Paper: The concepts of scalability...

A new paper is out which looks at the concepts of scalability - what is meant by it and how to health promotion interventions consider scalability.

"Increased focus on prevention presents health promoters with new opportunities and challenges. In this context, the study of factors influencing policy-maker decisions to scale up health promotion interventions from small projects or controlled trials to wider state, national or international roll-out is increasingly important. This study aimed to: (i) examine the perspectives of senior researchers and policy-makers regarding concepts of 'scaling up' and 'scalability'; (ii) generate an agreed definition of 'scalability' and (iii) identify intervention and research design factors perceived to increase the potential for interventions to be implemented on a more widespread basis or 'scaled up'. A two-stage Delphi process with an expert panel of senior Australian public health intervention researchers (n = 7) and policy-makers (n = 7) and a review of relevant literature were conducted. Through this process 'scalability' was defined as: the ability of a health intervention shown to be efficacious on a small scale and or under controlled conditions to be expanded under real world conditions to reach a greater proportion of the eligible population, while retaining effectiveness. Results showed that in health promotion research insufficient attention is given to issues of effectiveness, reach and adoption; human, technical and organizational resources; costs; intervention delivery; contextual factors and appropriate evaluation approaches. If these issues were addressed in the funding, design and reporting of intervention research, it would advance the quality and usability of research for policy-makers and by doing so improve uptake and expansion of promising programs into practice.

Health Promot Int. 2013 Sep;28(3):285-98. doi: 10.1093/heapro/dar097. Epub 2012 Jan 12.

Milat AJ, King L, Bauman AE, Redman S."

Paper: Framework for analysing collective action events on Twitter

This freely available paper (PDF) is one for the nerdy person like me who wants a bit of theory and a framework to figure out what goes on when Twitter is used for collective action.

It's a shortish, easy to read and I think valuable addition to our thinking and understanding of the use oif Twitter for large scale change.

Readiness for change diagnostics: Some evidence

I'm ambivalent about the concept of "evidence" for much of the change and improvement work we do in healthcare because so many of the concepts and processes are contested.  However, that doesn't stop me checking for evidence and testing my own prejudices.


There are a number of papers  and publications which touch on the topic of readiness for change.  



Review: Conceptualization and Measurement of Organizational Readiness for ChangeA Review of the Literature in Health Services Research and Other Fields
Weimer, Amick & Lee
All literature reviews need to be considered as a service to humanity. This one covers the concept of readiness for change in healthcare and reviews 43 instruments in use.




Assessing organisational readiness for change: use of diagnostic analysis prior to the implementation of a multidisciplinary assessment for acute stroke care

Sharon Hamilton, Susan McLaren and Anne Mulhall

This team conducted a comprehensive review and evaluation using multiple strategies which I like. They also used the Team Climate Inventory.

^{Monograph: Assessing & enhancing readiness for change; implications for technology transfer.}

^{Backer, David & Soucy}

^{Not a peer-reviewed paper as such, but it has some excellent perspectives on what readiness for change means - and doesn't mean.}

Systems Antecedents for Dissemination and Implementation; A Review and Analysis of Measures
Emmons, Weiner, Fernandez, TuThe conclusion in this paper seems ot be there is no common ground for the use of measures or consistency in the way in which they are applied, hence leading to difficulties in figuring out what might be the best strategy.


There are many more papers - if you find any, please leave notes in the comments box.

Readiness diagnostic tools for spread, scaling up, dissemination

So how do you know whether your organisation is ready to embark on a program to adopt existing good ideas / evidence in a systematic way?

As in previous posts, most of the answer to this question is a no-brainer - you know the answers already (see previous posts).  However, sometimes it's nice to have a checklist or set of tools to help you check whether what you know about is actually in place.

There are many general tools / checklists available which check whether your team or organisation is ready to do something different.  Most of these assess the culture of the group. The disadvantage here, which is why I suspect many people avoid these types of tools, is if you find out that your culture is not ready, many people lack the patience to go through the necessary cultural change - or they just don't have the time for this "pre-work".

Generic tools can be useful for learning about your organisation though they can be a good (and time-wasting) displacement activity by organisations.

The best types of diagnostic tools are those which are specific to the change in hand.  Specific means they are designed around and for the type of change proposed.

1. One of the best examples I know of specific diagnostic tools come from, the US National Council on Aging. For their Chronic Disease, Falls and Depression scale up plans they have open access tools which can be completed online or you can download the PDF to read through.  Each of these is specific to the adopting community and the type of innovation proposed for scale up / spread / dissemination.
2. NICE - yes, the National Institute for Health & Clinical Excellence (NHS) has been at the forefront of providing tools that support the introduction of evidence. These are excellent spreadsheets, populated with the NHS data and ready to use.  Unfortunately, I don't hear about them being used on a regular basis - especially by commissioners.

The problem with tools and diagnsotics is no difference than the problem with any other thing we want to spread or be adopted - most people would prefer to create their own because the credibility for many members of staff lies in the excitement and status of creating their own, rather than using someone else's. If you're offered a diagnostic tool - have a good look at it - if it is specific to the innovation it may be very useful for you.

Readiness for spread, dissemination, scaling up

Spread, scaling up, dissemination, diffusion - whatever you want to calls it - does NOT happen in healthcare in the automatic "tipping point" way of Gladwell.  This is largely because in healthcare, the NHS being one great example, the desire to spread is a top-down prescriptive one - which is most companies would be dealt with a a large scale implementation project.  Similarly, just focusing on how to describe and communicate  the innovation is not enough. (I've written about this in previous posts.)

Whatever you call it and whatever methods you use, there is evidence that there are some key factors which need to be in place before you set off on a large scale "thingy".  These are not clever, and, in fact, are annoyingly obvious. Obvious does not mean simple.  You already know about the list below and one major step forward in your large scale work is to examine why you're not working on these "readiness" factors.

1. Strategic focus: if the imitative is not named and talked about in the organisation (and team) level as a strategic piece of work to do, then it's probably not a large scale change or one which will be given priority
2. Executive sponsor: who in the organisation is responsible and accountable for the implementation (not the planning) of the change?
3. Day-to-day leadership: is the initiative being talked about?
4. Spread aim: is there a clear aim and method of measuring progress for spread / scaling up?
5. Spread / scaling up Plan: is there one? Is there one that scales down each level of implementation?
6. Costs: are the costs of the change clear? DO they include the staff time coasts? Is there an agreed ROI for the scale up?
7. How will fidelity be ensured? (Fidelity = what is scaled up / spread is the same as the initiator project)

Some references:

(There are many references available in peer-reviewed papers, however, as many of you have complained you don't have access to these, I have listed some more general and open access references. If you know of other easy access references then please comment on this blog.)

• IHI: A framework for spread
• Agency for Healthcare Research & Quality: Innovation readiness for spread
• Some of my books: Rolling out your project includes a whole section on diagnosing readiness for change. 

90 Day Projects

I've written about 90 day projects over the last couple of years:

1. How to implement 90 day projects
2. What are 90 day projects
3. Large Scale projects are seldom a linear process
4. Push vs Pull: Twitter Case Study 90 day Project

Many months on I am still convinced that we spend far too long on our healthcare projects. The tradition is they are planned for 18 months - often regardless of the size and difficulty of the change required. There are some changes which may need to be part fo a three to five year project, and others that can be achieved in 7, 30 or 90 days.

If you have examples of 90 day projects successful or not, then please leave a note in the comments. Thanks

The meaning of Implementation Climate

I've just read a new paper about implementation climate and how it differs from organisational climate - all part of the "readiness for change" strategies than many of us use.  You can read the whole paper at Implementation Science (online - open access). I've pasted the abstract here, though I recommend you read the whole paper.

The meaning and measurement of implementation climate.

Weiner BJ, Belden CM, Bergmire DM, Johnston M.

Abstract

BACKGROUND:

Climate has a long history in organizational studies, but few theoretical models integrate the complex effects of climate during innovation implementation. In 1996, a theoretical model was proposed that organizations could develop a positive climate for implementation by making use of various policies and practices that promote organizational members' means, motives, and opportunities for innovation use. The model proposes that implementation climate--or the extent to which organizational members perceive that innovation use is expected, supported, and rewarded--is positively associated with implementation effectiveness. The implementation climate construct holds significant promise for advancing scientific knowledge about the organizational determinants of innovation implementation. However, the construct has not received sufficient scholarly attention, despite numerous citations in the scientific literature. In this article, we clarify the meaning of implementation climate, discuss several measurement issues, and propose guidelines for empirical study.

DISCUSSION:

Implementation climate differs from constructs like organizational climate, culture, or context in two important respects: first, it has a strategic focus (implementation), and second, it is innovation-specific. Measuring implementation climate is challenging because the construct operates at the organizational-level, but requires the collection of multi-dimensional perceptual data from many expected innovation users within an organization. In order to avoid problems with construct validity, assessments of within-group agreement of implementation climate measures must be carefully considered. Implementation climate implies a high degree of within-group agreement in climate perceptions. However, researchers might find it useful to distinguish implementation climate level (the average of implementation climate perceptions) from implementation climate strength (the variability of implementation climate perceptions). It is important to recognize that the implementation climate construct applies most readily to innovations that require collective, coordinated behavior change by many organizational members both for successful implementation and for realization of anticipated benefits. For innovations that do not possess these attributes, individual level theories of behavior change could be more useful in explaining implementation effectiveness.

SUMMARY:

This construct has considerable value in implementation science, however, further debate and development is necessary to refine and distinguish the construct for empirical use.

Most popular posts on the Spread Good Practice blog

Here is the list of the most popular posts on this blog for the last 6 months.  If I'd had to guess I'd not have guessed these - nothing like a good bit of measurement to separate fact from opinion!

Model 2: data, information, knowledge, wisdom 22 Dec 2010, 1 comment 640 Pageviews

The quickest way to spread scale up change 21 Jul 2010 484 Pageviews

Model 1: data, information, knowledge, wisdom 20 Dec 2010 339 Pageviews

Using Twitter in the Classroom or Organisation 2 Sep 2010 320 Pageviews

Productivity 1: Operational Efficiencies are not e... 24 Oct 2010, 1 comment 284 Pageviews

When stories and Powerpoint clash

A mantra I keep hearing is "we need to tell stories to influence change." I agree with this, however, I do have a few provisio's

• if the story has no relevance to your message then why are you telling it?
• if you provide a personal story to illustrate your values then please make sure it connects with the audience at the time (please update and avoid repeating)
• when you use PowerPoint to tell your story there seems to be a dissonance - the method is not matching the intent

As a method of influence, especially for large scale change, stories work well because they contain the emotive meme that a PowerPoint presentation usually lacks.  So let's use stories, but let's use them advisedly and with care.

Large Scale what? Change, outcome, implementation or impact?

I prefer the phrase "large scale outcome" or "Large scale implementation" to the more generic "large scale change". Why? When the words outcome and implementation are included it feels more active, more directive, more specific.

For example, it is possible to have a large scale change that is not resulting in the outcomes you set out to achieve. A huge amount of change can happen and yet only a small scale impact is achieved.

Equally it is possible to have a large scale impact from a a small change that might affect only a small scale (numbers and geography). Using Pareto analysis can provide organisations with hints on where to leverage the smaller changes for the bigger impacts.

By focusing on impacts, by elevating the results we want, we can design organisation and system interventions to deliver targeted outcomes. In my experience, many groups who talk of large scale change are ending up creating busy-work that is not specifically directed at delivering a large scale outcome. For me change does not equal outcome or impact.

I'm reminded of a quote from Thoreau which runs along the lines of "It is not enough to be industrious; what are you industrious about?"

Social media kits: CDC as a good example

Whatever your position on H1N1 swine flu, there is no doubting the news spread fast across the world.  Many change programs would like to emulate this type of activity; it is the Holy Grail of large scale change.

The CDC (Center for Disease Control and Prevention) in the USA is an excellent example.  I challenge organisations to respond as quickly, thoroughly and extensively as them.  In the case of H1N1 they didn't have a vast amount of planning time, though I suspect they had some contingency plans in place, to come up with a range of social media / social marketing tools.  So the first point to note is these were available almost instantly.  No waiting 2 - 3 months for a communications and marketing department to negotiate with an IT department following the meetings of the Change program division etc.... in order to get something done.

Secondly the CDC appreciates and understands the value of social media in getting messages out and helping them to spread, hopefully quicker than the virus they are focusing on.  Their H1N1 swine flu social media page  has:

• widgets; a whole variety to suits your own needs
• mobile information
• buttons
• online videos
• podcasts
• ecards
• rss feeds
• twitter link
• image sharing
• as for social networks you can find them on Facebook, mySpace, DailyStrength

Using social media is not the only way to communicate.  However, well done CDC for showing the way, probably breaking some rules in the process, and demonstrating to laggardly public sector organisations and departments how social media can be of value and no great sweat to implement.

Large scale change or spreading good practice?

As a Rotarian I have recently been involved in a project to help the Masai Mara community in Tanzania get clean water near their homes. We're working with an inspirational fledgling charity called Weston Turville Wells for Tanzania. They have already enabled the installation of wells, are looking for more as well as more ambitious projects.

My link to this work has helped me understand more about some of the differences between "spreading good practice" and "large scale transformation". Well, it has sort of helped - it also raises more questions for me...

Think of community of 4,000 people which is made up of smaller communities (think small town and suburbs). It costs around £3,000 to install a well that will support a small sub-set of a suburb. One way to help the whole 4,000 community is to take the "good practice/good idea" of the single well and replicate this across the community, say building 15 or 20 wells. Twenty wells will cost around £60,000. There is no doubt that this will transform the lives of the whole community.

Another option, is to spend £60,000 and build a pipeline from a source of water in a mountainous area not far away. The impact of doing this is also a large scale transformation for the community. It is ambitious in scale, impact and ingenuity is required to implement a reliable solution.

So which would be your choice? Option 2 sounds great and at first glance looks sustainable. However, it will take many months, possibly a year or so, to raise the funds, get the permissions and then build. During this time the community is without a viable water supply within any close distance of their homes. Option 1 feels suspiciously like a quick fix with the added difficult dynamic of the spread of the wells not feeling (my feeling) democratically spread. However, money can be found "per well" and work can start in a very short time. The individual well is a solution is tried and tested. In addition the charity has ensured there is local support from within the community to help maintain them.

I can see that both options are transformative for the community. The outcome will make a difference to daily life and health. The process may also be transformative and everyone gets involved with the well / pipeline building process. Option 1 is more emergent, flexible and bottom up type approach. Option 2 is more planned, organised and top down approach. The both/and would be to have a pipeline and some wells - but then I'm torn between the extra cost of doing this where more wells can be provided for another community...

For the record, we've gone for supporting the provision of a well - right now. The essence being that in some cases a quick fix is a good one and when it comes to water, every day without it is a trial.


What would you do?

Tips for making decisions in change programs

In Everett Rogers’ seminal work, “The Diffusion of Innovations” there is some very interesting suggestions on the importance on the decision making process as part of the innovation adoption dynamic. This decision-making focus is often left out of references to his work though I have always found it helpful when I am working with others to implement large scale changes in complex systems as well as the adoption of known best practices into more simple structures.

Rogers points out that the action of decision-making is the point of action in adopting a new idea. Others may try to persuade me, though nothing will matter until I have made a decision to adopt. You cannot make that decision for me. With this in mind, one of the most helpful questions I know to ask when encouraging the adoption of a new idea is “How can I help you make the decision?” This is starting with the premise that they are not forced into adopting the solution and I am open to helping in whatever way might be useful.

Rogers never got into the complexity of the decision-making process. One of the texts I find useful is “Crucial Conversations; Tools for Talking when the stakes are high” by Kett Patterson, Joseph Grenny, Ron McMillan and Al Swtitzler. They highlight four of the most common methods for making decisions and give ideas on how best to work with each.

Command; defined as a process where there is no involvement of others. This may also be a preference of some people who would prefer not to have to make a decision (or be responsible / accountable for making it).

Consult: is when you ask for input before making your choice. The essence is leaders still make the final decision, though with the ideas, opinions and views of others in mind.

Vote: work when everyone involved agrees to continue to support the final decision, even if they voted the other way. This works when there are a number of options.

Consensus; can be frustrating and time wasting unless carried out properly and with a focused intent. The authors suggest this option should only be used where the issue is high stake, complex and where everyone must absolutely support the choice.

So what has decision-making got to do with the spread of good practice and other large scale improvements?

In my experience, complex change programmes can feel very overwhelming. We spend a huge amount of time planning, working out what we want to get out of it and then how we might go about it. All programmes and especially the complex ones need a whole heap of decisions to be made before we even get to action, and then all those impacted by the change have their own decision making process to go through when the implementation starts. The problem for changes that are large in scale is the amount of detail, levels and complexity involved. The decision-making tactics need to reflect this.

So I use the following list as a diagnostic for the decision-making processes in a spread and large scale change programme. These can be used at the programme team level or the adopting team level.

1. For the programme itself, so we know what the meta decision-making process is (vote, consensus etc)? Have we agreed which issues need what type of decision process?

2. What is the key decision that needs to be taken in order for this new idea / change to be implemented in the workplace? Is this decision different for different people?

3. Who cares about the decision? If anyone cares about it yet they do not have to change their behaviour as part of the implementation process, how might we have a decision-making process that reflects this?

4. Who has to agree to the decision in order for us to gain benefits from the implementation? How does this affect our choice of the type of decision-making process we use as part of getting our work implemented.

How will you make your next decision?

Managing Large Scale Transitions

Whether spreading good practice from one team to the whole organisation or leading a more ambitious large scale change, managing the transition from one state, today, to a desired future state, is worth some thought. I am not sure that I, the leader, can "manage" the transition as any behavioural change required is very personal to the people impacted by it. The process is something they need to go through and make meaning of, themselves. However, as the leader of any large scale intervention there are a few things I can do to help.

The work of William Bridges where he provides a model of managing transitions, I believe is useful for our behavioural type interventions. His work is primarily focused on the individual and also on the organisation. The nub of the model is that we go through three phases as part of coming to terms with a new situation: endings, the whitewater and then a new beginning. I find this a helpful way to think of the change process.

1. Endings; what will individuals, teams and organisations be losing as part of this change? How can I help this be made explicit? Has this been taken into account in the planning? How can I as leader help people mark and celebrate their endings?
2. The whitewater; this is an analogy that Bridges uses to describe the stage between ending and beginning. It is messy, uncertain, unclear, scary and nearly always feels faster than we can cope with. It is also a time of great creativity and innovation. As a leader, what am I doing to support people through this stage? What temporary structures and processes would be helpful? What mechanisms do I have in place to harness the ideas that will arise? How can I support these suggestions?
3. Beginnings; so much of our planning work is in designing the future. The expectation is the beginning is the start, rather than the two phases listed above. To what extent am I so focused on the beginning that I am disabling the transition process? How will I know when a new beginning is emerging.

While the model is designed for individuals and teams, it has relevance for large scale interventions across systems. For example, I can use it to help me discover the meaning of the change for different groups of people in different organisations. Especially by seeking to understand the endings. Sometimes one team's loss is another organisation's proposed new beginning (though they will also have some endings). By looking at these dynamics across the system I will gain insight into what may be the scale of transition and thus also the pacing of it.

Methods for involving people in large scale change

Every now and then I come across a really useful website with content that presses all the right buttons. If you're interested in the topic of large scale change or spreading good practice and are looking for participative methods that involve the users, consumers, clients and population base - then have a look here:

http://www.peopleandparticipation.net/display/Methods/Browse+Methods

This is a UK government funded site called peopleandparticipation.net and needs to be congratulated for its simplicity and focus.

Building communities for scaling up requires skill & training

Although all of us can hold conversations, network to varying degrees, can manage a meeting and send an email, I am not sure these generic skills are enough to build both the face-to-face and online communities that we'll be needing for the large scale changes that many organisations I am working with have planned.

A few years ago there was a big push on ensuring that the leaders of improvement projects had the basic project management skills to help them on their way. Likewise we train facilitators of groups in how to perform their role. Building communities and understanding the fundamentals of how they work and what techniques you can employ, when, is part of a set of skills that can be developed by building on what you already know. To despatch an untrained and unsupported person to facilitate a program of large scale change, scaling up or spread (whatever you'd like to callit) without some appropriate social and technical input is most likely to doom them and their program to a lesser set of outcomes.

Is it because we think we know how to have a conversation and have a relationship that we are too afraid to learn any more or to reach our for help when we are taking on large and important change programs?