The experience of the successful site is used to further refine and sharpen the set of ideas or changes that were used during the initial improvement work. The resulting "spread package" makes it easier for the new sites to adopt the new ideas by using multiple levels (from concepts to more specific ideas) to explain the ideas and by incorporating tools, tips, and other details harvested from the successful site.

These two types of communication can go on simultaneously. The second or third pilot site needs detailed information and support about how to make the changes, while the larger organization needs to be introduced to the spread initiative. Building awareness in the larger organization can help you identify the next sites to be drawn into the spread initiative (i.e., four, fifth, and sixth pilots, etc.). As awareness grows in the organization, those who are interested in the improvements will seek additional information about implementing the changes.

View communication to support spread as a campaign: know your target audience and tailor your messages to them. Include two types of communication as you build your spread communication campaign: 1) build awareness of the improvements that will attract potential adopters, and then 2) provide more technical information about how to make the changes for those who are ready to adopt them.

A website can be an effective method for providing technical information about the improvements, serving as a repository for data, communication messages, and tools, as well as providing a link between those with questions and the experts with the knowledge to help them. But these activities can also be organized using alternative methods, if the resources for establishing a website are not present. In addition, a website is not an appropriate vehicle for other aspects of knowledge management such as conversations, gathering information from conference calls and listservs, etc.

Knowledge management is the process of gathering information about spread as it unfolds in the organization. Some methods for doing this include:

• Formal surveys or questionnaires
• Talking and listening to key messengers and adopters
• Websites that both provide information and enable adopters to share their activities and lessons about the process

Executive leaders have the ultimate responsibility for spread in the organization. During the initial phases of a spread effort, they ensure the topic is a key strategic initiative of the organization, align the goals and incentives of the organization with the topic, designate an executive sponsor for spread, and assign a day-to-day manager for spread (see Leadership). Once a spread strategy has been developed and is underway, leaders visibly support spread through written messages and presentations, review progress and address barriers, and make adjustments to the spread plan as needed (see Communication).

A number of factors can be used to assess an organization’s readiness for spread, including the following:

• The presence of successful sites (either internal or external to the organization)
• The inclusion of the improvements in the organization’s strategic plan
• Someone from leadership whose is responsible for spread
• The absence of any obstacles, adverse goals, incentives, or major distractions (e.g., mergers, reorganizations, financial uncertainty, etc.)

Feedback should be given in two directions — up to the executive leadership and down to the sites in the target population making the improvements. In both cases, two types of information are useful for feedback: progress in reaching the outcome targets and progress in the rate of spread of the improvements in the spread package.

A measurement system for spread includes the main outcome measures of the process or system of interest, as well as a measure for the rate of the spread. The outcome measure for spread is often the same measure that was used by the pilot site, although during the spread effort the measure encompasses the entire target population rather than being limited to the pilot site. The rate of spread is a new measure that is introduced to guide the spread effort. It tracks the progress of the adoption of the specific improvements across the sites in the target population.

There are important considerations in expanding a data collection approach from a single pilot site to the system level. As with all measurement for improvement, to reduce the burden of data collection, sampling should be used in assessing improvement in spread projects. Other things to consider in collecting data at the system level include availability of data in automated systems, building data collection into the current patient care process, and refining the sampling plan.

Some things to consider in moving from the pilot site to other sites in your target population include:

• The relationship of the new sites to the pilot site (e.g., from one primary care site to another, from a primary care site to a specialty clinic that serves as a referral source for the pilot site, etc.)
• The presence of champions
• Availability of resources

The important thing is to be flexible: build your plan around people who emerge as potential adopters from your initial communication campaign.

See the changes recommended in the Set-Up for Spread and Communication sections for more information.

Diffusion theorists and the experience of organizations that have been successful in spreading improvements suggest that while an initial set-up and infrastructure are needed to support spread, the adoption of new ideas cannot be mandated. Long-term successful spread relies on matching the needs and interests of the target population to the new ideas, in effect creating a "pull system" for the new ideas.

It is the responsibility of senor leadership in the organization to establish a solid foundation to support spread. Set-up activities include selecting the target population that is expected to adopt the improvements; identifying those in the target population that make the decision to adopt the improvements; determining if successful site(s) exist either within the organization or externally that can serve as examples for others; engaging key partners from either within the organization or externally to support the spread effort; and developing a plan to attract adopters in the target population.

The key messenger often comes from outside the target population, but may also be someone within the target population who has learned about the improvements and is willing to play the role of spreading information about them to others. The most effective messengers within the target population are opinion leaders, i.e., those that others in the population respect and look to for guidance and information.

Reinvention is part of the spread process, since each site in the target population has to adapt the improvements or "better ideas" to their own environment. One way to maintain the integrity of the core set of improvements is to make them easy to use. If the core set of improvements is packaged so that a site in the target population can readily understand and use the information, the site will be more likely to begin with the recommended improvements. The spread agent can also play a role in identifying sites that may be sidetracked by extensive and unnecessary reinvention, and provide guidance about how to accelerate improvement by using the spread package as the starting point for improvements.

See the changes in the Social System section for more information.