Why Do So Many Promising Innovations Fail to Spread? Don Goldmann, - - PowerPoint PPT Presentation

Why Do So Many Promising Innovations Fail to Spread?

Don Goldmann, MD Chief Medical and Scientific Officer, IHI Clinical Professor of Pediatrics, Harvard Medical School Professor of Immunology and Infectious Diseases, and Epidemiology, Harvard TH Chan School of Public Health @Dagoldmann

ARM 2016

Technical Specifications and Core Concepts

• Most innovators are sloppy about documenting the technical

specifications of their innovation so that others can understand exactly what is needed to implement the innovation

– Technical specifications include infrastructure requirements, supply chain,

personnel and resources, data systems, and other elements critical for success

• In particular, it is important to document the core concepts which

must be implemented with fidelity, versus those elements which must be adapted to local contexts and conditions

• Lessons from the Commonwealth Fund/IHI Innovators Network

Core Specifications & Local Adaptations: Rapid Response Teams (METs)

MEWS >=5

Reliable method for identifying deteriorating patients in real time Appropriate assessment and care as soon as possible (with necessary cross-coverage)

MEWS >=4 2 Nurses 1 Physician 1 Paramedic 1 Physician 1 Physician

Action Theory

Core Concepts/Technical Specifications Local Adaptations/Tasks

Standardized equipment available at point of care

Family member suspicion

Intubation & tracheotomy equipment, drugs, etc.

Mixed Results in Scaling Up Surgical Checklists: Oversimplifying Core Concepts and Context?

Conclusions: Implementation of surgical safety checklists in Ontario, Canada, was not associated with a significant reductions in operative mortality or complications.

A Michigan Keystone initiative also failed to show reductions in complications, but the checklist was not faithful to the core specifications of the Gawande/WHO checklist

Possible Explanations for Disappointing Results

• Mandates lead to a “check the box” mentality, not thoughtful

implementation

• Nearly 100% compliance in an entire province for all checklist

elements??

• No attention to differences in Ontario hospitals or to

variability in surgical service context within these hospitals

• Implementation was rapid and not accompanied by team

training or serious efforts to change operating theatre culture

• Rates of complications and mortality were much lower in

Ontario at baseline than in the Gawande study, even post- intervention (“ceiling effect”)

So Let’s Follow a Concept from Innovation to Prototype to Spread and Scale-Up

Degree of Belief in Change Ideas

degree of belief

Innovation/Prototype Phase

(set design targets, develop Ideas and predictions, and draft an initial conceptual model and change package)

Pilot Phase

(test and revise/amend conceptual model and change package)

Adapt, Spread, Scale-Up

(implement and disseminate a successful change package)

High Moderate Low Formative Summative

A Scale-up Framework

Adoption Mechanisms

Set- up Build Scalable Unit, Prototype Test Scale-up, Diverse Contexts Go to Full- Scale

Support Systems Phases

• f Scale-

up

Best Practice exists New Scale-up Idea

Leadership, communication, social networks, culture

• f urgency and persistence

Learning systems, data systems, infrastructure for scale-up, human capacity for scale-up, capability for scale-up, sustainability