Why It Matters
“Improvers must avoid the ‘replica trap’ of adoption — that is, the belief that they can accomplish the same result widely by simply doing the exact same thing.”
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Avoid the Scale-Up “Replica Trap”

By IHI Multimedia Team | Tuesday, March 3, 2020

Replica Trap

Photo by Arshad Pooloo|Unsplash

To scale up and sustain change, adaptation is essential. The following excerpt from the IHI Psychology of Change Framework to Advance and Sustain Improvement white paper explores the “adapt in action” domain of the framework.

Many health improvers experience quality improvement methods as motivational. Action demonstrates people’s courage and is an exercise of their power. This can generate a reinforcing mechanism of activating people’s agency in a virtuous cycle — action begets action. IHI encourages improvers to take action by asking, “What can we do by next Tuesday?”

The Plan-Do-Study-Act (PDSA) cycle is an opportunity for testing, learning, and adaptive development — it’s okay to make mistakes, and it’s essential to analyze and learn from them. Data provide clues that reveal bright spots to harvest and share, or trends and patterns to address. Comparing performance across teams, units, and organizations can be intrinsically motivational for pride in work. Variation gives people energy to change behaviors. Tracking rates of improvement over time can be transformed into the urgency to act.


Take the Psychology of Change Online Course with Coaching to Understand Scale Up and Adaptation


When quality improvers turn to scaling and sustaining impact, the name of the game is to adapt. There is no data to suggest that a “perfect innovation” spreads on its own. Likewise, improvers must avoid the “replica trap” of adoption — that is, the belief that they can accomplish the same result widely by simply doing the exact same thing.

People’s agency to adopt and adapt must be activated. Therefore, it is critical to understand what aspects of an improvement are essential and non-negotiable and must be held to tightly. It is equally important to hold everything else loosely to activate the agency of other improvement leaders, teams, units, and organizations to adapt the change.

As improvers work together to adapt changes in new contexts, it leads to intrinsically motivational experiences of autonomy, growth, and community. Learning occurs as improvers make small and big (internal and external) adjustments through PDSA cycles in pursuit of an improvement effort’s aim, their team’s capacity, and their own growth. As people make choices about how to test and improve in action, they experience feelings of autonomy and growing mastery. And as they act with others, they experience a feeling that they are not alone. In other words, adapting in action can generate increased commitment to quality improvement.

Lessons from the 100,000 Lives Campaign

IHI’s 100,000 Lives Campaign exemplifies this lesson. In the Campaign, thousands of improvement leaders in more than 4,000 hospitals across the United States implemented six core improvements to reduce harm and deaths in a period of 18 months, resulting in over 100,000 lives saved. The IHI team could have taken the approach of telling improvement leaders how to demonstrate fidelity; instead, they distributed power to those implementing the improvements, providing coaching and support to regional field offices across the country, which in turn provided coaching and support to participating hospitals in their regions. Why? Because that is where the action was: the learning and breakthroughs happened at the point of care.

At its peak, the Campaign’s Mentor Hospital Network consisted of more than 200 participating hospitals from nearly all 50 states, from large urban academic medical centers, to mid-sized community hospitals, to small rural hospitals. The Mentor Hospitals presented on quarterly “office hour” calls for Campaign participants, sharing failures (and successes) with transparency.

While participants appreciated the faculty experts on the call, the majority of questions were directed to Mentor Hospitals since they were peers at the point of care facing similar challenges. Their influence was immense; they showed people, credibly, how to adapt in action.

Improvement leaders can put conditions in place for adapting in action to be motivational to those involved in the action. How? First, improvers can identify adaptive formulations of the problem and solution — a basic acknowledgment that people need to adapt changes in some way. Next, improvers can incorporate motivational action design principles (see the Unleash Intrinsic Motivation section of the IHI Psychology of Change Framework white paper), emphasizing that all successes and failures are important, and that there is something for all team members to learn. Most importantly, leaders can minimize the burden of judgment and the pressure to get a result by shifting the focus to learning the way toward the goal. The learning is the result, enabling teams to adapt to achieve the aim. People can rarely learn all that they need to learn to succeed until they begin to do it — understanding proceeds from action, rather than preceding it.

To learn more about adapting in action, download the free IHI Psychology of Change Framework white paper.

You may also be interested in:

The Psychology of Change Online Course with Coaching

The Missing Piece in Improvement: Understanding How to Motivate Change

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