Planning for Scale: A Guide for Designing Large-Scale Improvement Initiatives

How to cite this paper:

McCannon CJ, Schall MW, Perla RJ. Planning for Scale: A Guide for Designing Large-Scale Improvement Initiatives. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008. (Available on

This IHI white paper aims to support those that are planning to take effective health care practices from one setting or isolated environment and to make them ubiquitous across a health care system, region, state, or nation. It is a preparation tool which is meant to guide conversation and thinking prior to the launch of a large-scale improvement effort (i.e., one that seeks to stimulate change in complete, geopolitical areas through mobilization of hundreds or thousands of constituent organizations).
Since 2004, several nations have launched voluntary, large-scale initiatives to improve the quality and safety of their health care systems, with more to come. Through direct participation in — or consultation to — these initiatives in the United States, Canada, Scandinavia, the United Kingdom, and Japan, the Institute for Healthcare Improvement (IHI) has learned much about the complexities associated with such ambitious work.
IHI has generated — and iteratively tested and refined — a list of questions that serve as a discussion guide for those contemplating multi-stakeholder improvement initiatives that involve many caregiving organizations in a district, region, or nation. These questions fall into six categories:
  • Motivation
  • Foundation
  • Aim
  • Nature of the intervention
  • Nature of the social system
  • Network building (communication and support)
The questions should be considered by a core group of stakeholders — those with experience in and influence over the problem in question — in the months leading up to the launch of a large-scale improvement effort. Some questions might not be relevant for some initiatives; negative or incomplete answers to any of them need not halt action.


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