“You’ve innovated something in your setting that works really very well, and it isn’t your responsibility to necessarily think about or make it work in other settings. So, where are the champions that take this … and take it further?”
Gregory Pawlson, Blue Cross Blue Shield of America
Innovators are often clinicians, academics, or health care professionals who develop creative programs to address local needs and challenges. Though these efforts can produce valuable information that can be used to improve health care delivery on a larger scale, innovators are generally not concerned with propagating their program across a variety of settings and/or do not have the skill set necessary to do so. The work of spreading an innovation is often unfamiliar—and possibly uncomfortable—for the innovators, and it may be neither possible nor practical for innovators to acquire proficiency in the many areas required to comprehensively spread an innovation. Though there may be a subset of innovators who want to be spreaders, these individuals are somewhat rare, representing more of the exception than the norm. Rather, many innovators do not view themselves in the spreader role, indicating the need to link innovators with spread agents who can offer targeted expertise in spreading innovations. Encapsulated in the questions posed by Veronica Nieva of Westat, “How do we help these innovators (who are not spreading their innovations)? Do they need to be partnered with other kinds of people who might help them spread? What is the setup? What is the infrastructure for spread for that kind of innovator?”
Overall, participants supported the idea that the role of the innovator is distinct from that of the spreader. As previously noted, innovators are frequently clinicians who are attempting to solve a local problem and/or academics who want to contribute to the research field and publish their work. They often do not conceptualize or design an innovation with the goal of spreading it beyond their home setting and do not have the time, knowledge, or desire needed to promote the spread of their innovation on a larger scale. Herbert Smitherman from Wayne State University & Health Centers and Detroit Foundation, Inc., summarized this concept in his comments during Hali Hammer’s fishbowl presentation, noting that “what Hali is doing … is trying to solve a local problem in her community, and I don’t look at it as even Hali’s role or any of these innovators to really try to help us … scale and spread.” Hali Hammer also provided some insight into the mindset of academic clinicians regarding how they view their role in developing and spreading innovations: “In academic medicine, what we do is we publish. We study, and then publish, and that’s our proxy for an agent getting the word out.” Recognizing the spectrum of players needed to spread an innovation, Hammer advocated for the role of spread agents, urging, “We need a person who will understand the beauty of what we are doing, and whose job it is to go to other places and help them figure out how to spread our innovation.” As she and many others acknowledged, innovators could greatly benefit from working with spread agents, described by Marie Schall from the Institute for Healthcare Improvement (IHI) as “people who will work with innovators to help them package, sell, and share whatever their innovation may be.” The idea of using spread agents is supported by others who identified the need for “intermediary” organizations to facilitate spread. For example, Cooley and Kohl (2005) assert that originating (innovating) organizations and adopting organizations could benefit from an intermediary organization focused on the scaling up process.
Beyond assisting innovators with spreading their innovations, spread agents may also be needed to recognize worthwhile innovations that would be useful and spreadable to other health care providers, systems, or settings. Innovators may not have the “bird’s-eye view” to know that they are doing innovative work that could be used to improve health care across the nation. Carolyn Clancy, Director of AHRQ, highlighted this idea: “Oftentimes when you visit an exciting community or a health care system and they’re doing something totally amazing, they kind of tend to believe that since we’re doing it, so is everybody else.” She used the example of the Henry Ford Health System’s innovative approach to screening all patients for depression: They assumed this was common practice until they attended a national meeting and learned the contrary. This anecdote demonstrates that innovators may not always recognize the ways in which they are transforming practice or the merits of their work, and having spread agents who can detect these innovations and facilitate their spread could have a meaningful impact on the quality of health care in America.
Once the benefits and purpose of spread agents have been established as a more abstract concept, identifying who spread partners might be and what roles they might play are important next steps. Participant comments and learnings from previous scale up and spread efforts undertaken by the AHRQ Innovations Exchange indicate that understanding the roles and identities of spread agents continues to develop and evolve. In addition to the spread agents who directly help innovators package and “sell” their innovations, another role is the connector: individuals or groups who can bridge different stakeholder communities and serve as an intermediary between innovators and adopters. Possible connectors may be advisory boards or consultants who have the resources and capabilities to link innovators with funders, adopters, or even spread agents or other stakeholders. Connectors can orchestrate the involvement of the stakeholders and generate momentum to spread an innovation.
Another similar yet slightly different spread agent is the “spread organization.” Spread organizations were distinguished as having some mission, activities, or purpose to support the spread of innovations and may include organizations such as IHI, Quality Improvement Organizations (QIOs), professional societies, technical assistance centers, and more, though these organizations may have somewhat different functions or strengths for spreading innovations. For example, IHI has well established channels, collaboratives, and frameworks for large-scale spread of innovative programs (Massoud et al. 2006). QIOs are present in each state and charged with improving the effectiveness, efficiency, and quality of health care services, a mission that is aligned with and ripe for spreading innovations. Professional societies knit together similar providers across the country and have the potential to create far-reaching awareness of innovative programs through their dissemination channels, while technical assistance centers can offer support to both innovators and adopters about the operational steps needed to spread or implement an innovation.
In the rare cases when an innovation has built sufficient momentum to create an interested market, it may be feasible to build a spread organization that operates on a commercial basis. For example, HealthMapRx™ was designed to help potential adopters implement the successful medication therapy management program popularized in Asheville. HealthMapRx™ provides consultation and specialized training, development of pharmacist networks, templates, and reports on patient data. Another successful example of creating a private consulting practice to spread an innovation is the formation of Action Pact Development, LLC, which evolved from earlier efforts to spread the household nursing home model started at the Meadowlark Hills Retirement Community in Manhattan, Kansas.8 Such efforts to build commercial consulting spread organizations are still relatively rare in health care.
New types of spread agents may emerge as the call for health care transformation escalates. Some participants in the Million Hearts™ event suggested that the role of the spread agent could be undertaken by other stakeholder groups. For example, David Pope, CreativePharmacist.com Brands, suggested that AHRQ, CDC, CMS, and other Federal agencies are well positioned to serve as spread agents, asserting that they have the capability to “be able to attach people together to say hey, I’ve been there. I’ve created something. Let me help you along.” Adam Zavadil, Alliance of Community Health Plans, also described an interesting peer network model. He shared how members of the alliance created a network of implementers who were attempting to adopt a medical home innovation within their communities. The adopter “champions” who were going to implement the practice changes in their own organizations used the support network to talk to one another, keep momentum going, and troubleshoot implementation barriers, which resulted in successful spread of the innovation.
Again, though the mechanisms, roles, and characteristics of spread agents are continually evolving, it is clear that the onus to spread an innovation does not rest solely with its creator. Instead, there must be a spreader infrastructure to connect innovators and their ideas to adopters who can benefit from them. The absence of such an infrastructure will likely slow down spread efforts, ultimately hindering progress toward significant improvements in health care.
8 Building a Consultation Path for Spreading Innovation in Long-Term Care. http://www.innovations.ahrq.gov/node/.