“Which pieces of this innovation are really going to be critical? This knowledge can generate the spiral of spread.” - Michael Harrison, AHRQ
Any conversation about scale up and spread must explore the specific features of the innovation. Discussions from the events identified the characteristics and structure of the innovation that optimize successful proliferation, which involved clarifying spread goals, preparing an innovation for spread, reducing costs, ensuring fidelity to the model, and clearly articulating the benefits of the innovation. Though these themes partially reflect the innovation characteristics that Everett Rogers defined as influencing the decision to adopt or reject an innovation (i.e., triability and complexity/simplicity), many of the suggestions captured during these events provide a different perspective about what constitutes an innovation’s readiness to spread.
Prepare the innovation for spread
There was general agreement that innovations should undergo some purposeful preparation for spread. Event participants thought that innovations should be tailored for spread by refining and simplifying the elements of the innovation, since scaling a simple, well-defined innovation is intuitively easier. Recommendations included identifying the “core elements” of an innovation – those that make it not only unique and specific, but also functional for replication – and focusing on how to make the innovation most efficient. Additional suggestions included considering the patient and family perspective when preparing an innovation for spread, perhaps even seeking their input when determining which innovation attributes are crucial to preserve, and integrating scale up and spread activities into the initial planning phases of an innovation.
Clarify spread goals
Innovators interested in spread need to clarify their goals for spread in order to guide their strategies for spread. As Lisa Suennen explained, “Whether it’s selling five widgets or world domination, whatever it is, it needs to be something that defines what are you trying to be when you grow up? And how are you going to know when you got there measurably?” For example, innovators with a goal of national spread of a treatment protocol or formation of a for-profit health information technology (HIT) firm would be likely to opt for more complex spread strategies than those hoping to spread a program throughout their local communities.
Cost issues were consistently mentioned throughout the scale up and spread events. To this end, innovations should aim to reduce the costs associated with implementing and sustaining the program. The costs of adopting the innovation should not be prohibitive and, to the extent possible, should be minimized to a reasonable and manageable level.
Adam Zavadil advised also looking for the “hidden costs” of an innovation such as departmental costs and warned that without accounting for such expenses, the cost savings associated with the innovation may be misleading to health plans and other payers. He also cautioned innovators to consider costs borne by patients and their families, such as time away from work and transportation costs. Hidden costs can also include services such as the remote weight measurement devices in Linda Wick’s innovation or exercise activities in Joseph’s Skelton’s innovation that are vital to its success, but that are not covered by major payers. The result is that they must be absorbed by the innovator’s organization, reducing the innovation’s overall cost effectiveness.
For innovations that are primarily provider-based, another cost-reduction strategy is to limit the role of expensive providers and use alternative staffing and technology as much as possible. For example, Janelle Moerer encouraged innovators to think about “the new workforce or what new technician could begin to emerge to take some of the cost out.” When appropriate or feasible, Sharon Schindler Rising recommended use of group sessions since this approach offers a valuable network and support for patients and families, while also achieving efficiencies for the provider organization.
Ensure fidelity to the model
Tom Graf explained that the Geisinger Health System found after experimentation that innovations are best spread when they are “95% baked.” This prescription leaves little room for local variation, and may have to be adjusted somewhat for spread across different health system models. Geisinger takes further steps to ensure that a site can successfully adopt a highly developed innovation, including careful selection of early adopter sites and supply of technical assistance and other resources. David Dorr said that the Care Management Plus evaluates adopters over time to track their fidelity to the model.
Strongly state the benefits of the innovation
For an innovation to spread, its benefits must be strong, compelling, and communicated in a comprehensible way to target audiences. Sometimes translating outcomes from scientific to lay audiences can be challenging. In the case of Joseph Skelton’s obesity program, for example, the key indicator of weight loss in growing children needs a more accessible measure than the BMI z score, the scientific measure of weight loss. In the words of Steve Shields, “[A]ny deep change is really hard to explain to people. And so a key thing is you have to find a way to show a measurable way of improvement or you won’t get anywhere.” Additionally, articulating the advantages of certain innovations, such as those aiming for long-term benefits, may be more difficult since the current health care climate and reimbursement structure tend to recognize the value of programs that produce near term results.