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The Elusive Coverage and Completeness

By Carol Haraden | Tuesday, May 21, 2013

This blog post was written by Carol Haraden, IHI Vice President and patient safety expert, in collaboration with Kedar Mate, IHI Vice President, and Amelia Cline, IHI Research Assistant.

Spreading improvement success from the pilot unit to the rest of the organization is one of quality improvement’s greatest challenges. We know this kind of spread is vital to having a continuously improving organization, but it is a problem that seems to be plaguing everyone doing this work, no matter the context.

Here’s an all too common example: a hospital dramatically reduces their central line infection rate in the intensive care unit and starts to see improvement in their organization-wide metrics. The leadership is thrilled with their success and begins to focus its energy on the next big hurdle: reducing sepsis mortality. What is the problem? The improvements they have seen in their safety metrics have allowed them to overestimate the spread of that work. They have stopped short of implementing the practice of using a central line bundle in all units and all sites where patients receive central lines, leaving potential harm and mortality "on the table."

After 15 years of studying, learning, and teaching about organizational spread at IHI, we know that achieving true coverage and completeness remains a persistent barrier to improvement. It is a challenge in quality improvement of all types – not just with safety bundles – and it is one of the problems IHI’s innovation team is focusing on.

We’re seeking answers to questions like:

  • What does it take to go the last mile and bring about organizational change across the board?
  • How do you compel that last service line or practitioner to adopt and sustain a change?
  • Has anyone created a successful spread plan that continues to push and track the spread from the first pilot unit until you've reached full coverage and completeness?

To find answers, we’re first reaching out to a few of IHI's friends and experts in the field to hear what they have to say. We start with a simple question: "What systems or improvements in your organization have you been able to spread to all relevant beds, teams, and units?" In response we have heard, almost universally, heavy sighs and echoes of the challenges.

We are still working on it here at IHI, but a few themes and best practices are starting to emerge.

Tactics for leadership:

  • Constancy of purpose: set the expectation that leadership will keep asking and that staff cannot wait out this "flavor of the month".
  • Have a realistic understanding of change fatigue and how much process improvement the organization can do at once.
  • Manage improvement for spread rather than catering your methods to the best performers.
  • Build in necessary redundancies in the system to catch lapses in spread.
  • Create a visual display of coverage and completeness to track progress.
  • Create half-life type goals rather than finite targets so the organization does not become complacent once a target has been achieved.

Tactics for bringing along those who have not yet adopted the change:

  • Get the vital few on board (the majority will follow). The remainder will need to be managed.
  • Understand what prevents the remaining few from coming on board.
  • Use your champions and quickly find a success story. Measure and spread the word. Some of the most effective champions are the ones who are former hold outs.
  • Start small with the skeptical and unwilling, asking questions like "Will you try it for a day?"
  • Use leadership to force the issue. Be straightforward and ask, "Do you know something that we don't? If you do, we need to understand it. If not, you need to get on board."

We’re asking you next: What systems or improvements in your organization have you been able to spread to all relevant beds, teams, and units? What visual displays did you use to help? How do you push your organization over that last hump?


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