|By Brian Mittman, PhD, Senior Advisor, Department of Veterans Affairs (VA) Center for Implementation Practice and Research Support; Senior Scientist, Department of Research and Evaluation, Kaiser Permanente Southern California; Member, Innovations Exchange Editorial Board|
Health service innovation champions as well as policy and practice leaders have a great interest in promoting the widespread adoption of innovations that have been shown to be effective in improving performance. Key factors that influence the success of scale-up and spread efforts include the features of innovations, the target settings, the role of innovation leaders in promoting implementation, and effective strategies for facilitating the scale up and spread of innovations.
Definitions and Key Points
Widely accepted definitions of the terms “scale up” and “spread” are not available, in part because research on these concepts within the implementation science field remains relatively new and sparse. Researchers working with ExpandNet (a World Health Organization initiative focused on reproductive health) have defined scale up as “deliberate efforts to increase the impact of health service innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and program development on a lasting basis.”1 The concept of spread is generally understood as meaning to extend widely over a large area, or to cause something to do so. Some researchers have used the term “dissemination” to describe the large-scale roll-out, scale up, or spread of an innovation following its implementation in a limited number of settings.
It is important to guard against the “implementation fallacy,” which is the assumption that good ideas will be adopted spontaneously. We must keep in mind that innovations are not self-spreading or self-replicating. Society’s enormous investment in research to develop health care innovations will fail to yield significant benefit if they are not implemented appropriately in practice, and this does not happen spontaneously. To fully achieve the promise of innovations, we need active implementation efforts that are guided by implementation research.
Overcoming Challenges to Scale Up and Spread
When an innovation is implemented and evaluated in a small-scale research environment, we tend to attribute successful adoption to the implementation process itself. Yet to some extent, success may be attributable to the availability of exceptional resources that are provided by a central project team, including individualized technical assistance, funding for new services, and support for hiring and training of new staff. As a result, efficacy-oriented implementation studies may produce findings that cannot be applied readily in other practice settings, but must be followed by effectiveness-oriented implementation studies that do not involve access to the extra resources that typically are available only in the context of grant-supported research.
In addition to coping with the lack of special resources, successful scale-up and spread efforts must deal with challenges related to the features of the innovation itself, as well as challenges related to the features of target adopters, environmental conditions, innovation champions, and scale up and spread strategies.
Innovation features. We’ve known for decades that certain features of innovations—including benefits, relevance, feasibility, and adoptability—increase the likelihood that an innovation will spread and achieve widespread adoption. If some or many of these features are absent, potential adopters have limited options: They may look for ways to modify the innovation, identify tradeoffs that can help compensate for shortcomings, or seek alternative innovations.
Target adopters. An organization that is seeking to adopt an innovation needs to have appropriate resources, including staffing, skills, time, space, equipment, and funds. If any of these are absent or limited, the organization that is seeking to adopt an innovation may be able to develop them in order to better support the implementation process.
Environmental conditions. The environment plays a greater role in scale-up and spread efforts than in small-scale implementations, which are heavily influenced by “push” factors such as a research team that exhorts staff at an intervention site to adopt innovative practices. In contrast, scale up and spread efforts rely more on demand (or “pull”) factors, such as external pressures, regulatory or normative expectations, incentives and rewards, and other supportive resources. If these environmental factors are absent or limited in organizations seeking to adopt an innovation, it may be possible to develop some of them.
Innovation champions. Innovations rarely spread spontaneously, but typically require a dedicated person or organization to encourage, guide, and support widespread adoption. The innovation champion must possess appropriate attributes such as resources, capacity, skill, respect, and influence.
Scale-up and spread strategies. The characteristics of the scale-up and spread strategy or intervention are important factors. Key principles include the need to develop, enhance, or leverage demand (pull); communication to achieve awareness of the innovation and understanding of requirements; and any technical assistance, tools, and resources that may be needed.
Based on this brief overview, we can identify several factors that can contribute to successful scale-up and spread efforts. First, innovation adopters need to develop and enhance demand, and align any available incentives and expectations. Second, adopters must communicate in ways that promote awareness, support accurate assessment of costs and benefits, and convey an understanding of the requirements. Third, potential adopters should provide technical assistance, tools, and resources, including guidance for adaptation of the innovation and for management of the organizational context. Finally, adopters must recognize and address heterogeneity across settings with regard to needs, circumstances, capabilities, and other factors.
Scale Up and Spread: Advancing Research, Practice, and Policy
Research in this area has been quite limited. Most of the published studies of scale up and spread in health care have been conducted in developing countries by researchers working in the global health and international development fields. The U.S. research community has been late to this party. As a consequence, we lack an adequate inventory of designs, methods, measures, and other research tools that are optimized for scale up and spread research. U.S. research funders are just starting to invest in implementation research, and within that context, investment in scale-up and spread research is even more limited.
A set of recommendations for accelerating scale-up and spread research, practice, and policy emerged from a state-of-the-art conference that was held in 2010, and from followup activity in late 2011.2 Our research group identified the following key goals:
Concerted efforts to advance the field of implementation research, and particularly scale up and spread, can help ensure that health care innovations that show initial promise will be adopted in other settings, thereby maximizing the prospects for improving health care delivery in a wide variety of settings.
- Increase awareness of the need for greater attention and activity to support scale up and spread, including research, practice, and policy activity. Key focus areas include the role of education and incentives, and the possibility of convening multistakeholder groups to assess the status of the field and develop a blueprint for further progress.
- Facilitate better information exchange, collaboration, and use of existing knowledge regarding scale up and spread. Key goals include synthesizing knowledge and building communities of practice and other mechanisms to promote collaboration and the exchange of ideas.
- Develop, evaluate, and refine innovative scale-up and spread methods, including novel incentives and pull strategies. This would entail an expansion of research activity and funding, as well as the development of strategies and taxonomies relevant to scale up and spread.
- Develop and apply new approaches for evaluation of scale-up and spread activities. This would include the development of suitable measures, evaluation approaches, and methods for overcoming barriers to effective evaluation.
- Expand the capacity for policy, practice, and research activities focusing on scale up and spread. Training and mentorship opportunities would be important ways to achieve these goals.
About the Author
Brian Mittman, PhD, is the past director of (and current senior adviser to) the VA Center for Implementation Practice and Research Support and a senior scientist at the Kaiser Permanente Southern California Department of Research and Evaluation. He is Editor-in-Chief Emeritus of the journal Implementation Science (http://www.ImplementationScience.com) and has affiliations with the RAND Health Program and UCLA School of Medicine. His research interests include implementation science, health care quality improvement, and health care management.
Disclosure Statement: Dr. Mittman reported having no financial interests or business/professional affiliations relevant to the work described in this article.
Norton WE, McCannon CJ, Schall MW, et al. A stakeholder-driven agenda for advancing the science and practice of scale-up and spread in health. Implement Sci. 2012;7:118. [PubMed]