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Building a culture of support

Accreditation Connection, November 21, 2005

Maria Schall, MA, director of IHI's Spread Initiative, says it takes persistent leadership to speed up the process of spreading and driving improvement through the building of an appropriate organizational culture.

She lamented that spreading improvement across healthcare organizations takes longer than it should. One of the challenges for organizations engaging in quality improvement is moving beyond initial success and maintaining improvement over time. What often occurs is the "bathtub effect"--initial decline in failure rates, maintained for a time, and then an increase back to previous failure rates.

Developing and understanding improvement and moving to spread-- and thereby maintaining improvement--is related to building a culture and making the infrastructure changes to support it, Schall says.

When is your organization ready for spread? When you have confidence that the changes will yield positive, measurable results. "You have to distinguish between improvements that are just beginning to be discovered and those that have been shown to work in other places," Schall says.

The bottom line is if a change gets positive results in other places, then it's ready for spread.

Even with positive results, however, spread is not an easy task. One of the keys is to get "early adopters" on board. "Work with the people that are willing to work with you," Schall says. Early adopters are a way to get started as opposed to trying to get everyone on board at once.

When done successfully, early adopters will lead to an early majority within your organization, followed by a late majority, and finally the laggards. "There are a number of phases to developing a plan--successive waves of adopters," Schall says. 

Schall described four levels of spread activity:

Level 1: Leadership support and general communication

Level 2: Integration of early adopters

Level 3: Potential adopters moved to action

Level 4: Feedback to monitor and facilitate behavior change and improved outcomes

Integration of adopters involves "going a little deeper into the organization," Schall says.

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