lisa schilling, rn, mph vice president, cmi center for...

Leadership Lessons for Spread and Scale Lisa Schilling, RN, MPH Vice President, CMI Center for Health Systems Performance

IHI Forum

Orlando, FL

December9, 2014

Session Objectives

Engage in discussion about learning and challenges in spread

Describe how initiative complexity and local culture impact spread

Identify strategies to address challenges

Disclosures

Faculty have nothing to disclose

“The Greatest glory in living lies not in never falling,

but in rising every time we fall.” - Nelson Mandela

The Framework P5

Adoption

Mechanisms

Set-up Build Scalable

Unit

Test Scale-

Up

Go to Full-Scale

& Sustain

Support

Systems

Phases of

Scale-up

Best

Practice

exists

New Scale-

up Idea

Leadership, communication, social networks, culture of urgency

and persistence

Learning systems, data systems, infrastructure for scale-up,

human capacity for scale-up, capability for scale-up

Components of a Learning System For

Improving Complex Dynamic Systems

Set up of the Learning System – System level measures, which define the purpose, plotted over time on control

charts

– Segmentation of the population; e.g. by socio-economic status

– Explicit theory or rationale for system changes based on current knowledge

Sequential testing over a wide range of conditions – Learn by testing changes sequentially using PDSA cycles

– Use comparison groups to learn about special causes and context

– Analyze informative cases: “Act for the individual learn for the population”

Learning during scale-up and spread – Use 5x scale up to learn about system changes at full scale

– Use factorial structures to learn about the interaction of changes and contexts

– Establish a team to manage and oversee learning from the portfolio of initiatives

The IHI Spread Model

Making policy as a metaphor for spread

policy1n pl -cies1. (Government, Politics & Diplomacy) a plan of action adopted or pursued by an individual, government, party, business, etc

UK National School for Government 2006

Evidence

Experience & Expertise

Judgment

Resources

Values Habits &

Traditions

Lobbyists & Pressure Groups

Pragmatics & Contingencies

| © 2011 Kaiser Foundation Health Plan, Inc. For

internal

December 7,

2014

9

What Really Matters

PRACTICE TRANSFERRABILITY

December 7,

2014

What Really Matters


| © 2011 Kaiser Foundation Health Plan, Inc. For

internl us only.

December 7,

2014

What Really Matters


Your Biggest Challenges

Buy in from staff and executive leadership

Speed of adoption

Standardizing vs customizing

Sustaining or “making it stick”

Large complex program adoption and management

Discussion Groups

Identify biggest challenges to spread

Move to a table on this topic

Discuss 3 items:

– Challenges

– Ideas

– One change you will try

Appendix

Phase 1 Determine Organizational Readiness

Start with the

end in mind

Align

improvement to

strategic objects

Assess site

readiness

to receive

© Kaiser Permanente 2014 reproduce by permission only

15

Start with the

end in mind

Determine what

is being spread

Define target

population &

end state

Establish

timeframe to

achieve scale

Define

measurement

strategy

including spread

measures

Align improvement to

strategic objects

Determine if

improvement links

with strategic goals

Craft a

compelling

message “start

with why”

Determine key

members of

chartered teams -

who are the key

stakeholders &

sponsorship

Assess practice

readiness to spread

Complete

assessment of

host site

readiness to

spread

Plan for or

identify sites

based on

learnings

Revisit scale,

scope and speed

Assess site

readiness

to receive

Complete

readiness to

receive

assessment

tool

Plan for

sequencing

based on

learnings

Create monitor

and review plan

How Does

It Work?

Simplicity

Cultural Fit

Business Case

Tools

Implementation Support

Practice readiness to spread

Demonstrated Sustainability

Demonstrated Transfer

Adaptability

Unintended Consequences

Does It Work? Will It Work

Elsewhere?

Comparative Performance

Outcome vs. Process

Improvement Attributable to Practice

Strength of Evidence

Logic Model

Key Components

Specific Processes

OrganizationalEnablers

Barriers and Risks

Will It Spread?

16


Organizational

Culture

Project Management & Championship

Training

Measurement and Monitoring

Site readiness to receive

Staff Capacity & Competency

Space

Technology

Operational Infrastructure (# of units involved, relationships)

Leadership

Alignment

Operational

Resources

Strategic Alignment with Goals and Priorities

Sponsorship & Leadership

Oversight Infrastructure

Cultural Readiness for Change

Implementation

Infrastructure

17


How much variation? Adapt locally vs. copy exactly

Adapt locally

Theory (Paul Plsek)

– Health care is a Complex Adaptive System

– Find local Attractors

– Use only Simple Rules

Strength

– Spread is more likely to occur if importers can adapt to their needs

Copy exactly

Theory (Gabriel Szulanski)

– We’re not as smart as we think

– Experience beats cleverness

– First import, then improve

Strength

– Spread is more likely to get results if importers work with exporters to learn a proven model


18

Key components ≈ Minimum specifications

NW Transition Care Bundle ElementsWhat does the patient need? Transition Bundle

I will have what I need when I

return home

Risk Stratification with tailored care

I know when I should call and what

number to use when I need help

Specialized phone number on DC

Instructions

My regular doctor will know what

happened to me in the hospital

Standardized Same Day Discharge Summary

I understand my medications, how

to take them, and why I need them

Pharmacist reviewing medications in

hospital

PharmD phone call (high risk)

I will see my doctor soon after my

hospitalization

I know someone will check on me

when I am home.

MD appointments made in hospital within 5

(high risk) to 10 days.

RN follow up Call within 48 hours.

RN case mgmt 30 days (high risk)

2012 National Quality Conference9

19 © Kaiser Permanente 2014 reproduce by permission only

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