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.

Questions?