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Abstract
In this paper, we make a distinction between spreading and scaling innovations and spreading and scaling good practices for improvement, as many healthcare change practitioners often feel there is a “muddle” between them. We argue there are multiple factors where the spread and scale factors are similar for innovation and improvement, such as enabling leadership, the capacity and capability for spread and scale, a process of behaviour change, use of data and evidence and system alignment. However, there are multiple characteristics that may be different, including the level of complexity, the nature of the intervention, the approach to fidelity and adaptability, the source of the innovation or improvement and the outcome metrics. These insights enable us to be better equipped to design and deliver successful spread and scale strategies tailored to the specific intervention and situation and realise the full benefits of our change initiatives.
- Health Care Quality, Access, and Evaluation
- Health services research
- Policy
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Spreading and scaling of effective interventions in health and social care is seen as a priority for systems globally, aiming to maximise the value of these interventions and reach those who need them.1 Yet, spreading—the replication of an intervention from one location to multiple locations and scaling up—requiring infrastructural changes to support implementation at scale widely,2 remain huge challenges and topics of extensive exploration among practitioners, researchers and policy-makers.3
Most of the advice available to practitioners, and most research outputs, treat spreading and scaling innovation and spreading and scaling improvement as a similar generic approach. And despite previous calls for innovation and improvement to be seen as distinct,4 they are often blurred into one by researchers and policy-makers.5 As the American Society for Quality notes, although the two concepts are different, ‘innovation and improvement are often referred to in tandem’.6 We argue that this can lead to supoptimal design processes for spread and scale, confused roles and reduced outcomes.
We make a distinction between clinical innovations and good practices for improvement which is critical when planning for their spread and scale. We define a clinical innovation (herein ‘innovation’) as an idea, technology, medicine or object that is new to accepted standards of care and has the potential to offer a substantial positive impact on health-related outcomes with disruption to current service delivery models while a good practice for improvement (herein ‘improvement’) is a change to an existing practice that has been tested in one or more contexts and shown to improve outcomes, which may be adapted and adopted in other contexts.
The approach for spreading and scaling an innovation may be different to spreading and scaling an improvement. For instance, an innovative medicine such as asthma biologic injections for severe asthma,7 or a digital innovation such as the National Health Service App,8 or new equipment such as fractional exhaled nitric oxide measurement device,9 all represent something new to accepted care, and therefore, require a strategy that recognises this throughout the planning and implementation stages. In contrast, an improvement such as integrating patient tracking lists across an Integrated Care System,10 or introducing General Practitioners with Extended Roles11 or guidance for safe handovers, all represent a change to an existing practice, and therefore, require an alternative approach to spread.
The distinction is not always clear. There is a wide range of practices, technologies, pathways and other interventions to be spread and scaled that do not fit in a binary frame of ‘innovation or improvement’. There are situations where the introduction of an innovation requires changes in practice that could be categorised as an improvement. The spread process could move from one to the other. However, by distinguishing between these two concepts, even with these caveats, we can identify similarities and differences that help our understanding of the challenges and inform our choice of spread and scale strategy.
Commonality: elements of an effective spread and scale strategy that are shared for innovations and improvements
The literature and synthesis of the tacit knowledge of practitioners12 identifies shared characteristics that support the spread and scale of both innovations and improvements:
Culture and leadership: Having an enabling leadership approach creates the conditions where experimentation, learning and collaboration can flourish. It involves leaders in formal positions—often including working in coproduction with service users and teams working at the point of care to identify and spread solutions to problems. Change in clinical settings requires strong clinical leadership, working with others who can help make the change happen, such as middle managers.13 It requires balancing business as usual and the testing of new ways of working and a regulatory environment that supports modification without compromising patient safety. A well-led organisation with elements of a learning health system14 will provide a more receptive local context for the spread of innovations and improvements.
Capacity and capability: Adopters require the resources, time and energy (capacity) and the skills, knowledge and learning potential (capability) to identify, use and adapt the innovations or improvements for their own context. Previous work has highlighted the importance of adopters to be ability to distinguish between core elements of innovation, which are well defined, and peripheral elements, that are less clear and more flexible to manipulation by the adopting system.15
Behaviour change: Successful spread and scale involves a process of influencing people’s beliefs, attitudes and actions. People change their own behaviour, in response to other changes, so ‘pushing’ solutions onto people is typically a less effective strategy than supporting the behaviour change of adoptees and creating a ‘pull’ into the system.16 Professional networks can play a key role in peer to peer influencing for behaviour change.17
Data and evidence: Clear articulation of the evidence of potential benefit is needed to meet the level required by adopters. Different audiences will require different forms of evidence, such as clinical effectiveness, health economics and service user experience. The quality of evidence required for an innovation or improvement is intrinsically linked to its purpose18 and the opportunities for benefits and harms to service users.19
Finance and budgeting: Financial mechanisms, such as providing additional financial support for pathway transformation, are key. Alignment with annual health and care budget cycles to allow timely planning for change is important. Payment systems should reflect that improved patient outcomes may occur over a longer time frame, or downstream in the pathway of the point where the intervention was implemented.
System cohesion: This includes alignment of stakeholder priorities, clarity on roles and responsibilities for the intervention across the system and ensuring the intervention addresses a shared strategic priority with clearly articulated anticipated benefits. The decision process to identify which innovations or improvements should be prioritised and in which contexts by, for example, inclusion in commissioning or national guidelines, needs to be transparent and consistent. Alignment on how to capture unintended consequences or scale back an unsuccessful intervention should also be considered.
Sustainability: How a change is spread and adopted directly impacts on its sustainability.20 Where the spread process is developed collaboratively and people get the opportunity to test and adapt the change in their own context, it is more likely to be sustained than a change that is imposed on them.
Divergence: elements of an effective spread and scale strategy that might differ between innovations and improvements
Table 1 identifies 12 characteristics and describes how they might align or diverge for innovations and improvements. Every spread and scale context is unique so these characteristics are heuristics (rules of thumb) that are more likely or might apply in a given context, rather than hard and fast statements.21
Differences in spread and scale strategy between innovations and improvements
For illustration, an innovation such as a new drug only for hospital administration is a clearly defined entity with evidence of administration requirements, safety and anticipated benefits and risks. This new drug is likely to significantly advance treatment options or outcomes. Although the process of introducing the drug may be seen as simple,22 as clearly defined and bounded, the context in which it is implemented may be complex so causing disruption. There is likely to be a defined clinical leader who can influence colleagues within the small, connected clinical community.
In contrast, an improvement, such as a new service to treat people needing acute care at home rather than in hospital, may be more difficult to define with its many interdependent components, requiring local adaptation and review during implementation. The intervention is complex in nature, as is the context. Leadership requires developing strong relationships across professional and organisational boundaries to connect a large, diverse community across many health and care sectors.
Conclusions
The authors of this paper include a group of healthcare change practitioners who have felt this ‘muddle’ between spreading innovation and spreading improvement over two decades of practice. We have discussed the issue with hundreds of fellow innovators and improvers who agree that this is an issue but no one has written about it before.
Our motivation in writing this paper is to set out some of the differences between scaling and spreading innovations and improvements to support practitioners to make better choices in planning spread and scale strategies (figure 1). We recognise that it is sometimes difficult to differentiate between two separate buckets labelled ‘innovation and ‘improvement’ and that there is some overlap. However, our belief is that practitioners of innovation and improvement will be able to create more effective spread and scale strategies for action by taking account of the factors we have identified. We have created this opinion piece to reflect practitioner need and focus in this area, and also in the hope that by shining a light on this topic, it can be the focus of further research.
Spreading clinical innovation and spreading good practices for improvement.
What we offer is a set of factors that we have observed through many years of practice in scale-up and spread initiatives, at national and local levels in the UK and with other health and care systems internationally.23 Not every factor will apply in every spread and scale project. The ability to spread and scale remains one of the greatest challenges for leaders of change in the health system. We hope that by encouraging reflection about these factors, we can make it the smallest bit easier.
Ethics statements
Patient consent for publication
Acknowledgments
We would like to thank the artist Tanmay Vora, who was commissioned to design Figure 1.
Footnotes
HB and DK are joint first authors.
X @HelenBevan, @DianeKetley, @CharitiniSt
HB and DK contributed equally.
Contributors HB and DK contributed equally to this paper. HB and DK were responsible for the conception of the viewpoint and drafted the first version. RC, CS and HS reviewed the manuscript and contributed to subsequent versions. All authors approved the final version submitted.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.