Large-Scale Improvement Initiatives in Health Care

Draft Paper Commissioned for Conference – Please Do Not Circulate

Large-Scale Improvement Initiatives in Health Care:

A Review of the Literature

Rocco J. Perla,[1] Elizabeth Bradbury,[2]Christina Gunther-Murphy[3]

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 R. Perla,

Funding for this conference was made possible in part by grant 1R13HS019422-01 from the Agency for Healthcare Research and Quality (AHRQ). The views expressedin 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.

ABSTRACT

Background: The movement to improve the quality of health care does not lack established interventions, powerful ideas, and examples of success and breakthrough results.Uptake of these advances, however, is limited, uneven, and slow.As a result, many patients receive less than basic care, thereby increasing the risk of negative outcomes.A major challenge for health systems in the United States and globally is to spread these advances broadly and rapidly, adapting them for different care settings.

Aim: The goal of this paper is to provide a succinct review of the literature as it relates to the current thinking, practice, and knowledge base that informs large-scale improvement initiatives in health care as we seek to close the gap between best practice and common practice.

Method: We employed a largely non-systematic review of the literature followed by a modified Delphi technique, with three reviewers to organize themes that emerged during the review process.A standard review form was developed and used.The review was limited to large-scale spread efforts in hospitals and health care systems; the search method keyed on the following terms:large-scale, spread, scale-up, change, hospitals, health care, health systems, human factors, innovation, collaboration, quality improvement, learning networks, diffusion, improvement capability, capacity, re-engineering, outcomes measurement, evaluation, and social movements.Although there were no geographic limitations to the search, we excluded any works associated with large-scale spread in the public health sector or developing countries.Each of the main themes (primary drivers or factors) that emerged during the review were linked to secondary and tertiary factors and organized using a driver diagram.

Results:The four primary drivers that emerged during our review as important to success include: Planning and Infrastructure; Individual, Group, Organizational,and System Factors;The Process of Change; and Performance Measures and Evaluation.The Planning and Infrastructure Driver was defined by a focus on clear aims and a compelling vision, explicit guidance on the intervention (the “how”), a strong and committed management presence, and sufficient resources and infrastructure (materials, contact information, meeting rooms, standard resources) needed to execute the initiative.The Individual, Group, Organizational,and System Driver centered on understanding the social-cognitive dimension of spread—specifically,how people individually and in groups think about and interact with the innovation, the implications its adoption has for them personally and for their organization, and how organizational culture and capability can influence widespread adoption.Further, many reports of successful large-scale change had visible leaders and project champions who were close to the front lines.The Process of ChangeDriver was defined by at least three dimensions,including the extent to which the effort is actively pushed to participants,the underlying change theory that drives the work (e.g., social movement theory or the Model for Improvement), and the mechanism used to spread the intervention (e.g., campaign, collaborative, or extension agent model).Almost every report and study we reviewed recognized the importance of the Performance Measures and Evaluation Driver.This driver was characterized in the literature as a tension between the call for more controlled and rigorous approaches to assess, measure, and evaluate the factors associated with successful outcomes of large-scale improvement efforts and the inherent complexity of doing just that.As some authors pointed out, it was difficult to know with a high degree of confidence about the fidelity of implementation of the program in relationship to its specifications, the true effect of treatment spill-over, or how varying degrees of personal engagement and organizational norms influenced participant views of the initiative.

Recommendations: Based on our review, five recommendations and considerations emerged that may inform the field of large-scale improvement initiatives in health systems moving forward:

1. Additional research is needed to better understand the social-cognitive dimensions of large-scale improvement and change.
2. More systematic approaches are needed to assess and evaluate the effects of large-scale initiatives.
3. More work needs to be done to understand the economics, infrastructure requirements,and major levers of large-scale spread.
4. More guidance on how to establish and evaluate effective learning networks and collaboration is needed.
5. Much of the work on large-scale improvement is fragmented and would be well served by the creation of a repository cataloging different approaches and examples of large-scale spread.

Conclusion:Our brief review of the literature on large-scale improvement initiatives in hospitals and health systems identified a tremendous amount of work being done around the world to improve the care patients receive.There is no doubt that our non-systematic review has missed some important contributions to the field.Nonetheless, it is clear that the frequency of large-scale improvement efforts—the epitome of an applied science—appears to be growing rapidly and is believed to represent the fastest way to reduce morbidity and mortality among large numbers of patients (far more than isolated or local interventions).In this sense, the pace at which we learn from each other must be quick and the quality of our information very good.By addressing some of the limitations of the field outlined in this review, we can move toward a more solid knowledge base and more effectual learning.

Introduction

“The emerging health care funding challenge across the world, coupled with rising public expectations related to outcomes and quality of experience, requires health care leaders to make urgent and critical choices about which large-scale improvement approaches to adopt. The international health care movement has had enormous successes at the scale of individual services or system improvement, but has struggled to achieve large-scale spread with industry-level transformation of quality and cost.”

-- Jim Easton, National Director for Improvement and Efficiency NHS England

The movement to improve the quality of health care does not lack established interventions, powerful ideas, and examples of success and breakthrough results.Uptake of these advances, however, is limited, uneven, and slow.1As a result, many patients receive less than basic care, thereby increasing the risk of negative outcomes for both patients and providers.2A major challenge for global health systems is to spread these advances broadly and rapidly, adapting them for different care settings.

The goal of large-scale improvement in health care cannot focus solely on the eventual and rapid deployment of improved technologies and practices to achieve meaningful change and improved outcomes; those engaged in this work must address the issue of sustainable frameworks that stimulate continual learning and continuous improvement.The maturation and amalgamation of improvement science and the field of large-scale change puts this bold aim within reach.Indeed, the “science of improvement” and the “science of large-scale change and implementation” have gradually come together to form a nexus that now serves as the foundation for large-scale improvement initiatives in health care.While people like Rogers,3 Barabasi,4 Bandura,5 Dixon,6 and Cooperrider7 gave us frameworks and theories of large-scale change, people like Taylor,8 Deming,9 Juran and Godfrey,10 Shewhart,11 and Donabedian12 have given us something to spread—namely, specific and actionable models, ideas, strategies, and principles of improvement, quality, and collaboration that have been put to the test in all corners of the world.The question practitioners of large-scale change ask in a health care improvement context is not so much which interventions are the most appropriate for a particular setting, but ratherhow such interventions can be reliably and consistently delivered to all patients.

Simply put, those seeking to effect large-scale change in health care systems today must be equipped with the knowledge of improvement/operational science and large-scale change—and possess the skill to bring diverse stakeholders together to achieve a common end.

Against this backdrop, the goal of this paper is to provide a succinct review of the literature as it relates to the current thinking, practice, and knowledge base that informs large-scale improvement initiatives in health care.In this paper, the terms “large-scale improvement” and “scale up” refer to efforts that seek to stimulate positive and sustainable change in multi-state, regional, or national settings through the mobilization of hundreds or thousands of constituent organizations.The term “health care” refers broadly to local, regional, or national systems of organizing and delivering services for the prevention and treatment of disease and for the promotion of physical and mental well-being through hospitals, ambulatory, and home-care services.

One could argue that the current health care system in the United States is entering a phase of what Kuhn13 called “extraordinary science,” in which the conventions and rules of the past begin to rapidly deteriorate on the way to a new paradigm focused on quality, safety, equity, timeliness, accountability, collaboration, and learning, for which the conceptual infrastructure for large-scale change and rapid deployment of innovation in health systems is already established.Successful examples of such initiatives have begun to populate the literature, and this paper aims to capture and organize some of the lessons learned from those experiences to provide a clearer trajectory as we seek to close the gap between best practice and common practice.

Method

Due to time constraints, we employed a largely non-systematic review of the literature followed by a modified Delphi technique,14 with three reviewers to organize themes that emerged during the review process.The three reviewers (RP, EB, CGM) have direct experience and training in the areas of improvement science and large-scale spread initiatives in hospitals and health systems at the local, regional, and national level and have published in these areas.This review was limited to large-scale spread efforts in hospitals and health care systems; the search method keyed on the following terms:large-scale, spread, scale-up, change, hospitals, health care, health systems, human factors, innovation, collaboration, quality improvement, learning networks, diffusion, improvement capability, capacity, re-engineering, outcomes measurement, evaluation, and social movements.Although there were no geographic limitations to the search, we excluded any works associated with large-scale spread in the public health sector or developing countries.

Briefly, the modified Delphi approach involved five separate phases.During phase 1, the three reviewers independently identified 10 significant published articles that informed the topic, using any sources available to them.During phase 2, all three reviewers reviewed the 30 articles identified during the initial search for significance, excluding duplicate articles (n=1) and creating the initial list of articles (n=30).During phase 3, we shared this list of articles with three additional experts in the field of large-scale change to determine if any articles should be added to the list.Following this expert review, we added 9 articles to the initial list (with none deleted), leading to a final list of 39 articles requiring summarization and review.During phase 4, we distributed the 13 articles to be reviewed evenly among the three reviewers (matched by interest and expertise).In order to approach the reviews somewhat consistently, we developed a standard review form (Table 1).During phase 5, we discussed each of the themes that emerged during the independent reviews and then used them to create a driver diagram.15A driver diagram is a technique used to identify and explore key primary, secondary, and tertiary drivers (factors or concepts) related to a high-level aim (in our case, effective large-scale change).Lastly, we assessed each standard review form to identify tertiary drivers, and each tertiary driver was associated with the multiple references highlighted by the driver. Figure 1 presents the final driver diagram.

TABLE 1

The Diffusion of Innovation

Any discussion of large-scale spread and diffusion should acknowledge the tremendous impact of Everett M. Rogers and his model of how innovation diffuses over time and space.Many of the findings discussed below address, explicitly or implicitly, the foundation established by Rogers in his seminal book,Diffusion of Innovation, published in 1962.3Briefly, Rogers proposed the idea that adopters of innovations or new ideas could be categorized as innovators (2.5%), early adopters (13.5%), early majority (34%), late majority (34%) and laggards (16%).This distribution of adopters, resembling the normal distribution curve, provides a common conceptual-mathematical framework and language for innovation researchers to use as they try to understand how new ideas are adopted in different populations and the rate at which this adoption occurs and is sustained.The general framework outlined by Rogers—embraced by the social and technology sciences—informs much of the work and research in large-scale improvement initiatives in hospitals and health systems and serves as a key theoretical and empirical referent.

Summary of Findings

Our findings are organized by primary and secondary drivers.The four primary drivers that emerged during our review include: Individual, Group, Organizational and System Factors,Planning and Infrastructure,The Process of Change, and Performance Measures and Evaluation (Figure 1).The primary and secondary drivers are not mutually exclusive; rather, they interact with each other in different contexts to create and define a spread initiative.The findings below are not exhaustive, but they do point to general themes, ideas, and concerns that may have a general applicability to others involved in large-scale spread initiatives in health-systems.Recognizing the need to customize any such principles to a particular setting will be the rule and not the exception.

FIGURE 1

Driver #1:Planning and Infrastructure

Large-scale change efforts require thoughtful planning and a robust infrastructure to create a strong foundation on which to build the work. A number of key elements accelerate the change efforts during the planning stage: a compelling vision or aim for the work; a carefully developed intervention; solid management of the overall effort; and sufficient resources to run the initiative, both centrally and within participating organizations.

Vision and Aim: Large-scale change initiatives appeal to constituents through the use of attractive visions and compelling aims.For example, in Jonkoping County, Sweden, quality improvement projects used the phrase, “a good life in an attractive county,” to create a convincing vision of a patient-centered (versus disease-centered) system.16 The Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign and 5 Million Lives Campaign set ambitious and patient-centered aims (saving 100,000 lives from unnecessary mortality and avoiding 5 million instances of harm) to rally and inspire hospitals to take action against preventable mortality and harm.17, 18 Ganz’s work on social movements reinforces the value of goal setting and suggests that the challenge for organizers is to turn the high-level strategy into specific goals with real deadlines.19 Given the recent influx of health care efforts with and without specific aims and visions, the evidence base would be enhanced by comparative evaluations of large-scale change initiatives with and without aims to determine the specific contribution of this component to the overall effort.

Intervention: While a compelling vision is helpful for mobilizing organizations to act, large-scale efforts must provide explicit guidance to organizations on how, and not just what, to change. A key element of the “how” is the design of the intervention. The reviewed literature identifies a number of factors that make interventions more effective and more likely to spread within a social system. Greenhalgh et al. provide an extensive review of the characteristics of interventions that spread more readily.20 These characteristics include the often-cited elements of Everett Rogers’s diffusion model,3 such as relative advantage in effectiveness or cost-effectiveness over the existing process, compatibility with the values of adopters, simplicity of use, trialability (the ability of users to test the intervention before fully committing to its adoption), observability of the benefits, and reinvention (the ability for participants to modify the intervention to suit their needs). In addition, Greenhalgh et al. note other elements of the intervention to be considered, including the “soft periphery” (the ability to modify the intervention at the “edges”), degree of risk involved in adoption, the relevance of the intervention to everyday tasks, the knowledge required to use the intervention, and the level of support provided to participants during implementation.20