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Communicating and Spreading Success, workshop Feb 1, 2007


Communicating and Spreading Success Sponsored by: Health Quality Council of Alberta and Western Node of Safer Healthcare Now! February 1, 2007 Best Western Village ... – PowerPoint PPT presentation

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Title: Communicating and Spreading Success, workshop Feb 1, 2007

Communicating and Spreading Success Sponsored
by Health Quality Council of Alberta and
Western Node of Safer Healthcare Now! February
1, 2007 Best Western Village Park Inn 1804
Crowchild Trail NW, Calgary, Alberta Foothills II
Room 1 pm Welcome by Dr. John Cowell, CEO
HQCA 115 245 pm Using Quarterly Reports
Effectively! Virginia Flintoft, Project Manager,
Central Measurement Team Safer Healthcare Now!
University of Toronto 245 300 pm BREAK 300
430 pm What Now? Sustaining and Spreading for
Success Tanis Rollefstad, Improvement Advisor,
Western Node for Safer Healthcare Now! 445 pm
Mix and Mingle
Put title right in here
Communicating and Spreading Success John W.
Cowell, MD, FRCPC Chief Executive
Officer February 1, 2007
  • March 15, 2004

  • HQCA has embraced and tangibly supported SHN
    since its inception
  • Our focus is on health system quality, safety and
  • We work primarily from the citizens point of

  • We collaborate and work directly with all the
    health regions, professions and policy makers
  • Our Template is the Alberta Quality Matrix for
  • We believe effective performance management
    requires appropriate measurement at all levels

Whats happening in Alberta
  • 55 teams enrolled in Alberta
  • There are teams working on each of the 6 SHN
  • Alberta leads the west in providing data to the
    Central Measurement Team (CMT)

Whats happening in Alberta (cont.)
  • Over 90 of hospitals have submitted data to CMT
  • Analysis of the data will reveal whether the
    initiatives in each of the interventions result
    in improved clinical outcomes
  • It is anticipated the analysis and conclusions of
    this will ensure the spread of successful change

We have no doubt those of you working hard on the
interventions and collaborations are making a
positive difference on the patient experience.
What can we learn from SHNs Quarterly Reports?
  • Virginia Flintoft, RN MSc
  • SHN Central Measurement Team

  • Overview of the Quarterly Report format
  • Basic interpretation and caveats
  • Intervention-specific observations
  • Breakout Quiz
  • Questions

Quarterly Report format
Q.R. Date data submitted Months reported
1 April 06 June 06 Nov 05 June 06
2 April 06 Sept. 06 Nov 05 Sept. 06
3 April 06 Dec. 06 Nov 05 Dec. 06
or preceding months pooled and reported in
Quarterly Report format
Quarterly Report format
AMI 8 CLI 3 Med Rec 3 RRT 3 SSI 7 VAP
2 Total 26
Quarterly Report format
Quarterly Report format
Quarterly Report format
Quarterly Report format
  • Goals
  • Vary for each measure
  • Types
  • Evidence based
  • Based on local performance
  • AMI 8 CLI 1 MedRec 1 2
  • RRT 1 VAP 1
  • Set by team
  • RRT 2 3
  • Calculation method specified
  • at bottom of Raw Data Sheet

Quarterly Report format
  • Data Analyzed Presented
  • Nationally
  • by Node
  • Atlantic
  • Ontario
  • Quebec
  • Western
  • Paeds
  • by Implementation Stage
  • Baseline
  • Early
  • Full

Quarterly Report format
Your Job!!
Quarterly Report format
Raw Data Sheet from Measurement Workbook
Copy values in Final Calculation row on Raw
Data Sheet and paste into Local Team row (r7)
on Quarterly Report
Copy values in Final Calculation row on Raw
Data Sheet and paste into Local Team row (r7)
on Quarterly Report
Basic interpretation
  • Definitions
  • N (Teams) Number of teams reporting data for
    a specific month
  • Caveats
  • When N (Teams) lt5 the data is not stable due to
    too small a cell size
  • The number of teams reporting per month varies
  • each QR

Quarterly Report format
QR 1 data submitted April - June 2006
QR 2 data submitted April - Sept. 2006
  • Data becomes more stable as sample size

Basic interpretation
  • Definitions
  • Mean average score for the measure for the
    hospitals reporting data for that month.
  • Caveat
  • The more teams reporting the more stable
  • the mean.

Basic interpretation
  • Definitions
  • SD standard deviation - summary value for how
    widely dispersed the scores are around the mean.
    In a normal distribution 95 of all scores are
    within 2-SDs on either side of the mean.
  • Caveats
  • Very high SD indicates large variation in scores
    making it difficult to use the national average
    to interpret your performance.
  • Normal curve has no defined limits - a
    percentage is limited to 0 and 100. Therefore,
    2-SDs above or below the mean may be
  • gt100 or lt0.

  • To Unhide rows
  • highlight 1or 2 rows above below node
  • right click to display menu
  • select unhide

  • Minimum lowest score reported for a specific
  • Maximum - highest score reported for a specific
  • 25th percentile 25 of all teams reporting data
    for that month have a lower score.
  • Median (50th percentile) exactly half of the
    scores are above and below this value.
  • 75th Percentile - 75 of all teams reporting data
    for that month have a lower score.
  • It is better to be lt25th percentile for some

  • Bracketed measures (large)
  • Only included in National analysis
  • Used for calculating confidence intervals (CI)
  • Bracketed measures (small)
  • Lower and Upper Bound CI

  • Interpretation
  • Compare your performance (Local Team) to National
    mean month-over-month
  • Compare your performance to CI
  • if score falls between upper and lower bound
    statistically similar (Jan., Feb., Apr.)

No CI because 25th ile - Max100
Adjust to appropriate level
(No Transcript)
Definitions of Implementation Stages
  • Baseline Stage
  • Pre-intervention. Data collected for Baseline
    should be collected prior to implementing small
    tests of change and reflect the current process.

Definitions of Implementation Stages
  • Early (Partial) Implementation Stage
  • The team has set a clear aim(s) for this
    intervention (i.e. AMI, CLI, MedRec, RRT, SSI or
    VAP) identified which measures will indicate if
    the changes will lead to improvement and started
    to implement small tests of change (PDSA) to
    identify and refine processes, procedures and
    practices which will lead to improvement and
    achieving the aim. When the team is close to
    goal they are ready to move to Full

Definitions of Implementation Stages
  • Full Implementation Stage
  • The processes, procedures and practices are
    finalized and have lead to significant
    improvement. These practices on the selected unit
    are being consistently applied and monitored,
    showing a sustained performance at or close to
    goal. The team has achieved their aim(s) and is
    ready to spread to other areas.

  • Interpretation
  • Compare your performance (Local Team) to National
    monthly means match Implementation Stage
    (Baseline, Early, Full)
  • Cut, Paste and Create an annotated Run Chart

Cut Paste
Cut Paste
Cut Paste
  • Annotated run chart

Data Submission and Performance
National Intervention-specific (as of Nov.06)
  • AMI
  • ASA on arrival (AMI 1) - at or gtGoal
  • ASA _at_ discharge (AMI 2) - at or gtGoal
  • Beta Blocker _at_ discharge (AMI 3)- at or gtGoal
  • ACEi/ARB _at_ discharge (Ami 5)- at or gtGoal
  • Thrombolysis or Primary PCI at arrival (AMI 4a
  • small cell size, variation,
  • mean performance since May06 (4A)40-65 (4B)
  • Smoking Cessation Counselling (AMI 6)
  • mean performance 50-75 - is documentation

National Intervention-specific (as of Nov.06)
  • AMI (cont.)
  • Perfect Care (AMI 7)
  • issues related to exclusion criteria transfer
    in and out
  • Inpatient Mortality (AMI 8)
  • poor submission (only 2 teams since Sept)
  • All AMI teams should submit monthly using
    retrospective form

National Intervention-specific (as of Nov.06)
  • CLI, RRT VAP - ICU collaborative measures
  • CLI
  • data submission improved - 8-20 teams submitting
  • Bloodstream infection rate /1000 days (CLI 1)
  • CLIs now used routinely outside ICU you may
    choose to expand inclusion beyond ICU
  • Insertion Bundle (CLI 2)
  • National mean performance 50
  • Early Full Implementation 45-80
  • Maintenance Bundle (CLI 3)
  • Early Full Implementation 70

National Intervention-specific (as of Nov.06)
  • CLI, RRT VAP (cont.)
  • RRT
  • data submission improved - 11-19 teams submitting
  • Percent of codes outside of ICU (RRT 2) 70-90
    high SD
  • Utilization Rapid Response Team (RRT 3) 1-200
    high SD
  • VAP
  • better submission Nationally (21-41 teams/month)
  • VAP Bundle compliance (VAP 2) between 57-83 -
  • Be sure your teams are applying revised
    definition (CDC)

National Intervention-specific (as of Nov.06)
  • Medication Reconciliation
  • Excellent rates of submission 27 to 69
  • Intentional Undocumented Discrepancies (MedRec 1)
  • Median from 0.6 down to 0.26
  • Unintentional Discrepancies (MedRec 2)
  • Median ranges from 0.57 to 1.00
  • Likely due to CCHSA requirement and Western

National Intervention-specific (as of Nov.06)
  • Surgical Site Infection
  • Excellent rates of submission likely due to
    Western Collaboration
  • Timely Prophylactic Antibiotic (SSI 1)
  • Appropriate prophylactic antibiotic (SSI 2)
  • Appropriate Hair Removal (SSI 4)
  • Appropriate selection of prophylactic antibiotic
    (SSI 7)
  • Glucose control for Major Cardiac (SSI 5) 3 to
    5 sites / month
  • Glucose control applicable beyond Major Cardiac
  • Normothermia (SSI 6) 60 to 70

National Intervention-specific (as of Nov.06)
  • Surgical Site Infection (cont.)
  • Strong move to full implementation
  • Percent Clean Surg w/ Surgical Infection (SSI 3)
  • Low submission rate likely due to difficulty
    monitoring SSI
  • Appropriate selection of Prophylactic antibiotics
    (SSI-7) to be revised by SSI faculty

Sharing the Quarterly Reports
  • With who do you (KOCs Team Leaders) share the
    QR info?
  • Team, Sr. Mgmt, Board
  • What should you tell each group?

Breakout Groups
  1. Complete the quiz together
  2. Determine the message(s) for your assigned group
    (i.e. Team, Sr. Mgmt, Board)
  3. Report back

  • Thank you for your interest in SHN!
  • Contact Information
  • Name Virginia Flintoft
  • Address University of Toronto
  • Phone/email 416-946-8350

Sustaining and Spreading for Success
  • T. Rollefstad
  • SIA Western Node
  • February 1 2, 2007

Safer Healthcare Now! Western Node
  • Participants will be able to
  • Understand the principles of sustainability and
    spreading successful initiatives
  • Identify how spread elements can be applied in a
    local setting
  • Select strategies to enhance sustainability and
    spread in their local organization

Definition of Sustainability
  • The Modernisation Agencys working definition of
    sustainability is
  • when new ways of working and improved outcomes
    become the norm.
  • holding the gains and evolving as required,
    definitely not going back.

How to Spread Good Ideas A systematic review of
the literature on diffusion, dissemination and
sustainability of innovations in health service
delivery and organisation Report for the National
Co-ordinating Centre for NHS Service Delivery and
Organisation R D (NCCSDO) April 2004 prepared
by Trisha Greenhalgh, Glenn Robert, Paul Bate
University College London Olympia Kyriakidou,
Fraser Macfarlane University of Surrey Richard
PeacockUniversity College London
Definition of Spread
  • Spread is the extent to which learning and change
    principles have been adopted in other parts of
    the organisation that could benefit from them.
  • Improvement knowledge generated anywhere in the
    healthcare system becomes common knowledge and
    practice across the healthcare system.
  • NHS Modernization Agency 2003

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

The Diffusion Curve
tipping point

Adopter Categories
Early Majority
Late Majority
Early Adopters
from Rogers, 1995
7 Deadly Sins of Spread!
Roger Resar, MD Carol Haraden, PhD
  • The things weve learned NOT to do
  • Start with a large pilot area Go Big or Go Home
  • 2. Find one person to do It ALL
  • 3. Be vigilant and work harder

  • 4. If it works in the pilot Unit, DONT change it
    for spread
  • 5. Appoint the successful team leader as the
    driver for spread to the WHOLE hospital
  • 6. Look at the deficits on a quarterly basis
  • 7. Early on expect marked improvement in hospital
    wide outcomes
  • http//
  • 88B76B53EBE4/0/Haraden_Resar7SpreadlySins.ppt

Assessed for Risk of Hypothermia
Positive Conditions
  • For Spread

  • Synthesized findings on major improvement
    initiatives in the UK
  • Describes the main factors found to contribute to
    successful spread and sustainability

(No Transcript)
Factors Affecting Spread
  • Ownership of the initiative
  • Effective Relationships
  • People who influence
  • Leadership
  • Dedicated resources
  • Process of implementation
  • Incentives
  • Staff Engagement
  • Support at senior level
  • Local context
  • Nature of initiative
  • Readiness for Improvement
  • Evidence of Improvements
  • Integration into practice

Where are you at?
  • Assessment Activity

  • Think of one area you will spread to next
  • Using the FACTOR WEB Tool
  • Take 10 minutes to rate each of the Factors
    affecting spread
  • 0 weak 5strong
  • Place a dot on the circle which intersects the
    factor line
  • Join the dots and shade the inner area

(No Transcript)
Real improvement comes from changing systems,
not changing within systems. Berwick
Testing versus Implementation
  • Testing trying and adapting alternatives under
    multiple conditions
  • Implementation making a change part of the day
    to day operation of the system
  • No implementation should fail

Creating a New System
Hold the Gains
Improvement (test, implement)
Strategies to Hold the Gains I. During testing
  • Replicate gains under a variety of conditions
  • Test the changes under a wide range of conditions
    (robust design)
  • Judgment samplings
  • Planned groupings
  • Foolproof the new process/procedure
  • Reduce likelihood of mistake/error
  • Use short feedback loops
  • Use technology where appropriate

Hold the Gains II. During Implementation
  • Seek and use input from others
  • Use multiple PDSA cycles to implement the change
  • Collect data over time when conditions are
    expected to change
  • Redesign support processes for new process
  • Address the social aspects of change

Hold the Gains III. After Implementation
  • Old System New System
  • Some Inhibitors
  • We met our goals
  • We assumed the improvement would hold
  • Other priorities took all resources away
  • (not on senior managements radar screen)
  • No strategies or did not learn how to hold the
  • Infrastructure not in place
  • Isolated project with a start and finish

Key Components to Hold the Gains After
  • Communication
  • Infrastructure
  • Effective Control System
  • Integrate into organization
  • Regular communication
  • Informed with data
  • Support processes
  • Leadership acountability
  • Continue measuring
  • Keep Core principles but allow customization
    based on real issues
  • Formalize documents
  • Embed in orientations

Creating a New System
Hold the Gains
Improvement (test, implement)
Readiness to Begin Spreading Changes
  • There are demonstrated results from Collaborative
  • There is will to spread the work of the
    Collaborative in the organization
  • Ensure strategy is a key initiative for the
  • A senior leader is responsible for spread of the

Adoption is a DOING thing!
In a concrete targeted way
Happens over time
Thru a SOCIAL system
Adapted from Rogers, 1995
(C) 2001, Sarah W. Fraser
Spread Model
Communicated Modes Purpose Messengers
Based on materials from IHI and Veterans Health
What the Improvement Team Can Do to Help with
  • Help to make the case for change
  • Make it easier for others to do the work
  • Develop the messengers

Attributes of the Change that Affect the Rate of
  • Relative advantage
  • Compatibility with current system
  • Simplicity of the change and transition
  • Testability of the change
  • Ability to observe the change and its impact

Spread Check List Better Ideas that Spread
  • We address the innovations
  • Relative advantage (it is better than
  • Trialability (you can test it first)
  • Observability (you can see it)
  • Compatibility with current values (it fits)
  • Simplicity (its simple to understand and do)

Source Diffusion of Innovations, Everett Rogers
Spread Check List Better Ideas
  • We can describe our changes (what), why the
    changes were made and benefits to patients and
    staff (tell the story)
  • We can easily show our successes and results
    (show the data)
  • We have documented our story through storyboards,
    presentations, newsletters, seminar materials,
    reports to senior leaders, videos, engaging
    stories, FAQs etc.
  • We continually assess the value and quality of
    our transfer materials

Communication Plan
  • Awareness of the initiative
  • Document benefits
  • Show comparative data
  • Use multiple communication channels
  • Technical knowledge
  • Explain changes succinctly
  • Involve successful units in providing technical
  • Train your messengers

Spread Check List Communication
  • We have used multiple channels for communication,
    focusing on interactive, peer-to-peer and
    face-to-face methods
  • We communicate early and often
  • We have identified our messengers, our connectors
    and salespeople
  • We have trained our staff and provided them with
    the tools to tell the story

Spread Check List Developing the Messengers
  • We have chosen the right messengers
  • Trusted
  • Technically competent
  • Full member of local group
  • We have used a two step approach
  • From team to opinion leaders and connectors
  • From opinion leaders and connectors to their
  • We have adequately educated the messengers to
    deliver the message

Social System
  • Content, context, and community
  • Understand the relevant circumstances affecting
    peoples ability/willingness to adopt the changes
  • Take advantage of the existing relationships
    within the system
  • Develop communities of practice among those
    with similar roles

Some Things to Consider about the Social System
  • Behavior change is not just about action
  • What is the plan to integrate adopters willing to
    get involved?
  • What are the peer-to-peer opportunities?

Plan to Reach all Units in Target Population
  • Identify who will make the adoption decision
    (individuals, practice group, department,
    facility, etc)
  • Consider the following in planning the sequence
    for spread
  • Coverage versus completeness
  • How best to optimize the learning with the
    addition of new units
  • Relationship of the units to the pilot sites
  • Champions exist or can be developed
  • Availability of resources

Spread Check List Target Population Social
  • We have identified our target population and
    spread community
  • We have tried to understand context of our target
  • We have identified existing relationships,
    opinion leaders, innovators and early adopters in
    the target population
  • We have allowed the target population to adapt
    our changes to fit their environment

Leaderships Role in Spread
  • Leadership
  • Topic is a key strategic initiative
  • Executive sponsor assigned
  • Day-to-day managers identified
  • Goals and incentives are aligned
  • Set-up for spread
  • Target population
  • Are pilot sites successful?
  • Identify key groups who make adoption decision
  • Initial strategy to reach all sites

Topic as a Key Strategic Initiative
  • CCHSA Medication Reconciliation is a Required
    Organizational Practice
  • CCS Canadian Cardiovascular Society has AMI
    Best Practice Guidelines
  • IHI SHN has built momentum and awareness of 6

Spread Check List Leadership
  • We have an overall spread plan
  • Our spread activities are included in strategic
    and business plans of our organization
  • We have visible and active support from our
    senior leader to spread our changes
  • Roles and responsibilities for spread are clearly
  • Senior leader assures success, remove barriers,
    make case for change
  • Day to day leaders communicate, develop
    messengers, educate, make it easy for others to
    do the work

Additional Considerations
  • Developing the Communication Plan
  • Strengthening the Social System
  • Developing the Measurement and Feedback System

Measurement and Feedback
  • Data collected on
  • Outcome measures
  • Measures to track spread of specific changes
  • Reporting to provide feedback
  • Link to follow up guidance and action
  • Data and reporting at different levels within the
  • Both leadership and front line

Outcome Measure
Tracking the Spread of the Changes
Outcome Measure - VHA
Average Waiting Time for Next Available
Appointment (Days)
Measures using Small Multiples Overall System
and 4 sites
Overall Outcome Measure
The graphs for each site are called small
multiples. They are designed for a quick visual
comparisons of the data from each Site. The
graphs are all presented on the same waiting time
scale (0 to 100 days) and time scale (4/00 -
Spread Check List Infrastructure
  • Measures about our changes and spread plans are
    reviewed by our team and our sponsor
  • More balancing, upstream and downstream
  • Less frequent
  • We have a method/process for knowledge transfer
    (including improvement science), continual
    learning and sharing information

  • Take 10 minutes to review the Spread Checklist
  • Check off the items your team has accomplished
  • What area/s still needs work?

Put it all together into a Plan
Developing a Plan for Spread
  • Develop a Spread AIM
  • Leadership
  • Set-up/ infrastructure
  • Communication
  • Social System
  • Measurement and Feedback


Developing a Spread Aim
  • Spread What
  • Target Level of Performance
  • Spread to Whom
  • Time frame

Developing an Initial Spread Plan
  • Consider how the organization structure can be
    used to facilitate spread
  • How are adoption decisions made?
  • What infrastructure enhancements will assist in
    achieving the Aim?
  • How will the spread efforts be transitioned to
    operational responsibilities?


Sample Spread Aim Prevent Ventilator Associated
Pneumonia by Implementing the Vent Bundle
  • Spread What Ventilator Bundle
  • Target Level of Performance Zero Cases of VAP
  • Spread to Whom All ICUs in our 10 hospital
  • Time Frame By September 2007


Sample Spread Aim Prevent Adverse Drug Events by
Implementing BPMH and Documentation form
  • Spread What BPMH Documentation form
  • Target Level of Performance Zero unintentional
  • Spread to Whom All units in our 10 hospital
  • Time Frame By September 2007

Levels of Spread Activities Level 1
  • Set-up/Infrastructure
  • Establishing steering committees
  • Orienting leadership groups
  • Organizing data collection
  • Developing materials
  • Identifying successful sites
  • General Communication
  • Wide spread dissemination of information about
    the initiative
  • Sending out comparative data
  • Holding meetings with a broad range of potential

Level 2 Spread Activities
  • Identification of Early Adopters
  • The push of general communication from Level 1
    results in pulling adopters to the project
  • The number and different categories of adopters
    identified are good measures for LEVEL 1
  • The key activity here is identification of the
    early adopters and a plan for how they will be
    integrated into the work

Level 3 Spread Activities
  • Strategies to Get Adopters to Action
  • Organizing purposeful peer-to-peer interaction
    that integrate adopters identified in your LEVEL
    2 activities (e.g. mentoring, visiting, meetings
    with specific invitation lists, and group
    discussions around materials on the website)
  • Champions for successful sites identified in
    Level 1 can help to provide the technical support
    needed although each early adopter should be able
    to add to the knowledge exchange  

Communication Plan
  • Building Awareness
  • Moving adopters from decision to action
  • Supporting and mentoring adopters

Level 4 Spread Activities
  • Feedback loops for LEVEL 3 activities
  • Collecting and reviewing data on the adoption of
    the key changes and the outcome measures
  • The aim is to understand how LEVEL 3 activities
    might be refined to improve upon results and how
    this might be best communicated with adopters
  • Feedback and adjustments may be needed for
  • Communication plans
  • Materials and information
  • Support and mentorship
  • Infrastructure issues
  • Social system issues

(No Transcript)
Spreading the Story
  • Describes steps to developing a communication
  • How to for telling the story
  • Quick read

Sarah Fraser - Health Management June 2000 10-12
Some Theory on Spread
  • Everett Rogers Adopter categories Attributes of
    an innovation Different aspects of communication
  • John Seely Brown Content, context, community
  • Malcolm Gladwell Tipping point Stickiness
    factor Law of the few Power of context
  • Nancy Dixon Explicit and tacit knowledge
  • James Prochaska Stages of Change Model
  • Albert Bandura Preconditions for change
    Motivation Modeling and guided enactment

  • Strategies for Spreading Improvements in Health
    Care, October 14, 2004 Marie W. Schall,
    Institute for Healthcare Improvement
  • Holding the Gains and Spread, July 11, 2006
  • Bruce Harries, Improvement Associates
  • The Seven Spreadly Sins, October 18, 2006
  • Roger Resar, MD Carol Haraden, PhD
  • Sustainability and Spread, August 28, 2006
  • Diane Jacobsen, MPH, CPHQ, IHI National Director

  • 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.

  • 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.
  • 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.