Transcript Slide 1

Getting to Scale: Spread
IA Graduate Seminar, May 18, 2010
Lisa Schilling RN MPH VP, Healthcare Performance Improvement
Jim Bellows, PhD Senior Director Evaluation and Innovation
Objectives for today
• Discuss models and thinking about what
“spread” means and considerations for
effective application
• Consider how to apply models in your
area
• Access tools to help local sites assess
readiness to spread and adopt practices
2
What you have already learned
The Sequence for Improvement
Make part
of routine
operations
Test under
a variety of
conditions
Theory &
Prediction
Develop a
change
3
Spread a change to
other locations
to here!
Implement a
change
Test a
change
Don’t go from
here …
Source: Bob Lloyd, IHI 2009
Act
Plan
Study
Do
More you already learned…
AxQ=E
A= strategies to build acceptance and
commitment (culture, accountability)
Q= quality of technical solution (both the
change and the reliable application of
change)
4
Source: Jack Welch
Influencers of Implementation
and Spread
Will
 Values
 Alignment/prioritizati
on
 Relationships
 Communication
 Goals /measures
Ideas
 Change package
 Effective practices
 learning
5
Source: IHI 2009
Execution
• Infrastructure and
resources
• Method
• Monitoring/feedback
Conceptual Models for Spread
Psychological:
 Diffusion
 Transtheoretical: readiness for change
Infrastructure:
 Breakthrough Series Collaborative model
 IHI Framework for Spread
 Campaign model
 Multiplicative spread
Other:
 Hybrid models
6
Many good recipes…
Compelling
Need to Move
3 H’s
Destination
OURS
(Cycles of Scrutiny)
Ownership
Uniformity
What Gets Us There
4WD
 Leadership alignment
 Standardization / Systemization
 Project Management
 Data that drives
7
Reliability
Sustainability
Elements Important for the
Rate of Adoption
• Relative Advantage
• Compatibility
• Complexity
• Trialability
• Observability
8
Source: Everett Rogers
Mental Model for Spread
9
Source: Institute for Healthcare Improvement, 2006.
Applying this in Operations
Organizational
Alignment
Low
Test and
ReplicateDiffusion
Innovate
Test and
Replicate Collaboratives
High
Just Do It
High
10
Source: Stacey 2002
Test and
ReplicateWaves
Transferability
Low
Definitions
Just Do It
Test and Replicate: Waves
•
Use project management to implement
•
•
Go fast; replicate with little variation
Pilot in 1-3 sites first, then spread to 5-10
sites, then to all the rest of the sites
•
Drive spread, highly coordinated and
planned progression of spread, testing
especially in first two sites to implement
practice to build will and transferability of
practice
Test and Replicate: Diffusion
•
Implement in a few sites to increase level
of agreement among stakeholders
•
Encourage spread, go slow, minimal
highly coordinated or centralized effort
with
Test and Replicate: Collaboratives
•
•
Use IHI’s Breakthrough Series
Collaborative model
Focused infrastructure, accountability,
learning and sharing to create change
package
11
Innovate
•
Use innovation methods such as IDEO
•
Go slow, prototype, replicate, refine and
spread
•
High failure rate to get practice
More Tools to Apply in Operations
1
2 Readiness to
Spread and
Receive
Organizational
Alignment
Low
Test and
ReplicateDiffusion
Innovate
3 Methods for
Monitoring
Spread
Test and
Replicate Collaboratives
High
Just Do It
12
Source: Stacey 2002
4 Supporting a
Test and
ReplicateWaves
High
Learning
Culture
Low
Transferability
A Tool to Lead Spread in 9 Steps
Determine organizational readiness for spread
1.
2.
3.
4.
Start with the end in mind
Determine whether linked to strategic objectives of
organization
Assess readiness to spread (using tool)
Assess readiness to receive (using tool)
Develop a plan:
5.
6.
Choose spread approach.
Develop a plan for spread
Execute on the plan:
7.
8.
9.
13
Prepare for testing and implementation
Gather information over time to allow adjustment of
spread plan
Identify sites in need of support
Spread Tool (steps 1-4)
Step
Determine organizational readiness for spread
1. Start with the
end in mind
Determine
How
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
14
2. Link to
strategic
objectives
3. Assess
readiness to
spread
Determine
Complete
Complete
whether linked to
strategic goal,
align incentives
readiness to
spread
assessment
with team
readiness to
receive
assessment with
team
Plan
for sites
based on
learning
Plan
Revisit
Create
Craft
a
compelling
message and
cascade
Charter
team
scale,
scope and
speed
4. Assess
readiness to
receive
for
sequencing
based on learning
monitoring and
review plan
Spread Tool (step 5-6)
Develop a plan
Step
5. Choose
spread
approach
Use
How
results
from steps 3
and 4 to
determine
alignment/
transferability
Choose
spread
approach
Plan
resources
15
6. Develop a
plan for spread
Create full
description of
change package
Create a
measurement plan
including impact
on system
performance
Plan to monitor
extent of spread
both the change
package and scale
achieved
Plan
infrastructure
and resources elements to scale,
new role
requirements,
technology
Identify
experts
who will teach
others re practice
Determine
physical
and relationship
linkages/proximity
Spread Tool (steps 7-9)
Execute on the Plan
8. Gather info
and adjust
plan
9. Identify site
in need of
support
Implement
Manager
Ensure
practices to
share
learning and
progress
Sufficient
Step
7. Feedback
to adopters
Monitor
How
rate
of adoption
and
determine
adjustments
needed:
-messages
– Capable
messengers
16
-Transition
issues
support
time to test
and
implement
Adopters
understand
methods
Technical
support
middle
management (or
process owners)
engaged
throughout
Determine
sustainability
metrics;
thresholds that
trigger specified
remedial actions
Plan
content,
technical and
implementation
support
Tools to Plan and
Lead Spread
Jim Bellows
Topics
• Specify your goal(s) in spreading a successful
practice
 Be clear about your role
• Assess practice readiness for export
• Assess site readiness to import
18
What is your spread goal?
Spread what? From where to where?
State your Project Goal here. Remember your goal should be S.M.A.R.T.
(Specific, Measurable, Agreed Upon, Realistic, Time-based)
Objectives
List measures to support the Project Goal and Objectives.
Outcome Measure(s):
Process Measure(s):
19
Typical spread goals
• Bring <practice> to our medical center from
<Region>
• Help other medical centers adopt our successful
practice
• Get all the units in our medical center adopt
<practice> that has been so successful in <pilot unit>
• Bring <practice> from <Region> to all the units in our
medical center, beginning with <demo unit>
• Program Office says we all need to do <practice>, so
let’s do it
20
Your spread goal defines you
role in supporting spread
Typical goal
Pattern
Bring <practice> to our medical
center from <Region>
External1 Importer
Help other medical centers adopt
our successful practice
1External Exporter
Get all the units in our medical
center adopt <practice> that has
been so successful in <pilot unit>
1Many
Distributor
Bring <practice> from <Region> to
all the units in our medical center,
beginning with <demo unit>
External
1Many
ImporterDistributor
21
Role
Tasks will depend on your role
in spread
Importer
Exporter
Distributor
Importer-Distributor
External1
1External
1Many
External1Many
Confirm practice
Confirm practice
Confirm practice
Confirm practice
readiness for export readiness for export readiness for export readiness for export
Market the practice;
find a distributor
Assess your site
Assess import site
Assess alignment
readiness for import readiness for import and readiness
across all sites
Assess alignment
and readiness
across all sites
Choose an import
model
Choose an import
model
Choose a
distribution model
Choose a model for
import and dist’n
Import!
Export!
Distribute!
Choose a
demonstration site
Import! (and evaluate)
Distribute!
22
Practice Readiness-forExport Assessment
Why assess
Readiness for Export?
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 import/distribute a practice that was:
 Too complicated?
 Expensive, with little return?
 Not the best way to get the job done?
Solution? Due diligence – don’t conclude too quickly that a practice is
ready for export
24
Readiness for Export
Assessment
KP Readiness-for-Spread Assessment
About This Tool
The purpose of this tool is to help KP succeed in spreading successful practices widely. One key factor is picking the
ripest opportunities – some practices aren’t really ready to be spread widely. This tool can help program champions
and KP leadership understand whether a promising practice is ripe for successful spread across KP. Using it can
prevent wasting energy from trying to spread a practice that has not yet been developed sufficiently. The tool can
1. Impact
onmight
Primary
Objective
highlight the aspects of a practice or its documentation
that
need
to be strengthened to support wide scale
spread. It is meant as a discussion tool to support informed decision making and to help set realistic expectations. It
is not intended to create “hoops to jump through,” or The
to interfere
with
efforts
thatrelate
enjoytostrong
support.
first criteria
for spread
a promising
practice
impact on
the primary objective addressed.
What is the one primary objective of the practice or intervention assessed?
2. Impact on Other Aspects of Care
Who To Involve in the Assessment Process
 Patient Safety
 Physician/Staff Work Experience
The assessment can be used in two distinct settings, 
described
below
along with ideal participants Equity
Effectiveness
of Care
1. Push – Program champions can use the tool to
the question:
“Could
my program
orisEfficiency
practice
 address
Patient Experience

Successful
spread
of promising
practices
affected be
not only by their impact on the primary objective but also by intended or unintended impact on other aspects
spread widely from its current demonstration site(s)? Facilitator:
A Business
KP Improvement
Advisor or other person,
of care delivery.
3.
Case
is the primary measure
of
impact?transfer.
__________________________________________________
not directly responsible for the program, whoWhat
is knowledgeable
about
practice
Participants:
Program
Do not rate here
the impact
on primary
objective
rated in
Section
1. understanding of their business case. All other factors being equal, practices with positive business
Promising
practices
are unlikely
to spread
without
a clear
champion, implementation lead, front-line staff.
on investment – not only that the financial benefits (cost savings,
Element
Start-Up cases are more likely to spread successfully. A positive business case means a positive return
Well-Established
2. Pull – Senior leaders can use the tool to address theElement
question: “Is this
ororpractice
for transfer
Start-Up
Well-Established
costprogram
avoidance,
revenue ripe
enhancement)
exceed the costs, but that the benefits accrue to entity that bears the costs, the benefits
are as certain as the costs, the
4. Transferability
into my area or Programwide?” Facilitator:
Leader or staff of
a Program
Office
orPotentially
Regional
unit responsible
foraffects
benefits
develop
in a reasonable
time frame,
and
the potential
be harvested
real “hard
dollars (e.g.
reduced
Number
of potentially
affects
Potentially
1-10% ofbenefits can
Potentially
affects into
all members,
or green”
a subpopulation
of 10%
or moreadmissions translated into
Magnitude
Potential
for adverse
Potential
have (i.e.
beenpractices
been
by ifone
or can
Patient
Safetymembers
affected
is implementation
0.1%-1%
of
members
members
all olderRisks
adults,
all members
cardiovascular
disease,
alldemonstrate
decreased
hospital
costs
member).
Research
inper
and
beyondimpact
healthhas
care has
shown issues
that promising
arehave
most
likelyassessed
towith
spread
they
be Data
readily
observed positive
in a demonstration site at then
supporting spread of successful practices. Participants:
Program
champion,
lead,
not locally,
been assessed
identified
and
mitigation
more
subject
matter
and well
or no adverse
impact
unknown
is less than
with
an
inpatient
stay
orexperts
surgical
procedure,
etc.)impact
(consider
factors
including
process
piloted
are simple, can be adapted
to local
needs,
fitmembers
with existing
work
culture
and
norms,(SMEs)
and align
with leadership
goals
and strategies. Practices
Improvement Advisor, and two or more “peer reviewers”
who
can or
provide
an independent
perspective.
measures have been
are believed to be absent or negligible
0.1% of total
reliability and safety culture)
Element
are
more
likely
to
further
as/if
they
sustained
by performance
multiple sites
and attaining
reliable
OR…impact
Potential
issues Relative
have
been
Relative
onspread
impact
on mature
primary – being adopted
Relative and
impact
on primary
measure(s)
is
more
than implementation among earlier adopters.
Start-Up
Well-Established
implemented
membership
Instructions
Support
structures
tools
help accelerate
transfer
site.improvement
identified
but notand
addressed
SME: _____________________
primary
performance
performance
measure(s)
is 11- from site
20%to(e.g.
from 40% to 50%)
impact
has yet
measure(s)
is operating
5-10% cost
20%
(e.g. improvement
from 40%
Costs
1. Scan through the four main sections to get an overview of No
main
areas
forbeen
assessment.
Substantial
would
Modest operating
costs can be
Modest operating and start-up costs
No costs for implementation – changes work of
observed,
orCare
relative
(e.g.
improvement
rom
to 46%)
(operating
costs
require
significant
reallocation
of
covered
within
existing
operations
can
be
covered
within
existing
staff
rather
than positive
adding staff
Potential
for
adverse
impact
has
Potential
issues
have
been
Risks
have
been
assessed
by one or existing
Data
demonstrate
Effectiveness
of
2. The rows within each section present key elements of readiness
for successful
spread.
For each
element,
Element
Start-Up
Well-Established
impact
is less
than 5%
to been
43%) assessed
and
start-up
costs) 40%
resources
budgets,
but start-up
would require
operations
budgets
not
identified
and mitigation
more subject
matter experts (SMEs) andNo startup
impact
or no adverse impact
(consider
factors
including
investment
simple statements illustrate different levels of readiness,
from
Start-Up
to delivery
Well Established.
investment
fromhave
other
sources
measures
been
are
believed
toProcesses
be absent and
or negligible
of evidence-based care and Observability
No
pilot
sites
are
available
to
Processes
and
benefits
can
be
benefits
are
readily
Processes
and benefits can be readily
OR… Potential
issues Robustly
have been
3. For each row:
Impact
has needs)
not been
Compelling
anecdotal
measured
improvement
Robustly
measured
improvement
in real,
outcomes: observed at scale in 2+ KP Regions
Confidence addressing
patient
observe
OR benefits
are implemented
not savings
observed
by
potential
adopters
at 1savings
observable
at “downstream”
2-4 pilot sites
identified
but
not
addressed
SME: _____________________
No
savings
anticipated
are projected
but
Substantial
have been
Substantial savings
have been documented
information
in processesModest
or factors
thatpilot
are
 First each participant rates the practice on their own. assessed
CircleSavings
all the statements
that describe
readily the
observable
site
Downstream
outcomes:
Fewer
never
events,
reduced
has
not
been
demonstrated
projected
but
not
documented
(cost reduction or
plausibly related to downstream
Robustetc.
measurement of savings, e.g. trended
practice. Be realistic – assess the practice as it is,Patient
not how
you
hope it will be.OR…
Use
judgment in deciding
complications
chronic
disease,
improved
satisfaction,
Potential for adverse impact
has but casual
Potential issues have been
Risksofhave
been
assessed
by one
Data demonstrate
positive
cost avoidance)Simplicity
Experience
outcomes,
Measurement
savings
is less
thanorby annotated
significantwithin a single
Requires
participation
by 4+ relationship
Requires participation by
2-3 units ofRequires
participation
2-3 units orrun charts
Can beshow
implemented
improvement
which statements to circle – do your best to capture
the spirit
of including
the assessment,
notbeen
details
of the has
wording.
not
assessed
identified
and (e.g.
mitigation Robusttlyrobust
more
subject
matter confounding,
experts (SMEs)
andimprovement
impact or
nopre/post
adverseanalysis
impact with
(consider
factors
service, Measured
not been
established
measured:
annotated
runno
charts
possible
OR
units or functions
(e.g. well
primary
or functions; interactions
must(e.g.
be Trended
functions,
but handoffs
andshow
organizational
unit and without broader
in processes or factors
have
been significanttrending,
are believed
toOR
be pre/post
absent
oranalysis
negligible
reliability,
improved
follow Then the facilitator leads a brief discussion to produce
a “sense
of the and
group.”
Record
theissues
consensus
on measures
clinician-patient
relationships,
with comparison
comparison
no comparison
group,
etc.)
ER,process
and laboratory)
negotiated
and tested improvement
accountabilities
are
clear
and
simple group
modification of current delivery system
OR… Potential
have
been
of interest,
but care,
implemented
up after discharge,
increased use
personalization)
group
a master copy of the assessment tool. Don’t get hung
up on unanimity. It’s OKmeasurement
toidentified
record but
ais range
of
not addressed
SME: _____________________
less
of
KP.org)
No
revenue
enhancement
Modest
revenue
enhancement
is
Substantial
revenue
enhancement
is
Substantial
revenue
enhancement
beenand simple; the
Revenue
Adaptability
Adaptation has occurred over time
Adaptation has occurred, without
Key components arehas
known
than robust (e.g. Adaptations have resulted in
responses.
OR…
anticipated
projected but has
not
been
projected but not
yet documented
documented
(increased total
failure to OR…
achieve results
at 1
pilot
site without compromising
compromising
results, at 2+
diverse
range of acceptable variation has been
possible
confounding,
measured
improvement
in risk factors
clear,
Potential
for adverse impact
has demonstrated
Potential issues have Robustly
been
Risks have
been assessed
by one that
or have aData
demonstrate positive
Physician/Staff
Work
4. For each section:
revenue
or revenue no trending,
anticipated
results
sites
that
adopted
the
practice
identified
and
communicated
Data
revenue
enhancement
is not andRobust
measurement
of revenue
no
Measured improvement
strongly established,
causal
relationship
downstream
outcomes
not been
assessed
identifiedinand mitigation
moreon
subject
matter
expertsto(SMEs)
impact
or no adverse
impact
per using
member)
 First each participant assigns an Overall scoreExperience
on their own,
the 1-10
scale.
Circle
Use outcomes
robust
(e.g.
possible
confounding,
no
enhancement,
comparison
group) the score.
downstream
or wellimproved
hand
hygiene,
use
of medications
that reducee.g. trended run charts OR
measures
have been (e.g. requires
are
believed
toFits
begreater
absent
or with
negligible
(consider factors including Cultural
FitbePotential
Implementation
requires
some
smoothly
existingpre/post
work analysis
Fitswith
smoothly
with existing
OR…
issues established
have
judgment, considering all the elements in the section.
The Overall score needn’t
an average
of been
no comparison
group,
etc.)
comparison
group work cultures, and
risk implemented
factors, butImplementation
heart attack trending,
risk, reduced
waiting times)
simplicity and fit with existing
changing
significant
aspects
of
adjustment
of
work
culture
or
roles,
culture
and
norms
goes
beyond
to fit with staff hopes and desires
identified
but
not
addressed
SME:
_____________________
measurement
is less than robust
scores representing each element. In some cases processes)
it might make
sense for the Overall
scoreexceed
to be
based
onFinancial
culture
roles
fundamental
Financial costs work
financial
costs but
are
roughly
equal tochanges
Financial
benefits
substantially
Financial
benefits substantially exceed costs,
Improvement
has been
robustly
measured in more than
1 site and
Return on
(e.g.and
possible
confounding,
no no
the lowest score for any element.
benefits (the practice may
still be nofinancial
benefits
exceed costs,
but transfers would be
and accrue to the entity that bears the costs
has been sustained
over time.
Investment
trending,
comparison
group)
Alignment
Not
clearly
aligned
Directly
supportive
butreturn
Arguably
aligned
withortop-tier KP
Direct, measurable,
Potential
adverse
has with KP
Potential issues
have
been of lower-tier
Risks have
been
assessed
bytoone
Data demonstrate
positive substantial impact on one
justified
on for
the
basis
ofimpact
other
needed
to
the
benefits
the
Equity a “sense of theGoal
 Then the facilitator leads a brief discussion to produce
group.”
Circle
the
consensus
goals/strategies at national
or
not mitigation
top-tier KP goals/strategies
goals/strategies,
but impact
top 10
goals/strategies
not
assessed
identified
and
more that
subject
experts (SMEs)
and is less
impact or of
noKP’s
adverse
impact
benefits,
e.g.
compliance)
entity
borematter
the costs
(consider
equity acrossdissent
groups from
score on a master copy of the assessment
tool. If some
participants
thebeen
consensus,
note the
Overall
1
2
3
4
5
6
7
8
9
10
local
level
than
direct
and
substantial
measures have
been Program/Regional/local
are believed to be absent or negligible
defined by health literacy, gender,
Cascading
Leadership
has provided
an unambiguous
(use judgment,
OR…are
Potential
have are
been Benefits
range of outliers.
Costs
certain issues
but benefits
have been demonstrated
Benefits have been demonstrated as
Benefits have been demonstrated
as robustly
Certainty
and
implemented
race/ethnicity, and/or
sexual
alignment
is missing
weak _____________________
message
that the
is unacceptable,
based on all
above)
identified
but not
addressed
SME:
less
certainand
as robustly as costs,
but will
accrue or robustly
as costs, but will accrue 1-2
as costs and will
occur during
thestatus
same quo
budget
Timing
5. When scores are completed for all four sections,
go
to the Scoring
and Summary
page
follow
the
orientation)
with clear Program/Regional/local alignment
3 or more years later
years later
year
instructions. The Scoring and Summary also includes simple
recommendations about where tothefocus
energy
(Record here the biggest gaps to address andNot
greatest
strengths
tomonths
build on.)
Comments
yet
sustained
for
6+
Performance
has
been
sustained
for
Data
demonstrates
sustained
performance for
Sustainability
Implementation
sustained
6-12
Overall
4
5 could translate
6
7 into
9
10 into real
in strengthening readiness for spread.
Harvesting potential benefits 1 Translating2potential 3
benefits into
Benefits
directly
Benefits8 would translate
directly
Harvestability
at any KP site
year at one site
1+ year
months
at no
1+ more
KP sites real dollars, but1+
(use judgment, based on all above) could require painful
measures,
real dollars would
require
other actors could
dollars (e.g. reduced drug costs)
Facilitator – Please complete the following information on the
master copy.
such as closingReliability
facilities orand performance
than routine
management
undermine
(i.e.
contract
hospitals
data
80-90% reliability has been
95%+ reliability has been documented in
Performance is measured, but no
eliminating
positions
efficiencies
couldon.)
raise prices
if KP utilization
Facilitator (name, position)
Date
are biggest
not available
documented
in control chart(s)
control chart(s), with balancing measure(s)
(Record here
the
gaps to address
and thecontrol
greatest
strengths
build
Comments
charts
show to
reliability
decreases)
________/________/________
Overall
Implementation
No change package is available
1
2
No comprehensive change
3
4but sample tools and
5
package,
Change package is available, with
6 metrics,
7 case studies,8etc.
tools,
Support
Pilot site champions are not
Participants(use
(name,
position)
judgment,
resources are shared
readily available for consultation
Pilot site champion(s) are available
based on all above)
1.
Pilot site champion(s) are available for on-site troubleshooting
2.
(Record here the biggest gaps to address and the greatest
strengthsbytophone
build on.)
Comments
for consultation
IT tools are built but not transferable
3.
Regional/Medical Center affiliations
4.
Overall
1
2
3
4
5
6
7
(use judgment,
5.
based on all above)
6.
(Record here the biggest gaps to address and the greatest strengths to build on.)
Comments
For more information about this tool or to provide feedback on the tool, please contact
either:
Jim. [email protected] – Senior Director, Center for Evaluation and Innovation, Care Management Institute
[email protected] – VP for Health Care Performance Improvement and Execution Strategy
We welcome feedback and suggestions!
Practice Assessed (title or description)
25
Active knowledge management supports
9 ongoing
10improvement; tacit knowledge
transfer is underway among adopters
Decision support and work flow tools are
available in KPHC or other systems
8
9
10
Readiness for Export covers
four areas
1. Impact on
2. Impact on Other
Primary Objective
Aspects of Care
3. Business Case
4. Transferability
• Magnitude
• Patient Safety
• Costs
• Observability
• Confidence
• Effectiveness of
Care
• Savings
• Simplicity
• Revenue
• Adaptability
• Return on
Investment
• Cultural Fit
• Certainty and
Timing
• Sustainability
• Patient
Experience
• Physician/Staff
Work Experience
• Equity
26
• Harvestability
• Goal Alignment
• Implementation
Support
Using the Readiness for Export
tool – Section 1
1. Impact on Primary Objective
Element
Start-Up
Magnitude
No impact
has yet
been
observed,
or <5%
Confidence Impact
has not
been
assessed
Overall
(based on
all above)
27
1
Well-Established
Impact on
primary
performance
measure(s) is
5-10%
Relative impact on
primary performance
metric(s) is 11-20%
Relative impact on
primary performance
measure(s) is more
than 20%
Compelling
anecdotes
OR…
Weakly
measured
improvement in
processes
Robustly measured
improvement in
processes
Robustly measured
improvement in real,
“downstream”
outcomes (e.g. fewer
never events, improved
satisfaction, etc.)
2
3
4
5
6
7
8
9
10
Using the Readiness for Export
tool – Section 2
2. Impact on Other Aspects of Care
Element
Start-Up
Patient
Experience
Potential
impact
has not
been
assessed
Potential
issues have
been identified
and mitigated
Risks have been
assessed by SME
and are believed to
be negligible
Data demonstrate
positive impact or no
adverse impact
Physician/
Staff Work
Experience
Potential
impact
has not
been
assessed
Potential
issues have
been identified
and mitigated
Risks have been
assessed by SME
and are believed to
be negligible
Data demonstrate
positive impact or no
adverse impact
Overall
(based on
all above)
28
1
Well-Established
2
3
4
5
6
7
8
9
10
Using the Readiness for Export
tool – Section 3
3. Business Case
Element
Start-Up
Savings
No savings
anticipated
Modest savings
are projected
but not
demonstrated
Substantial savings
have been projected
but not documented
Substantial
savings have
been
documented
Certainty
and Timing
Costs are
certain but
benefits are
less certain
Benefits have
been
demonstrated
as robustly, but
will accrue 3+
years later
Benefits have been
demonstrated as
robustly, but will accrue
1-2 years later
Benefits have
been
demonstrated as
robustly and will
occur during the
same budget
year
Harvestability
Harvesting
potential
benefits could
require
painful
measures
Translating
benefits into real
dollars would
require only
routine
efficiencies
Benefits could translate
directly into real dollars,
but might not (i.e.
contract hospitals could
raise prices)
Benefits would
translate directly
into real dollars
(e.g. reduced
drug costs)
29
Well-Established
Using the Readiness for Export
tool – Section 4
4. Transferability
Element
Start-Up
Simplicity
Requires
participation
by 4+ units
or functions
Requires
participation by
2-3 units;
interactions
must be tested
Requires participation
by 2-3 units;
accountabilities are
clear and simple
Requres no
modification of
current delivery
system
Adaptability
Adaptations
have
resulted in
failure
Adaptation has
occurred at 1
pilot site with
good results
Adaptation has
occurred, without
compromising results,
at 2+ diverse sites that
adopted the practice
Key components
are known;
acceptable
variation is
known
Cultural Fit
Requires
significant
changes in
work culture
and roles
Implementation
requires some
adjustment, but
no fundamental
changes
Fits smoothly with
existing work culture
and norms
Fits smoothly
with staff hopes
and desires
30
Well-Established
Readiness for Export
Assessment
KP Readiness-for-Spread Assessment
About This Tool
The purpose of this tool is to help KP succeed in spreading successful practices widely. One key factor is picking the
ripest opportunities – some practices aren’t really ready to be spread widely. This tool can help program champions
and KP leadership understand whether a promising practice is ripe for successful spread across KP. Using it can
prevent wasting energy from trying to spread a practice that has not yet been developed sufficiently. The tool can
1. Impact
onmight
Primary
Objective
highlight the aspects of a practice or its documentation
that
need
to be strengthened to support wide scale
spread. It is meant as a discussion tool to support informed decision making and to help set realistic expectations. It
is not intended to create “hoops to jump through,” or The
to interfere
with
efforts
thatrelate
enjoytostrong
support.
first criteria
for spread
a promising
practice
impact on
the primary objective addressed.
What is the one primary objective of the practice or intervention assessed?
2. Impact on Other Aspects of Care
Who To Involve in the Assessment Process
 Patient Safety
 Physician/Staff Work Experience
The assessment can be used in two distinct settings, 
described
below
along with ideal participants Equity
Effectiveness
of Care
1. Push – Program champions can use the tool to
the question:
“Could
my program
orisEfficiency
practice
 address
Patient Experience

Successful
spread
of promising
practices
affected be
not only by their impact on the primary objective but also by intended or unintended impact on other aspects
spread widely from its current demonstration site(s)? Facilitator:
A Business
KP Improvement
Advisor or other person,
of care delivery.
3.
Case
is the primary measure
of
impact?transfer.
__________________________________________________
not directly responsible for the program, whoWhat
is knowledgeable
about
practice
Participants:
Program
Do not rate here
the impact
on primary
objective
rated in
Section
1. understanding of their business case. All other factors being equal, practices with positive business
Promising
practices
are unlikely
to spread
without
a clear
champion, implementation lead, front-line staff.
on investment – not only that the financial benefits (cost savings,
Element
Start-Up cases are more likely to spread successfully. A positive business case means a positive return
Well-Established
2. Pull – Senior leaders can use the tool to address theElement
question: “Is this
ororpractice
for transfer
Start-Up
Well-Established
costprogram
avoidance,
revenue ripe
enhancement)
exceed the costs, but that the benefits accrue to entity that bears the costs, the benefits
are as certain as the costs, the
4. Transferability
into my area or Programwide?” Facilitator:
Leader or staff of
a Program
Office
orPotentially
Regional
unit responsible
foraffects
benefits
develop
in a reasonable
time frame,
and
the potential
be harvested
real “hard
dollars (e.g.
reduced
Number
of potentially
affects
Potentially
1-10% ofbenefits can
Potentially
affects into
all members,
or green”
a subpopulation
of 10%
or moreadmissions translated into
Magnitude
Potential
for adverse
Potential
have (i.e.
beenpractices
been
by ifone
or can
Patient
Safetymembers
affected
is implementation
0.1%-1%
of
members
members
all olderRisks
adults,
all members
cardiovascular
disease,
alldemonstrate
decreased
hospital
costs
member).
Research
inper
and
beyondimpact
healthhas
care has
shown issues
that promising
arehave
most
likelyassessed
towith
spread
they
be Data
readily
observed positive
in a demonstration site at then
supporting spread of successful practices. Participants:
Program
champion,
lead,
not locally,
been assessed
identified
and
mitigation
more
subject
matter
and well
or no adverse
impact
unknown
is less than
with
an
inpatient
stay
orexperts
surgical
procedure,
etc.)impact
(consider
factors
including
process
piloted
are simple, can be adapted
to local
needs,
fitmembers
with existing
work
culture
and
norms,(SMEs)
and align
with leadership
goals
and strategies. Practices
Improvement Advisor, and two or more “peer reviewers”
who
can or
provide
an independent
perspective.
measures have been
are believed to be absent or negligible
0.1% of total
reliability and safety culture)
Element
are
more
likely
to
further
as/if
they
sustained
by performance
multiple sites
and attaining
reliable
OR…impact
Potential
issues Relative
have
been
Relative
onspread
impact
on mature
primary – being adopted
Relative and
impact
on primary
measure(s)
is
more
than implementation among earlier adopters.
Start-Up
Well-Established
implemented
membership
Instructions
Support
structures
tools
help accelerate
transfer
site.improvement
identified
but notand
addressed
SME: _____________________
primary
performance
performance
measure(s)
is 11- from site
20%to(e.g.
from 40% to 50%)
impact
has yet
measure(s)
is operating
5-10% cost
20%
(e.g. improvement
from 40%
Costs
1. Scan through the four main sections to get an overview of No
main
areas
forbeen
assessment.
Substantial
would
Modest operating
costs can be
Modest operating and start-up costs
No costs for implementation – changes work of
observed,
orCare
relative
(e.g.
improvement
rom
to 46%)
(operating
costs
require
significant
reallocation
of
covered
within
existing
operations
can
be
covered
within
existing
staff
rather
than positive
adding staff
Potential
for
adverse
impact
has
Potential
issues
have
been
Risks
have
been
assessed
by one or existing
Data
demonstrate
Effectiveness
of
2. The rows within each section present key elements of readiness
for successful
spread.
For each
element,
Element
Start-Up
Well-Established
impact
is less
than 5%
to been
43%) assessed
and
start-up
costs) 40%
resources
budgets,
but start-up
would require
operations
budgets
not
identified
and mitigation
more subject
matter experts (SMEs) andNo startup
impact
or no adverse impact
(consider
factors
including
investment
simple statements illustrate different levels of readiness,
from
Start-Up
to delivery
Well Established.
investment
fromhave
other
sources
measures
been
are
believed
toProcesses
be absent and
or negligible
of evidence-based care and Observability
No
pilot
sites
are
available
to
Processes
and
benefits
can
be
benefits
are
readily
Processes
and benefits can be readily
OR… Potential
issues Robustly
have been
3. For each row:
Impact
has needs)
not been
Compelling
anecdotal
measured
improvement
Robustly
measured
improvement
in real,
outcomes: observed at scale in 2+ KP Regions
Confidence addressing
patient
observe
OR benefits
are implemented
not savings
observed
by
potential
adopters
at 1savings
observable
at “downstream”
2-4 pilot sites
identified
but
not
addressed
SME: _____________________
No
savings
anticipated
are projected
but
Substantial
have been
Substantial savings
have been documented
information
in processesModest
or factors
thatpilot
are
 First each participant rates the practice on their own. assessed
CircleSavings
all the statements
that describe
readily the
observable
site
Downstream
outcomes:
Fewer
never
events,
reduced
has
not
been
demonstrated
projected
but
not
documented
(cost reduction or
plausibly related to downstream
Robustetc.
measurement of savings, e.g. trended
practice. Be realistic – assess the practice as it is,Patient
not how
you
hope it will be.OR…
Use
judgment in deciding
complications
chronic
disease,
improved
satisfaction,
Potential for adverse impact
has but casual
Potential issues have been
Risksofhave
been
assessed
by one
Data demonstrate
positive
cost avoidance)Simplicity
Experience
outcomes,
Measurement
savings
is less
thanorby annotated
significantwithin a single
Requires
participation
by 4+ relationship
Requires participation by
2-3 units ofRequires
participation
2-3 units orrun charts
Can beshow
implemented
improvement
which statements to circle – do your best to capture
the spirit
of including
the assessment,
notbeen
details
of the has
wording.
not
assessed
identified
and (e.g.
mitigation Robusttlyrobust
more
subject
matter confounding,
experts (SMEs)
andimprovement
impact or
nopre/post
adverseanalysis
impact with
(consider
factors
service, Measured
not been
established
measured:
annotated
runno
charts
possible
OR
units or functions
(e.g. well
primary
or functions; interactions
must(e.g.
be Trended
functions,
but handoffs
andshow
organizational
unit and without broader
in processes or factors
have
been significanttrending,
are believed
toOR
be pre/post
absent
oranalysis
negligible
reliability,
improved
follow Then the facilitator leads a brief discussion to produce
a “sense
of the and
group.”
Record
theissues
consensus
on measures
clinician-patient
relationships,
with comparison
comparison
no comparison
group,
etc.)
ER,process
and laboratory)
negotiated
and tested improvement
accountabilities
are
clear
and
simple group
modification of current delivery system
OR… Potential
have
been
of interest,
but care,
implemented
up after discharge,
increased use
personalization)
group
a master copy of the assessment tool. Don’t get hung
up on unanimity. It’s OKmeasurement
toidentified
record but
ais range
of
not addressed
SME: _____________________
less
of
KP.org)
No
revenue
enhancement
Modest
revenue
enhancement
is
Substantial
revenue
enhancement
is
Substantial
revenue
enhancement
beenand simple; the
Revenue
Adaptability
Adaptation has occurred over time
Adaptation has occurred, without
Key components arehas
known
than robust (e.g. Adaptations have resulted in
responses.
OR…
anticipated
projected but has
not
been
projected but not
yet documented
documented
(increased total
failure to OR…
achieve results
at 1
pilot
site without compromising
compromising
results, at 2+
diverse
range of acceptable variation has been
possible
confounding,
measured
improvement
in risk factors
clear,
Potential
for adverse impact
has demonstrated
Potential issues have Robustly
been
Risks have
been assessed
by one that
or have aData
demonstrate positive
Physician/Staff
Work
4. For each section:
revenue
or revenue no trending,
anticipated
results
sites
that
adopted
the
practice
identified
and
communicated
Data
revenue
enhancement
is not andRobust
measurement
of revenue
no
Measured improvement
strongly established,
causal
relationship
downstream
outcomes
not been
assessed
identifiedinand mitigation
moreon
subject
matter
expertsto(SMEs)
impact
or no adverse
impact
per using
member)
 First each participant assigns an Overall scoreExperience
on their own,
the 1-10
scale.
Circle
Use outcomes
robust
(e.g.
possible
confounding,
no
enhancement,
comparison
group) the score.
downstream
or wellimproved
hand
hygiene,
use
of medications
that reducee.g. trended run charts OR
measures
have been (e.g. requires
are
believed
toFits
begreater
absent
or with
negligible
(consider factors including Cultural
FitbePotential
Implementation
requires
some
smoothly
existingpre/post
work analysis
Fitswith
smoothly
with existing
OR…
issues established
have
judgment, considering all the elements in the section.
The Overall score needn’t
an average
of been
no comparison
group,
etc.)
comparison
group work cultures, and
risk implemented
factors, butImplementation
heart attack trending,
risk, reduced
waiting times)
simplicity and fit with existing
changing
significant
aspects
of
adjustment
of
work
culture
or
roles,
culture
and
norms
goes
beyond
to fit with staff hopes and desires
identified
but
not
addressed
SME:
_____________________
measurement
is less than robust
scores representing each element. In some cases processes)
it might make
sense for the Overall
scoreexceed
to be
based
onFinancial
culture
roles
fundamental
Financial costs work
financial
costs but
are
roughly
equal tochanges
Financial
benefits
substantially
Financial
benefits substantially exceed costs,
Improvement
has been
robustly
measured in more than
1 site and
Return on
(e.g.and
possible
confounding,
no no
the lowest score for any element.
benefits (the practice may
still be nofinancial
benefits
exceed costs,
but transfers would be
and accrue to the entity that bears the costs
has been sustained
over time.
Investment
trending,
comparison
group)
Alignment
Not
clearly
aligned
Directly
supportive
butreturn
Arguably
aligned
withortop-tier KP
Direct, measurable,
Potential
adverse
has with KP
Potential issues
have
been of lower-tier
Risks have
been
assessed
bytoone
Data demonstrate
positive substantial impact on one
justified
on for
the
basis
ofimpact
other
needed
to
the
benefits
the
Equity a “sense of theGoal
 Then the facilitator leads a brief discussion to produce
group.”
Circle
the
consensus
goals/strategies at national
or
not mitigation
top-tier KP goals/strategies
goals/strategies,
but impact
top 10
goals/strategies
not
assessed
identified
and
more that
subject
experts (SMEs)
and is less
impact or of
noKP’s
adverse
impact
benefits,
e.g.
compliance)
entity
borematter
the costs
(consider
equity acrossdissent
groups from
score on a master copy of the assessment
tool. If some
participants
thebeen
consensus,
note the
Overall
1
2
3
4
5
6
7
8
9
10
local
level
than
direct
and
substantial
measures have
been Program/Regional/local
are believed to be absent or negligible
defined by health literacy, gender,
Cascading
Leadership
has provided
an unambiguous
(use judgment,
OR…are
Potential
have are
been Benefits
range of outliers.
Costs
certain issues
but benefits
have been demonstrated
Benefits have been demonstrated as
Benefits have been demonstrated
as robustly
Certainty
and
implemented
race/ethnicity, and/or
sexual
alignment
is missing
weak _____________________
message
that the
is unacceptable,
based on all
above)
identified
but not
addressed
SME:
less
certainand
as robustly as costs,
but will
accrue or robustly
as costs, but will accrue 1-2
as costs and will
occur during
thestatus
same quo
budget
Timing
5. When scores are completed for all four sections,
go
to the Scoring
and Summary
page
follow
the
orientation)
with clear Program/Regional/local alignment
3 or more years later
years later
year
instructions. The Scoring and Summary also includes simple
recommendations about where tothefocus
energy
(Record here the biggest gaps to address andNot
greatest
strengths
tomonths
build on.)
Comments
yet
sustained
for
6+
Performance
has
been
sustained
for
Data
demonstrates
sustained
performance for
Sustainability
Implementation
sustained
6-12
Overall
4
5 could translate
6
7 into
9
10 into real
in strengthening readiness for spread.
Harvesting potential benefits 1 Translating2potential 3
benefits into
Benefits
directly
Benefits8 would translate
directly
Harvestability
at any KP site
year at one site
1+ year
months
at no
1+ more
KP sites real dollars, but1+
(use judgment, based on all above) could require painful
measures,
real dollars would
require
other actors could
dollars (e.g. reduced drug costs)
Facilitator – Please complete the following information on the
master copy.
such as closingReliability
facilities orand performance
than routine
management
undermine
(i.e.
contract
hospitals
data
80-90% reliability has been
95%+ reliability has been documented in
Performance is measured, but no
eliminating
positions
efficiencies
couldon.)
raise prices
if KP utilization
Facilitator (name, position)
Date
are biggest
not available
documented
in control chart(s)
control chart(s), with balancing measure(s)
(Record here
the
gaps to address
and thecontrol
greatest
strengths
build
Comments
charts
show to
reliability
decreases)
________/________/________
Overall
Implementation
No change package is available
1
2
No comprehensive change
3
4but sample tools and
5
package,
Change package is available, with
6 metrics,
7 case studies,8etc.
tools,
Support
Pilot site champions are not
Participants(use
(name,
position)
judgment,
resources are shared
readily available for consultation
Pilot site champion(s) are available
based on all above)
1.
Pilot site champion(s) are available for on-site troubleshooting
2.
(Record here the biggest gaps to address and the greatest
strengthsbytophone
build on.)
Comments
for consultation
IT tools are built but not transferable
3.
Regional/Medical Center affiliations
4.
Overall
1
2
3
4
5
6
7
(use judgment,
5.
based on all above)
6.
(Record here the biggest gaps to address and the greatest strengths to build on.)
Comments
For more information about this tool or to provide feedback on the tool, please contact
either:
Jim. [email protected] – Senior Director, Center for Evaluation and Innovation, Care Management Institute
[email protected] – VP for Health Care Performance Improvement and Execution Strategy
We welcome feedback and suggestions!
Practice Assessed (title or description)
31
Active knowledge management supports
9 ongoing
10improvement; tacit knowledge
transfer is underway among adopters
Decision support and work flow tools are
available in KPHC or other systems
8
9
10
Try using the Readiness for
Export tool – Scoring
Section
1. Impact on Primary
Objective
4
Overall score: ____
Weakest element(s):
Impact hasn’t been
measured well enough
2. Impact on Other
Aspects of Care
3
Overall score: _____
Weakest element(s):
Recommendations by Score

 1-4 Focus on improving performance and
measurement at pilot site
 5-7 Begin assessing impact on other aspects of
care delivery while continuing to improve
performance and documentation
 8-10 Focus your energy elsewhere (but sustain the
gains; don’t let performance slip)

 1-4 It’s time to look beyond your primary
objective; bring in others with responsibilities
for aspects of care that might be affected
 5-7 Strengthen documentation and/or
measurement of impacts on other aspects of
care
Is there any impact on  8-10 Focus your energy elsewhere (but keep
looking for synergies)
Patient Experience?
32
Interpreting the Readiness for
Export scores
• This isn’t a pass/fail test
 Low ratings in some areas are an alert to challenges you
may face
• What you do with the scores depends on your role
 Importer: Consider a different practice? Or proceed with your
eyes wide open
 Exporter: Keep developing your practice; consider partnering
with others
 Distributor: Review your goals carefully; if you proceed
consider spreading slowly and embracing variation
33
Embrace the “funnel” – Some innovations
should spread (…some shouldn’t)
Keep Perspective
 Be realistic about readiness for
spread, and promote an
innovation only when its value and
transferability have been
demonstrated
 Assess transferability rigorously:
trialability, simplicity, fit with KP
culture, etc.
 Evaluate!
34
Site Readiness-toImport Assessment
Jim Bellows
Why assess
Readiness to Import?
Have you ever…
… tried to import a practice that was successful for the innovator, but
you just couldn’t make it work at your site?
… tried unsuccessfully to interest others in a practice that seemed
great to you?
… had a senior leader ask you to import/distribute a practice when:
 Your organization was focused on other goals?
 Leadership was not aligned, giving conflicting direction?
 People were dealing with significant changes or disruptions?
Solution? Due diligence – don’t conclude too quickly that your
organization is ready to receive a practice from elsewhere, no matter
how good it seems
36
Try it for your project!
37
11 Key Components of
Readiness-to-Import
Organization
• Sponsorship & leadership
• Oversight Infrastructure
• Strategic Alignment with Organization’s Goals & Priorities
• Cultural Readiness
Resources
• Staff
• Identified Project Management & Championship
• Training requirements
• Space
• Technology Requirements
• Operations Infrastructure
• Measurement & Monitoring
38
Sponsorship and Leadership
Key
Component
Sponsorship
& leadership
Definition
Rating Scale (0-4, see definition
column and comments below)

Consider the targeted sponsors for this
initiative.



39
Establish genuine
commitment and support
for changes, rather than
simple compliance
Get involved in the
change, understand it, and
promote it (Express, Model,
& Reinforce)
Take personal responsibility
and allocate sufficient
time and resources to
ensure the change is
sustained
Trustworthy, influential,
respected and believable
0 =No evidence that sponsor behaviors
have been exhibited; no desire to
sponsor this initiative
1 = Limited evidence of sponsor
behaviors; limited desire
2= General evidence of sponsor
behaviors, with inconsistent
performance; some desire
3= Evidence of sponsor behaviors; desire
to sponsor this initiative
4= Evidence of sponsor behaviors
sustained over time; strong desire to
sponsor this initiative
Strategic Alignment with Goals
and Priorities
Key
Component
Strategic
Alignment
with Goals &
Priorities
Definition


40
Change aligns with
strategic priorities and
the organizational goals
The specifics of what is
being asked are clear, the
benefits (including ROI)
apparent, and the impact
on affected
department(s)/functional
units defined
Rating Scale (0-4, see definition
column and comments below)
Consider the alignment of this initiative
with goals and priorities, as well as
impact on those affected:
0 = No alignment with priorities; impact
on affected unit(s) is unclear
1= Some alignment with priorities OR
goals; impact on the affected unit(s) is
substantial given benefits
2 = Some alignment with priorities AND
goals; impact on affected unit(s) is
justifiable
3 = Adequate alignment with priorities
and goals
4 = Complete alignment with priorities
and goals; impact on affected unit(s)
is minimal
Technology Requirements
Key
Component
Technology
Requirements
Definition
 There is enough
technology of the right
type to support the change
 There is a commitment to
budget for long-term
maintenance and
sustainability of the
technology
41
Rating Scale (0-4, see definition
column and comments below)
Consider technology implementation and
sustainability requirements:
0 = Requirements have not been
adequately defined
1 = Requirements have been adequately
defined but there are significant budget
gaps
2 = Requirements adequately defined;
some budget gaps
3 = Requirements adequately defined; no
budget gaps
4 = Requirements adequately defined; no
budget gaps; sponsor commitment to
maintaining technology over time
Try it for your project!
42
Scoring the tool provides
general guidance
Guidance on interpreting scores
Any score of 0 or 1 on a single “readiness” attribute: Strong consideration
should be given to addressing these attributes prior to initiative
implementation unless there is clear rationale while this attribute is not
important for the success of the project
Total score of 22 or less: Strong consideration should be given to not
proceeding on until the main drivers for this score are adequately addressed
Total score of 23 to 33: Makes sense to proceed with caution, addressing
the trouble spots identified in this assessment
Total score of 34 or more: Indicate a high likelihood of success in terms of
initiative implementation with appropriate considerations for any single low
score as defined in bullet #1 above.
Use judgment in interpreting the scores and
deciding how to proceed
43
The Readiness Assessments can
guide your decisions about spread
Alignment
to Import
Readiness
Low
Test and
ReplicateDiffusion
Innovate
Test and
Replicate Collaboratives
High
Just Do It
44
Source: Stacey 2002
Test and
ReplicateWaves
High
Low
Readiness
for Export
Transferability
How much variation?
Adapt locally vs. copy exactly
Adapt locally
Theory (Paul Plsek)
 Health care is a
Complex Adaptive System
 Find local Attractors
 Use only Simple Rules
Strength
 Spread is more likely to occur if
importers can adapt to their
needs
45
Copy exactly
Theory (per Gabriel Szulanski)
 We’re not as smart as we think
 Experience beats cleverness
 First import, then improve
Strength
 Spread is more likely to get
results if importers work with
exporters to learn a proven
model
Measurement and
Feedback for Spread
Lisa Schilling
Measuring Spread
• Rate of adoption
• Practice reliability map across sites
• “Energy map” of initiatives across sites
• Outcomes
47
Rate of Adoption –
Sustainability and Penetrance
48
Rate of Adoption Multiple Ideas
Iowa Health System: 10 Hospitals in Iowa and Illinois
System-wide Diffusion - Hazard Areas - At Least 1 per facility
10
10
9
9
8
8
# IHS facilities
Facilities participating
Iowa Health System: 10 Hospitals in Iowa and Illinois
System-wide Diffusion - Exec Walk Arounds
7
6
5
4
3
7
6
5
4
3
2
2
1
1
0
0
Jun-01 Jul-01 Aug-01 Sep-01 Oct -01 Nov-01 Dec-01 Jan-02 Feb-02 Mar-02 Apr-02 May-02 Jun-02 Jul-02 Aug-02 Set p 02 Oct -02 Nov-02
LS1
Jun-01 Jul-01 Aug-01 Sep-01 Oct -01 Nov-01 Dec-01 Jan-02 Feb-02 Mar-02 Apr-02 May-02 Jun-02 Jul-02 Aug-02 Set p 02 Oct -02
LS2
LS1
System-wide Diffusion - Medication FMEA
10
10
# facilities completed FMEA
# facilities using in 1+ or more units
Iowa Health System: 10 Hospitals in Iowa and Illinois
System-wide Diffusion - Unit Briefings
9
8
7
6
5
4
3
2
1
0
Jun-01 Jul-01 Aug01
Sep01
Oct- Nov- Dec01 01 LS1 01
Jan02
Feb02
LS2
M ar02
Apr02
M ay02
Jun- Jul-02 Aug02
02
Setp
02
Oct02
Nov02
Source: IHI, Iowa Health system 2010
49
LS2
9
8
7
6
5
4
3
2
1
0
Jun-01 Jul-01 Aug01
Sep- Oct -01 Nov01
01LS1
Dec-
Jan-
Feb-
Mar-
Apr-
May-
01
02
02 LS2
02
02
02
Jun- Jul-02 Aug02
02
Set p
Oct -
Nov-
02
02
02
Before: Monitoring Reliable
Practice Across Sites
4/18/2006
Moa
Date:
Hospital:
Shift:
WAVE
1
1 East
1
1 West
1
2 East
1
2 West
2
3 East-Tele
2
3 West-Tele
2
4East
2
M/B
2
Malama W
3
Malama E
3
Peds
% Yes
% Yes
% Yes
% Yes
% Yes
% Yes
% Yes
% Yes
% Yes
% Yes
% Yes
Component
#
100%
67%
100%
100%
100%
67%
100%
0%
100%
1CN
Was the staffing assignment complete before your arrival
on shift?
100%
SP
100%
67%
67%
100%
100%
100%
100%
100%
67%
2CN
Was patient care information printed/prepared before
you came on shift?
67%
SP
100%
86%
100%
70%
83%
92%
78%
100%
82%
1
Do you know the name of the nurse who took care of
your patients on the previous shift?
93%
SP
100%
71%
92%
70%
83%
92%
78%
92%
55%
2
Was patient care information report printed prior to your
arrival?
93%
SP
93%
50%
75%
70%
58%
92%
72%
62%
27%
3
Was the information in the kardex and neuron in
agreement at the beginning of the shift?
93%
SP
100%
100%
100%
100%
80%
83%
92%
78%
62%
45%
G
4
Is a patient care board available in your room?
79%
21%
42%
10%
17%
58%
61%
8%
0%
5
Was the plan of care written on the board from the prior
shift?
100%
G
100%
100%
100%
100%
80%
92%
100%
94%
77%
27%
B
6
Did shift change happen face-to-face?
100%
93%
79%
83%
30%
67%
67%
83%
0%
0%
B
7
did shift change happen at the bedside?
86%
50%
71%
92%
40%
75%
58%
44%
0%
9%
B
8
Did you receive report in ISBAR format?
29%
21%
42%
20%
42%
25%
33%
0%
0%
9
For patients who could have teachback, did you do
patient teach-back during the oncoming report?
50%
B
86%
93%
92%
80%
75%
75%
83%
31%
0%
10
Was the patient's understanding of the plan similar to
your plan of care?
86%
B
93%
71%
75%
40%
83%
75%
83%
69%
0%
11
Was the goal for plan of care achieved from the previous
shift?
93%
B
64%
86%
92%
40%
67%
58%
67%
15%
9%
14
Do you plan on giving shift change report in ISBAR
format?
79%
B
50
Questions
Pink = shift preparation
Source: KP Hawaii NKE 2007
Orange= Goal board
Yellow= bedside round with patient teach back use
After: Monitoring Reliable
Practice Across Sites
Date: 8/22/2006
Hospital: Moa
Shift: All Shifts
WAVE
1
1 East
1
1 West
1
2 East
1
2 West
2
3 East-Tele
2
3 West-Tele
2
4East
2
M/B
2
Malama W
3
Malama E
3
Peds
% Yes
% Yes
% Yes
% Yes
% Yes
% Yes
% Yes
% Yes
% Yes
% Yes
% Yes
Component
#
100%
33%
100%
100%
100%
100%
100%
100%
33%
1CN
Was the staffing assignment complete before your arrival
on shift?
100%
SP
100%
33%
100%
0%
100%
100%
100%
100%
33%
2CN
Was patient care information printed/prepared before
you came on shift?
100%
SP
89%
91%
100%
100%
67%
100%
82%
100%
100%
1
Do you know the name of the nurse who took care of
your patients on the previous shift?
100%
SP
100%
73%
100%
100%
100%
100%
64%
70%
55%
2
Was patient care information report printed prior to your
arrival?
92%
SP
100%
64%
100%
100%
67%
70%
91%
90%
91%
3
Was the information in the kardex and neuron in
agreement at the beginning of the shift?
77%
SP
100%
100%
100%
100%
100%
100%
100%
91%
90%
100%
G
4
Is a patient care board available in your room?
100%
82%
77%
100%
100%
80%
64%
30%
45%
5
Was the plan of care written on the board from the prior
shift?
69%
G
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
B
6
Did shift change happen face-to-face?
92%
67%
73%
85%
86%
67%
20%
82%
90%
73%
B
7
did shift change happen at the bedside?
54%
100%
73%
92%
100%
100%
70%
91%
60%
45%
B
8
Did you receive report in ISBAR format?
100%
55%
77%
86%
100%
10%
55%
0%
27%
9
For patients who could have teachback, did you do
patient teach-back during the oncoming report?
23%
B
100%
100%
92%
100%
100%
40%
91%
60%
82%
10
Was the patient's understanding of the plan similar to
your plan of care?
100%
B
100%
82%
100%
100%
67%
50%
91%
70%
82%
11
Was the goal for plan of care achieved from the previous
shift?
92%
B
100%
100%
85%
100%
100%
80%
91%
60%
64%
14
Do you plan on giving shift change report in ISBAR
format?
77%
B
51
Questions
Pink = shift preparation
Source: KP Hawaii NKE 2007
Orange= Goal board
Yellow= bedside round with patient teach back use
“Energy Map”
Sacramento/Roseville
Performance Improvement Portfolio Management Grid
Roseville Medical Center
9-Apr-10
PROJECT
Lead IA
MCH
PreOp
MCH MCH PICU MCH
PCC
1N 1S 2N 2S 3N 3S ICU OR PACU SPD L&D NICU PED MB MM EVS Rx SW
Resource Management
OR Throughput
KH
A
HAPU
RD
S
S
S
S
S
S
S
Falls
RD
S
S
S
S
S
S
S
NKE/Service/Rounding
KBS
P
P
P
P
P
P
P
Workplace Safety
TA
A
A
A
A
A
A
A
Eliminate Infection/C-diff
RD
P
P
P
P
P
P
P
RFO
RD
Medication Errors
SC/LP
P
P
P
P
P
P
P
Purchasing Supplies
MD
Employee Morale
RP
Core Measures
JG
Diversity Project
TN
Workflow/6S
RD/KJ
ErgoNurse PI Project
TA
Sepsis PI Project
DF
Leadership Development
TO
Attendance
RD
Empathy
RD
Bereavement
JS
Lean
TPMG
A
A
A
A
A
A
RD/AMH
A
A
A
P
Vol Spir't Mbr
Proc FOL FOL RCO
ED ADT Svs Care Svs HR Sedn ASU PACU ESC TPMG
A
A
A
A
A
A
P
S
A
S
S
A
A
S
A
A
A
A
A
A
A
P
A
A
SP
SP
A
S
P
P
P
P
P
A
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
A
A
A
P
P
A
P
A
A
A
P
P
P
P
P
A
A
A
P
P
A
A
A
STATUS
Advising/Teaching
Committees
RIM+, PIL 1 & PIL 2 Training
UBT lauches
COSQO
Patient Quality
UBT consultants
Quality Department Workflow
Consultants Partnership "A" Team
Surgical Safety Summits
National/Quality Conferences
NCAL IA Peer Group
ORCC/HRST
Mentoring P-T IAs
IA
Initials
52
Source: Ryan Darke 2010
Planned
Active
Sustain
Spread
P
A
S
SP
Outcomes: Adverse Drug
Event Rates
Aim: 50% Reduction in ADEs System-wide in 2002
Iowa Health System
Adverse Drug Events:
% of Sampled Charts with Harm Levels ADEs E-I
Targets: 2002 = 10%, 2003 = 4%
30%
% of Charts
20%
20%
Reduced Sample Size
14%
9%
9%
10%
10%
10%
6%
6%
4%
5%
6%
5%
11%
6%
6%
3%
'03 Target 4%
10%
3%
2%
4%
0%
N-01
53
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
Source: IHI, Iowa Health System 2010
F-03
M -03
A-03
M -03
J-04
Outcomes: Mortality Rates
54
Exercise for your portfolio
• In planning spread what variables do
you need to monitor over time?
• Which ways would you monitor and
report progress of your spread effort?
55
Support a Learning
Culture
Jim Bellows
What is the biggest part of
this model?
57
Source: Institute for Healthcare Improvement, 2006.
Practices spread best through
personal contact
58
Who do you go to when you
need information or support?
People’s answers define a
social network map
Key nodes are not
necessarily formal leaders
59
Social networks take work
• Communicate 6 times x 6 ways
• Foster relationships
 Get people together
• Send importers to meet with exporters
60
Knowledge Management – Moving
learnings through social networks
• Content
 Case studies, especially patient cases
 Stories – what seemed to work, what didn’t
 Evaluation results
• Structure and process
 Informal exchange
 Face to face visits and meetings
 Wikis, IdeaBook, SmartBook, …
61
Rapid spread of complex change:
A case study in inpatient palliative care
BMC Health Services Research
2009, 9:245
Della Penna R, Martel H, Neuwirth EB, Rice J, Filipski MI, Green J, Bellows J
Results: Compelling evidence of impacts on patient satisfaction and
quality of care generated ‘pull’ among adopters, expressed as a
remarkably high degree of conviction about the value of the model.
Broad leadership agreement gave rise to sponsorship and support
that permeated the organization. A robust social network promoted
knowledge exchange and built on an existing network with a strong
interest in palliative care. Resource constraints, pre-existing programs
of a different model, and ambiguous accountability for implementation
impeded spread.
Conclusions: A complex, hospital-based, interdisciplinary intervention in a
large health care organization spread rapidly due to a synergy
between organizational ‘push’ strategies and grassroots-level pull.
The combination of push and pull may be especially important when
the organizational context or the practice to be spread is complex.
62
How can you reach your spread goal?
• Identifying social networks and
communicating through them
• Establishing channels for knowledge
management and creating relevant content
63