How to create change that sticks and spreads

@HelenBevan
Some definitions
Diffusion: "the process in which an innovation is communicated
through certain channels over time among the members of a social
system”
Rogers 1962
Spread: “deliberate efforts to increase the impact of innovations
successfully tested in pilot or experimental projects so as to benefit
more people and to foster policy and program development on a
lasting basis”
Norton and colleagues 2012
Going to scale (or scale up): “at least 60% of the target population
that could potentially benefit from the programme receives it”
Rabin and colleagues (2012)

@HelenBevan
How do we measure success?
“Unless a program can be replicated and
sustained on a large scale, it will not be
transformational…..
We can no longer evaluate programs simply
based on how well they’ve performed in a
given locality. Instead, we need to factor in
their potential to achieve scale”
McKinsey on Society

@HelenBevan
From 2001 to 2005, I was
responsible for the
Research into Practice
team within the NHS
Modernisation Agency
The team role was to
promote the spread and
sustainability of service
improvement and helped
to build a body of
knowledge
We found that the factors
of sustainability are also
the factors for effective
spread
Spread and sustainability

@HelenBevan
We have more than 20 years experience of
spreading large scale change
“It has been positively
reviewed and reported in the nursing
& healthcare press and its implementation
is proven to produce significant savings in
productivity & efficiency”
White et al 2013
One of the most widely adopted and impactful
improvement programmes in the history of the NHS; “releasing
time to care”, typically 10-20% of the time of clinical professionals. The
changes were adopted by 78% of NHS hospital wards, 68% of mental health
wards, 54% of NHS operating theatres and 49% of community health
teams across England (SHA statistics) as well as 44 territories
across the globe
New Zealand: 19% of time“
released to care”
Oregon USA:
multi-factorial
improvements
Scotland:
“20% of time
released to care”
A significant,
positive impact on staff
engagement
Irish
research: the
effects were
sustained over
time
800,000
pledges;
engaged two
thirds of all NHS
organisations
Our most
successful ever
digital
campaign

@HelenBevan
Source: http://slideplayer.com/slide/9034724/
The “classic” approach to spread
– the jury is out!

@HelenBevan
Because the reality is often different

@HelenBevan
Enthusiasts Visionaries Pragmatists Conservatives Laggards
Source: Geoffrey Moore, building on
the work of Everett Rodgers
Beware the chasm
The typical effect sizes of spread activities are perhaps 10-20% at
best (Grimshaw)

@HelenBevan
Emerging themes in spread
• Increasing attention to the demand side, to
better understand the adopter’s point of view
• Coalition building (social movements and
social media)
• Increasing attention to system conditions
• Acknowledgement of context sensitivity
• The importance of co-design for subsequent
scaling
Source: David Albury

@HelenBevan
Nine repeating patterns from pilot programmes
#1
Promising pilot programmes are rarely
replicated successfully from pilot localities to
others; the wider and more complex the change,
(i.e., involving multiple organisations) the least
likely that spread will happen

@HelenBevan
Kaiser Permanente spread model
Just do it
Innovate
Test and
replicate
CLEAR
COMPLEX
CHAOTIC
COMPLICATED
Source: Schall and Schilling

@HelenBevan
#2
Most of the early effort and energy is needed to
make the pilot programme functional and issues
of spread & scale often end up being an
afterthought

@HelenBevan
#3
We typically focus on extrinsic motivators to
change, rather than intrinsic & we don’t align the
motivators; as a result, change is often experienced
by people at the front line as “have to” (imposed)
rather than “want to” (embraced)

@HelenBevan
Intrinsic motivation
People engage in the
activity for the pleasure
and satisfaction of doing it
Invokes many positive
behaviours
Extrinsic motivation
People engage in the
activity for the rewards or
avoiding punishment
Any external influence is
referred to as extrinsic
motivation
Images: pixgood.com

@HelenBevan
The power of extrinsic drivers

@HelenBevan
Three types of levers for large scale change
‘Prod mechanisms’
targets
performance
management
price & payment incentives
regulation
competition
‘Proactive support’
relies on building
‘intrinsic motivation’ in
staff to make
the right changes to
improve
‘People focused’
education and training
national contracts
professional
regulation
clinical
quality standards
Type one:
Type two: Type three:
Source: Health Foundation report Constructive
comfort: accelerating change in the NHS 2015

@HelenBevan
Three types of levers for large scale change
‘Prod mechanisms’
targets
performance
management
price & payment incentives
regulation
competition
‘Proactive support’
relies on building
‘intrinsic motivation’ in
staff to make
the right changes to
improve
‘People focused’
education and training
national contracts
professional
regulation
clinical
quality standards
Type one:
Type two: Type three:
Source: Health Foundation report Constructive
comfort: accelerating change in the NHS 2015
Less than 10%
of the potential
for
improvement at
system level
can be
delivered
through type
one change
Claire Alcock

@HelenBevan
#4
People outside of pilot locality don’t feel any
ownership of, or emotional connection with, the
pilot project. As a result, the change processes
can end up being “pushed” onto other localities
rather than “pulled” by them

@HelenBevan
Closed innovation Open innovation
As a pilot test site , we want to
be left alone for a period of
time so we can work it out for
ourselves
As a pilot test site, we seek to
continuously get ideas and
guidance from leading thinkers and
practitioners outside our local area
We will test our new ways of
working internally “to
destruction”. When we are
confident they will work, we
will offer to share our “best
practice innovations” with
others
A wider group has contributed to
the innovation process, beyond our
host organisation; people from
other localities already feel that
they own it. Spread is more likely to
be “done with” not “done to” and to
be “pulled” not “pushed”

@HelenBevan
The power of co-creation

@HelenBevan
Open innovation is
a mindset, not just
a process
We would love to
share with others
but there don’t
seem to be any
takers

@HelenBevan
#5
Even where we are able to create replicable change
concepts from the pioneering localities, if we don’t
have an implementation approach for spread that
engages different local contexts, it doesn’t work

@HelenBevan
Innovations won’t put down roots if the ground
isn’t fertile
Source: David Fillingam
• National and regionally led
improvement initiatives have their place
• But “ sheep dipping” managers and clinical
leaders in programmes external to their local
communities is unlikely to have lasting benefit
• What’s more the learning won’t spread to
other communities (or even be sustained in its
place of origin) unless each community has its
own locally developed and owned culture and
system of improvement

@HelenBevan
There is a tendency towards “cargo cult”
improvement
Attempts are made to
spread/replicate new models from
pilot projects without a proper
understanding of how they work.
They end up reproducing the
superficial outer appearance but not
the mechanisms that produced the
outcomes in the first instance
(Dixon-Woods & colleagues 2011)
Cargo cult http://www.learningsolutionsmag.com/articles/1909/nuts-and-bolts-the-cargo

@HelenBevan
What is the best way to spread new
knowledge?
Source of data: Nick Milton
http://www.nickmilton.com/2014/10
/why-knowledge-transfer-
through.html
Social connection/discussion is
14 times more effective
than
written word/best practice
databases/toolkits etc.
Source of image: www.happiness-one-quote-time.blogspot.com

@HelenBevan
#6
The pioneer localities have limited bandwidth to coach
others & spread best practices

@HelenBevan
#7
Local leaders are understandably much more
concerned with local change than they are with
spread
Leaders of the macro level system must act as
catalysts for spread
Nine repeating patterns from pioneer/pilot type
programmes

@HelenBevan
“Choreographers of complexity”
Scale up efforts should be overseen by a
“choreographer of complexity”:
“An analogy can be made to the role a
choreographer takes in a dance company. Their job
is to produce a finished work that integrates many
different performance elements; music, dance, and
storytelling. This must be done by making trade offs
and finding synergies within the available resources
of the [organisation or system], and all the while
driving toward an ultimate vision.”
McClure and Gray (2015b)

@HelenBevan
#8
The commitment, characteristics & skills of local
clinical leaders is often the crux issue for change in
specific settings

@HelenBevan
“Perhaps the single most important influence on
programme response by individual units—either in
promoting or resisting change—was the extent of
consensus and coalition among the senior medical and
nursing staff….
[Consultant says] ‘I think it’s been successful because it’s a
unifying program, it’s one of the few things that we’ve
done that hasn’t been just a doctor thing, or just a nurse
thing, it’s involved the doctors and the nurses together.’”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3704826/

@HelenBevan
#9
Sustainability of change is as much of a
challenge as spread of change. The same
receptive local contexts create the conditions
for both spread and sustainability (See
Buchanan and colleagues)

@HelenBevan
Few evaluative studies look beyond
the pioneers to the issues of scale &
spread so empirical evidence is
limited

@HelenBevan
The Change Challenge
Tapping the collective brilliance
of the NHS

@HelenBevan
What does the NHS workforce think?
14,000 contributors recently identified 10 barriers to
change:
Confusing strategies
Over controlling
leadership
Perverse incentivesStifling innovation
Poor workforce
planning
One way
communication
Inhibiting
environment
Undervaluing staff
Poor project
management
Playing it safe
Source: Health Service Journal, Nursing Times, NHS Improving Quality, “Change
Challenge” March 2015

@HelenBevan
What does the NHS workforce think?
14,000 contributors recently identified 11 building blocks
for change:
Inspiring & supportive
leadership
Collaborative working
Thought diversityAutonomy & trust
Smart use of resources
Flexibility &
adaptability
Long term thinking
Nurturing our people
Fostering an open
culture
A call to action
Source: Health Service Journal, Nursing Times, NHS
Improving Quality, “Change Challenge” March 2015
Challenging the
status quo

@HelenBevan
Project Aristotle: http://qz.com/625870/after-years-of-intensive-
analysis-google-discovers-the-key-to-good-teamwork-is-being-nice/
After years of intensive analysis, Google
discovers that the key to high performing,
teams that deliver change is
psychological safety

@HelenBevan
Ideas and new ways of working get spread
when there is:
a critical problem that the innovation is addressing OR a major
opportunity that it is realising
wide engagement in the design and development of the
innovation (involving potential adopters right from the start)
strong evidence of:
• desirability (relative advantage) and
• feasibility (ease of integration into current working practices
and systems, and/or adaptability to local context) and
• viability (compelling business case)
priority above other innovations, either by having an influential
champion(s) or ‘top down’ (senior leader-led)
Harnessing of professional networks
an approach that doesn’t focus purely on WHAT we do in terms
of scaling, but the WAY that we do it.
Source: David Albury

@HelenBevan
What do the leaders who get the best spread
results do? They:
Source: McCannon
• Attempt remarkable things (provocation and optimism)
• Talk about justice
• Have a shared story
• Apply many levers
• Play jazz (adaptive, creative)
• Keep it simple (e.g., interventions, measurement
systems)
• Model trust
• Seek affection and give recognition
• Break rules (avoid consensus, condense timescales)

@HelenBevan
The conclusions of the very first national spread programme
in the NHS (National Booked Admissions programme from
1998) are still highly relevant
This evaluation has shown that there
are no magic bullet solutions….The main source of
change and service improvement has to come from within
each and every NHS organisation. Renewed effort now needs
to be put into developing the staff and organisations that can
embrace the kind of cultural change foreshadowed by the
NHS Plan. No amount of guidance, support, hectoring or
cajoling can substitute for the lack of capability and
understanding among the staff delivering care to patients of
the need to reshape the provision of services.
Chris Ham & colleagues, 2002

@HelenBevan
References
• Barker P, Reid A, Schall M (2016) A framework for scaling up health interventions: Lessons from large-
scale improvement initiatives in Africa Implementation Science
• Buchanan D et al (2007) The sustainability and spread of organizational change: modernizing
healthcare
• Clay-Williams R et al (2014) Do large-scale hospital- and system-wide interventions improve patient
outcomes: a systematic review BMC Health Services Research
• De Silva D (2014) Spreading improvement ideas: tips from empirical research The Health Foundation
• Gartner (2014) The Gartner hype cycle
• Greenhalgh T et al (2004) Diffusion of Innovations in Service Organizations: Systematic Review and
Recommendations Milbank Quarterly
• Grimshaw J et al (2012), Knowledge translation of research findings Implementation Science
• Kastelle T (2016) We’ve hit peak innovation (hype)
• McClure D & Gray I (2015a) Scaling: Innovation’s Missing Middle
• McClure D & Gray I (2015b) Managing the journey to scale up innovation in the humanitarian and
development sector
• NHS Institute for Innovation and Improvement (2012) The spread and adoption tool
• McCannon J (2011) The spread problem
• Moore G (2015) Crossing the chasm: marketing and selling products to mainstream customers
• Norton W et al (2012) A stakeholder-driven agenda for advancing the science and practice of scale-
up and spread in health
• Perla R et al (April 2015) Health Care Reform And The Trap Of The “Iron Law” Health Affairs blog
• Randall S (2015) Using communications approaches to spread improvement The Health Foundation
• Schall M & Schilling L (2014) An introduction to spreading effective practices and From sustainability
to spread and scale up

@HelenBevan
Today in England is

@HelenBevan
For our break, we will
have a RCT

@HelenBevan
• Randomised Coffee Trial!
• Randomised Coffee Trial!
Randomised Coffee Trial!

@HelenBevan
fabnhsstuff.net/fabchangeday/rct/ or google “Fab stuff RCT”

@HelenBevan
Outcomes of Randomised Coffee Trials

@HelenBevan
Join in one of our national Randomised Coffee Trials
fabnhsstuff.net/fabchangeday/rct/ or google “Fab stuff RCT”
Mental health – for anyone interested in mental health issues
Dementia – for anyone interested in dementia issues
Staff wellbeing – for anyone interested in how staff are cared for
Patient Safety – for anyone with an interest in ensuring patient
safety across the health and social care system
Home First – looking at the issues around how people who have
long-term health conditions receive care outside of hospital
Learning and Leading Together – for anyone interested in how
patients and healthcare staff can work together in genuine
partnership
MatExp – for anyone interested in improving maternity experience
– women and families as well as professionals

@HelenBevan
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How to create change that sticks and spreads

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