BOX 9-4
The Framework for Spread

The Framework for Spread, developed by the Veterans Health Administration (VHA) in partnership with the Institute for Healthcare Improvement (IHI), describes six focus areas to consider when attempting to spread an innovation across a system: leadership, identification of better ideas, communication, social systems, measurement and feedback, and knowledge management. These components were put into practice with the goal of expanding the use of innovations that improve access to care. First, leaders set a systemwide goal of expanding access and communicated that goal broadly. They showed their support by allocating funding and staff time to the initiative, aligned other ongoing projects with the new goal, and established points of contact and steering committees to lead and manage the effort. To communicate the initiative and its advantages, the organization developed a booklet and used its website to explain and communicate the ideas, including examples of success with the initiative in other settings. Next, the VHA identified a target group of clinics that would serve as early adopters of the initiative and would influence their peers to promote further spread. These learning initiatives were undertaken in waves to raise awareness and transfer technical knowledge to early adopters, with extra education being provided when needed. Finally, the VHA monitored its success in spreading the access-to-care initiative by measuring clinic wait times and the percentage of clinics that had implemented the initiative and by using the VHA website to share tips and successes. As a result of these efforts, wait times for primary care appointments decreased from 60.4 days to 28.4 days in 2 years.

SOURCE: Nolan et al., 2005.

overstated, positive deviance is an approach that organizations can use to encourage learning from those that are farther along. The premise of positive deviance is that certain members of a community possess wisdom about the solution to a problem and that other community members can generalize this wisdom to their own institutions to improve performance (Bradley et al., 2009). The approach calls for in-depth analysis of the processes and workflows that improve quality in learning organizations that face risks similar to those faced by the potential adopting organization. With incentives to adopt new practices in place, the adopting organization then tests innovations by taking advantage of existing organizational resources to increase buy-in and the sustainability of the change. Finally, implementation of the innovation is monitored, and the results are communicated to stakeholders and other potential adopters (Bradley et al., 2009; Marsh et al., 2004). Box 9-5 presents an example of the use of the positive deviance approach to improvement.

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