Understanding Spread of Innovation Medical Home Grantee Meeting July, 2004

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Understanding Spread of InnovationMedical Home
Grantee MeetingJuly, 2004

• Charlie Homer, MD, MPH
• National Initiative for Childrens Healthcare
  Quality
• Boston, MA

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Why talk about spread?

• What are we trying to achieve by 2010?
• All children and youth with special health care
  needs will receive ongoing comprehensive care
  within a medical home.
• Where are we now?
• Thats why

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How did we get here?

• Identification of unmet needs
• Innovationnew programs
• Demonstration projects
• The challenge is not to build more pilot
  programs, but to find a way to replicate selected
  reforms to create an entire system that works.
  Rudy Crew
• Early spread activities
• Mentorship Network
• Medical Home Learning Collaborative

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Defining Diffusion (Spread) of Innovation

• Diffusion the process by which an innovation is
  communicated through certain channels over time,
  among the members of a social system
• Innovation an idea, practice, or object that is
  perceived as new by an individual or other unit
  of adoption
• Diffusion includes both spontaneous and planned
  spread
• Our focus here is planned
• Diffusion of InnovationsEverett Rogers (1962,
  1971, 1983, 1995, 2005)

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Diffusion or Spread
BETTER IDEAS
COMMUNICATED
In a certain way
Happen over time
Thru a SOCIAL system
Adapted from Rogers, 1995
(C) 2003, Sarah W. Fraser
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Adoption of Hybrid Seed Corn in Two Iowa
Communities
Cumulative Number of Adopters
Number of Farmers in Communities
Source Based on Ryan and Gross (1943).
Year
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Adoption of an Innovation
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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

Tipping point
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What are the steps in adopting new technologies
Knowledge
Persuasion
Decision
Implementation
Confirmation
Pre-contemplation Contemplation Action Maintenance
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What influences the pace?

• Nature of the innovation
• Type of decision
• Nature of the social environment
• Channels of communication
• Leadership and management of spread (Promotion)

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What gives some innovations legs

• Relative advantage
• Simplicty
• Compatibility
• Observability
• Trialability

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Spread Potential and the Medical Home
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Better Ideas

• Case for the new system
• The reasons people would want to make the changes
• Description of the new system
• What is being spread
• The concepts and ideas that form the content of
  the new system
• Transition materials
• Specific methods, examples, and documents to
  assist people in adopting the content

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Communication

• What are the messages?
• Will building
• Technical
• Who are the audiences?
• Multiple Stakeholders
• How much to communicate?
• Over-communicate x10
• Customize medium to purpose

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The WAY in Which We Communicate is Important
SHARE INFORMATION
SHAPE BEHAVIOUR
General Publications flyers newsletters videos art
icles posters
Personal Touch letters cards postcards
Face-to-face one-to-one mentoring seconding shadow
ing
Public Events Road shows Fairs Conferences Exhibit
ions Mass meetings
Interactive Activities telephone email visits semi
nars learning sets modeling
(C) 2001, Sarah W. Fraser
Adapted from Ashkenas, 1995
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Match Content and Format of Messages to Change
Stage

• Awareness
• Broad marketing and communication
• Persuasion
• Data feedback
• Decision
• Case studies, individualized communication
• Implementation
• Tools and resources
• Access to technical expertise
• Confirmation
• Feedback
• Leadership

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Change and Information
change
renewal
denial
ENCOURAGEMENT
FACTS
anger
acceptance
bargaining
SUPPORT
depression
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How can we describe those who adopt technologies?
Innovators
Early Majority
Late Majority
Early Adopters
Laggards
2.5
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13.5
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Using the Adopter Information

• Whom will you engage in the spread process, how,
  and when?
• Identifying opinion leaders
• On this issue (), to whom do you go for advice
  whom you can trust?
• With whom do you interact regularly?

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Spread Model

Better Ideas -Case for new ideas

-Description of the new ideas
-Transition
materials
Social System -Unit for spread
-Key
messengers
-Listeners/Connectors
-Communities of practice
-Motivators
incentives -Ability to adapt changes

Communicated
-Modes -Purpose
Infrastructure

Leaders responsible for spread
-Staging plan
-Technical support
-Knowledge
management -Measurement/Feedback
Slide by Kevin Nolan, IHI Annual Forum 2001
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Project Scoping Where Should a New Project
Begin?
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Project Scoping Given a new project, where
should we start our work?

• Do we have design targets?
• Do we have ideas that will achieve these design
  targets?
• What is our degree of belief that these ideas
  will give us the desired results in all the
  target settings?
• High degree of belief ? adapt and spread ideas
• Moderate degree of belief ? test ideas
• Low degree of belief ? generate new ideas

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IHI/NICHQ Project Scoping
Collaborative Teams
Deep Dive Team
Innovation Team
Phase 0Generate new ideas
Phase 1Planning
Breakthrough Series
Phase 2 Concept design
Observation
Screen
Phase 4 Pilot testing
Phase 3 Prototype testing
Synthesis
Milestone 1
Milestone 2
Generate new ideas
Test new ideas
Spread new ideas
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Leading Spread

• Decide intent to spread
• Understand the improvements
• Build confidence that improvements will achieve
  their aims
• Set measurable performance aims

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Infrastructure to Support Dissemination

• Staging Strategy a plans to reach all adopting
  units which units, what changes, and when
• Technical Support - Where people can go with
  questions regarding the changes
• Knowledge Management - How the new learning will
  be gathered and made available to others
• Measurement / Feedback - Monitoring and
  interacting with people on performance

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Adopter Groups Staging
Early Adopters
Early Majority
Late Majority
Spread Project Timeline
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Spread Strategy Matrix
Acare plans, Bcare coordinator, Cregistry
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Monitoring the Changes
Key Changes
Clinics
Entry in each cell designates status of each of
key changes in each clinic
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Tracking the Spread of the Changes
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Developing Spread Plan
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Highest leverage changes to accelerate spread of
the medical home?

• Case
• Transition Materials
• Technical assistance
• Communication
• Rewards and Incentives
• Leadership
• Tracking
• Learning

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Developing Spread Plan
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Developing Spread Plan
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The VA BTS on Reducing Delays and Wait Times

• Goal - Reduce delays in access to care (waiting
  time from appointment request to day of
  appointment and wait times on day of a scheduled
  appointment (time spent in clinics) by at least
  50
• 160 Clinics
• Timeframe July 1999 to March 2000
• Results
• Median wait time for an appointment for both
  primary and specialty clinics decreased from 48
  days to 22 days, an improvement of 54 (26 days)
• 36.6 of teams met or exceeded their individual
  team aim for the Collaborative as reflected in an
  assessment score of 4 or higher

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VHA Advanced Clinic Access Spread Project

• Spread What A sustainable system for patient
  access by spreading key access changes
• Spread to Whom All clinicians (approximately
  10,000) in six clinic types (Primary Care, Eye
  Care, Audiology, Cardiology, Orthopedics,
  Urology) in 172 medical centers over 400
  outpatient facilities, and more than 10,000
  specific clinics throughout the US.
• Time frame March 2001 - January 2003
• Challenges Large target population developing
  good examples decentralized structure competing
  priorities

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VHA ACA Strategy for Spread

• Organizational Infrastructure
• Provide leadership at national, VISN, and
  Facility levels
• Use measurement for monitoring and accountability
• Provide technical support about ACA
• Information
• Ensure broad awareness
• Provide technical information
• Communication
• Launch a National Campaign coordinated with local
  action
• The Social System
• Create a high functioning network of POCs and
  Access Coaches (national and local)

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Infrastructure Measurement / Feedback
Average Waiting Time for Next Available
Appointment (Days)
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VA ACA Diffusion Curve for One Network
517 performance clinics 1700 all clinics
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Results of VA Spread Project

• Reduced waiting times in all six clinical
  performance areas (FY200 2002)
• Waiting times in Primary Care dropped from 60.4
  days to 28.2 days nationally
• VHA system absorbed approximately 900,000 new
  patients entering the system while supply (number
  of FTEs) increased by only 2.3

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Results - Waiting Times for all Clinics
Sept, 2001
Sept, 2002
Sept, 2000
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Monitoring SpreadInventory of tested changes

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Other Spread Initiatives

• Bureau of Primary Health Care
• Multiple National Collaboratives
• Different Chronic Conditions (and prevention)
• Idea Care Model
• Communication Strategies
• Audiences/Stakeholders
• Measures

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BPHC Spread Report
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BPHC Spread Report-Implementation
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National Health Service, England

• Waits and Delays
• Cancer Care
• Diabetes
• Orthopedics

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NHS Spread Strategy

• Use of Trusts as unit of spread
• Acute Care, Primary Care
• Management expectations for performance
• Detailed measurement scheme
• Link to payment/incentives
• Risk of gaming

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Example of a Diffusion Curve
NHS National Primary Care Development Team
Patients in Practices Covered by the Primary
Care Collaborative
From Sir John Oldham OBE MBA FRCGP
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NYC Immunization

• Building on existing initiatives
• Systematic assessment of
• Messages
• Communication strategies
• Customization to level of readiness
• Benefits through use of immunization registry

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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, IlIrwin ,1978.

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References

• Kotler P., Roberto E. Social Marketing
  Strategies for Changing Public Behavior, Free
  Press, 1989
• Gladwell, M. The Tipping Point. Boston Little,
  Brown and Company, 2000.
• 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.
• 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.
•