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."

New systems model to simulate spread and adoption of good practice

I've worked with Ken Thompson of Bioteams to develop a systems simulation of the spread and adoption of good practice.  Our aim has been to provide a method for individuals and teams to play about with different strategies and to model the impacts of those strategies. It's not a prediction tool, but rather one which helps you gain an insight into the complexities  It's been important to us to produce a simulation which provides an adoption curve - having an idea of the speed (or not) of spread is crucial to your planning.

The simulation is ready for testing. It's not perfect, and we'd love to demo it and take your feedback on how to make it even better. Feel free to tweet Sarah @sarahfraser or Ken @kenthompson, leave a reply to this blog, or email Sarah, if you'd like to have a go.

A screenshot of the main screen is below. You can choose your strategies and then simulate, quarter by quarter, the rate of adoption. There are other input screens where you can assess your readiness for change and where you can enter details about the strategies you'd like to use.

Spread and implementation; making practices real

At a recent awayday for a team in Sweden who are working to improve the experience of life for  the elderly, I had the fortune to listen to and work with Bodil Jonsson. I was thinking out loud and expressing my concern that the use of the word “spread” may allow people using it to disengage with the reality of what is involved. There is an ease by which leaders say “spread”, and then disengage themselves from the detail of what it means. So insteadI tend to use “implementation” as this word, to me, has a more active feel, and directs the users to consider what might be involved.

Bodil suggested the Swedish word “forverkliga” (please imagine the two dots on the o). This means to make real”. This was a light bulb moment for me. Think about guidelines; is the issue to spread them, to implement them – or to make them real. I like forverkliga because reality is made in one’s own context, thus enabling adaption, without further explanation And making real is far more than the objective task of copying another’s good idea. Instead it is the process of taking another’s idea and focusing on the added value to, say, the patient; unless something is made real, there is no value.

In my mind’s eye I say websites full of stories and examples, of guidelines and exhortations – and at once, saw useful information, that was of no value unless “made real”.

Forverkliga.

Paper: Complexity science and spread

Well, the best bit about this paper for me is the introduction of the terms SUS - scale up and spread!  It focuses on self organisation (complexity science principle) and how the complexity of healthcare and all the interactions are part of the problem of SUS programs.

Now, I'm biased and I'm with Ralph Stacey who says that when we think we can "control" or "use" self organisation then we are operating with a mindset not much different from Taylorism (see his work on complex responsive processes which superceded complex adaptive systems around 2001).

Whilst using insights from complexity science is useful, it is just that - an insight. When it comes to moving on to a more practical thought about - "so what do we do now", CAS and Complexity Science as such, falls flat.  There is a well trodden, pragmatic and practical systems theory and modelling that would be helpful in understanding interdependences - "Systems Thinking". Unfortunately it requires a bit of effort to grasp and seems not to have the cachet of "complexity science". Shame.

Soc Sci Med. 2012 Jul 4. [Epub ahead of print]
How complexity science can inform scale-up and spread in health care: Understanding the role of self-organization in variation across local contexts.
Lanham HJ, Leykum LK, Taylor BS, McCannon CJ, Lindberg C, Lester RT.

Paper: Three Collaborative models for scaling up evidence-based practices

In "101 ways to improve your collaborative" I described a number of ways to spread / scale up innovations using the collaborative model in different formats.  In this paper

Adm Policy Ment Health. 2012 Jul;39(4):278-90.
Three collaborative models for scaling up evidence-based practices.
Chamberlain P, Roberts R, Jones H, Marsenich L, Sosna T, Price JM.

... the authors explore the merits and demerits of the Rolling Cohort, The Cascading Dissemination Model, and the Community Development Team.

Readiness for change - an adopter's diagnostic tool

The Agency for Healthcare Research and Quality (USA) has a fabulous tool that can be used by potential adopters in helping them decide whether to adopt an innovation in their organisation. Whilst the questions appear rather basic, they are comprehensive, evidence based and the way in which the diagnostic has been put together really helps the decision-making process.

I commend it to you.

Download the PDF Diagnostic here

No benefits from spread, scaling up unless the baseline is poor?

I've been going on about the issue of top-down spread / scaling up initiatives which overstate the benefits. For example, if the pilot projects gets a 50% improvement, then that is, of course, relevant to their baseline. And we can only translate this benefit across a system f we know the baseline of all the individual potential beneficiaries. The worse we can do is take a national average and then assume everyone can get the same 50% improvement that the pilot site obtained.

I've written about this in "Undressing the Elephant: Why good practice doesn't spread in healthcare" and it's great to see a systematic review based around diabetes care that supports the notion that "interventions solely targeted at healthcare professionals seem to be beneficial only is baseline HbA(1c) control is poor". [This research and paper was funded by Ontario Ministry for Health]

Lancet. 2012 Jun 16;379(9833):2252-61. Epub 2012 Jun 9
Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis.
Tricco AC, Ivers NM, Grimshaw JM, Moher D, Turner L, Galipeau J, Halperin I, Vachon B, Ramsay T, Manns B, Tonelli M, Shojania K.

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.

Paper: An Operationalization of the Interactive Systems Framework Support Systems

This paper has a long and complicated title.The bottom line seems fairly straightforward - that train the trainers (TOT) activities and technical assistance (TA) can lead to success when scaling up the adoption of evidenced based practices.

Am J Community Psychol. 2012 Jun 19.
Using a Training-of-Trainers Approach and Proactive Technical Assistance to Bring Evidence Based Programs to Scale: An Operationalization of the Interactive Systems Framework's Support System.
Ray ML, Wilson MM, Wandersman A, Meyers DC, Katz J.