Spread and adoption model Webinar for AAC Rapid Uptake Products

1. Spread and adoption modelWebinar for AAC Rapid Uptake Products

2. Purpose of this session The aim of this webinar is to describe and introduce the work we’ve done in Wessex over the past 9 months to research and develop a standardised, evidence based approach to the spread and adoption of innovations in our region. We call this the ‘spread and adoption model’. It’s a work in progress. We are testing and refining it in the field and sharing it more widely for comment. The key output of our spread and adoption model is a “spread and adoption plan”. We will introduce this as part of today’s session It has been agreed amongst the AHSN Chief Officer’s that we will use this S&A model and plan to support the spread of the AAC RUP’s.

3. S&A planning template Templates can be considered bureaucratic and become documents that sit on the shelf once completed… However – we see the creation of the S&A plan as a dynamic and ongoing process. The first draft is just the first iteration. The template and resulting plan comes alive when all 15 AHSN’s (and the other lead bodies for particular products) work with partners to test and refine the responses to the template and all feed this intelligence back. We are then able to see patterns, learn, and adjust our support for adoption accordingly. The patterns might be specific to a particular product meaning we can collectively consider a national solution/solutions.  Populating the template is itself part of creating a conversation that is more receptive to adoption. 

4. Developing the model We started by reviewing the published literature on what supports successful spread and adoption. A key source is How to Spread Good Ideas1, a 400 page systematic review of the literature on spread in health services commissioned by the Department of Health and published in 2004. We’ve read a lot and we include some of the other key references at the end. We have used the evidence of what supports successful spread and adoption to design a model made up of six interconnected components. 1 How to Spread Good Ideas. A systematic review of the literature on diffusion, dissemination and sustainability of innovations in health service delivery and organisation. Trisha Greenhalgh et al. April 2004.

5. The S&A Model Spread in Systems Implementation Planning Understanding the adopters Spread through networks Embedding Innovations Understanding the Innovation The method starts by analysing the essential characteristics that will determine how the innovation spreads The programme builds understanding of when and how innovations are most effectively spread in systems and how the system and leaders support this. The method maps and understands the potential adopters – individuals, organisations and systems - and identifies key decision makers, opinion leaders, champions and networks. Innovations primarily spread through the social networks that link people together. The method develops targeted spread plans for each innovation Innovations are sustained and embedded when the advantage over the previous technology is measured and observable to the adopters & their organisation implementing health technology programmes involves a great deal of work. The method includes a checklist that covers the main factors that determine successful implementation. Today will cover the innovation, adopters and network elements of the model

6. Understanding the innovation • Different innovations spread and get adopted at different rates. Some never spread at all. • The perceptions that people have of an innovation is predicted to account for between 50% and 85%2 of the variance in the rate of spread. Six attributes of the innovation perceived by its potential adopters seem most influential: • Advantage- people are more likely to adopt something that they think is going to help them. They will weigh up the perceived gains of change with the perceived risks of the status quo. Clinicians will expect there to be good evidence of these advantages if they are going to change their practice and adopt it. This is often thought to be the most important attribute. • Compatibility- with the needs, values and beliefs of the potential adopter. • Complexity- simple innovations spread faster than complicated ones. When the innovation is complex, adopters need to understand and trust that there will be enough resource and support. • Adaption- people are more likely to adopt an innovation when they are able refine or modify it to suit their own needs (sometimes referred to as re-invention). • Observable- people are more likely to adopt an innovation when they can see it in action elsewhere and see the benefits to them. • Trialling- people are more likely to adopt an innovation when they can test it on a small scale first.

7. Understanding the innovation S&A model template The template starts with a description of the innovation, the problem it solves/ opportunity it takes and reviews the underpinning evidence base. We then analyse and record how the innovation measures up to these 6 attributes. We try to do this from the perspective of the potential adopters – where necessary taking different perspectives clinicians, commissioners, patients to determine the value proposition to the user(s). Tip: Many of the nationally prioritised innovations such as ITT/ ITP have headline statements of advantage of possible national financial savings. We work to get behind this and describe the quality attributes as well – and to do this at unit of potential adoption e.g. a hospital department or GP practice. Case study - Heartflow

8. Understanding the innovation Questions?

9. The S&A Model Spread in Systems Implementation Planning Understanding the adopters Spread through networks Embedding Innovations Understanding the Innovation The method starts by analysing the essential characteristics that will determine how the innovation spreads The programme builds understanding of when and how innovations are most effectively spread in systems and how the system and leaders support this. The method maps and understands the potential adopters – individuals, organisations and systems - and identifies key decision makers, opinion leaders, champions and networks. Innovations primarily spread through the social networks that link people together. The method develops targeted spread plans for each innovation Innovations are sustained and embedded when the advantage over the previous technology is measured and observable to the adopters & their organisation implementing health technology programmes involves a great deal of work. The method includes a checklist that covers the main factors that determine successful implementation. Today will cover the innovation, adopters and network elements of the model

10. Understanding the adopters The most common model used to understand potential adopters is innovation diffusion curve developed by Everett Rogers in 19622 (see figure opposite). This classifies the population of adopters in five categories:

11. Understanding the adopters Greenhalgh et al1 feel that the 5 adopter categories are an over-simplification – that adopters are not passive recipients of innovations: “Rather… they seek innovations out, experiment with them, evaluate them, find (or fail to find) meaning in them, develop feelings about them, challenge them, worry about them, ‘work around them’, talk to others about them, develop know-how about them, modify them to fit particular tasks, and attempt to improve or redesign them (often through dialogue with others)” And adoption happens in organisations as well as with individuals – with multiple decisions by multiple actors. “The adoption process within organisations should be recognised as complex, iterative, organic and untidy.” Horton et al 4 make the case for a greater emphasis on adopters – that invention is only half the story. “People sometimes fall into the trap of thinking that when an idea has been successfully demonstrated or piloted then the hard work is done. But exploiting the full potential of a new idea requires successful replication at scale – and this takes time, skill, resource and imagination.”

12. Understanding the adopters • S&A model template • The template supports the analysis of who the potential adopters are: • The organisation (e.g. acute Trusts) • The specialities/ departments (e.g. cardiology and radiology) • The key decision makers (e.g. clinical director and Divisional manager) • The groups of staff that will be required to adopt the innovation • The commissioner perspective • Whether patients have an influence on adoption Case study – Home Blood Pressure Monitoring

13. Understanding the adopters Spread and adoption reviews with our Trusts To deepen our understanding of the adopters in Wessex we are undertaking S&A reviews in our Trusts – to understand the roles and processes they use toIdentify; Decide; and Implementinnovations and identify ways to improve this. We’re building up a picture of what influences S&A in Trusts: Draft Key finding. The majority of the nationally prioritised innovations are aimed at acute Trusts. The key decision maker is most likely to be the appropriate Speciality Lead Clinician – with the decision on whether to adopt being made at a Divisional Board.

14. The S&A Model Spread in Systems Implementation Planning Understanding the adopters Spread through networks Embedding Innovations Understanding the Innovation The method starts by analysing the essential characteristics that will determine how the innovation spreads The programme builds understanding of when and how innovations are most effectively spread in systems and how the system and leaders support this. The method maps and understands the potential adopters – individuals, organisations and systems - and identifies key decision makers, opinion leaders, champions and networks. Innovations primarily spread through the social networks that link people together. The method develops targeted spread plans for each innovation Innovations are sustained and embedded when the advantage over the previous technology is measured and observable to the adopters & their organisation implementing health technology programmes involves a great deal of work. The method includes a checklist that covers the main factors that determine successful implementation. Today will cover the innovation, adopters and network elements of the model

15. Spread through networks There is a consensus in the literature that top-down pressure and mandating adoption of an innovation rarely works: “While mandatory participation might ensure that organisations join a programme, it does not by itself achieve acceptance of a new intervention or the motivation to implement it.” 4 Decisions to adopt an innovation are context specific and have strong social and psychological aspects. There is a consensus of the importance of networks in the diffusion of innovations: “It is a key principle of diffusion of innovations theory that most innovations spread primarily through interpersonal influence, and that the ‘channels’ through which such influence flows are the social networks that link individual members of a social group.” 1 • We can think of these networks as being the principle way that the different populations of adopters watch what each other are doing – how the early majority find out what the early adopters are doing and so on. Important roles operate in networks, that can influence spread and adoption: • Opinion leaders– are the highly respected people in organisations and networks who influence others. • Champions– are the key individuals who use their belief, commitment and relationships to keep pushing adoption in their own organisation and finding ways around organisational barriers. They are often found outside of formal structures or authority.

16. Spread through networks The importance of horizontal networks that bring together the key decision makersand potential users of the innovation to explore its attributes is a major part of the model. S&A model template The template supports the analysis of the networks that bring our potential adopters together, where they can explore the attributes of the innovation. There are a number of formal networks that are helpful e.g. STP groups; Clinical Senate; Deanery. But we are really looking for the informal clinical networks that clinicians and professionals instigate and maintain themselves as part of how the professional development of their service and speciality. There a lot of these – but finding them can take some detective work. We look for the opinion formers and champions in these networks. Case Study – Home blood pressure monitoring

17. Detail surrounding the final three elements of the S&A Model Spread in Systems Implementation Planning Understanding the adopters Spread through networks Embedding Innovations Understanding the Innovation The method starts by analysing the essential characteristics that will determine how the innovation spreads The programme builds understanding of when and how innovations are most effectively spread in systems and how the system and leaders support this. The method maps and understands the potential adopters – individuals, organisations and systems - and identifies key decision makers, opinion leaders, champions and networks. Innovations primarily spread through the social networks that link people together. The method develops targeted spread plans for each innovation Innovations are sustained and embedded when the advantage over the previous technology is measured and observable to the adopters & their organisation implementing health technology programmes involves a great deal of work. The method includes a checklist that covers the main factors that determine successful implementation.

18. Thank you for listening Discussion

19. Reporting and document update mechanism RUP lead 7 RUP 1 (Lead AHSN [x]) RUP 2 (Lead AHSN [x]) RUP 3 (Lead AHSN [x]) RUP 4 (Lead AHSN [x]) RUP lead 5 RUP lead 6 AHSN 1 AHSN 2 AHSN 1 AHSN 2 AHSN 1 AHSN 2 AHSN 1 AHSN 2 AHSN 1 AHSN 2 AHSN 1 AHSN 2 AHSN 1 AHSN 2 AHSN 3 AHSN 4 AHSN 3 AHSN 4 AHSN 3 AHSN 4 AHSN 3 AHSN 4 AHSN 3 AHSN 4 AHSN 3 AHSN 4 AHSN 3 AHSN 4 AHSN 5 AHSN N+1 AHSN 5 AHSN N+1 AHSN 5 AHSN N+1 AHSN 5 AHSN N+1 AHSN 5 AHSN N+1 AHSN 5 AHSN N+1 AHSN 5 AHSN N+1

20. Detail surrounding the final three elements of the S&A Model Spread in Systems Implementation Planning Understanding the adopters Spread through networks Embedding Innovations Understanding the Innovation The method starts by analysing the essential characteristics that will determine how the innovation spreads The programme builds understanding of when and how innovations are most effectively spread in systems and how the system and leaders support this. The method maps and understands the potential adopters – individuals, organisations and systems - and identifies key decision makers, opinion leaders, champions and networks. Innovations primarily spread through the social networks that link people together. The method develops targeted spread plans for each innovation Innovations are sustained and embedded when the advantage over the previous technology is measured and observable to the adopters & their organisation implementing health technology programmes involves a great deal of work. The method includes a checklist that covers the main factors that determine successful implementation.

21. Implementation planning • There is a consensus in the literature that implementing innovations is hard. To be successful we need: • The individuals and teams to be motivated to change • Support from the right levels (e.g. approved business case, senior sponsor, commissioner support) • Resources – the time and skills required to implement the change • Measurement and review of the expected benefits of the change • There is an additional challenge that we need to be aware of – the ‘replicability problem’ 4. That when an individual or team take up a new innovation, it doesn’t work as well as it did first time around. We don’t just want uptake – we want successful and sustained uptake – and this is more likely to happen when: • Implementation is based upon local context and the innovation can be be adapted to fit this. • There is recognition of the need for cultural change, relationship building and new ways of working (and these don’t lend themselves to compulsion) • There is an ongoing role for peer networks to support change and share experiences.

22. Implementation planning S&A model template The spread and adoption planning template contains a checklist to begin the process for planning the implementation and sustained use of an innovation. This can be simultaneously used for multiple organisations. Impact modelling Understanding the need for an innovation is essential – are we solving a real problem? As part of our work with the Wessex maternal medical network, we have determined the extent of the opportunity, and applied this to the local population, as hospital and regional level. As a result of this, we can begin to them model the opportunity, and potential benefits resulting. Business Case Our innovation reviews of provider Trusts has identified the importance of clear business case and decision making processes that is designed to be timely and make sure that the innovation is right for the Trust, is funded properly, will be implemented well and will deliver a set of benefits that can be measured and reviewed. We are currently exploring the potential to develop common business cases for innovations that can be used by multiple Trusts.

23. Embedding innovations • The literature describes how innovations are more likely to be sustained and embedded when: • The benefits of the innovation are observed, measured and reviewed by the adopters and their organisation/ system ongoingly • Adopters continue to share their experience and results in their peer networks • The innovation is accepted as “this is how we do things” as a result of continued work to normalise the innovation

24. Spread in Systems • The S&A Model supports our long-term commitment to improving the spread and adoption of innovations in Wessex that improve health and care. • The literature describes the key determinants that make some organisations and systems more readily adopt innovations. • For organisations, three determinants are identified: • Structural – mature organisations with effective devolved structures and decentralised decision making • Knowledge capability – systematically identifying, interpreting and sharing new knowledge • Receptive to change – strong leadership, clear strategic vision, good managerial relations, visionary staff in key positions, prepared to experiment and effective monitoring and feedback mechanisms • Systems more readily adopt innovations when they have effective networks and their organisations look externally for ideas. The S&A Model aims to support these key determinants across Wessex. The S&A reviews with our Trusts directly support their capability to innovate. Our work to map and develop relationships with the peer networks create the conditions for a culture of innovation.

25. Key references supporting our work Greenhalgh, T., Robert, G., Bate., How to Spread Good Ideas. A systematic review of the literature on diffusion, dissemination and sustainability of innovations in health service delivery and organisation. April 2004. Rogers EM. Diffusion of Innovations. 4th Ed. 1995. Tim Horton et al. The Spread Challenge. How to support the successful uptake of innovations and improvements in health care. The Health Foundation. September 2018 Greenhalgh, T., How to implement evidence based health care, 2018. Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P. & Kyriakidou, O., Diffusion of innovations in service organizations: systematic review and recommendations. The Milbank Quarterly, 2004. The Nuffield Trust, Falling short: Why the NHS is still struggling to make the most of new innovations, 2017. European Commission, Expert Panel On Effective Ways Of Investing In Health(EXPH): Disruptive Innovation - Considerations for health and health care in Europe, 2016. Berwick, D., Disseminating Innovations in Health Care, 2003. McCannon, J., Massoud, M.R. and ZierAlyesh. A., Many Ways to Many, 2016. Greenhalgh, T., Wherton, J., Papoutsil, C., Lunch, J., Hughes, G., A’Court, C., Hinder, S., Procter, R. & Shaw, S., Analysing the role of complexity in explaining the fortunes of technology programmes: empirical application of the NASSS framework, 2018.