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How did two distinct quality improvement initiatives design for scale? The leaders of these nationwide efforts explain.
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Do These 4 Things When You’re Scaling Up Improvement

By Marie Schall | Tuesday, April 17, 2018


Not all improvement projects are part of national initiatives, but leaders involved in countrywide efforts have hard-won insights that can apply to all levels of scale-up. Tina Lynge, Program Director and Senior Adviser, Danish Society for Patient Safety, directs the Safe Hands Initiative, an effort to improve patient safety for Denmark’s elderly population by reducing pressure ulcers, medication errors, patient falls, urinary infections, and pneumonia (while improving oral and dental hygiene). Susan Hannah is working to achieve recommended milestones in child development and educational achievement across all of Scotland as head of the government’s Children and Young People Improvement Collaborative. IHI Senior Director, Marie Schall, gathered the following lessons learned from Lynge and Hannah. They are both faculty at the upcoming IHI/BMJ International Forum on Quality Improvement in Healthcare (May 2–4 in Amsterdam).

Have a Scale-up Plan from Day 1

Susan Hannah (SH): From our earlier initiatives we learned that it is important to support local efforts but to plan for scale from the start. We knew that we needed to be prepared to move to scale when the time is right. Our plan developed organically, with our most recent initiative, The Children and Young People Improvement Collaborative (CYPIC) building upon two earlier programs, the Early Years Collaborative and Raising Attainment for All. 

Tina Lynge (TL) – When we began in 2013 we decided to start with five of the 98 municipalities in Denmark. These five municipalities, who volunteered to work with us, became our test sites where we learned what it takes to improve safety in a community setting. We ensured that they represented different types of municipalities, e.g., size, location, etc. so that we would have experience to build on as we scaled up to similar types of municipalities across the country.

Build Improvement Capability and Engagement at the Local Level

SH – An important foundation to support scale up is to build improvement capability at the local level so that teams can own and drive the improvement efforts in their own systems.  Another important factor for us was the engagement of the leaders of the local health boards who endorsed, led, and guided the efforts in their districts. Both elements helped us support the initial improvements as well as to plan for – and expand – the scope of our programme.

TL -  As we worked with the original five municipalities we saw results and gained confidence that it was possible to apply improvement methods successfully in a community setting.  Combining quality improvement within a collaborative structure, we saw reductions in pressure ulcers and medication errors, and a 50 percent reduction in falls.

Use Stories to Accelerate Scale-Up

TL – Staff stories build participation as the work expands by inspiring others to embrace the changes in practice. One of our homecare nurses shared this reflection about her work in the collaborative: “I completely changed my view of citizen involvement. I remember that I was at the first learning seminar in 2013 and was a little skeptical about what we could get out of the project. I certainly thought we already involved the citizens as much as possible. But soon I realized how important a factor citizen involvement is in avoiding errors - and that my colleagues and I had to involve citizens and relatives even more than we already did. If we were to succeed, it was going to require some other workflows and another approach to what we were currently doing.”

SH – We also have been able to continue to build staff enthusiasm by having staff share the impact of the improvement on their day-to-day work. One Health Visitor commented, “As we started to work differently, we could see the benefits and it feels like a reduced work load. This has generated enthusiasm in the team, and has made us feel more in control of the processes... and, as a result of our work, team morale is higher and it is now part of how we work.”  Sharing these real-life experiences reassures new improvers that the effort of working on QI reaps great benefits for the workforce and for the families they serve.

Support New Teams as You Scale Up

SH — Our national group provides team and individual training and mentoring support for project leaders at the local level. Local leaders in turn facilitate and deliver large-scale collaborative learning opportunities for teams working on commonly shared areas of improvement. One such program focuses on accelerating the implementation of the Universal Pathway, a child development assessment and intervention pathway to support children and families. Outcomes tracked include the percent uptake of child health reviews and the quality of the review process. In one locality this work accelerated their progress to achieve 98 percent uptake within a year.

TL — We support local communities in building a culture of safety. Teams can do a lot of work, but if their organization, systems, and processes are not designed to work across boundaries, they will bump into barriers that will delay and even stop the improvement work, and then risk losing good will. Organizations need to develop the maturity to learn from errors and a culture where staff feel safe to speak up.

Editor’s note: To learn more, please register for B7: Designing and Managing Community-Based Scale-up Efforts at the IHI/BMJ International Forum on Quality Improvement in Healthcare (May 2–4 in Amsterdam).

You may also be interested in:
IHI White Paper: A Framework for Spread: From Local Improvements to System-Wide Change
Lessons Learned from Ghana's Project Fives Alive! A Practical Guide for Designing and Executing Large-Scale Improvement Initiatives

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