Understanding Spread of Innovation Medical Home Grantee Meeting

Understanding Spread of Innovation Medical Home Grantee Meeting July, 2004 Charlie Homer, MD, MPH National Initiative for Children’s Healthcare Quality Boston, MA Why talk about spread?  What are we trying to achieve by 2010? – All children and youth with special health care needs will receive ongoing comprehensive care within a medical home. Where are we now?  That’s why…  How did we get here?    Identification of unmet needs Innovation—new programs Demonstration projects ―The challenge …is not to build more pilot programs, but to find a way to replicate selected reforms to create an entire system that works.‖ Rudy Crew  Early spread activities – Mentorship Network – Medical Home Learning Collaborative Defining Diffusion (Spread) of Innovation     Diffusion: the process by which an innovation is communicated through certain channels over time, among the members of a social system Innovation: an idea, practice, or object that is perceived as new by an individual or other unit of adoption Diffusion includes both spontaneous and planned spread Our focus here is planned – Diffusion of Innovations Everett Rogers (1962, 1971, 1983, 1995, 2005) Diffusion or Spread “BETTER IDEAS” COMMUNICATED In a certain way Happen over time Thru a SOCIAL system Adapted from Rogers, 1995 (C) 2003, Sarah W. Fraser Adoption of Hybrid Seed Corn in Two Iowa Communities Number of Farmers in Communities 300 250 200 Cumulative Number of Adopters 150 100 50 0 1928 1929 1932 1938 Source: Based on Ryan and Gross (1943). Year 1941 1927 1930 1931 1933 1934 1935 1936 1937 1939 1940 Adoption of an Innovation Spread of Chronic Care Model Across Clinics 100 Percent of clinics implementing CCM 90 80 70 60 50 40 30 20 10 0 Total of 80 Clinics in Organization Sep- Oct 98 Nov Dec Jan- Feb 99 Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan- Feb 00 The “Tipping Point” ―The name given to that one dramatic moment in an epidemic when everything can change all at once.‖ - M. Gladwell “The part of the diffusion curve from about 10 percent to 20 percent adoption is the heart of the diffusion process. After that point, it is often impossible to stop the further diffusion of a new idea, even if one wished to do so.” - E. Rogers Spread of Chronic Care Model Across Clinics 100 Percent of clinics implementing CCM 90 80 70 60 50 40 30 20 10 0 Total of 80 Clinics in Organization Tipping point Sep- Oct Nov Dec Jan- Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan- Feb 98 99 00 What are the steps in adopting new technologies Knowledge Persuasion Decision Implementation Confirmation Pre-contemplation Contemplation Action Maintenance What influences the pace? Nature of the innovation  Type of decision  Nature of the social environment  Channels of communication  Leadership and management of spread (Promotion)  What gives some innovations “legs” Relative advantage  Simplicty  Compatibility  Observability  Trialability  Spread Potential and the Medical Home Score (1-5) Relative Advantage Simplicity Compatability Plan to Increase Trialability Observability Better Ideas  Case for the new system – The reasons people would want to make the changes  Description of the new system – ―What is being spread‖ – The concepts and ideas that form the content of the new system  Transition materials – Specific methods, examples, and documents to assist people in adopting the content Communication  What are the messages? – Will building – Technical    Who are the audiences? – Multiple Stakeholders How much to communicate? – Over-communicate x10 Customize medium to purpose The WAY in Which We Communicate is Important SHARE INFORMATION SHAPE BEHAVIOUR General Personal Interactive Publications Touch Activities flyers newsletters videos articles posters letters cards postcards Public Events Road shows Fairs Conferences Exhibitions Mass meetings Face-to-face one-to-one mentoring seconding shadowing telephone email visits seminars learning sets modeling (C) 2001, Sarah W. Fraser Adapted from Ashkenas, 1995 Match Content and Format of Messages to Change Stage   Awareness – Broad marketing and communication Persuasion – Data feedback   Decision – Case studies, individualized communication Implementation – Tools and resources – Access to technical expertise  Confirmation – Feedback – Leadership Change and Information change denial FACTS anger bargaining SUPPORT depression acceptance renewal ENCOURAGEMENT How can we describe those who adopt technologies? Innovators Early Late Majority Majority Early Adopters 2.5% 13.5% 34% 34% Laggards 16% Using the Adopter Information Whom will you engage in the spread process, how, and when?  Identifying opinion leaders:  – On this issue (…), to whom do you go for advice whom you can trust? – With whom do you interact regularly? Spread Model Better Ideas -Case for new ideas -Description of the new ideas -Transition materials Communicated -Modes -Purpose Social System -Unit for spread -Key messengers -Listeners/Connectors -Communities of practice -Motivators & incentives -Ability to adapt changes Infrastructure Leaders responsible for spread -Staging plan -Knowledge management -Technical support -Measurement/Feedback Slide by Kevin Nolan, IHI Annual Forum 2001 Project Scoping: Where Should a New Project Begin? A successful change High Degree of belief that the change will result in improvement Modera te Change still needs further testing. There is a risk of implementing at this stage. Unsuccessful proposed change Low Prototype Pilot Adapt & Spread Project Scoping: Given a new project, where should we start our work?    Do we have design targets? Do we have ideas that will achieve these design targets? What is our degree of belief that these ideas will give us the desired results in all the target settings? High degree of belief  adapt and spread ideas Moderate degree of belief  test ideas Low degree of belief  generate new ideas IHI/NICHQ Project Scoping Deep Dive Team Phase 0:Generate new ideas Screen Observation Phase 4: Pilot testing Innovation Team Phase 1:Planning Phase 2: Concept design Collaborative Teams Adapt and Spread: IHI Breakthrough Series (6 to 18 months time frame) Breakthrough Series Select Topic (develop mission) Participants (10-100 teams) Prework Develop Framework & Changes P A S D A S P D A S P D Dissemination Holding the Gains Publications Congress Expert Meeting Planning Group LS 1 AP1 LS 2 AP2 LS 3 AP3 etc. Action Period Supports LS – Learning Session (learning together) AP – Action Period (distance learning) Email (listserv) Visits Phone Conferences Assessments Monthly Team Reports Synthesis Phase 3: Prototype testing A Framework for Spread Leadership Measurement and Feedback Better Ideas Set-up Successful Sites Social System Knowledge Management Com m unic atio nS trate gie s © 2002 Institute for Healthcare Improvement Milestone 1 Milestone 2 Generate new ideas Test new ideas Spread new ideas Leading Spread Decide intent to spread  Understand the improvements  Build confidence that improvements will achieve their aims  Set measurable performance aims  Infrastructure to Support Dissemination  Staging Strategy – a plans to reach all adopting units – which units, what changes, and when  Technical Support - Where people can go with questions regarding the changes  Knowledge Management - How the new learning will be gathered and made available to others  Measurement / Feedback - Monitoring and interacting with people on performance Adopter Groups: Staging Early Adopters Early Majority Late Majority Spread Project Timeline Spread Strategy Matrix Jan North South East Feb Mar Apr May ABC AB A C B C West Central A=care plans, B=care coordinator, C=registry A BC ABC Monitoring the Changes Key Changes 1 Clinic 1 Clinic 2 PC1 PC2 2 3 4 5 Clinic 3 Clinic 4 Entry in each cell designates status of each of key changes in each clinic Tracking the Spread of the Changes Iowa Health System System-wide Diffusion - Medication FMEA # facilities completed FMEA 10 9 8 7 6 5 4 3 2 1 0 Jun01 Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- M ar- Apr01 01 01 01 01 01 02 02 02 02 LS1 LS2 M ay02 Jun02 Jul- Aug- Setp Oct- Nov02 02 02 02 02 Developing Spread Plan Spread Framework Component Case for Change Purpose Create materials that can be used by to convey message on why to make the changes Description of Describe changes in simpler way; show what’s Changes been done successfully Transition Materials Provide tools to support changes and guidelines for implementing them Modes of Provide clear and consistent messages Communication Highest leverage changes to accelerate spread of the medical home?         Case Transition Materials Technical assistance Communication Rewards and Incentives Leadership Tracking Learning Developing Spread Plan Spread Framework Component Opinion Leaders Purpose Provide role description for individuals; provide training and materials necessary for them to fulfill their roles Messengers and Connectors (Points of Contact) Communities of Practice Provide role description for individuals; provide training and materials necessary for them to fulfill their roles Take advantage of existing groups to reach and support all audiences Motivate practices to change Motivators and Incentives Developing Spread Plan Spread Framework Component Purpose Leadership Structure Staging Plan Provide high-level support to spread improvements Establish a plan for reaching all practices while using what’s learned in the process Technical Support Knowledge Management Provide technical support needed for practices to make the changes To disseminate the change package effectively, to gather new learning and make it available to others Measurement and Feedback To measure progress within practices and the initiative as a whole; provide feedback to practices The VA BTS on Reducing Delays and Wait Times  Goal - Reduce delays in access to care (waiting time from appointment request to day of appointment and wait times on day of a scheduled appointment (time spent in clinics) by at least 50%    160 Clinics Timeframe: July 1999 to March 2000 Results – Median wait time for an appointment for both primary and specialty clinics decreased from 48 days to 22 days, an improvement of 54% (26 days) – 36.6% of teams met or exceeded their individual team aim for the Collaborative as reflected in an assessment score of 4 or higher VHA Advanced Clinic Access Spread Project   Spread What: A sustainable system for patient access by spreading key access changes Spread to Whom: All clinicians (approximately 10,000) in six clinic types (Primary Care, Eye Care, Audiology, Cardiology, Orthopedics, Urology) in 172 medical centers over 400 outpatient facilities, and more than 10,000 specific clinics throughout the US. Time frame: March 2001 - January 2003  Challenges: Large target population; developing good  examples; decentralized structure; competing priorities VHA ACA: Strategy for Spread  Organizational Infrastructure – Provide leadership at national, VISN, and Facility levels – Use measurement for monitoring and accountability – Provide technical support about ACA  Information – Ensure broad awareness – Provide technical information   Communication – Launch a National Campaign coordinated with local action The Social System – Create a high functioning network of POCs and Access Coaches (national and local) average days 10 20 30 40 50 60 70 80 0 Mar-00 May-00 Jul-00 Sep-00 Nov-00 Jan-01 Mar-01 May-01 Jul-01 Sep-01 Nov-01 Jan-02 Mar-02 May-02 Jul-02 Sep-02 Nov-02 Jan-03 Mar-03 Primary Care Clinics open access 20 0 40 Average Days 100 60 80 Mar-00 May-00 Jul-00 Sep-00 Nov-00 Jan-01 Mar-01 May-01 Jul-01 Sep-01 Nov-01 Jan-02 Mar-02 May-02 Jul-02 Sep-02 Nov-02 Jan-03 Infrastructure: Measurement / Feedback Average Waiting Time for Next Available Appointment (Days) Eye Clinics open access VA ACA: Diffusion Curve for One Network 100 90 80 Percent of clinics VISN 2 ACA Spread 1999-2002 70 60 50 40 30 20 10 517 performance clinics 1700 – all clinics Internal Collab #3 starts Internal Collab #2 starts Internal Collab #1 starts Mar-00 Mar-01 Mar-02 Mar-03 Jan-00 Jan-01 Jan-02 Jan-03 Jul-00 Jul-01 Jul-02 May-00 May-01 May-02 May-03 Nov-99 Nov-00 Nov-01 Nov-02 Sep-99 Sep-00 Sep-01 Sep-02 Jul-03 0 % of N2 clinics using all of 10 key changes for ACA - PM clinics %of N2 clinics using all of 10 key changes for ACA - all clinics Sep-03 Results of VA Spread Project    Reduced waiting times in all six clinical performance areas (FY200 – 2002) Waiting times in Primary Care dropped from 60.4 days to 28.2 days nationally VHA system absorbed approximately 900,000 new patients entering the system while supply (number of FTEs) increased by only 2.3% Results - Waiting Times for all Clinics Improvement in Average Next Available Waiting Times P rimary Care Eye Clinics A udio lo gy Clinics Cardio lo gy Clinics Ortho pedic Clinics Uro lo gy Clinics 90 Average Next Available Wait Time (days) 80 70 60 50 40 30 20 End o f FY 2000 End o f FY 2001 End o f FY 2002 Sept, 2000 Sept, 2001 Sept, 2002 Monitoring Spread: Inventory of tested changes Instructions: A. Write in clinic info (site and name) at top of column. B. Rate the clinic for each of the 33 specific change ideas using the rating scale at the right. Ratings for Each Change Idea in the Matrix: Blank = Do not know the current status of this change idea 0 = This change idea is not applicable to this clinic 1 = Clinic has not worked on this change idea 2 = Clinic is planning on testing/adapting this change idea 3 = Clinic is currently testing/adapting this change idea 4 = Clinic has been successfully using this change idea for at least 3 months Clinic Info (Site, Name) Ten Key Changes for Advanced Access: Work down the backlog 33 Specific Change Ideas for Advanced Access: Gain immediate capacity Temporarily add appointment types Maximize activity at appointments (Primary) Extend intervals for return appointments Create alternatives to traditional face-to-face interactions Optimize patient involvement in care (Primary) Build service agreements betw een primary and specialty care (Specialty) Reduce demand for physician visits/ optimize team roles (Specialty) Reduce Demand Discharge patients to primary care from specialty care (Specialty) Other Spread Initiatives  Bureau of Primary Health Care – Multiple National Collaboratives – Different Chronic Conditions (and prevention) – Idea: Care Model – Communication Strategies – Audiences/Stakeholders – Measures BPHC Spread Report Phase 2 Narrative Report Health Disparities Collaborative Center Name: Hewlett Primary Health Services Cluster: NE State: VT Date: Oct 2003 Total # Provider Sites: 2 UDS#: X924T1 Organizational Aim:. To improve the quality of care of our patients with diabetes through implementation of the chronic care model, so that the percent of patients with at least two A1c's (at least 3 months apart) in the past 12 months is more than or equal to 90%. To spread this improvement ultimately to all chronically ill patients at all sites using the chronic care model. We will accomplish this by completing the following actions: 1. Define a plan to better manage the chronic illness care 2. Establish partnerships with identified community resources 3. Develop a documentation standard to include assessment, a treatment plan and a self management plan 4. Monitor all efforts of the QI Committee and report to the clinic staff and the National Health Disparity Collaborative 5. Educate health care delivery staff re model of chronic disease management focusing on self-management and the methodology of the model for improvement Initial Population of Focus and Site: Dr. Marcus Rivera at the Paterson site with an initial POF of 135 patients with diabetes. Progress on Spread of Care Model: Site Name Initial Condition of Focus Site 1: Paterson site Site 2: MacKenzie site Site 3: Site 4: Site 5: Diabetes Diabetes Spreading to the Following Condition Depression Number of Spread Providers 3 2 Registry Size DM: 261 Dep: 20 DM: 50 BPHC Spread Report-Implementation List of Changes Implemented List, by component of the Chronic Care Model, changes tested that have been adopted permanently. These changes are now part of the clinic routine. A one-sentence description is all that is needed. Component Community Date 6/02 Changes Implemented (Adopted permanently by the organization) The ―Quit-line Program‖ is in use for smoking cessation referral to replace the councilor lost to funding cuts. A kit with referral forms is available at each site. Community Resource Kit established for use by all staff to help link patients to resources in our area 4/03 Self Management 5/02 Adopted SMT for informational packet for family Utilizing a 1 page SM Tool exclusively Established SM Groups as an option for patients All no show visits are identified and the patients are then called to reschedule the missed appointment. After rescheduling a letter is sent emphasizing the importance of the visit and our concern regarding their continued diabetic care. A formal diabetes protocol which sets out responsibilities for each portion of the visit 10/03 Delivery System Design 3/03 5/03 Organization 9/02 The Board of Directors accepted the Chronic Care Model as the new National Health Service, England Waits and Delays  Cancer Care  Diabetes  Orthopedics  NHS Spread Strategy   Use of ―Trusts‖ as unit of spread – Acute Care, Primary Care Management expectations for performance  Detailed measurement scheme  Link to payment/incentives – Risk of ―gaming‖ Example of a Diffusion Curve NHS National Primary Care Development Team 20,000,000 18,000,000 16,000,000 14,000,000 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000 0 F eb 00 Patients in Practices Covered by the Primary Care Collaborative A p r00 Jun00 A ug 00 Oct 00 D ec00 F eb 01 A p r01 Jun01 A ug 01 Oct 01 D ec01 F eb 02 A p r02 Jun02 A ug 02 Oct 02 From :Sir John Oldham OBE MBA FRCGP NYC Immunization Building on existing initiatives  Systematic assessment of  – Messages – Communication strategies – Customization to level of readiness  Benefits through use of immunization registry References Attewell, P. 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Langley J, Nolan K, Nolan T, Norman, C, Provost L. The Improvement Guide. San Francisco: Jossey-Bass 1996. Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Implement Practice Guidelines. JAMA, Vol. 265(17); May 1, 1991, pg. 2202-2207. Prochaska J., Norcross J., Diclemente C. In Search of How People Change, American Psychologist, September, 1992. Rogers E. Diffusion of Innovations. New York: The Free Press, 1995.