Scaling Up:

Scaling Up: Beyond the Moral Imperative to Strategies and Tactics Nana A. Y. Twum-Danso, MD, MPH, FACPM Founder & CEO, MAZA Senior Advisor, The Billions Institute Adjunct Assistant Professor, Gillings School of Global Public Health, UNC Chapel Hill Connections 2018 Conference

Healthcare Georgia Foundation March 29, 2018 Atlanta

Learning Objectives 1. Gain an introduction to selected frameworks for designing and executing large scale improvement 2. Apply selected frameworks to a scale-up challenge within your own organization

Strategies

Leading Change Eight Stages for Leading Change* 1. Establish a sense of urgency (i.e. burning platform) 2. Create guiding coalition or influential group to lead change 3. Develop a vision to direct the change effort and a strategy to achieve that vision 4. Communicate change vision often and widely so all members of the organization can articulate and understand it 5. Empower broad-based action by removing obstacles, creating structures to support change and encouraging local innovation

6. Generate short-term wins and make them visible to increase support for change, build momentum and win over laggards 7. Consolidate gains and produce more change 8. Anchor new approaches in the culture (i.e. ‘hardwire’ new system into organizational structure and eliminate old system) *Source: Adapted from Kotter JP. Leading Change, 1996

Achieving System-Level Improvement 1. Set Direction: Vision, Mission, Strategy Making the future attractive

PUSH

Changing the old

PULL

3. Build Will • Understand gap between current & ideal performance • Set bold aims & allocate resources • Be courageous • Use stories and data • Shine a light on positive deviants

5. Execute Change 4. Generate Ideas

• Establish accountability for results • Develop cadence • Focus on “big dots” • Foster enabling culture • Communicate results

2. Establish the Foundation •

• Establish quality oversight body (e.g. committee) • Build QI capability in board, senior execs, managers & frontline Develop culture of data transparency and interrogation at senior level

Source: Adapted from Reinertsen et al, 2008

Model for Unleashing

Source: Adapted from McCannon J et al, 2017

• What intervention is your organization trying to scale up?

Vision & Aims • Vision: • This is our shared image of the alternate future we will create, and it is the glue that holds us together. • When you overlay the reason that I’m here on top of the reason that you’re here, you get to vision.

• Aim: • What we’re going to do about it now.

Rationale for Aims • Aim channels energy from vision to precision -- a thrilling vision without a clear first step is actually demotivating. • Aim creates tension and tension creates action.

• Aim tests commitment. • Aim creates shared ownership and interdependence.

Principles for Setting Compelling Aims  Understand full scale of problem you are trying to solve. • What is your denominator? • Which sub-groups are most affected? • Which sub-groups are being left behind? • Which sub-groups experience the worst morbidity/mortality?

Obesity Trends in the US, by State over Time

Lung Cancer Incidence Rates in the US, by County

Racial Disparities in Maternal & Infant Outcomes in the US

Source: NPR

% of Deaths by Stroke by County, Georgia 2016

Legend:

Source: Georgia Department of Health, OASIS

Principles for Setting Compelling Aims  Understand full scale of problem you are trying to solve. • What is your denominator? • Which sub-groups are most affected? • Which sub-groups are being left behind? • Which sub-groups experience the worst morbidity/mortality?  Which sub-group(s) is your organization focused on?  What proportion of that denominator are you planning to reach?

Principles for Setting Compelling Aims  Understand full scale of problem.  Understand where you are in the expansion process.

Phases of Expansion Prototype

Pilot

Spread

Movement

Institutionalization

Culture/Meme Change

(e.g., collaborative)

(e.g., campaign)

(e.g. farmworker’s movement)

(e.g., regs, policy)

(e.g., #MeToo Movement )

Principles for Setting Compelling Aims  Understand full scale of problem.  Understand where you are in the expansion process.  Observe the rule of 5-10x.

Playworks’ Previous Expansion 7 years 7x

1000

930

900 800

# Schools

700 600 7 years 13 x

500 400 300

5 years 10 x

200 100

129

1

10

1996

2001

0 2008

2015

Playworks’ Next Phase of Scale 5 years 8x

8000

7000

7000

# Schools

6000 5000 7 years 7x

4000 7 years 13 x

3000 5 years 10 x

2000

930

1000 1

10

129

1996

2001

2008

0 2015

2020

Principles for Setting Compelling Aims  Understand full scale of problem.

 Understand where you are in the expansion process.  Observe the rule of 5-10x.  Walk the line between electrifying and electrocuting.

 Specify how much, by when.  Rate it and chunk it.

“Rating”  A rate can be more useful for an aim than a total count.  Example:  We want to get 1,500 middle school students demonstrating competency in computing coding in our school district by the end of 2020.

versus  We want to get 50 new middle school students per month demonstrating competency in computing coding in our school district by the end of 2020.

“Chunking”

A Loose Aim “Our aim is to spread what we know to reduce the development of diabetes in the US population.”

A Reasonable Aim “Our aim is to spread our intervention to 60,000 prediabetics in the next three years.”

A Better Aim “Our aim is to spread our intervention to 60,000 prediabetics in the next three years by getting 350 clinics to get 180 pre-diabetics each to adopt.”

An Excellent Aim “Our aim is to spread our intervention to 60,000 prediabetics in the next three years by getting 350 clinics to get 180 pre-diabetics each to adopt (i.e., 5 people per month per clinic).”

Principles for Setting Compelling Aims  Understand full scale of problem.

 Understand where you are in the expansion process (i.e., prototype, pilot, spread, movement, institutionalization, or culture change).  Observe the rule of 5-10x.  Walk the line between electrifying and electrocuting.  Specify how much, by when.  Rate it and chunk it.  Own it. (Tight on aims, loose on everything else)

• What’s your aim for scaling your organization’s most effective intervention(s)? • Which phase of expansion are you in? • How much scale are you aiming for? • By when?

• Can you “rate” it or ”chunk” it to make it more actionable for those at the frontlines?

Tactics

An Inescapable Fact No matter whether you’re trying to:

• • • • •

Build a prototype… Replicate a service… Open source a model… Sell a product… Influence a government policy…

…your job at the end of the day is to support complex behavior change, and to do so at scale. Gugulev and Stern, 2015

“Complex behavior change at scale” = Helping lots of people to actually do something different consistently

Gugulev and Stern, 2015

How to Get From Here to There?

HERE (MY SUCESSFUL PROTOTYPE OR PILOT)

????????????????????????????????????????????????

THERE (MANY PEOPLE HAVE ADOPTED – AND ADAPTED – THIS NEW IDEA OR PRACTICE)

How to Get From Here to There?

HERE (MY SUCESSFUL PROTOTYPE OR PILOT)

AWARENESS

WILL

BEHAVIOR CHNAGE

THERE (MANY PEOPLE HAVE ADOPTED – AND ADAPTED – THIS NEW IDEA OR PRACTICE)

Weak Methods to Scale Proven Interventions • • • • • • • • •

Exhortations Disseminating Guidelines Publishing in Peer-Reviewed Journals Trainings Courses Websites Conferences Etc. Etc.

Better Methods to Scale Method

Examples

Extension Agency

US Department of Agriculture

Extension Agent, c. 1925

Better Methods to Scale Method

Examples

Extension Agency

US Department of Agriculture

90-day projects (“sprints”)

Proctor & Gamble

90-Day Project The “Itch”

What the heck is going on here? Why are we so stuck on this problem?

90-Day Project The “Itch”

The Scan (Days 1-30) Who is the best at this? Inside our system? In a different sector? In the whole world?

90-Day Project

The “Itch”

The Scan (Days 1-30)

Tiniest Test (Days 31-60) Can I test my top 2-3 hypotheses in the smallest possible unit (e.g., one clinic, one street, one community, one day)?

90-Day Project

The “Itch”

The Scan (Days 1-30)

Tiniest Test (Days 31-60)

Small Test (Days 61-90) Can I test this in a handful of other units? Or a “wedge?”

90-Day Project

The “Itch”

The Scan (Days 1-30)

Tiniest Test (Days 31-60)

Small Test (Days 61-90)

90 more days

Decision

Spread (e.g. via collaborative, etc.)

Better Methods to Scale Method

Examples

Extension Agency

US Department of Agriculture

90-day projects

Proctor & Gamble

Grassroots organizing

Farmworkers’ movement; political campaigns

Better Methods to Scale Method

Examples

Extension Agency

US Department of Agriculture

90-day projects

Proctor & Gamble

Grassroots organizing

Farmworkers’ movement; political campaigns

Communities of practice

United Nations; World Bank; research collectives

Better Methods to Scale Method

Examples

Extension Agency

US Department of Agriculture

90-day projects

Proctor & Gamble

Grassroots organizing

Farmworkers’ movement; political campaigns

Communities of practice

United Nations; World Bank; research collectives

Breakthrough Series Collaborative

Institute for Healthcare Improvement; Carnegie Foundation

Breakthrough Series Collaborative Model

Source: The Institute for Healthcare Improvement, 2008

The Model for Improvement Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?

Act

Plan

Study

Do

Source: Associates in Process Improvement

Improvement Aims Measures

Ideas for Improvement

Learning System

Better Methods to Scale Method

Examples

Extension Agency

US Department of Agriculture

90-day projects

Proctor & Gamble

Grassroots organizing

Farmworkers’ movement; political campaigns

Communities of practice

United Nations; World Bank; research collectives

Breakthrough Series Collaborative model

Institute for Healthcare Improvement; Carnegie Foundation

Wedge and spread (waved collaborative model)

IHI; University Research Co.

Waved Collaborative (Project Fives Alive!, Ghana) Target population Children < 5yrs old

Months

2007

Start Up: 1 to 8 Preparation Building will Baseline data

No. of QI teams No. of sub-districts Source: Sodzi-Tettey et al, 2015

2008

2009

60,000

Wave 1: 9– 22 Piloting Building will Demonstration

30 25

2009

2012-2015

500,000

1.7 million

3.3 million

Wave 2: 23 - 63

Wave 3: 24-90

Wave 4: 63 – 90

Scale up, and piloting scale Scale up & piloting up methods in new areas Scale up with evolving hybrid approaches 228 195

330 222

709 544

Better Methods to Scale Method

Examples

Extension Agency

US Department of Agriculture

90-day projects

Proctor & Gamble

Grassroots organizing

Farmworkers’ movement; political campaigns

Communities of practice

United Nations; World Bank; research collectives

Breakthrough Series Collaborative model

Institute for Healthcare Improvement; Carnegie Foundation

Wedge and spread (waved collaborative model)

IHI; University Research Co.

Campaign model

100,000 Homes Campaign; 100,000 Lives Campaign

Campaign Field Operations Structure

Ongoing communication

Central Campaign Leadership

Framing and narration; expert support; barrier removal

NODES (75)

Recruitment and support of local work

Local Exemplars

PARTICIPANTS

Rapid learning and implementation

100,000 Lives Campaign

Better Methods to Scale Method

Examples

Extension Agency

US Department of Agriculture

90-day projects

Proctor & Gamble

Grassroots organizing

Farmworkers’ movement; political campaigns

Communities of practice

United Nations; World Bank; research collectives

Breakthrough Series Collaborative model

Institute for Healthcare Improvement; Carnegie Foundation

Wedge and spread (waved collaborative model)

IHI; University Research Co.

Campaign model

100,000 Homes Campaign; 100,000 Lives Campaign

AND MANY MORE… Gamification, Innovation Prizes, etc., along with many hybrids

• How would you choose the best method(s) for your context?

Method Selection Questions What is the nature of the intervention or practice we seek to spread?

Five Attributes that Facilitate Diffusion of Innovations

Relative Advantage

Compatible

Simple

Trialable

Observable

59 Source: Adapted from Everett Rogers, 2003

Source: Rogers, 1995

Method Selection Questions What is the nature of the intervention or practice we seek to spread? What stage of development are we in (e.g., prototype, pilot)?

Phases of Expansion Prototype

Pilot

Spread

Movement

Institutionalization

Culture/Meme Change

(e.g., collaborative)

(e.g., campaign)

(e.g. farmworker’s movement)

(e.g., regs, policy)

(e.g., #MeToo Movement )

Method Selection Questions What is the nature of the intervention or practice we seek to spread? What stage of development are we in (e.g., prototype, pilot)? What is the nature of our audience and the social system we seek to influence?

Diffusion of Innovation Curve

Source: Everett Rogers, 1995

Billions Institute, LLC

Method Selection Questions What is the nature of the intervention or practice we seek to spread? What stage of development are we in (e.g., prototype, pilot)? What is the nature of our audience and the social system we seek to influence? How much authority do we have over the actors in question?

Finding the Balance Catholicism vs. Buddhism

• We are typically seeking to introduce standard operating procedure, AND YET… • We are empowering those at the front lines to determine how to best make that happen in their specific context: • • • •

E.g.: How do we make this work in our particular school, health system, city, county? E.g.: What memory aides (e.g., checklists) will serve us best? E.g.: What forcing functions can we create? E.g.: What are all of the possible failure modes? How can we avoid each?

Source: Sutton & Rao, Scaling Up Excellence, 2014

Method Selection Questions What is the nature of the intervention or practice we seek to spread? What stage of development are we in (e.g., prototype, pilot)? What is the nature of our audience and the social system we seek to influence?? How much authority do we have over the actors in question? What are the characteristics of the messenger(s)?

Choice of Messenger(s) is Crucial

Source: ClipArt-Library.com

Method Selection Questions What is the nature of the intervention or practice we seek to spread? What stage of development are we in (e.g., prototype, pilot)? What is the nature of our audience and the social system we seek to influence?? How much authority do we have over the actors in question? What are our constraints (e.g., money, time)?

• Select a method(s) for scale up of your organization’s most effective interventions(s)? • What can you do next Tuesday to start or accelerate the scale-up process?

Good Luck!

References • Kotter JP. Leading change. (Boston: Harvard Business School Press, 1996)

• McCannon J, Margiotta B, Alyesh AZ. Unleashing large-scale change: eight ways to grow an unstoppable movement. Stanford Social Innovation Review, June 2017 • McCanon J, Massoud MR, Alyesh AZ. Many ways to many: a brief compendium of networked learning methods. Stanford Social Innovation Review, October 2016

• Reinertsen JL et al. Seven leadership leverage points for organization-level improvement in Health Care (2nd ed’n). (Cambridge, MA: Institute for Healthcare Improvement, 2008). Available at www.IHI.org. • Rogers E. Diffusion of innovations (New York: Free Press, 2003) • Sutton RI & Rao Huggy. Scaling up excellence: getting to more without settling for less. (New York: Crown Business, 2014) • Sodzi-Tettey S, Twum-Danso NAY, Mobisson-Etuk LN et al. Lessons learned from Ghana’s Project Fives Alive!: a guide for designing and executing large-scale improvement initiatives. (Cambridge, MA, USA: Institute for Healthcare Improvement, 2015)

• The Institute for Healthcare Improvement: The Breakthrough Series: IHI’s collaborative model for achieving breakthrough improvement (Cambridge, MA: The Institute for Healthcare Improvement, 2003). Available at www.ihi.org.

Contact Information Nana A. Y. Twum-Danso, MD, MPH, FACPM Founder & CEO, MAZA Senior Advisor, The Billions Institute Adjunct Assistant Professor, Gillings School of Global Public Health, University of North Carolina at Chapel Hill [email protected] or [email protected] Phone: +1-404-213-8422 / Twitter: @ntwumdanso Web: www.billionsinstitute.com