Set-Up for Spread

While there are no clearly defined "stages" of spread, the activities involved in laying a solid foundation to support spread — the set-up for spread — should be addressed by the leadership of the organization early in the spread planning process. Although an organization and its leadership cannot successfully "mandate" spread, they can take certain actions and put specific structures in place that will "enable" the spread of the selected improvements within the organization. The set-up, as well as the other components of the Framework for Spread, create a pull system that attracts the intended adopters to first test and then embrace the improvements.


Changes for Improvement


Select the Target Population for Spread

The target population will differ depending on the improvements involved in moving from the old to the new system. For example, the target population for the spread of a safe, efficient, and effective medication system might include all medical-surgical units and the pharmacy. In the outpatient setting, the target population for the spread of improved access would be specific clinics or physician office practices.

  • Consider the different audiences within the target population (for example, physicians, nurses, technicians). Even though different audiences may be part of the same system, they may need to hear different messages and adopt different changes. In most cases, adopting new ideas in the target population cannot be dictated. Therefore, an initial spread strategy involves planning how to leverage successful sites, existing communication channels, available resources, and others entities to increase the rate of adoption.


Identify the Adopter Audiences 

An effective approach to spreading improvements acknowledges that there are different audiences within the target population. While multiple care providers and other staff are involved in patient care, those that are key to the process being improved must first make the decision to adopt the improvements. These members of the care team are considered the "audience" for initial information about the improvements. For example, to spread medication safety improvements, the key adopter audiences are usually the physician, nurse, and pharmacist since they are the primary persons involved in prescribing, dispensing, and administering medications. Once the key audiences decide to adopt the improvements, the entire care team, including nursing assistants, technicians, unit clerks and others, then need to embrace and carry out the improvements.
In the outpatient setting, the key adopter audience for changes to improve access as well as changes relating to improved care for patients with chronic conditions is often the primary care providers (PCPs). Once PCPs (often the physicians) make the decision to adopt the improvements, other members of the care team, such as the nurse practitioner, physician assistant, nurse, nursing assistant, schedulers and others, are central to actually making the improvements. For example, to successfully apply the methods for advanced access, the scheduler is a key team member since he/she handles incoming requests for appointments and assigns patients to the actual appointment slots.
  • Use input from your adopter audiences to plan the content and methods of communication to build awareness about the improvements.



Engage Key Internal and External Partners in Spread

Key partners both within and external to the organization can support spread in a number of ways, including: provide additional resources and expertise, help legitimize the spread effort by sending the message that the improvements are important, and link the target population with those outside the system that are engaged in a similar effort. Examples of key partners for spreading patient safety improvements might include national safety organizations, foundations supporting projects, national and state accrediting and quality review organizations, professional societies, trade associations, public and private payer groups, and others.

Key partners that have been helpful to office practices and clinics in spreading changes to improve access as well as care for people with chronic conditions include government agencies, foundations funding projects, professional societies, national and state accrediting and quality review organizations, national trade organizations, public and private payer groups, community-based resource and support organizations, and others.
  • Keep in mind that external partners are especially helpful in situations where the target population for spread cuts across organizations (e.g., hospitals or physician offices in a state that are not part of the same health system or organization). In these situations, the external partners may provide an organizing framework to bring providers together, and may serve as a catalyst for change by providing visibility and legitimization for the improvements.



Identify Successful Internal and External Sites

Successful sites (e.g., hospital patient care delivery units, departments, or services; physician offices or clinics) are those where the improvements to be spread have been tested and shown to be effective in achieving the desired outcomes. These sites often help to:

  • Explain the benefits of the changes to those in the target population
  • Identify systems issues that, once addressed, can speed the spread of the new ideas to new sites
  • Generate tools and resources to help make the changes easier for new sites to adopt
  • Provide mentors and teachers as a resource for others in the target population who want to learn more about the changes


  • In some cases, one site may have successfully implemented only some of the changes. If this happens, identify different sites that have implemented other changes, then construct a composite picture of the entire set of improvements to be spread.
  • Successful sites within the organization help to demonstrate that improvements can be made in "an organization like ours."
  • When external examples are used, acknowledge organizational characteristics or cultural differences that may exist. Explain why the external site is a positive example from which to learn, and that changes may need to be adapted to fit the target population's specific characteristics and culture.
  • Develop plans to create high-performing sites as part of the spread strategy if such sites do not exist either internally or externally. These "pilot sites" can be used to introduce and test new improvements as part of the spread strategy.



Develop a Plan to Attract Adopters

Since individuals in a social system do not adopt changes at the same time or at the same rate, moving new ideas from the site where the initial changes were made to the target population is not always a simple process. In his book, Diffusion of Innovations, Everett Rogers places adopters into categories classified from "innovators" to "laggards" based on their willingness to adopt changes over time and notes that the category may vary based on the change being adopted.


The initial spread strategy relies on broad-based communication about the improvements to identify those individuals who are most interested in learning about and implementing them. Knowing where these "early adopters" are located within the target population can inform and shape the initial spread strategy by identifying where to begin the spread effort.
  • Develop an initial plan to attract potential adopters since the adoption of new ideas cannot be dictated in most cases. Elements of the plan might include broad-based communication about the advantages of the new system, developing a process to identify people in the target population who are influential with their peers, or sharing comparative data with adopters.


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