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Keys to Effective Spread and Scale-up:Lessons Learned from Other Fields andSectorsJOE MCCANNON4.2.2014

Defining Terms (Stages of Expansion) Prototype: Test and adapt new ideas to learn whatworks in your system. Pilot: Apply to a slightly larger, more variedaudience. Spread: Actively engage individuals outside thepilot adopt the effective practice, reaching thelargest audience possible. Scale-up: Address the infrastructure issues thatarise during spread.

Where is the Project?Successful practicesHighDegree ofbelief that thechanges willresult inimprovementatsuccessivelylarger scalesChanges still needfurther testing.There is a risk inmoving to lotSpread

Standard Theory of Spread Well-refined intervention Deep knowledge of the intended audience Some method of persuasion Some method of dissemination of knowledge

Attributes of an Idea that Facilitate eObservable

Types of opters2%13%35%35%Traditionalists15%6Source: Rogers, 1995

Stimulants Empowerment RecognitionPOSITIVE Collaboration Enjoyment Payment Transparency Regulation PunishmentNEGATIVE

Methods for Spread Breakthrough Series Collaborative modelExtension agentsEmergency mobilizationCampaign modelGrassroots organizingWave sequence (wedge and spread)Broad and deepDivide and multiplyHybrid models

October 2013

Pitfalls and KeysPitfallVague goalsKey

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)

100,000 Homes Campaign Aim: House 100,000 of America’s most vulnerablehomeless by mid-2014. The math: 2-3 megacities to house 40% of their unshelteredpopulation;50 high-burden communities to house 300 per year;75 middle-burden communities to house 100 per year;125 lower-burden communities to house 100 each;10,000 families.

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an idea

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an ideaBarrier removal

Some Barriers Crowded marketplace of ideas Values Inertia Defensiveness Workload Weak hypotheses about what spreads new practice(e.g., publishing, web sites) Fear

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an ideaBarrier removalTheory lock

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an ideaBarrier removalTheory lockMany levers

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an ideaBarrier removalTheory lockMany leversLogic

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an ideaBarrier removalTheory lockMany leversLogicLogic AND emotion

Variation in Medicare Spending and Quality of CareTotal Rates ofReimbursement forNoncapitatedMedicare perEnrolleeSource: E. Fisher, D. Goodman, J. Skinner, and K. Bronner, Health Care Spending, Quality, and Outcomes, (Hanover: The Dartmouth Institute for HealthPolicy and Clinical Practice, Feb. 2009).

Ed Givens (Before)

Ed Givens (After)

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an ideaBarrier removalTheory lockMany leversLogicLogic AND emotionConsensus

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an ideaBarrier removalTheory lockMany leversLogicLogic AND emotionConsensusAdaptation

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an ideaBarrier removalTheory lockMany leversLogicLogic AND emotionConsensusAdaptationControlling

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an ideaBarrier removalTheory lockMany leversLogicLogic AND emotionConsensusAdaptationControllingUnleashing

The John Cusack Rule “Keep the set free of fear.” Create safe “container” for tryingand failing. Waste no will. Manage the control continuum.

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an ideaBarrier removalTheory lockMany leversLogicLogic AND id evaluation

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an ideaBarrier removalTheory lockMany leversLogicLogic AND id evaluationDaily data

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an ideaBarrier removalTheory lockMany leversLogicLogic AND id evaluationDaily dataTeaching programs

Pitfalls and KeysPitfallKeyVague goalsExplicit objectives (5 to 10x rule)Exhortation, pushing an ideaBarrier removalTheory lockMany leversLogicLogic AND id evaluationDaily dataTeaching programsLearning systems

Approaches to Supporting Behavior Change atScaleCommon approaches: Courses Web sites Conferences

Approaches to Supporting Behavior Change atScaleCommon approaches: Courses Web sites ConferencesAlternate approaches: Rhythmic testing (e.g., weekly, bi-weekly) Itinerant coaches Field operations (customer obsession)

Testable Resource Dimensions Human resources Financial resources Physical space Technology Oversight Delivery requirements (e.g., supplies)

“I think when people look back at ourtime, they will be amazed at one thingmore than any other. It is this – that wedo know more about ourselves now thanpeople did in the past, but that very littleof this knowledge has been put intoeffect.”Doris Lessing

Vague goals Explicit objectives (5 to 10x rule) Exhortation, pushing an idea Barrier removal Theory lock Many levers Logic Logic AND emotion Consensus Adaptation Controlling Unleashing Rigid evaluation Daily data Teaching programs Learning systems Design for success