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Helen Bevan@HelenBevan

Zoe Lord@ZoeLord1

How to create

change that sticks and spreads

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Scale up and spread: definitions

“deliberate efforts to increase the impact of innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and program

development on a lasting basis”Norton and colleagues 2012

“Going to scale’ [means] at least 60% of the target population that could potentially benefit from the

programme receives it”Rabin and colleagues (2012)

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How do we measure success?

“Unless a program can be replicated and sustained on a large scale, it will not be

transformational…..We can no longer evaluate programs simply based on how well they’ve performed in a given locality. Instead, we need to factor in

their potential to achieve scale”McKinsey on Society

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From 2001 to 2005, I was responsible for the Research into Practice team within the NHS Modernisation Agency

The team role was to promote the spread and sustainability of service improvement and helped to build a body of knowledge

We found that the factors of sustainability are also the factors for effective spread

Spread and sustainability

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We have more than 20 years experience of spreading large scale change

“It has been positivelyreviewed and reported in the nursing

& healthcare press and its implementation is proven to produce significant savings in

productivity & efficiency”White et al 2013

“Contributed

to a 51% reduction in

antipsychotic prescribing to

people with dementia”

Manchester Business

School

One of the most widely adopted and impactful improvement programmes in the history of the NHS; “releasing

time to care”, typically 10-20% of the time of clinical professionals. The changes were adopted by 78% of NHS hospital wards, 68% of mental health

wards, 54% of NHS operating theatres and 49% of community health teams across England (SHA statistics) as well as 44 territories

across the globe

New Zealand: 19% of time“released to care”

Oregon USA: multi-factorial improvements

Scotland: “20% of time

released to care”

A significant,positive impact on staff

engagement

Irish research: the effects were

sustained over time

Statistically significant positive effect on EVERY dimension of impact at both individual & organisational level

800,000 pledges;

engaged two thirds of all NHS

organisations

Our most successful ever

digital campaign

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But the reality is often different

With alarming regularity,

many promising pilots in the

health care improvement

and implementation field

have little overall impact

when applied more broadly”

Perla & colleagues,

Health Affairs blog,

April 2015

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Enthusiasts Visionaries Pragmatists Conservatives LaggardsSource: Geoffrey Moore, building on the work of Everett Rodgers

Beware the chasm

The typical effect sizes of spread activities are perhaps 10-20% at best (Grimshaw)

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Nine repeating patterns from pioneer/pilot type programmes

#1Promising pilot programmes are rarely replicated successfully from pilot localities to others; the wider and more complex the change, (i.e., involving multiple organisations) the least likely that spread will happen

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Kaiser Permanente spread model

Just do it

Innovate

Test and replicate

CLEAR

COMPLEX

CHAOTIC

COMPLICATED

Source: Schall and Schilling

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Nine repeating patterns from pioneer/pilot type programmes

#2Most of the early effort and energy is needed to make the pilot programme functional and issues of spread & scale often end up being an afterthought

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Nine repeating patterns from pioneer/pilot type programmes

#3We typically focus on extrinsic motivators to change, rather than intrinsic & we don’t align the motivators; as a result, change is often experienced by people at the front line as “have to” (imposed) rather than “want to” (embraced)

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Intrinsic motivationPeople engage in the activity for the pleasure and satisfaction of doing it

Invokes many positive behaviours

Extrinsic motivationPeople engage in the activity for the rewards or avoiding punishmentAny external influence is referred to as extrinsic motivation

Images: pixgood.com

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The power of extrinsic drivers

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Three types of levers for large scale change

‘Prod mechanisms’ targets

performance management

price & payment incentives regulation

competition

‘Proactive support’

relies on building ‘intrinsic motivation’ in

staff to make the right changes to

improve

‘People focused’ education and training

national contractsprofessional regulation

clinical quality standards

Type one:

Type two: Type three:

Source: Health Foundation report Constructive comfort: accelerating change in the NHS 2015

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Three types of levers for large scale change

‘Prod mechanisms’ targets

performance management

price & payment incentives regulation

competition

‘Proactive support’

relies on building ‘intrinsic motivation’ in

staff to make the right changes to

improve

‘People focused’ education and training

national contractsprofessional regulation

clinical quality standards

Type one:

Type two: Type three:

Source: Health Foundation report Constructive comfort: accelerating change in the NHS 2015

Less than 10%of the potential

for improvement

at system level can be

delivered through type one change

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Nine repeating patterns from pioneer/pilot type programmes

#4People outside of pilot locality don’t feel any ownership of, or emotional connection with, the pilot project. As a result, the change processes can end up being “pushed” onto other localities rather than “pulled” by them

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“In a world of mounting performance pressure, [organisations and change processes] need to evolve…the most successful will be those that

evolve into movements.

Success will be determined by their ability to mobilise, inspire and support an

ever-expanding array of participants extending far beyond their own four walls”

John Hagel, SXSW 2015http://www2.deloitte.com/us/en/pages/center-for-the-edge/articles/john-hagel-at-sxsw.html

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Closed innovation Open innovation

As a pilot test site , we want to be left alone for a period of

time so we can work it out for ourselves

As a pilot test site, we seek to continuously get ideas and

guidance from leading thinkers and practitioners outside our local area

We will test our new ways of working internally “to

destruction”. When we are confident they will work, we will offer to share our “best practice innovations” with

others

A wider group has contributed to the innovation process, beyond our

host organisation; people from other localities already feel that

they own it. Spread is more likely to be “done with” not “done to” and to

be “pulled” not “pushed”

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The power of co-creation

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Open innovation is a mindset, not just a process

Pioneer Locality

We would love to share with

others but there don’t

seem to be any takers

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#5Even where we are able to create replicable change concepts from the pioneering localities, if we don’t have an implementation approach for spread that engages different local contexts, it doesn’t work

Nine repeating patterns from pioneer/pilot type programmes

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Innovations won’t put down roots if the ground isn’t fertile

Source: David Fillingam

• National and regionally led improvement initiatives have their place• But “ sheep dipping” managers and clinical

leaders in programmes external to their local communities is unlikely to have lasting benefit

• What’s more the learning won’t spread to other communities (or even be sustained in its place of origin) unless each community has its own locally developed and owned culture and system of improvement

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There is a tendency towards “cargo cult” improvement

Attempts are made to spread/replicate new models from

pilot projects without a proper understanding of how they work.

They end up reproducing the superficial outer appearance but not the mechanisms that produced the

outcomes in the first instance (Dixon-Woods & colleagues 2011)

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What is the best way to spread new knowledge?

Source of data: Nick Milton http://

www.nickmilton.com/2014/10/why-knowledge-transfer-through.html

Social connection/discussion is 14 times more effective

than written word/best practice

databases/toolkits etc.

Source of image: www.happiness-one-quote-time.blogspot.com

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#6The pioneer localities have limited bandwidth to coach others & spread best practices

Nine repeating patterns from “pioneer-type” programmes in health and care in England

over the last 18 years

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#7Local leaders are understandably much more concerned with local change than they are with spreadLeaders of the macro level system must act as catalysts for spread

Nine repeating patterns from pioneer/pilot type programmes

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“Choreographers of complexity”

Scale up efforts should be overseen by a “choreographer of complexity”:

“An analogy can be made to the role a choreographer takes in a dance company. Their job is to produce a

finished work that integrates many different performance elements; music, dance, and storytelling. This must be done by making trade offs and finding synergies within the available resources of the [organisation or system],

and all the while driving toward an ultimate vision.”McClure and Gray (2015b)

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#8The commitment, characteristics & skills of local clinical leaders is often the crux issue for change in specific settings

Nine repeating patterns from pioneer/pilot type programmes

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“Perhaps the single most important influence on programme response by individual units—either in promoting or resisting change—was the extent of consensus and coalition among the senior medical and nursing staff….Transforming or boosting of efforts was most likely to occur when those

locally charged with implementation were sincere in their beliefs about the value of the programme, were able to create transdisciplinary alliances, had local credibility among peers, were prepared to tolerate debate but

exercise firmness, and used multiple tactics including role modelling, persuasion, sanctioning, reminders, and constant feedback….

[Consultant says] ‘I think it’s been successful because it’s a unifying program, it’s one of the few things that we’ve done that hasn’t been just a doctor thing, or just a nurse thing, it’s involved the doctors and the nurses

together.’” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3704826/

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Nine repeating patterns from pioneer/pilot type programmes

#9Sustainability of change is as much of a challenge as spread of change. The same receptive local contexts create the conditions for both spread and sustainability (See Buchanan and colleagues)

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Few evaluative studies look beyond the pioneers to the issues of scale &

spread so empirical evidence is limited

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Although studies in small samples provide useful insights regarding local barriers and facilitators to adoption, the relevance of these findings for efforts to achieve large-scale adoption (i.e., scale up or spread) in hundreds or thousands of institutions or communities is limited. Numerous practice-based efforts to scale-up and spread evidence-based health programs have been documented (although primarily in developing countries), but this work only rarely employs scientific methods for understanding and evaluating scale-up processes and strategies, and thus offers limited evidence and guidance for improving future scale-up efforts. Norton and colleagues

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What does the NHS workforce think? 14,000 contributors recently identified 10 barriers to change:

Confusing strategies

Over controlling leadership

Perverse incentivesStifling innovation

Poor workforce planning

One way communication

Inhibiting environment

Undervaluing staff

Poor project management

Playing it safe

Source: Health Service Journal, Nursing Times, NHS Improving Quality, “Change Challenge” March 2015

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What does the NHS workforce think? 14,000 contributors recently identified 11 building blocks for change:

Inspiring & supportive leadershipCollaborative working

Thought diversityAutonomy & trust

Smart use of resources

Flexibility & adaptability

Long term thinking

Nurturing our people

Fostering an open culture

A call to action

Source: Health Service Journal, Nursing Times, NHS Improving Quality, “Change Challenge” March 2015

Challenging the status quo

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The Change Model

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How does it work and aid spread?

Zoe Lord - Improvement Manager @ZoeLord1 #NHSTform

Start with the Our Shared Purpose

No order after Our Shared Purpose = better chances of

success, sustainability & spread…

Use all parts in equal measure

#NHSTform#NHSTformhttp://www.institute.nhs.uk/index.php?option=com_spread_and_adoption

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Actions supported by history#1:Build in considerations of spread and adoption right from the start of a major change strategy (not as an afterthought)

Make spread a whole system collaboration;

bottom up with top down support

Use adoption partners,

“sprints” for action & Challenge Prizes to build & sustain momentum &

interest in the wider community

Use social media & other

virtual channels to keep the wider

community connecting & learning from

each other

Encourage social interaction

& discussion to spread new knowledge,

rather than guidelines, best practice databases or

toolkits

Makethe “pioneers” part of a wider

learning community from the start & make

it easy for them to interact with

others

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Use all our levers for change, both intrinsic and extrinsic, to enable change to happen at scale

Actions supported by history#2:

Work on the deeper environmental/cultural

factors that create a receptive local context for change at least as hard as

we work on the new delivery processes

Create a spread strategy which aligns multiple drivers for

change & balances space for innovation with

mechanisms for managing complexity at

scale

Flip as many levers as possible from

acting as extrinsic drivers (“prods”) to acting as intrinsic motivators (“proactive support”) so

people want to not have to

Align regulatory and inspection functions to

incentivise rapid adoption of the new models of

delivery

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Actions supported by history#3:Create systems of support and encouragement for local leaders to

adopt the new models

Provide targeted development

in the system leadership, analytical & change

leadership skills needed to implement the new models

(these are surprisingly scarce) Don’t declare

victory too early; expect setbacks; cherish failures as opportunities to learn;

thank & praise those who are working hard &

risking much

Assess & grow the capability of the

improvement & leadership development resources and

support leaders to lead change from the

bottom up

Reinforce & role model transformational

behaviours

Create the opportunities and

support for teams to come together

(physically & virtually) to test, learn, develop and

improve

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What do the leaders who get the best spread results do? They:

Source: McCannon

• Attempt remarkable things (provocation and optimism)• Talk about justice• Have a shared story• Apply many levers• Play jazz (adaptive, creative) • Keep it simple (e.g., interventions, measurement systems)• Model trust • Seek affection and give recognition• Break rules (avoid consensus, condense timescales)• Go broad and deep• Respect/revere logistics

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The conclusions of the very first national spread programme in the NHS (National Booked Admissions programme from

1998) are still highly relevant

This evaluation has shown that thereare no magic bullet solutions….The main source of

change and service improvement has to come from within each and every NHS organisation. Renewed effort now needs to be put into developing the staff and organisations that can

embrace the kind of cultural change foreshadowed by the NHS Plan. No amount of guidance, support, hectoring or

cajoling can substitute for the lack of capability and understanding among the staff delivering care to patients of

the need to reshape the provision of services.Chris Ham & colleagues, 2002