ARM 2016 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
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) Core Concepts/Technical Local Adaptations/Tasks Specifications Family member suspicion Reliable method for identifying MEWS >=5 deteriorating MEWS >=4 patients in real time 2 Nurses 1 Physician Appropriate assessment and care 1 Paramedic as soon as possible 1 Physician (with necessary cross-coverage) 1 Physician Standardized equipment Intubation & available at point of tracheotomy care equipment, drugs, etc. Theory Action
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 Summative Formative High degree of belief Moderate Low Pilot Phase Innovation/Prototype Phase Adapt, Spread, Scale-Up (test and (set design targets, develop (implement and disseminate revise/amend conceptual Ideas and predictions, and draft a successful model and an initial conceptual model and change package) change package) change package)
A Scale-up Framework Best Practice Build Test Phases exists Set- Scalable Scale-up, Go to Full- of Scale- up New Unit, Diverse Scale up Scale-up Prototype Contexts Idea Leadership, communication, social networks, culture Adoption of urgency and persistence Mechanisms Learning systems, data systems, infrastructure for Support scale-up, human capacity for scale-up, capability for Systems scale-up, sustainability
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