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Best Practices and Learningsfrom IHI’s Spread and Network Methodology: How to Develop and Enhance Networks to Further Process ImprovementKathyDuncan,RN,Faculty,IHIKateO’Rourke,NetworkManager,IHIChristinaGunther‐Murphy,Director,IHI

D16/E16

These presenters have nothing to disclose

December12,2012

Objectives

Identify several strategies to develop and support a network

Describe practical tools used for spread of clinical elements throughout a network

Describe several key network theories

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Ground to Cover

Spread and disseminations definition and boundariesFramework overview

– Motivation– Foundation– Aim– Nature of the intervention– Nature of the social system– Network building

Deep dive into each element:– What to do– Examples– Hard-won lessons– Ideas to try

Summary and questions

Collective Experience

IMPACT Collaboratives

Hospital Quality Work

100,000 Lives Campaign

5 Million Lives Campaign

1,000 Lives Campaign

100,000 Homes Campaign

Advancing Excellence Campaign

Project JOINTS

Healthier Hospitals Initiative

Patient Safety First Campaign

Partnership for Patients

The Conversation Project

Surgical Safety Sprint

IHI Open School

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What Are We Talking About When We Say “Spread” or “Dissemination?”

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

There are many possible definitions for “a system” (e.g., a hospital, a group of hospitals, a region, a country)

Core Elements

Aim: What are you trying to accomplish by when?

Nature of the Social System: How are you accounting for the environment in which you are trying to spread?

Nature of the Intervention: What are you asking people to adopt?

Motivation: Why would anyone participate?

Foundation: Who else has adopted the intervention?

Network Building: What is the infrastructure for connection between participants?

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“All models are wrong, some are useful.” – George Box, Industrial Statistician

Who? What? Where? When? Why?

Effective Large Scale Change

Foundation

Aim

NetworkBuilding

Motivation

Nature of the Social

System

Nature of the

Intervention

AimWhatareyoutryingtoaccomplishbywhen?

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Aim

“Some is not a number, soon is not a time.”

Inspirational and aspirational

Back of the envelope calculations to develop strategy

Group process to generate number and gain buy-in

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What are we trying to accomplish?

Developing the Aim Statement

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Create an Aim That Is:

Aligned with the strategic priorities of the organization– Involve senior leaders in its creation and approval.

Consider:– What investments are we willing to make?

– What activities should we de-emphasize?

– What conflicts are we willing to resolve?

– What risks are we willing to take?

– How much disruption in the organization are we willing to support to make the transition to a better performing system?

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Tips for Creating Aim Statements

State the aims clearly – What do you want to accomplish

– How much?

– By when?

Define location or population

Set stretch goals

Include numerical goals/targets

Who is responsible for this aim? How are they held accountable?

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© 2005 Institute for Healthcare Improvement

Some Is Not a Number… Soon Is Not a Time

THE NUMBER:

100,000 LivesTHE TIME:

June 14, 2006 – 9 a.m. ET

Aim

The 100,000 Homes Campaign is a national movement of communities working together to find permanent homes for 100,000 of the country’s most vulnerable and chronically homeless individuals and families by July 2014.IHI asked hospitals participating in the Campaign to prevent 5 million incidents of medical harm over a period of two years (December 12, 2006-December 9, 2008).Save 100,000 lives by adopting six evidence-based interventions by June 14, 2006 at 9:00 am ET10 million conversations about what individuals want at the end of their life by 2015

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Sample Aim StatementOur organization intends to optimize a culture that promotes patient/family centered care, prevents harm and improves patient outcomes by providing safe, efficient, evidence-based care.

Specific goals to achieve by December 31, 2008: Reduce ICU mortality rate to < 8% a) Reduce ventilator associated pneumonia (VAP) by 30% b) Decrease vent LOS by 20%c) Maintain greater than 95% compliance with all 5 components of

the ventilator bundleReduce overall sepsis mortality rate by 20% a) Ensure sepsis resuscitation bundle use on at least 95% of all

appropriate patients b) Ensure sepsis management bundle use on a least 95% of all

appropriate patients

Back of the Envelope

The IHI Open School: “Worldwide, 2420 medical schools, 467 schools or departments of public health, and an indeterminate number of postsecondary nursing educational institutions train about 1 million new doctors, nurses, midwives, and public health professionals every year.”

In order to achieve the goal, what numbers would we need in terms of: – students enrolled on IHI.org?– students taking courses? Certifications?– In-person chapters?

Frenk, Julio, Lincoln Chen, Zulfiqar A. Bhutta, Jordan Cohen, Nigel Crisp, Timothy Evans, Harvey Fineberg, et al. 2010. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet376(9756): 1923‐1958.

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Tenant Profile - Before

Tenant Profile - After

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Aim – Hard Won Lessons

What not to do:

Avoid a time and a number

Ignore the heart of the work

What to do:

Ensure it aligns with the larger organizational goals, but still has an edge to it

Goldilocks

Ideas to Try

Getting Started:• Set a “what by when” goal• Have team create back of the envelope calculations; discuss

similarities and differences• Use thumbs up, neutral, or down to come to number agreement• Ask yourself: How is the heart of this work reflected in the aim?Accelerating Good Work:• Re-evaluate your aim. Will you reach it? If not, do not be afraid to

extend the time. How will you change your work to reach the aim?• Identify three of four stories that support your overall aim and bring a

face to the work• Set milestones along the way; what’s the trajectory of the work?

Where do you expect to be at interim periods?

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Nature of the Social SystemHowareyouaccountingfortheenvironmentinwhichyouaretryingtospread?

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Nature of the Social System –What to Do

Understand and account for subcultures:– Physicians vs. nurses vs. community workers

– ICU vs. Med/Surg

– Georgia vs. California

– US vs. UK

Think about who leads the charge and who brings up the back

Understand the ups and downs of regulations

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Reflection

Think about the social system you are trying to change.

What makes the system special?

What particular challenges does the system face?

How is your work taking these unique attributions and particular challenges into account?

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“Follow Us on Twitter”24

Letter Text:

“Requesting hard copy of Conversation Starter KitPlease mail to:…”

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Nature of the Social System – Hard Won Lessons

Take a second look. Are you being true to the environment or what you want it to be?

How are you accounting for a changing environment? (What works once won’t always work twice…)

Are there additional relationships you need to cultivate before getting started?

Is there more research needed about regarding the history of group dynamics?

Ideas to Try

Getting Started:

• Base recruitment strategies off what you know about the environment

• Build on success from other leaders or projects

Accelerating Good Work:

• Evaluate what has changed in the environment. How have you adjusted your work to account for the changes?

• Allow organizations to tailor content to specific needs. Create templates that organizations can alter.

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Nature of the InterventionWhatareyouaskingpeopletoadopt?

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Nature of the Intervention –What to Do

Once you think an intervention is simple enough, simplify againHelp participants sequence workAppeal to the nature of all types of facilities and use varied examples.Business case, how-to guide, annotated bibliographyMake tacit knowledge explicitStart with the willingPortfolio of interventions

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Attributes of Innovation

Relative advantage

Compatibility

Complexity

Trialability

Observability

(Hard core, soft periphery)

from E. Rogers, 1995

JOINTS Graph30

0

10

20

30

40

50

60

70

Resource usefulness

Not at all useful

Somewhat useful

Useful

Very useful

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Sequencing Methods

Identify the high leverage skills or capabilities;

Use data to identify problem areas;

Identify interventions with the highest probability of decreasing harm, mortality, or readmission rates;

Start with units with improvement capability or champions;

Start in areas where you are likely to see early success.

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Complexity

CLABSI SSI CA‐UTI VAP VTE

PU CA‐UTI Falls

OB

VTE CA‐UTI

ADE

Reliability and Teamwork

Rounding and Prevention

Risk Assessment

Monitoring & Titration

Working Across Microsystems

Care Transitions

TimeSept’ 10 Sept’ 13

Improving Outcomes for High-Risk and Critically Ill Patients Community: Institute for Healthcare Improvement

A Three to Thirty‐Six Month Initiative (series of projects)

Sepsis Resuscitation 

Bundle

Sepsis Management 

Bundle

Ventilator Bundle

Central Line 

Bundle

Multi‐disciplinary Rounds and Daily Goals

Rapid Response Team

Early Warning System

Glucose Control

End ofLife Care

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Nature of the Intervention – Hard Won Lessons

The Medication Reconciliation lesson

Put lots of time and energy into the resources you find helpful

Don’t focus on the exceptions (Pareto rule)

Simple to complex

Make sure it really is the right thing to do

Ideas to Try

Getting Started:

If you can’t count the steps on one hand, go back to the drawing board

Put asterisks by the most low resource places to start, but remind people they will have to do all the work eventually

Don’t make it too hard. (Pareto principle)

Accelerating Good Work:

Supplemental materials for specific types of organizations (e.g., pediatric)

Develop a gap assessment or tool to help people know where to start

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MotivationWhywouldanyoneparticipate?

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Motivation – What to Do

Align with local priorities AND push the envelope

Find figureheads to champion the work

Make sure there is a linkage to higher priorities

How does this solve someone else’s problem?

Develop a plan to engage leaders

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100,000 Lives Launch39

Motivation – Hard Won Lessons

Even if your paycheck depends on the work, don’t make it seem like it

Do too much too quickly

Overuse figureheads

Figureheads need to have more friends than enemies

Not letting figureheads slow down your pace

Three step registration process for Project JOINTS. Technology our enemy. Don’t want to waste any will

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Motivation – Ideas to Try

Just Getting Started:Identify a key figurehead to launch the workAlign the will by using relatable examples (patients, teams, families, time savings, etc)Make it really easy to sign up – low barrier to join. Don’t want to turn anyone away.

Accelerate Good Work:Build relationships beyond the figureheadUpdate often – data, cases, successesPut yourselves on a board/all staff/executive team meeting agenda for 90 days from now to report out on your work and results

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FoundationWhoelsehasadoptedtheintervention?

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Foundation – What to Do

Include letters of support

Kick off calls with high ranking leaders

Pull examples from other units, organizations

Tell the story of the testing (pilot unit to third floor)

Find people that look like intended adopters (“We are not Boston.”) Testing with local stuff and similar facilities

Use recognized brands

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Foundation – What Not to Do

Depend on these leaders too frequently

Make sure you are using people with a good reputation

Shouldn’t be about the person. What do they represent?

Ideas to Try

Getting Started:

Record the story of testing

Identify well-liked peers

Accelerate Good Work:

Develop an alignment grid

Name drop

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Network BuildingWhatistheinfrastructureforconnectionbetweenparticipants?

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Network Building – What to Do

Highlight others on callsCall for examples from the field Listservs for participants to ask/answer questionsPeople want to be connected to othersUnderstand what type of network you are trying to createStart with the end in mind The network is a living thing that must be tended and shaped and loved (it is a deliberate, managed process)The value of celebration and recognition (economy)The value of affection

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Networks

A network is a collection of nodes (people, organizations) with a specific set of ties (connections, relationships) between them.

Network research is important because it allows one to better understand, or even visualize, the invisible structures underlying all human interactions.

These structures influence the way people behave, make decisions, and share information.

Whole Network Concepts

Purpose (the reason for its existence)

Role (how the network promotes value among members)

Function (what the network actually does e.g., community building, sharing knowledge, convening stakeholders)

Form (the structural and organization characteristics of the network)

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Value of Recognition

“Not sure if you had anything to do with this recognition, but you have no idea how much it has impacted our hospital. It has given us the jolt of energy around quality that we needed. We have focused all week on celebrating and refocusing around quality. Thanks for all you do. You really make the fight worthwhile!”

-Hospital Quality Manager

Campaign Field Operations Structure

FACILITIES (2000‐plus)

NODES (approx. 75)

*Each Node Chairs 1 Network

*30 to 60 Facilities per Network

Introduction, expert support/science, ongoing orientation, learning network development, national environment for 

change

Ongoing communication

IHI and Campaign Leadership

Local recruitment and support of a smaller network through communication/collaboratives

Implementation (with roles for each stakeholder in 

hospital and use of existing spread strategies)

Mentor Hospitals

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Network Building – Hard Won Lessons

Have every answer come from you

If you build it, they will come

Technology as a barrier to what people want to be doing

Depending on one relationship

Know your audience

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Ideas to Try

Getting Started:

Think about where you want to be at the end of the work; imagine an infrastructure to accomplish it

Who would be the first two people you’d want to include and with what frequency and format would you like to connect?

Create a node structure

Accelerating Good Work:

Test a new strategy for the type of network you are creating

Identify additional contacts

Identify opportunities for recognition and celebration

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Core Elements - Summary

Aim: What are you trying to accomplish by when?

Nature of the Social System: How are you accounting for the environment in which you are trying to spread?

Nature of the Intervention: What are you asking people to adopt?

Motivation: Why would anyone participate?

Foundation: Who else has adopted the intervention?

Network Building: What is the infrastructure for connection between participants?

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Just Remember…

“An ounce of action is worth a ton of theory. Don't be too timid and squeamish about your actions.” -

Ralph Waldo Emerson

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Questions?

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