Government As Innovation Catalyst: Lessons From The Early Center For Medicare And Medicaid Innovation Models.

Congress established the Center for Medicare and Medicaid Innovation (CMMI) to design, test, and spread innovative payment and service delivery models that either reduce spending without reducing the quality of care or improve the quality of care without increasing spending. CMMI sought to leverage these models to foster market innovation and accelerate the transformation of payment and care delivery to achieve the Triple Aim of better health, better care, and lower cost. This article provides a perspective on the design and execution of CMMI's five initial models, the resulting outcomes and lessons, and how their core concepts evolved within and spread beyond CMMI. This experience yields three key insights that could inform future efforts by CMMI and public and private payers, including model designs and policy decisions. These insights center on the need for iterative testing and learning guided by market feedback, more realistic time frames to demonstrate impact on cost and quality, and greater integration of models.

How complexity science can inform scale-up and spread in health care: understanding the role of self-organization in variation across local contexts.

Health care systems struggle to scale-up and spread effective practices across diverse settings. Failures in scale-up and spread (SUS) are often attributed to a lack of consideration for variation in local contexts among different health care delivery settings. We argue that SUS occurs within complex systems and that self-organization plays an important role in the success, or failure, of SUS. Self-organization is a process whereby local interactions give rise to patterns of organizing. These patterns may be stable or unstable, and they evolve over time. Self-organization is a major contributor to local variations across health care delivery settings. Thus, better understanding of self-organization in the context of SUS is needed. We re-examine two cases of successful SUS: 1) the application of a mobile phone short message service intervention to improve adherence to medications during HIV treatment scale up in resource-limited settings, and 2) MRSA prevention in hospital inpatient settings in the United States. Based on insights from these cases, we discuss the role of interdependencies and sensemaking in leveraging self-organization in SUS initiatives. We argue that self-organization, while not completely controllable, can be influenced, and that improving interdependencies and sensemaking among SUS stakeholders is a strategy for facilitating self-organization processes that increase the probability of spreading effective practices across diverse settings.

How it's done: Keys to implementation of delivery system reform.

The vision of Obamacare - including the expansion of health care coverage to millions more Americans - rests in no small part on the reduction of health care waste and the spread of cheaper, more sustainable models of health care delivery. Though this will require thoughtful policy, powerful payment incentives and innovative new models of care delivery, it will also require all health care industry stakeholders to execute rapid, large-scale change in practice much more effectively. This paper offers nine strategies for more successfully managing this transformative change.

A stakeholder-driven agenda for advancing the science and practice of scale-up and spread in health.

BACKGROUND: Although significant advances have been made in implementation science, comparatively less attention has been paid to broader scale-up and spread of effective health programs at the regional, national, or international level. To address this gap in research, practice and policy attention, representatives from key stakeholder groups launched an initiative to identify gaps and stimulate additional interest and activity in scale-up and spread of effective health programs. We describe the background and motivation for this initiative and the content, process, and outcomes of two main phases comprising the core of the initiative: a state-of-the-art conference to develop recommendations for advancing scale-up and spread and a follow-up activity to operationalize and prioritize the recommendations. The conference was held in Washington, D.C. during July 2010 and attended by 100 representatives from research, practice, policy, public health, healthcare, and international health communities; the follow-up activity was conducted remotely the following year. DISCUSSION: Conference attendees identified and prioritized five recommendations (and corresponding sub-recommendations) for advancing scale-up and spread in health: increase awareness, facilitate information exchange, develop new methods, apply new approaches for evaluation, and expand capacity. In the follow-up activity, 'develop new methods' was rated as most important recommendation; expanding capacity was rated as least important, although differences were relatively minor. SUMMARY: Based on the results of these efforts, we discuss priority activities that are needed to advance research, practice and policy to accelerate the scale-up and spread of effective health programs.

A nationwide quality improvement project to accelerate Ghana's progress toward Millennium Development Goal Four: design and implementation progress.

QUALITY PROBLEM: The gap between evidence-based guidelines and practice of care is reflected, in low- and middle-income countries, by high rates of maternal and child mortality and limited effectiveness of large-scale programing to decrease those rates. CHOICE OF SOLUTION: We designed a phased, rapid, national scale-up quality improvement (QI) intervention to accelerate the achievement of Millennium Development Goal Four in Ghana. Our intervention promoted systems thinking, active participation of managers and frontline providers, generation and testing of local change ideas using iterative learning from transparent district and local data, local ownership and sustainability. IMPLEMENTATION: After 50 months of implementation, we have completed two prototype learning phases and have begun regional spread phases to all health facilities in all 38 districts of the three northernmost regions and all 29 Catholic hospitals in the remaining regions of the country. To accelerate the spread of improvement, we developed 'change packages' of rigorously tested process changes along the continuum of care from pregnancy to age 5 in both inpatient and outpatient settings. LESSONS LEARNED: The primary successes for the project so far include broad and deep adoption of QI by local stakeholders for improving system performance, widespread capacitation of leaders, managers and frontline providers in QI methods, incorporation of local ideas into change packages and successful scale-up to approximately 25% of the country's districts in 3 years. Implementation challenges include variable leadership uptake and commitment at the district level, delays due to recruiting and scheduling barriers, weak data systems and repeated QI training due to high staff turnover.

Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign.

BACKGROUND: Little is known about how hospital organizational and cultural factors associated with implementation of quality initiatives such as the Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign differ among levels of healthcare staff. DESIGN: Evaluation of a mixed qualitative and quantitative methodology ("trilogic evaluation model"). SETTING: Six hospitals that joined the campaign before June 2006. PARTICIPANTS: Three strata of staff (executive leadership, midlevel, and frontline) at each hospital. RESULTS. Surveys were completed in 2008 by 135 hospital personnel (midlevel, 43.7%; frontline, 38.5%; executive, 17.8%) who also participated in 20 focus groups. Overall, 93% of participants were aware of the IHI campaign in their hospital and perceived that 58% (standard deviation, 22.7%) of improvements in quality at their hospital were a direct result of the campaign. There were significant differences between staff levels on the organizational culture (OC) items, with executive-level staff having higher scores than midlevel and frontline staff. All 20 focus groups perceived that the campaign interventions were sustainable and that data feedback, buy-in, hardwiring (into daily activities), and leadership support were essential to sustainability. CONCLUSIONS: The trilogic model demonstrated that the 3 levels of staff had markedly different perceptions regarding the IHI campaign and OC. A framework in which frontline, midlevel, and leadership staff are simultaneously assessed may be a useful tool for future evaluations of OC and quality initiatives such as the IHI campaign.

Learning networks for sustainable, large-scale improvement.

Large-scale improvement efforts known as improvement networks offer structured opportunities for exchange of information and insights into the adaptation of clinical protocols to a variety of settings.

Miles to go: an introduction to the 5 Million Lives Campaign.

BACKGROUND: The Institute for Healthcare Improvement (IHI)'s 5 Million Lives Campaign targets a reduction of five million instances of harm from December 2006 through December 2008. The campaign continues the six interventions of the 100,000 Lives Campaign and adds six more. DEFINITION OF MEDICAL HARM AND SETTING THE GOAL: The campaign's aim is to support the reduction of medical harm, so defined: "Unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment, or hospitalization, or that results in death." The goal of a reduction of five million incidents of harm in two years is based on an estimate that 40 to 50 incidents occur per 100 admissions, for a total of 15 million incidents of medical harm each year in the United States. THE 5 MILLION LIVES CAMPAIGN'S "PLATFORM": This campaign's six new interventions address the prevention of pressure ulcers, reduction of methicillin-resistant Staphylococcus aureus (MRSA) infection, prevention of harm from high-alert medications, reduction of surgical complications, delivery of reliable and evidence-based care for congestive heart failure, and getting hospitals' boards of directors on board. CONCLUSION: Together with complementary partner initiatives, the 5 Million Lives Campaign is intended to act as a major driver of national improvement.

Strategies for the scale-up of antiretroviral therapy in South Africa through health system optimization.

In the face of the massive burden created by human immunodeficiency virus/acquired immunodeficiency syndrome and other infectious diseases, developing nations must find ways to rapidly begin treatment for infected persons. Although infusions of personnel, supplies, and diagnostics would make a major contribution to expanding the capacity to treat these diseases, the lack of these resources creates a long-term challenge, and there is a need for additional approaches to spread effective interventions that can leverage existing resources and the much-needed infusions of new resources. This article describes one such approach-applied in several forms in South Africa-that aims to significantly increase the number of patients receiving antiretroviral therapy.