@HelenBevan
Helen Bevan
How to create change that sticks and spreads
@HelenBevan
Some definitions
Diffusion: "the process in which an innovation is communicated through certain channels over time among the members of a social
system”Rogers 1962
Spread: “deliberate efforts to increase the impact of innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and program development on a
lasting basis”Norton and colleagues 2012
Going to scale (or scale up): “at least 60% of the target population that could potentially benefit from the programme receives it”
Rabin and colleagues (2012)
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How do we measure success?
“Unless a program can be replicated and sustained on a large scale, it will not be
transformational…..We can no longer evaluate programs simply based on how well they’ve performed in a given locality. Instead, we need to factor in
their potential to achieve scale”McKinsey on Society
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From 2001 to 2005, I was responsible for the Research into Practice team within the NHS Modernisation Agency
The team role was to promote the spread and sustainability of service improvement and helped to build a body of knowledge
We found that the factors of sustainability are also the factors for effective spread
Spread and sustainability
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We have more than 20 years experience of spreading large scale change
“It has been positivelyreviewed and reported in the nursing
& healthcare press and its implementation is proven to produce significant savings in
productivity & efficiency”White et al 2013
“Contributed
to a 51% reduction in
antipsychotic prescribing to
people with dementia”
Manchester Business
School
One of the most widely adopted and impactful improvement programmes in the history of the NHS; “releasing
time to care”, typically 10-20% of the time of clinical professionals. The changes were adopted by 78% of NHS hospital wards, 68% of mental health
wards, 54% of NHS operating theatres and 49% of community health teams across England (SHA statistics) as well as 44 territories
across the globe
New Zealand: 19% of time“released to care”
Oregon USA: multi-factorial improvements
Scotland: “20% of time
released to care”
A significant,positive impact on staff
engagement
Irish research: the effects were
sustained over time
Statistically significant positive effect on EVERY dimension of impact at both individual & organisational level
800,000 pledges;
engaged two thirds of all NHS
organisations
Our most successful ever
digital campaign
@HelenBevanSource: http://slideplayer.com/slide/9034724/
The “classic” approach to spread – the jury is out!
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Because the reality is often different
With alarming regularity,
many promising pilots in the
health care improvement
and implementation field
have little overall impact
when applied more broadly”
Perla & colleagues,
Health Affairs blog,
April 2015
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Enthusiasts Visionaries Pragmatists Conservatives LaggardsSource: Geoffrey Moore, building on the work of Everett Rodgers
Beware the chasm
The typical effect sizes of spread activities are perhaps 10-20% at best (Grimshaw)
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Emerging themes in spread
• Increasing attention to the demand side, to better understand the adopter’s point of view
• Coalition building (social movements and social media)
• Increasing attention to system conditions• Acknowledgement of context sensitivity• The importance of co-design for subsequent
scaling
Source: David Albury
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Nine repeating patterns from pilot programmes
#1Promising pilot programmes are rarely replicated successfully from pilot localities to others; the wider and more complex the change, (i.e., involving multiple organisations) the least likely that spread will happen
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Kaiser Permanente spread model
Just do it
Innovate
Test and replicate
CLEAR
COMPLEX
CHAOTIC
COMPLICATED
Source: Schall and Schilling
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#2Most of the early effort and energy is needed to make the pilot programme functional and issues of spread & scale often end up being an afterthought
Nine repeating patterns from pilot programmes
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#3We typically focus on extrinsic motivators to change, rather than intrinsic & we don’t align the motivators; as a result, change is often experienced by people at the front line as “have to” (imposed) rather than “want to” (embraced)
Nine repeating patterns from pilot programmes
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Intrinsic motivationPeople engage in the activity for the pleasure and satisfaction of doing it
Invokes many positive behaviours
Extrinsic motivationPeople engage in the activity for the rewards or avoiding punishmentAny external influence is referred to as extrinsic motivation
Images: pixgood.com
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The power of extrinsic drivers
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Three types of levers for large scale change
‘Prod mechanisms’ targets
performance management
price & payment incentives regulation
competition
‘Proactive support’
relies on building ‘intrinsic motivation’ in
staff to make the right changes to
improve
‘People focused’ education and training
national contractsprofessional regulation
clinical quality standards
Type one:
Type two: Type three:
Source: Health Foundation report Constructive comfort: accelerating change in the NHS 2015
@HelenBevan
Three types of levers for large scale change
‘Prod mechanisms’ targets
performance management
price & payment incentives regulation
competition
‘Proactive support’
relies on building ‘intrinsic motivation’ in
staff to make the right changes to
improve
‘People focused’ education and training
national contractsprofessional regulation
clinical quality standards
Type one:
Type two: Type three:
Source: Health Foundation report Constructive comfort: accelerating change in the NHS 2015
Less than 10%of the potential
for improvement at
system level can be
delivered through type one change
Claire Alcock
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#4People outside of pilot locality don’t feel any ownership of, or emotional connection with, the pilot project. As a result, the change processes can end up being “pushed” onto other localities rather than “pulled” by them
Nine repeating patterns from pilot programmes
@HelenBevan
Closed innovation Open innovation
As a pilot test site , we want to be left alone for a period of
time so we can work it out for ourselves
As a pilot test site, we seek to continuously get ideas and
guidance from leading thinkers and practitioners outside our local area
We will test our new ways of working internally “to
destruction”. When we are confident they will work, we will offer to share our “best practice innovations” with
others
A wider group has contributed to the innovation process, beyond our
host organisation; people from other localities already feel that
they own it. Spread is more likely to be “done with” not “done to” and to
be “pulled” not “pushed”
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The power of co-creation
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Open innovation is a mindset, not just a process
Pioneer Locality
We would love to share with
others but there don’t
seem to be any takers
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#5Even where we are able to create replicable change concepts from the pioneering localities, if we don’t have an implementation approach for spread that engages different local contexts, it doesn’t work
Nine repeating patterns from pilot programmes
@HelenBevan
Innovations won’t put down roots if the ground isn’t fertile
Source: David Fillingam
• National and regionally led improvement initiatives have their place• But “ sheep dipping” managers and clinical
leaders in programmes external to their local communities is unlikely to have lasting benefit
• What’s more the learning won’t spread to other communities (or even be sustained in its place of origin) unless each community has its own locally developed and owned culture and system of improvement
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There is a tendency towards “cargo cult” improvement
Attempts are made to spread/replicate new models from
pilot projects without a proper understanding of how they work.
They end up reproducing the superficial outer appearance but not the mechanisms that produced the
outcomes in the first instance (Dixon-Woods & colleagues 2011)
Cargo cult http://www.learningsolutionsmag.com/articles/1909/nuts-and-bolts-the-cargo-cult-of-training/pageall
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What is the best way to spread new knowledge?
Source of data: Nick Milton http://
www.nickmilton.com/2014/10/why-knowledge-transfer-through.html
Social connection/discussion is 14 times more effective
than written word/best practice
databases/toolkits etc.
Source of image: www.happiness-one-quote-time.blogspot.com
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#6The pioneer localities have limited bandwidth to coach others & spread best practices
Nine repeating patterns from pilot programmes
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#7Local leaders are understandably much more concerned with local change than they are with spreadLeaders of the macro level system must act as catalysts for spread
Nine repeating patterns from pioneer/pilot type programmes
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“Choreographers of complexity”
Scale up efforts should be overseen by a “choreographer of complexity”:
“An analogy can be made to the role a choreographer takes in a dance company. Their job is to produce a
finished work that integrates many different performance elements; music, dance, and storytelling. This must be done by making trade offs and finding synergies within the available resources of the [organisation or system],
and all the while driving toward an ultimate vision.”McClure and Gray (2015b)
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#8The commitment, characteristics & skills of local clinical leaders is often the crux issue for change in specific settings
Nine repeating patterns from pilot programmes
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“Perhaps the single most important influence on programme response by individual units—either in promoting or resisting change—was the extent of
consensus and coalition among the senior medical and nursing staff….
[Consultant says] ‘I think it’s been successful because it’s a unifying program, it’s one of the few things that we’ve
done that hasn’t been just a doctor thing, or just a nurse thing, it’s involved the doctors and the nurses together.’”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3704826/
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#9Sustainability of change is as much of a challenge as spread of change. The same receptive local contexts create the conditions for both spread and sustainability (See Buchanan and colleagues)
Nine repeating patterns from pilot programmes
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Few evaluative studies look beyond the pioneers to the issues of scale &
spread so empirical evidence is limited
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The Change Challenge
Tapping the collective brilliance of the NHS
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What does the NHS workforce think? 14,000 contributors recently identified 10 barriers to change:
Confusing strategies
Over controlling leadership
Perverse incentivesStifling innovation
Poor workforce planning
One way communication
Inhibiting environment
Undervaluing staff
Poor project management
Playing it safe
Source: Health Service Journal, Nursing Times, NHS Improving Quality, “Change Challenge” March 2015
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What does the NHS workforce think? 14,000 contributors recently identified 11 building blocks for change:
Inspiring & supportive leadershipCollaborative working
Thought diversityAutonomy & trust
Smart use of resources
Flexibility & adaptability
Long term thinking
Nurturing our people
Fostering an open culture
A call to action
Source: Health Service Journal, Nursing Times, NHS Improving Quality, “Change Challenge” March 2015
Challenging the status quo
@HelenBevanProject Aristotle: http://qz.com/625870/after-years-of-intensive-analysis-google-discovers-the-key-to-good-teamwork-is-being-nice/
After years of intensive analysis, Google discovers that the key to high performing,
teams that deliver change is psychological safety
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Ideas and new ways of working get spread when there is:a critical problem that the innovation is addressing OR a major
opportunity that it is realisingwide engagement in the design and development of the innovation
(involving potential adopters right from the start)strong evidence of:• desirability (relative advantage) and • feasibility (ease of integration into current working practices and
systems, and/or adaptability to local context) and• viability (compelling business case)
priority above other innovations, either by having an influential champion(s) or ‘top down’ (senior leader-led)
Harnessing of professional networksan approach that doesn’t focus purely on WHAT we do in terms of scaling,
but the WAY that we do it. Source: David Albury
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What do the leaders who get the best spread results do? They:
Source: McCannon
• Attempt remarkable things (provocation and optimism)• Talk about justice• Have a shared story• Apply many levers• Play jazz (adaptive, creative) • Keep it simple (e.g., interventions, measurement
systems)• Model trust • Seek affection and give recognition• Break rules (avoid consensus, condense timescales)
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The conclusions of the very first national spread programme in the NHS (National Booked Admissions programme from
1998) are still highly relevant
This evaluation has shown that thereare no magic bullet solutions….The main source of
change and service improvement has to come from within each and every NHS organisation. Renewed effort now needs to be put into developing the staff and organisations that can
embrace the kind of cultural change foreshadowed by the NHS Plan. No amount of guidance, support, hectoring or
cajoling can substitute for the lack of capability and understanding among the staff delivering care to patients of
the need to reshape the provision of services.Chris Ham & colleagues, 2002
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References• Barker P, Reid A, Schall M (2016)
A framework for scaling up health interventions: Lessons from large-scale improvement initiatives in Africa Implementation Science
• Buchanan D et al (2007) The sustainability and spread of organizational change: modernizing healthcare • Clay-Williams R et al (2014)
Do large-scale hospital- and system-wide interventions improve patient outcomes: a systematic review BMC Health Services Research
• De Silva D (2014) Spreading improvement ideas: tips from empirical research The Health Foundation• Gartner (2014) The Gartner hype cycle• Greenhalgh T et al (2004)
Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations Milbank Quarterly • Grimshaw J et al (2012), Knowledge translation of research findings Implementation Science • Kastelle T (2016) We’ve hit peak innovation (hype)• McClure D & Gray I (2015a) Scaling: Innovation’s Missing Middle • McClure D & Gray I (2015b)
Managing the journey to scale up innovation in the humanitarian and development sector• NHS Institute for Innovation and Improvement (2012) The spread and adoption tool• McCannon J (2011) The spread problem• Moore G (2015) Crossing the chasm: marketing and selling products to mainstream customers• Norton W et al (2012)
A stakeholder-driven agenda for advancing the science and practice of scale-up and spread in health• Perla R et al (April 2015) Health Care Reform And The Trap Of The “Iron Law” Health Affairs blog• Randall S (2015) Using communications approaches to spread improvement The Health Foundation• Schall M & Schilling L (2014)
An introduction to spreading effective practices and From sustainability to spread and scale up
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Today in England is
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For our break, we will have a RCT
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• Randomised Coffee Trial!• Randomised Coffee Trial!
Randomised Coffee Trial!
@HelenBevanfabnhsstuff.net/fabchangeday/rct/ or google “Fab stuff RCT”
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Outcomes of Randomised Coffee Trials
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Join in one of our national Randomised Coffee Trials
fabnhsstuff.net/fabchangeday/rct/ or google “Fab stuff RCT”
Mental health – for anyone interested in mental health issues Dementia – for anyone interested in dementia issues Staff wellbeing – for anyone interested in how staff are cared forPatient Safety – for anyone with an interest in ensuring patient safety across the health and social care systemHome First – looking at the issues around how people who have long-term health conditions receive care outside of hospitalLearning and Leading Together – for anyone interested in how patients and healthcare staff can work together in genuine partnershipMatExp – for anyone interested in improving maternity experience – women and families as well as professionals
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