Frameworks for scale-up, spread and sustain

Picture of Suzie Creighton

Published on 18 August 2021 at 10:30

by Suzie Creighton


We’ve talked about scale up and spread and how to sustain quality improvement (QI) across your organisation. Now we’re going to focus on how exactly you create and achieve your frameworks for scale-up and spread. We’ll be looking at how some of the ‘big names’ of QI recommend you do this – including the Institute for Healthcare Improvement (IHI), Health Improvement Scotland and the Mayo Clinic – and pick out some guidance and recommendations for you.

As the IHI say: ‘A key factor in closing the gap between best practice and common practice is the ability of health care providers and their organizations to rapidly spread innovations and new ideas’. So, let’s jump in!


IHI framework for spread

Let’s start with the IHI and their Framework for Spread. Work into developing a spread framework was initially commissioned in 1999 via an IHI team. Their aim was to ‘develop, test, and implement a system for accelerating improvement by spreading change ideas within and between organizations.’

They published the Framework for Spread whitepaper in 2006 which supports a wide range of spread - from large scale system-wide changes to more local improvements. The paper builds on the theory that although 'pockets of excellence' exist in our healthcare systems, somehow, knowledge of these better ideas and practices may not necessarily be shared.

The document is divided into two parts. The first section is looking at how to prepare for spread by establishing an aim and developing a spread plan. This sets out knowledge and research collected from the authors and briefly talks about the plans that they have supported since starting their framework for spread work in 1999.

The authors talk about preparedness for spread and how to work out if you and your project are ready for the next step, including establishing an aim for spread, which addresses the ‘who, what, and where’.

They then go into more detail about the ‘spread plan’, which looks more specifically at the ‘how’ of spread and should include a range of communications which will help you to reach your target audience, as well as creating a way to measure your progress.

Then, they explain how to execute and refine your spread plan as well as setting out plans for the future ‘to continue to find and research the most effective spread strategies and methods for organizations with specific structures and cultures.’

The second half of the document looks at how - from 2001 to 2003 - the Veterans Health Administration (VHA) used a Framework for Spread to deploy improvements and reduce waiting times for patients in over 1,800 out-patient clinics.  This is well worth a read. It sets out how the VHA spread these ideas and achieved such impressive and sustained results.



IHI scale up framework

The IHI published the Scale-up Framework in 2016 which provides well researched guidance on how you can ‘scale up’ an initiative or QI idea from a very small scale to a much larger region. By setting out four distinct improvement phases, the framework guides QI teams through the scaling up process, looking at the following four distinct steps which will lead to success:


  1. Set up – In this initial phase, the authors recommend trying to understand the current state of the project, using processes like driver diagrams and change packages to predict the likely impact of the changes, if successfully implemented.
  2. Build the scalable unit - In this section, the authors focus on the ‘scalable unit’ which is described as: ‘the smallest administrative unit that will be replicated during scale up'. They recommend testing the initial theory, working with several small settings and building the idea that these early change ideas will result in improvement.
  3. Test scale up – This step of the process involves testing scale up by testing the ‘change package’ from stage 2. Once again, looking at building confidence that implementation will result in improvement and looking at what infrastructure will be needed to support even wider implementation.
  4. Go to full scale and sustain - The final step looks at replicating on a larger scale the results from the earlier stages and build on the implementation benefits from the previous stages.


You can read more about the framework in the overview blog ‘Evolving the IHI Scale-up Framework’. This article looks at the report, as well as the three dominant themes ‘that exist to varying extents in a number of existing scale-up frameworks: a sequential approach to getting to full scale, the factors that enhance the receptivity of the environment into which the intervention is being scaled, and the system-level factors that are required to support scale-up.’



Healthcare Improvement Scotland spread and sustainability framework

The ‘Guide on spread and sustainability’ written by Healthcare Improvement Scotland in 2013 looks in close detail at the spread and sustainability of quality improvement in healthcare. It signposts existing resources and present them in a practical way, using visual aids and links to help support understanding of spread and sustainability.

The document explores four elements of spread and sustainability. These are innovation, spread, decision to adopt and implementation. They also provide a range of helpful accompanying documents and hints and tips for each element of the journey.


Schermata 2021-08-25 alle 14.13.58


Figure 1: Proposed Spread and Sustainability framework

For example:

Innovation: ‘Bear in mind the innovation attributes when designing and/or when spreading new ideas. Example: Doing demonstrations of a new practice increases the new idea observability and reduces its complexity. Therefore it will be more easily adopted and implemented.’

Spread: The authors talk about two approaches to spread: dissemination and diffusion, which help to prevent 'improvement islands'

Decision to Adopt recommends identifying motivated and capable people who will be likely to adopt and implement innovations.

Implementation: The authors recommend that giving assistance at an early stage of the process is absolutely critical for successful deployment of QI ideas, whether this is managed by improvement collaboratives or by direct access to experts.

Health Education Scotland also provide a worksheet to help people reflect on their innovations, which you might find useful.



Mayo Clinic model of diffusion

The Joint Commission Journal on Quality and Patient Safety has given an overview of the Mayo Clinic Model of Diffusion, which they say ‘embraces engineering principles, leverages spread techniques, and establishes the appropriate cultural environment.'

The model has been in development since 2004, using a mixture of reviewing associated literature and benchmarking 30 leading healthcare and other organisations, looking at the challenges of diffusion and of standardising best practice.

The Model of Diffusion contains three primary enablers and five key elements.

The three primary enablers are:


  • Culture
  • Engineering
  • Infrastructure/systems support.


The five key elements are:


  1. Leadership – The Mayo model recommends a combination of collective and authoritative institutional decisions.
  2. Value creation teams – leading the 'divergent thinking' and moving to 'convergent thinking.
  3. Diffusion Actions – the managed diffusion phase starts after ‘best practice’ is approved.
  4. Operational implementation – meaning the work needed for communication and training and management needed for diffusion and spread.
  5. Best practice review – It's vital to use measures to revisit the new practice to make sure it's still relevant.


They also supply a really helpful checklist, which may help support your framework and planning for spread.

With the amount of material and guidance available in the QI space to help you plan for spreading your QI ideas, we hope you will be sufficiently inspired and equipped with the necessary tools and background to create your own strategies to spread and sustain quality improvement. Good luck!





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