A key factor in closing the gap between the best known practice and common practice is the ability of health care providers and their organizations to rapidly spread innovations and new ideas to others. Pockets of excellence exist in our health care systems, but knowledge of these better ideas often remains isolated and unknown to others.
The Problem
Why is it that improvements developed in one part of the health care system fail to be adopted by others? One clinic may develop a new way to ensure that all diabetics have their HbA1c levels checked on a regular basis, or one medical/surgical unit in a hospital may develop a consistent way to reduce pain for post-operative patients. But too often these improvements remain unknown and unused by others. Organizations face several challenges in spreading good ideas, including the characteristics of the innovation itself; the willingness or ability of those making the adoption to try the new ideas; and characteristics of the culture and infrastructure of the organization to support change.
Better Models Exist
Our model for spreading changes throughout an organization or system, the Framework for Spread, is based on the work of the following theorists:
Based on the organizational characteristics and practices suggested by these theorists, along with the experience of organizations that have been successful at spreading changes, we have developed a Framework for Spread, built on the following components:
Sample Results
A number of organizations have demonstrated that the spread of improvement is possible.
Bureau of Primary Health Care (BPHC), US Department of Health and Human Services
Over the past five years, through a joint initiative between the BPHC, a division of the US Department of Health and Human Services, and the Institute for Healthcare Improvement, hundreds of federally funded community health centers from around the country have adopted the Chronic Care Model as a way to deliver optimal care for their patients, achieving dramatic improvements in clinical outcomes such as HbA1c levels for diabetics and symptom-free days for asthmatics.
The BPHC’s spread strategy focuses on involving every community health center in the country in the Health Disparities Collaboratives on improving care for people with chronic conditions. The first group of clinics decreased HbA1c levels for patients with diabetes in their registries from 9.19 to 8.35 in the first 12 months. HbA1c levels for patients with diabetes in the second group of clinics dropped from 8.54 to 8.10 in only eight months.
Veterans Health Administration
In April 2001, the Veterans Health Administration (VHA) launched a national spread project called the Advanced Clinic Access Initiative that has dramatically reduced waiting times for outpatient clinic appointments for veterans. Building on the work of 134 clinics that had participated in a national Collaborative on Reducing Delays and Wait Times, the Advanced Clinic Access Initiative used a national steering committee and a web of "points of contact" and physician leaders who served as "access coaches" to share the principles and methods of improved access with 1,800 clinics in selected clinical areas, including Primary Care, Audiology, Cardiology, Eye Care, Orthopedics, and Urology.
Reductions in waiting times were reported in all of the selected clinical areas. The greatest improvements were seen in Primary Care, where the national waiting times for the next available appointment decreased by 53 percent, from 60.4 days at the end of fiscal year 2000 to 28.2 days at the end of fiscal year 2002. At the same time that the waiting time for the next available appointment for veterans was decreasing nationally, the VHA system was also able to meet the demand for services for approximately 900,000 new patients entering the system, while the supply (i.e., number of full-time equivalents) increased by only 2 percent.
National Health Service (UK)
As part of a nationwide effort by the United Kingdom’s National Health Service (NHS) to improve care for patients with coronary heart disease (CHD), the National Primary Care Development Team (NPCDT) spread a model of care that consistently includes the prescription of aspirin, beta blockers, and satins for these patients. Primary care practices participated in regional Collaboratives, where they learned how to redesign systems and processes to ensure the consistent delivery of good quality care for patients.
The percentage of the 3,500 primary care practices prescribing beta blockers for their post-acute myocardial infarction (MI) patients greater than 90 percent of the time increased from less than 5 percent in 2001 to 35 percent in 2002. Because studies show that this practice cuts patients' risk of dying or having a second heart attack by as much as 40 percent, the improvements made in the practices translates into 800 lives saved as a result of this project.
