.• Failure very useful here, even expected.• Few people impacted (limited staff, few patients).• Need to build improvement documentation for
permanent implementation and spread of successful changes.
Test --> Implement --> Spread• Implementing: Making this change a part
of the routine day-to-day operation of your practice.• More people impacted than during testing.• Increased resistance compared to testing. • Generally requires more time than testing.• Some additional revisions may be needed.• But don’t expect failure here because you have
documented success of changes.
Test --> Implement --> Spread• Spreading: Adapting change to additional
areas (other practices) or other patient populations beyond diabetes.• Useful for multi-site practices, systems.• Good population management processes work
across chronic diseases and prevention.• Application to other conditions is important for
NCQA recognition and Meaningful Use.
Deg
ree
of b
elie
f tha
t the
cha
nges
will
re
sult
in im
prov
emen
t
High
Developing the Change
Testing and Adapting the
Change
Implementing Then Spreading the Change
Successful changesBeginning to implement
and spread.
Changes still need further testing. There is a risk of moving to implementation and spread.
Unsuccessful proposed changes
Low
Moderate
What’s the status of each of your changes?
Change 1
Change 3
Change 2
API –Lloyd Provost
InnovatorsEarly
Adopters
EarlyMajority
LateMajority
Laggards2.5% 13.5% 34% 34% 16%
from Rogers, 1995
Adopter Categories
The “Tipping Point” • “The name given to that one dramatic moment in
an epidemic when everything can change all at once.”
- M. Gladwell
• “The part of the diffusion curve from about 10 percent to 20 percent adoption is the heart of the diffusion process. After that point, it is often impossible to stop the further diffusion of a new idea, even if one wished to do so.”
- E. Rogers
Spread of Chronic Care Model Across Clinics
0
10
20
30
40
50
60
70
80
90
100
Sep-98
Oct Nov Dec Jan-99
Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan-00
Feb
Perc
ent o
f clin
ics
impl
emen
ting
CCM
Total of 80 Clinics in Organization
The “Diffusion Curve”
Diffusion Depends on 6 Factors1. Relative advantage over current practice2. Compatibility with current culture and
practice3. Simplicity 4. Observability5. Trial ability6. Timing of return on investment
Everett Rogers, The Diffusion of Innovation
Developing a Spread Plan• Is improvement a key strategic initiative?
• Is there a budget for spread?• Has time been allocated for spread?• Are goals and incentives aligned?
• Identify and develop your spread champions.• Leverage your improvement data—tell your
improvement story!• Document your ROI.
Rest of Practiceor Across System
A PS D
A PS D(Tests to adapt changes, then implementation)
Population of Focus for the initial improvement (pilot population)
A PS D
Target Population for Spread
The Communication Plan• Document benefits • Show comparative data• Use multiple communication channels • Explain changes succinctly• Involve successful units in providing technical
support• Measure and provide feedback
The Social System• Understand the relevant circumstances
affecting peoples’ ability/willingness to adopt changes.
• Take advantage of the existing relationships within the system.
• Develop “communities of practice” among those with similar roles (peer-to-peer support and learning).
Your Thoughts• What changes have you already spread?• How has the spread gone?
• Any resistance to overcome?• What barriers are keeping you from
spreading?
References•Attewell, P. Technology Diffusion and Organizational Learning, Organizational Science, February, 1992 •Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986.•Brown J., Duguid P. The Social Life of Information. Boston: Harvard Business School Press, 2000.•Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the Bell System, 1971 –1982, Organization Science, Vol.8, No. 5, September - October 1997.•Dixon, N. Common Knowledge. Boston: Harvard Business School Press,
2000.•Fraser S. Spreading good practice; how to prepare the ground, Health Management, June 2000.•Gladwell, M. The Tipping Point. Boston: Little, Brown and Company, 2000.•Kreitner, R. and Kinicki, A. Organizational Behavior (2nd ed.) Homewood, Il:Irwin ,1978.
References•Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco: Jossey-Bass 1996.•Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Implement Practice Guidelines. JAMA, Vol. 265(17);
May 1, 1991, pg. 2202-2207. •Myers, D.G. Social Psychology (3rd ed.) New York: McGraw-Hill, 1990.•Prochaska J., Norcross J., Diclemente C. In Search of How People Change, American Psychologist, September, 1992.•Rogers E. Diffusion of Innovations. New York: The Free Press, 1995. •Wenger E. Communities of Practice. Cambridge, UK: Cambridge University Press, 1998.
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