Paper Commissioned for Conference – Please Do Not Circulate

Framing a Discussion on Scale-up and Spread

C. Joseph McCannon[1]

This paper was commissioned by the conference chairs for delegates of the inaugural Conference to Advance the State of the Science and Practice on Scale-up and Spread of Effective Health Programs, Washington, DC, July 6-8.Correspondence to CJ McCannon, .

Funding for this conference was made possible in part by grant 1R13HS019422-01 from the Agency for Healthcare Research and Quality (AHRQ). The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. The Commonwealth Fund, The Veteran’s Health Administration, The Donaghue Foundation and The John A. Hartford Foundation also provided meeting support.

Framing a Discussion on Scale up and Spread

Commissioned Paper: Conference to Advance the State of the Science and Practice on Scale-up and Spread of Effective Health Programs (July 6-8, 2010)

C. Joseph McCannon

In the last ten years, hard work and thoughtful research has yielded several emergent theories of how to spread effective health care and public health practice in order to realize large-scale improvement in performance and outcomes. Drawing in part on work from other fields and investigations from other social sciences, this thinking has been important and valuable, yielding common themes and concepts that are helpful to those planning scale-up projects.

Many large-scale change initiatives, however, still fail, and learning about scale-up is unevenly distributed, often limited to what works within health care and public health organizations (as opposed to across institutions and geopolitical entities). As such, this paper – and the conference it supports – seeks to summarize at a high level what we do presently know about key factors in spreading effective practice while suggesting some persistent challenges and gaps in knowledge that must rapidly be closed in order to more broadly reduce human suffering.

For our purposes here, we are defining scale-up as the activity of bringing effective local practices, prototypes or knowledge to all who might benefit from them in a specified area (e.g., system, country, region). We also acknowledge that this paper cannot be comprehensive in its scope; if it succeeds it will provide a framework for conversation and further exploration.

What is Known: A Framework

The other papers commissioned for the Conference to Advance the State of the Science and Practice on Scale-up and Spread of Effective Health Programs (July 6-8, 2010) offer an analysis of prior research and analysis in this field with attention to health care, public health and international (emphasis on developing world) contexts. Taken together, they suggest several common,essentialconsiderations in planning, executing and analyzing scale-up efforts, which are consistent with seminal texts.[1][2][3][4][5][6][7][8][9][10][11][12][13][14]These works form the basis for our discussion in this conference and createa core meeting framework.

This framework suggests that six factors seem to influence effectiveness in spreading interventions in health care and public health (See Figure One):

  1. The current environment for changein which scale up will occur;
  2. The foundation (or pre-history) for the work in question;
  3. The framing (especially aims) for the work in question;
  4. The nature of the intervention to be spread;
  5. The structural context into which the intervention will be spread; and
  6. The method for spreading new knowledge and executing change (including the method of evaluation).

Though there is nothing to suggest that these factors must be considered in sequence (indeed, they will often be managed in parallel), they are all important tosuccessfully spreading change.

The current environment for change refers to how conducive the larger geopolitical system in question is to spreading a new practice at the moment in which we seek to scale up. Specifically, what is the political and economic environment? How highly do the public, political leaders and other influential stakeholders prioritize the change in question, given a vast array of possible areas for improvement? What is the present vision for change in the system?What are emergent incentives for change (e.g., legislation, litigation, recognition, payment)? In essence, is there sufficient local will for large-scale improvement and who will lead it?

The foundation (or pre-history) for the intervention in question refers to all of the work in the area that has taken place before the launch of the spread effort under consideration; it considers whether the initiative in question is in its early days (low awareness or confidence in the change in question) or nearing a point of greater maturity where its likelihood of being adopted is much greater (high levels of awareness and confidence). A higher sense of readiness has a great deal to do with the degree to which researchers have established the efficacy of the intervention in question and the degree to which its introduction has been pilot tested for effectiveness under a variety of different circumstances (e.g., day shift versus night shift; rural setting versus urban setting, etc.).

The framing for the scale-up process refers to the way in which the scale-up initiative communicates its vision, values and aims. Aim-setting, in particular, is a crucial activity insofar as it must energize the audience that could adopt the change without overwhelming or discouraging it. It is important to seek explicit, quantifiable changes in outcome, but to also tend to more tacit changes (in culture, for instance, or local skill at improving) that could result from successful dissemination. It is also important to understand whether the scale-up effort is simply seeking to replicate a successful intervention or to solve a particular problem through the use of multiple levers for change (e.g., policy, regulation), which could entail considerably more complexity.

Figure One – Major Factors Influencing Scale-up

The nature of the intervention refers to inherent qualities of the change in question that will increase or decrease its likelihood of adoption. Attributes of note – per Rogers – include relative advantage, cultural compatibility, complexity (or lack thereof), “trialability” and “observability.”[15] Scalable design for health care and public health requires attention to each of these factors, adapted to health care and public health, with attention to things like the evidence base (potential for impact), a practice’s potential intellectual and emotional resonance with prospective adopters and the resources required to introduce it.

The structural contextrefers to fixed infrastructure and patterns of behavior in the local environment into which the practice in question is spread. A successful effort to scale up a new behavior will thoroughly understand health care delivery and public health systems, formal and informal relationships among the potential adopters, organizational tendencies, financing paradigms, local rules and geography, and it will thoughtfully stratify its strategy based on how innovative or tentative different individuals and organizations are with respect to the new practice.

The method refers to how those managing the spread of the initiative will actually introduce the new practice and see to it that it is reliably adopted by the field. Many methods exist – campaigns, quality improvement collaboratives, extension agent models, regulatory frameworks and many more – but skill lies in selecting the appropriate method (or methods)given all of the contextual factors listed above.[16][17][18] Effective dissemination also requires a system for efficiently collecting data from participating entities, for evaluating progress in such a way that it informs scale up efforts as they happen,for rapidly harvesting and redistributing new knowledge and assessing the ultimate impact of the effort in question. Equally – and regardless of method –dogged devotion to the logistics of managing the implementation process is an essential driver of success.

Taken together, these major considerations heavily influence the outcome of scale-up initiatives. Ultimately, they help those who seek to disseminate better practice to understand why they should spread (framing), what they should spread (nature of the intervention), when they should spread (current environment, foundation), to whom they should spread it (structural context) and how they should do so (method).

Gaps in Knowledge and Performance

Carrying out sound strategy and tactics in each of these areas is very important. Successfully tending to all of these considerations, however, is difficult, and there is great room for improvement in executing most scale-up initiatives. Identifying gaps in knowledge, policy and performance is a core task of this conference, helping us to understand where we must invest to advance the field. Key questions mightinclude:

  • Current environment for change
  • Given finite resources, how can key stakeholders (donors, political leaders, practitioners, researchers) initially determine what should be spread, prioritizing particular ideas and practices?
  • Which incentives are most likely to stimulate interest and, ultimately, change in behavior? When should they be used?
  • Is the existence of a coalition of stakeholders a precondition for large scale spread? If so, what are effective methods for change agents to form or work within such coalitions?
  • Foundation
  • How should we scan practice and the evidence base to identify best practices?
  • What are acceptable criteria for determining readiness to spread? What contribution can implementation science make in helping to inform the selection of scale-up/spread strategies?
  • What is the best design for a prototype project? How can we factor sustainability into the prototype phase?
  • Framing
  • How should scale-up programs select their aims? What are typical (aggressive) patterns of spread, in terms of rate and scale?
  • How can change efforts introduce narrative methods in order to increase emotional engagement of prospective participants?
  • Nature of the Intervention
  • What are the key principles of scalable intervention design?
  • What are the most common errors in design?
  • How can we design complex interventions that cross multiple care settings (e.g., interventions for managing chronic disease or interventions that touch both health care and public health systems)?
  • Structural Context
  • How can we best assess how receptive a given locality will be to a new idea or intervention?How can we determine readiness to adopt based on harder-to-define local mores (e.g., beliefs, values, prior failures)
  • How can we best assess local skill at change management (i.e., adopting and reliably introducing a new practice)?
  • What local pitfalls most commonly undo scale-up efforts?
  • Method
  • Which method for spreading change is appropriate for which circumstance (based on differences in scale, resources, local skill, local will, etc.)?
  • What alternative approaches to spreading change have we not yet tested or discovered?
  • When should we seek to replicate successful prototypes? When should we seek a different approach to influencing change (e.g., legislation, networks)?
  • How do we develop effective communication strategies based on the attributes of the intervention and the characteristics of the intended audience?
  • What is the proper role of technology in facilitating effective scale-up? Which technologies seem most promising?
  • What are the best forms of monitoring and evaluation to help scale-up occur most effectively? What are the most efficient forms of data collection to help in the evaluation process?

Beyond the specific gaps in knowledge and practice in each of these areas, there is a general challenge to spread what we know about scale-up; to help others who are seeking to spread to avoid “recreating the wheel.” There exists a need to organize donors, policymakers, practitioners and researchers in this field into a community of learning – another goal for this conference.

Desired Conference Outputs

Thisconference will invite major stakeholders in the typical scale-up process – namely policymakers and donors, federal and international agencies, researchers and practitioners - to identify these gapsby comparing current circumstances to an idealized future state. The group will then develop a blueprint for future research and action to address these challenges, which will consist of:

  1. A collection of hypotheses about key factors in large-scale change to be researched and tested in ongoing work (demonstration projects) or emerging scale-up projects;
  1. A set of “performance challenges” for the field, attempting to spread effective interventions at a rate and on a scale previously unseen, for possible adoption by large agencies and national organizations interested in improving health and health care;
  1. A vision for building spread and scale-up in health care as a field, in and of itself.

If successful,the aggregated work of the attendees and other interested experts, over the months and years to follow the conference, will yield durable guidance for future funders, researchers and practitioners on how to manage the scale up process, along with an evolving blueprint for systems, nations and networks seeking to more effectively spread effective interventions.

[1]Faculty, Institute for Healthcare Improvement

[1]Massoud MR, Nielsen GA, Nolan K, Schall MW, Sevin C. A Framework for Spread. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006.

[2]Simmons R, Fajans P, Ghiron L. Scaling up health service delivery. Geneva: The World Health Organization, 2007.

[3] Victora C, Hanson K, Bryce J, Vaughan P. Achieving universal coverage with health interventions. Lancet. 2004; 364: 1541-1548.

[4]Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC, USA: National Academies Press; 2001.

[5] Rogers E. Diffusion of Innovations. New York: The Free Press, 1995.

[6]Manham LJ, Hanson K. “Scaling up in international health: what are the key issues?” Health Policy and Planning. 2010; 25:85-96.

[7] Dougherty D, Conway P. The “3T’s” Road Map to Transform US Health Care. JAMA. 2008; 299 (19):2319-2321.

[8] Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Quarterly. 2004; 82: 581-629.

[9]Cooley L., Kohl R. Scaling Up: From Vision to Large-scale Change. Washington, DC: Management Systems International, 2006.

[10]McCannon CJ, Schall MW, Perla RJ. Planning for Scale: A Guide for Designing Large-Scale Improvement Initiatives. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008.

[11] McCannon CJ, Berwick DM, Massoud MR. The Science of Large-Scale Change in Global Health. JAMA. October 24/31, 2007; 298: 1937 - 1939.

[12] Berwick DM. Disseminating innovations in health care. JAMA. 2003;289(15):1969-1975.

[13] Bradach J. Scaling Impact. Stanford Social Innovation Review. Summer 2010.

[14] McCannon CJ, Schall MW, Perla RJ. Planning for Scale: A Guide for Designing Large-Scale Improvement Initiatives. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008.

[15]Rogers E. Diffusion of Innovations. New York: The Free Press, 1995.

[16]Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 Lives Campaign: Setting a goal and a deadline for improving health care quality.Journal of the American Medical Association. Jan2006;295(3):324-327.

[17] Wilson T, Berwick DM, Cleary P. What do collaborative improvement projects do? Experience from seven countries. Joint Commission Journal on Quality and Safety. 2003;29(2):85-93.

[18] McCannon CJ, Perla RJ. Learning networks for sustainable, large-scale improvement. Joint Commission Journal on Quality and Patient Safety. 2009 May;35(5):286-291.