1 Scaling up high-impact interventions M. Rashad Massoud, MD, MPH, FACP Director, USAID Applying Science to Strengthen and Improve Systems Project Senior

1

Scaling up high-impact interventions

M. Rashad Massoud, MD, MPH, FACP

Director, USAID Applying Science to Strengthen and Improve Systems Project

Senior Vice President, Quality & Performance Institute

University Research Co., LLC – Center for Human Services

USAID Applying Science to Strengthen and Improve Systems

What do we mean by “Spread” or “Scale-up”?

The science of taking a local improvement (intervention, idea, process) and actively disseminating it across a system

……Joe McCannonJoe McCannon

Institute for Healthcare Improvement, Cambridge, MA


What do we know about the spread of good practices?

• Smoking cessation counseling: 21%• Mammography screening: 27%• Warfarin for Atrial Fibrillation: 40%• ACE inhibitors for CHF: 36%

……Agency for Health Research & Quality (AHRQ)Agency for Health Research & Quality (AHRQ)

Physician compliance with evidence-based interventions:

Publication

Bibliographic databases

Submission

Reviews, guidelines, textbook

Negative

results

variable

0.3 year

6. 0 - 13.0 years50%

46%

18%

35%

0.6 year

0.5 year

9.3 years

It takes 17 years to turn 14 per cent of original research to the benefit of patient care.It takes 17 years to turn 14 per cent of original research to the benefit of patient care.……Agency for Health Research & Quality (AHRQ)Agency for Health Research & Quality (AHRQ)

Dickerson, 1987

Koren, 1989

Balas, 1995

Poynard, 1985

Kumar, 1992

Kumar, 1992

Poyer, 1982

Antman, 1992

Negative results

Lack of numbers

Expertopinion

Inconsistentindexing

17:14

Original research

Acceptance

Implementation


Diffusion of Innovations: Attributes of an Innovation

• Relative advantage• Compatibility• Complexity• Trialability• Observability

E. Rogers, Diffusion of Innovations, 1995E. Rogers, Diffusion of Innovations, 1995


Diffusion of Innovations:Categories of Adopters

2.5% 13.5% 34% 34% 16%

E. Rogers, Diffusion of innovations,1995

EarlyAdopters

Innovators

EarlyMajority

LateMajority

Laggards


Key Insights on Diffusion Theory

• Attributes of Innovation

• Categories of Adopters

• Spread of Idea vs. Directed Change in Systems


Set-up-Target population -Adopter audiences -Successful sites -Key partners-Initial spread strategy

Social System-Key messengers -Communities -Technical support-Transition issues

Communication Strategies (awareness & technical)

Knowledge Management

Measurement and Feedback

Leadership-Topic is a key strategic initiative

-Goals and incentives aligned-Executive sponsor assigned

-Day-to-day managers identified

Better Ideas-Develop the case -Describe the ideas

A Framework for Spread



Three Key Questions

• What do we want to spread?

• To whom do we want to spread? By when?

• How are we going to spread?


How Do We Spread?

Many possible ways:

• Natural diffusion • Extension agents• Emergency mobilization• Spread through a collaborative• Spread through a virtual collaborative • Campaign spread• Wave sequence spread• Hybrid models



Wave Sequence Spread

USAID Applying Science to Strengthen and Improve Systems12

Principles of Scale-Up

1. Begin with scale-up in mind

2. If you can reach all-at-once – you should!

3. If you cannot, then consider a phased approach:– Look for nested systems– Test prototypes & expand in multiples of 5-10

4. How factors change in going to scale:– Arithmetic scale up– Favorable scale-up

5. Information systems

6. Communication needs

7. Oversight needs with scale-up

USAID Applying Science to Strengthen and Improve Systems13

Key Lessons Learned

• Results are the key drivers• Enabling people to make changes in their work

– Systems thinking– Equip with PDSA’s– Assistance to the teams in the form of site visits – Leadership Support– Role Modeling– Normative/regulatory support

• People working under constraints can be very creative • Scale-up efforts require meticulous attention to detail• Champions who developed the prototypes are critical

for leading the scale-up in wave sequence spread• Leadership from within the system

14

New Learning about the Rate of Spread


0.0

20.0

40.0

60.0

80.0

100.0

A05

S05

O05

N05

D05

J06

F06

M06

A06

M06

J06

J06

A06

S06

O06

N06

D06

J07

F07

M07

A07

M07

J07

J07

A07

S07

O07

N07

D07

J08

F08

Month

% o

f HIV

+ pa

tient

s a

sses

sed

for a

ctiv

e TB

at e

ach

visi

t

52 DEMONSTRATION SITES 29 FIRST WAVE SPREAD SITES

Uganda - Comparison of Demonstration and Spread Sites Screening for Active TB in HIV+ Patientsaverage of 17,500 HIV+ patients per month in original sites; 5,000 in spread sites

CQI interventions

Baseline

Baseline

CQI Interventions

% of HIV+ patients seen in that month that were screened for active TB, based on Patient register


Niger: Percent of children triaged on arrival

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Old sites New sites

Niger - Comparison of Demonstration vs. Spread IMCI Sites for the % Children Triaged on Arrival


Key Results: Maternal and Neonatal Mortality Reduction – Basic ProCONE

Trend in Compliance with Criteria in Prenatal Care in San Marcos and 7 Additional Health Areas during Expansion Phase

A total of 143 facilities participating

78

90

85 8587

94 95

9594

68

72

63

84

7368 75

8883

90 91

80

85 81 8884

18

36

50

58 5966 69 65 72

74 77 80 80 78 84 8284

0

10

20

30

40

50

60

70

80

90

100

Demonstration Phase Expansion Phase

E.9 F.9 M.9 A.9 M.9 J.9 J.9 A.9 S.9 O.9 N.9 D.9 J.10 F.10 M.10 A.10 M.10Numerator 412 721 1230 1373 1421 1530 1670 1483 1485 1432 1485 1261 1574 1586 1459 1190 657Denominator 2310 2011 2467 2367 2402 2306 2427 2271 2073 1929 1924 1574 1963 2046 1737 1456 780Services reported 129 118 139 133 134 135 134 132 124 114 110 94 118 117 97 83 55% Services reported 90 83 97 93 94 94 94 92 87 80 77 66 83 82 68 58 38

Interventions:•Advocacy for securing micronutrients•Training of staff in prenatal care needed due to high turnover rate


Rwanda - Comparison of Demonstration vs. Spread site for the % Partners of Women in ANC Tested for HIV

Rwanda: percentage of partners tested

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J

% o

f p

art

ners

teste

d

Old Sites: % (16) New Sites: % (20)


Percentage of deliveries where Active Management of Third Stage of Labor -AMTSL- was implemented in accordance to standards. Three groups of hospitals (started 2003-2004,

n=55; 2005, n=21; 2007, n=10) . Total 86 hospitals reporting 2003-2009. Ecuador.

0

10

20

30

40

50

60

70

80

90

100

Per

cen

tag

e

% 2003-2004 0. 1514 1621 3237 3739 4142 4048 5159 5755 55 5857 6565 6168 6665 6966 6571 6463 6771 73 7681 8080 8579 7679 8679 8683 9095 9495 9795 93 8990 9495 9796 9692 9793 9391 9594 9697

% 2005 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1538 5559 4367 6277 8481 8474 7878 7984 82 8889 9389 8277 8182 8079 8487 8892 9084 8892 88 8991 8592 9592 9693 8889 9492 8891 9192

% 2007 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21 4044 5156 8879 9485 7693 90 8985 8987 8596 9795 9497 10 1010 9810

Jl-03AgSpOt Nv DcEn FbMr ABMyJn Jl AgSpOcNv Dc EnFb MrAbMyJn Jl AgSpOcNvDc EnFb MrAbMyJn Jl AgSpOcNv DcEn FbMr AbMyJn Jl AgSpOcNv Dc EnFb MrAbMyJn Jl AgSpOcNvDc EnFb MrAb

2003 2004 2005 2006 2007 2008 2009

Documents

1 Scaling up high-impact interventions M. Rashad Massoud, MD, MPH, FACP Director, USAID Applying Science to Strengthen and Improve Systems Project Senior