Enhancing Improvement Sustainability & Spread in California Chronic Care: Lessons from LS3 Collaborative

1. California Chronic Care Learning Communities Initiative Collaborative Holding the Gains and Spread Learning Session 3 June 8, 2005 Angela Hovis Improvement Advisor

2. “There is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new order of things….” -Nicolo Machiavelli, The Prince

3. Objectives • Enable you to apply current knowledge about holding and spreading improvements to your setting • so that you can sustain and spread the improvements in this project and • so that you have skills to sustain and spread other improvements in future activities.

4. Collaborative Time Frame12 months How well do successful teams “hold the gains” and spread after LS3? Participants Select Topic Prework Expert Meeting P P Develop Framework & Changes A D A D S S Beyond LS 3 LS 1 LS 2 LS 3 PlanningGroup Strategy: -test -implement -hold the gain -spread

5. Creating a New System Improvement Spread Hold Gains BETTER Improvement Hold Gains Spread

6. 2003 IHI Survey on Holding the Gains Brief History-surveyed 33 successful teams from different collaboratives. Objective: To determine if successful teams involved in IHI Collaboratives sustained their progress after the end of the final learning session.

7. Question: What is your current level of performance compared to the end of the final learning session for the key outcome measure? Summary 97% of teams at least “held the gains” from the BTS 67% of teams are now performing better than at end of BTS

8. Additional Survey Findings

9. General impressions • The power of internal publicity • Commitment to real sustainability versus “quick hits” (leadership, resources, ambition) • Understanding that the end of the formal collaborative is only the beginning (and that success is only a step in the right direction)

10. After ImplementationSome Inhibitors: Old System New System • “We met our goals” • “We assumed the improvement would hold” • Other priorities took all resources away (not on senior management’s radar screen) • Did not learn how to hold the gains • Infrastructure not in place

11. “We are what we repeatedly do; excellence is not an act, but a habit.” -Aristotle

12. Plan to Hold the Gains: Three Key Components Infrastructure Effective Control System Social Aspects of Change

13. Plan to Hold the Gains: Infrastructure • Address training and development of new skills • Make changes to job descriptions, policies, and procedures • Assign ownership for improvement and maintenance work of the new process • Senior leaders held responsible for the efforts to sustain the change and remove inhibitors that might allow slippage back to the old system

14. Plan to Hold the Gains: Design Effective Control System • Plan to standardize new process, link to other processes whenever possible • Continue to monitor measures for performance and outcomes • Outcome measures required • Process measures may be desirable as early warning signals

15. Run Chart Class referral Goal Setting Class referral Goal setting

16. Using Shewhart Control Limits to Detect Important Changes in SC System Class referral Goal Setting Old system Not holding gain; Things getting worse Act to correct New system

17. Address the Social Aspects of Change • Provide information on why the change is being made and how the change will effect people (WIFM) • Show appreciation for people’s efforts • Understand and address the causes of resistance • Publicize the results and learning

18. While Holding Gains, Spread BeginsSpread: Adoption of an Innovation Target Population in your Aim Statement - Reach more patients Population for Spread • Other clinicians- Other clinics - Other chronic • conditions

19. Understanding Spread: Learning from Examples • Spreading Innovations to Patients: brown Rice instead of white rice - Contra Costa/Richmond Health Center • Spontaneous Spread – Yoga classes at Silver Avenue Family Health • Sharing collaborative info with SB and presentations - San Francisco Gen. Hosp. and San Mateo Medical Center • Getting Started with Influential Partners - Santa Clara Valley Medical Center • Local champions share knowledge to small groups of providers - Contra Costa/Richmond Health Center

20. Adoption is a DOING thing! “BETTER IDEAS” COMMUNICATED In a certain way Happens over time Thru aSOCIALsystem (C) 2001, Sarah W. Fraser Adapted from Rogers, 1995

21. Adoption Curve 100 Percent Adopting 50 0 Time

22. Leadership’s 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

23. What the Improvement Team Can Do to Help with Spread • Help to make the case for change • Provide examples of PDSAs • Make it easier for others to do the work • Provide examples of PDSAs • Share tools • Host a site visit to show new process (tacit knowledge) • Be a messenger to a new site

24. Steps to Adoption Knowledge Persuasion Decision Implementation Confirmation

25. Adopter Categories Innovators Early Majority Late Majority Early Adopters Laggards 16% 2.5% 34% 13.5% 34% from Rogers, 1995

26. How “Spreadable” are your Improvements?(1=not at all, 5=absolutely) Rogers’ Attributes of Change”

27. Spread: The messages we communicate are important • To build will: • Highlight need for change • Highlight potential for change • Good ideas (concepts) • Pragmatic guidance for implementation Which one works best? • Both messages needed • Different receivers respond differently

28. Table Exercise 5 minutes: Imagine that you have only 2 minutes with a colleague to create interest in your improvement work. Plan a 2 minute (or less) talk to “pitch” or sell a change or group of changes your team has implemented. Consider addressing the factors that influence the adoption of an innovation. Will pitch to the group.

29. Bibliography • Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986. • 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. • Gladwell, M. The Tipping Point. Boston: Little, Brown and Company, 2000. • Lomas J, Enkin M, Anderson G. etc. Opinion Leaders vs Audit and Feedback to Implement Practice Guidelines. JAMA, Vol. 265(17); May 1, 1991, pg. 2202-2207. • Rodgers E. Diffusion of Innovations. New York: The Free Press, 1995.