7 Spreadly Sins - what not to do when spreading improvement

In this article, we’re going to be looking at what the Institute for Healthcare Improvement (IHI) has identified as ‘7 Spreadly Sins’ when spreading improvement – i.e. what not to do when you are trying to spread your healthcare improvement project! We’re also going to suggest effective ways that you enhance spreading your Quality Improvement (QI) ideas across your organisation.

The below graphic from the IHI sums up what are these seven spreadly sins that we are going to explore.

So, let’s dive in! 

Sin 1

Don’t do this: Don’t bother testing — just do a large pilot.
Do this instead: Start with small, local tests and several PDSA cycles.

If you’ve been working in QI for some time, you will know that ‘Plan Do Study Act’ (PDSA) cycles are key to making and testing improvement QI changes. We’ve looked at how vital these are in the QI process in other blogs. So, if you want to dive into a bit more detail, please do take a look at our piece: ‘Design and test changes using PDSA cycles’.

Essentially, PDSAs are recommended as they help you efficiently and thoroughly evaluate and test your ideas in a structured, four step method – rather than diving in with a huge pilot and no preparatory work or measures.  There is so much support for this method, and it’s standard practice in QI, so we highly recommend it!

Sin 2

Don’t do this: Give one person the responsibility to do it all.  Depend on “local heroes.”
Do this instead: Make spread a team effort.

Spreading QI across an organisation - or more widely - really is a team effort. Even if you have a ‘local hero’ who can help on your spread project, it will not work if you give them all the responsibility for  spreading your QI project.  If you are in this position, it’s really worthwhile spending time on planning your QI for spread improvement by building up your team in a measured and practical way. In our blog ‘How to assemble your team for a successful improvement project’ we look at practical ways in which you can create your QI team, which may be worth a look.

In its piece ‘Science of Improvement: Forming the Team’, the IHI recommend that ‘Effective teams include members representing three different kinds of expertise within the organisation: system leadership, technical expertise, and day-to-day leadership.’ These are all elements that you should be looking for when you go to choose your team to help spread your improvements as a team effort.

Sin 3

Don’t do this: Rely solely on vigilance and hard work.
Do this instead: Sustain gains with an infrastructure to support them.

Vigilance and hard work can be key components of successful QI projects. But you can’t rely on these alone without a solid infrastructure to sustain your goals. The BMJ Open Quality paper: ‘Quality Improvement Project Guide’ sets out how you can sustain your QI changes once you have deployed and tested your solution locally.

You can think about creating an implementation plan which helps you sustain the gains and incorporate them into your processes. We’ve put together a template for an implementation plan that you can download for free. It will support you in working through the steps you need to sustain your gains.

Sin 4

Don’t do this: Spread the success unchanged. Don’t waste time ‘adapting’ because, after all, it worked so well the first time.
Do this instead: Allow some customisation, as long as it is controlled and the core elements are clear.

If you are ready to deploy your QI changes more widely across the group, it may be tempting to dive straight in and replicate what you’ve successfully achieved during your PDSA cycles. However, it’s worthwhile being flexible on this and being open to any changes that wider team members might suggest. This is where controls and measures are really important, as you can check and tweak things as you go.

Being open to suggestions and supporting and reviewing suggested customisations to your QI project gives more flexibility and helps more people become involved – as long as you can measure and make sure that it’s obvious what the customisation will achieve.  Solutions such as Life QI can be helpful in this regard. They enable you to keep your QI data in one place, and access, review and monitor projects as you progress.

Sin 5

Don’t do this: Require the person and team who drove the initial improvements  to be responsible for spread throughout a hospital or facility.
Do this instead: Choose a spread team strategically and include the scope of the spread as part of your decision.

As with Spreadly Sins number 2, this ‘sin’ is about focussing on the individual or team rather than looking at the bigger picture. You may have been really successful with your team and QI lead in your local PDSAs, and built up a really good and measured practice. But spread is all about sharing the knowledge and expertise. So it’s really important that you look at choosing your spread team strategically, and not put all the responsibility on the person and team who drove the initial improvements.

While building your team, also bear in mind the scope of your planned spread, as well as what type of expertise you need in the team for sustained and successful spread. There are lots of helpful reports and guidance that can help you form your team. In its piece ‘Science of Improvement: Forming the Team‘, the IHI recommends that - when creating your spread team - you also need to identify and find the types of expertise thus: technical expertise, system leadership and day to day leadership. In addition to these, you would also need to find a project sponsor.

You might also want to look at East London NHS Foundation Trust piece on characteristics of a QI team. It can be really helpful when looking at the dynamics of your spread team.

Sin 6

Don’t do this: Expect huge improvements quickly then start spreading right away.
Do this instead: Create a reliable process before you start to spread.

Setting off on your spread journey without a reliable process in place, can damage the spread of your QI project. This is where a Spread Plan can support you. Try taking a look at this spreadsheet from NHS Education for Scotland. It walks you through your ‘readiness for spread’ and will help you formulate your plan.

It’s this methodology and preparedness that is recognised in the Kings Fund report ‘Embedding a culture of quality improvement,’ where one of its roundtable participants to the study says ‘It’s striking how relatively few trusts have a recognisable improvement methodology. Those that do, seem to be thriving. I think we ought to get to the point where it’s the norm'. With processes in place - and means in which to check progress set up before you spread - you can be ready to face any bumps in the road in your QI journey.

Sin 7

Don’t do this: Check huge mountains of data just once every quarter.
Do this instead: Check small samples daily or frequently so you can decide how to adapt and spread practices.

Checking data is a really important part of your QI success, but it doesn’t need to be a difficult or onerous process, and you certainly shouldn’t do it only once every quarter! This is again where you and your team might find a solution such as Life QI. With all your data in one place it makes it easy to monitor and check data on a regular basis – as well as find out what other QI teams are doing which may help guide you in your journey.

Hopefully this blog has given you some ideas on how to counter the ‘Seven Spreadly Sins’ in QI. There are plenty of other documents you could use, including the really helpful ‘Spread and adoption tool’ from the NHS Institute for Innovation and Improvement.  Good luck on spreading your QI innovations!