Taking Best Practices to Scale: Spreading Effective Healthcare Practices & Programs

1. Taking Best Practices to Scale:Spreading Effective Healthcare Practices & Programs C. Joseph McCannon, IHI Brian S. Mittman, VA Wynne E. Norton, UAB Denise Dougherty, AHRQ Michael Harrison, AHRQ September 29th, 2010AHRQ Annual Research Meeting AHRQ #R13HS019422

2. Objectives Achieving large-scale implementation requires a new set of research, policy, and practice efforts to understand and address these challenges and facilitate scale-up and spread. This session will (1) describe a series of activities, including a state-of-the-art conference held in July, that the presenters launched to stimulate greater interest and activity in scale-up and spread and (2) engage session attendees in generating ideas for additional activities needed to accelerate scale-up and spread of effective health programs throughout the United States and abroad.

3. Overview Introduction & Initial Activities Overview of Conference Example of Working Group Deliverables & Post-conference Activities Comments from AHRQ Structured Discussion

4. Introduction & Initial Activities

5. Definition of Scale-up/Spread “Deliberate efforts to increase the impact of health service 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” --Simmons, Fajans, Ghiron, 2007

6. Why Scale-up/Spread Now? Portfolio of Effective Health Innovations • Demonstrated efficacy and/or effectiveness • Variety of settings, populations, and behaviors • Guidelines, initiatives, simple and complex behavioral interventions, etc. • Examples • AHRQ Health Care Innovations Exchange • National Registry of Evidence-based Programs & Practices • Cancer Control P.L.A.N.E.T. • National Guideline Clearinghouse

7. Why Scale-up/Spread Now?Effective D/I Strategies • Increasing emphasis on D/I research • Increasing identification of effective or promising D/I strategies • Examples • Technical Assistance (Hamdallah et al., 2006) • Organizational change models (Glisson & Schoenwald, 2005) • Models, theories, and frameworks (see Glasgow et al., 1999; Wandersman et al., 2008) • Reviews (see Bero et al., 1998; Grimshaw et al., 2006; Grol & Grimshaw, 2003)

8. Why Scale-up/Spread Now? Need to Plan Ahead • Scale-up rarely happens automatically • Scaling-up requires significant preparation and planning • Human and financial resources • Political and policy support • Community, organization, and agency collaboration and buy-in • State, regional, and/or national coordination • Issues faced during small-scale studies or pilots are different—and typically less complex—than those faced in large-scale trials or initiatives

9. Increasing Focus on Scale-up/Spread • Research • Cluster RCTs and PCTs • Embedded research, mixed methods • Frameworks, lessons learned, reviews • Case Studies • Scaling up health service delivery: from pilot innovations to policies and programs (Simmons, Fajans, & Ghiron, 2007) • Best Practices in Scaling-up (JSI, 2006) • Case Studies in Global Health: Millions Saved (Levine, 2007) • Meetings & Organizations • ExpandNet/WHO • USAID: Research and Evaluation Methods for Scaling-up Evidence-based Interventions

10. Initial Scale-up/Spread Activities • Think tank, NIH D&I Conference, January 2009 • Presentations from NIH, Kaiser Permanente, AHRQ, RWJF, VA, CDC, and UCONN and discussion with session attendees • Working dinner meeting, January 2009 • 30 stakeholder representatives from AHRQ, Commonwealth Fund, CMS, HRSA, IHI, NIH, Harvard, RWJF, John A. Hartford Foundation, Kaiser Permanente, SAMHSA, VA, and the Universities of Michigan, Connecticut, Washington (St. Louis and Seattle) • What action is needed by key stakeholder groups to facilitate scale-up/spread? • Preliminary recommendations for promoting scale-up/spread

11. Initial Scale-up/Spread Activities • Health Funders Bending the Curve: Accelerating the Journey from Evidence to Adoption, Donaghue Foundation & RWJF, June 2009 • Discuss opportunities and challenges with adoption of research findings so funds can have greatest impact • Attendees included AHRQ, CA HealthCare Foundation, Commonwealth Fund, Grantmakers in Health, VA, Kellogg Foundation, John A. Hartford Foundation • Commissioned Study, 2009-2010 • Funded by Donaghue Foundation • Semi-structured interviews with 10 exemplary programs • Barriers, facilitators, and initial recommendations for scaling-up health promotion/disease prevention interventions

12. Next Steps Need for larger, more comprehensive meeting on scale-up/spread Include researchers, practitioners and policymakers Public health and health care State-of-the-Art conference…

13. Scale-up/Spread Conference

14. A Conference to Advance the Science & Practice of Scale-up/Spread of Effective Health Programs July 6-8th, 2010 in Washington, D.C. Organizers: Joe McCannon (IHI), Brian Mittman (VA), and Wynne Norton (UAB) Funders: AHRQ, Commonwealth Fund, VA, Donaghue Foundation, and John A. Hartford Foundation Planning Committee Members: IHI, NIMH, VA, CMS, Karolinska, Gates Foundation, AHRQ, Commonwealth Fund, URC, and Univ. Wisconsin

15. Attendees • IHI • UAB • VA • RWJF • AHRQ • CMS • Gates Foundation • Kaiser Permanente • CDC • U.S. Dept of Education • NIMH • CIHR • Stanford • USCF • UNC • Johns Hopkins • Harvard • Yale • Georgetown • USAID/URC • AHA (HRET) • Karolinska Institute • ExpandNet • Blue Cross Blue Shield • John A. Harford Foundation • Health Partners • Donaghue Foundation

16. Conference Aims • To review existing knowledge and current practices related to the scale-up and spread of effective practice in health care and public health; • To identify key challenges and gaps in current research, policy, and practice related to scale-up and spread in health care and public health; • To develop and disseminate a detailed agenda outlining critical research, policy, and practice initiatives on these topics for the next five to seven years; and • To launch specific activities to operationalize this agenda, creating a plan of action to prioritize research, policy, and practice activity and initiating powerful demonstrations of regional, national, and international scale-up in health care and public health.

17. Conference Format • Modeled after VA State-of-the-Art meetings • Brief introduction and background • Small working groups, product-oriented • Evening session speakers • Huggy Rao (Stanford) • Nancy Dixon (GW) • Rashad Massoud (URC) • Russ Glasgow (Kaiser) • Chris Goeschel (Johns Hopkins) • Anne-Marie Audet (Commonwealth)

18. Conference Content • General meeting overview, logistics, worksheets • Background papers and case studies • Working bibliography • Database of research and practice activities • Commissioned papers • Health care (Perla et al., IHI) • Public health (Edwards, CIHR) • International (Øvretveit , Karolinska) • General framework (McCannon, IHI)

19. Working Groups Working Group Charge: • Envision the ideal system for scale-up and spread • Identify gaps between current state and future state • Make detailed recommendations for action Working Group Chairs: • Health Care Research: Denise Dougherty, AHRQ • Policy: Maulik Joshi, HRET/AHA • Public Health Research: Todd Molfenter, Univ. Wisconsin • Health Care Practice: Marie Schall, IHI • Public Health Practice: Jürgen Unützer, Univ. Washington

20. Recommendations • Create more thoughtful incentives for scale-up/spread (e.g., funding, recognition, career advancement) • Stimulate donor-researcher-funder coordination in order to coordinate goals, priorities and activities • Enhance “pull” systems of change to complement “push” efforts • Develop environments for learning and sharing on scale-up • Knowledge exchanges, webinars, curricula

21. Recommendations • Develop tools and resources on executing scale-up and spread • How-to guides (what, when, and how to spread for different types of interventions) • Case studies • Taxonomies • Technologies • Develop and catalogue expanded research methods and improved data collection systems

22. Example of Conference Working GroupHealth Care Research Working GroupChair: Denise Dougherty, AHRQ

23. Deliverables & Post-Conference Activities

24. Short-Term Deliverables VA-sponsored scale-up/spread webinar series Peer-reviewed publications Detailed agenda for research and practice, including “performance challenges” (meeting proceedings) Update and expand scale-up/spread databases and resource listings (e.g., tools, literature, projects/programs) Presentations at targeted meetings Interactive Scale-up/Spread Listserv

25. Potential Longer-Term Actions Active contribution to major scale-up projects Advocacy: Active connection to donors, policymakers, etc. Durable learning network: Case studies, information exchanges, community of practice Annual gathering Course development Tool development

26. Comments from AHRQ AttendeesMichael Harrison, PhDDenise Dougherty, PhD

27. Thank you!Scale-up/Spread Blog: http://www.ihiscaleupconference10.blogspot.com