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Spreading Improvement

Much improvement work starts in small local projects and unfortunately fails to embed or spread. This section looks at what can help to sustain the gains and how to grow the work by spreading into other services, scaling up across regions or organically through networks considering the tensions of fidelity and adaptation to local context.

The process of moving from local ‘successful’ project, to enabling the intervention to grow into a programme, with wide take up among other geographically dispersed services, which are then able to achieve similar results from applying the intervention is one of the key challenges for quality improvement in health care.

All the focus and attention to detail that enabled the initial successful development is still needed to scale up the work, together with a depth of management expertise, and the skills to explain the concept, inspire others, offer support and training in the approach, while at the same time accepting that adopters will introduce different approaches and adaptations to the intervention that can be equally successful.

Four key elements to support spread and scale up are:

  • Deep understanding of the improvement idea and what has to be implemented with fidelity across healthcare settings to produce the same improvement.
  • Clarity of the change mechanism that brings about improvement and the QI tools to achieve this.
  • Using co-production approaches to involve patients and front-line staff in the local implementation and adaptations to make the intervention work in their setting.
  • Support for ‘adopter’ teams and celebration of second leaders that emerge through the scale-up process.

Preparing a locally developed intervention for scaling up requires acknowledgement of the complexity of the intervention.   A clear definition with itemised components will help potential adopters to understand what is likely to be involved and if they are ready to take it on.  The process of itemising the core elements helps to inform the discussion about the extent of local adaptability that is desirable and necessary for the intervention work in different contexts and the core essential components which must be retained.  Fidelity refers to the degree to which an intervention or programme is delivered as intended by the originators of the intervention.  It is important to strike a balance between top-down dissemination of a fixed intervention, versus each team deciding for themselves how to implement the intervention and what to include.  It is one of the keys to success for scale-up to get this balance right.

The Health Foundation – The spread challenge


Greenhalgh T, Papoutsi C. Spreading and scaling up innovation and improvement, BMJ 2019; 365: l2068 doi:10.1136/bmj.l2068


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