Spread and scale – what’s the difference?

The NHS Scotland Quality Improvement Hub’s document 'The spread and sustainability of Quality Improvement in Healthcare,' states that ‘Across the UK, a third of healthcare improvement projects never spread beyond their particular unit, a further third are embedded within their own unit and spread across an organisation, and a final third are spread across their own and other similar organisations.'

Whereas this might sound a slightly bleak statistic, in this article, we are going to look at spread and scale in QI and how large-scale improvement can be achievable with the right amount of planning, commitment and support. 

You may have successfully completed a series of PDSA cycles and you want to implement your QI project results elsewhere… now you need to decide how to go about this!

Definitions of Spread and Scale in QI

The first thing you have to decide when you are looking at implementing your QI project more widely, is how to do this. And this is where ‘spread’ and ‘scaling up’ come in! But what is the difference between ‘spreading’ and ‘scaling up’? Let’s take a look!

In the article ‘Spreading and scaling up innovation and improvement’ the authors define spread and scaling up in QI thus:

• Spread – replicating an initiative somewhere else
• Scale-up - building infrastructure to support full scale implementation.

East London NHS Foundation Trust (ELFT) also defines spread and scale in their article ‘Scale up and Spread’.

They describe ‘spread’ as 'when best practice is disseminated consistently and reliably across a whole system and involves the implementation of proven interventions in each applicable care setting.’   

Whereas their definition of ‘scaling up’ is 'the process by which new working methods are tested by an increased number of teams to increase degree of belief they work, overcoming infrastructure issues that arise.’

Spreading and scaling up take place in QI once you have carried out your initial testing and when you have run a series of successful PDSA cycles. This is when you are able to share the results you have achieved and effectively embed changes across your organisation.

So now we are more familiar with the definitions of spread and scale. Which approach will you choose and how do you go about choosing?

When to scale up and when to spread

In the BMJ article: ‘Spreading and scaling up innovation and improvement’, the authors state: ‘Disseminating innovation across the healthcare system is challenging but potentially achievable through different logics.’ It is certainly possible to scale up and spread quality improvement projects, but it requires structured planning and preparation to carry this out effectively.

In truth, as every QI project is different, albeit subtly, the process of choosing whether you scale up or spread is a very personal one. There is no definite ‘right or wrong’ answer. However, ELFT have produced a checklist which you can use to decide whether you want to scale up or spread. The checklist guides you through different areas of your project and we would highly recommend using this document to prompt and guide your decision.

How do you spread improvements?

If you are wanting to spread the improvements you have achieved in your PDSA or QI project, the BMJ Quality Improvement Project guide advises: ‘Sustainable projects start small and then grow and spread.’

You will need to put time into planning your spread, by creating a schedule and highlighting roles and responsibilities for team members. You will also need to ensure that you put time into promotion and communication, as well as reviewing progress of your spread.

In the presentation 'Managing Spread and Creating Sustainability' the presenter sets out 'What not to do....if you want spread to occur!' This looks at the benefits of starting small, having a core team and explores how to spread successful results once you have carried out a successful pilot.

By setting expectations for improvement and communicating these widely, you will be more likely to be successful in spreading QI. Highlighting patient benefits can really help - as well as creating champions for your spread.  

Data for feedback is also helpful for spreading improvement, so you can continually review what's going well and make adjustments. A solution such as Life QI can be helpful here. It allows you to keep all your QI data and evidence in one place, and use the evidence of successful change ideas to spread and scale projects and multiply your QI impact.  

NHS Education for Scotland has a checklist ‘Readiness for Spread’ that you might want to look at, which talks you through a series of prompts and questions.

The Health Foundation’s report 'Spreading improvement ideas' has 10 top tips for spreading good practice, drawn from the empirical research:

1. Get a range of people to involve in both implementation and dissemination of ideas, including clinical and managerial leaders.
2. View people as active change agents, not passive recipients.
3. Emphasise how initiatives address people’s priorities.
4. Target messages differently for different audiences.
5. Provide support and training to help people understand and implement change.
6. Plan dissemination strategies from the outset.
7. Dedicate time for dissemination.
8. Dedicate funds for dissemination.
9. Make use of a wide range of approaches such as social media, opinion leaders and existing professional networks.
10. Evaluate the success of innovations and improvements, but also the extent of uptake and dissemination within teams, organisations and more broadly. Things that are measured tend to get more emphasis, so measuring dissemination may help to ensure that it's a priority.

How can you scale up your impact?

In the article ‘A framework for scaling up health interventions,’ the authors report on approaches to scaling up QI successes.

They describe the four steps which help you to scale up and adopt interventions:

1. Set-up, this helps set the scene for introducing the intervention that will be scaled up;
2. Develop: this means developing the thing which is an early testing phase;
3. Test of Scale-up – this is when you test the intervention in different settings;
4. Go to Full Scale – this is a rapid part of the plan where you roll out to a large number of sites and introduce to many.

NHS Education for Scotland’s checklist ‘Readiness for Spread’ Scotland also recommends that if you are going to implement a project to full scale, improvement should have been sustained in the sites where you are currently testing or implementing changes.

We’ve talked about the importance of planning for both scaling up and spreading QI changes. But successful implementation of an improvement project requires a well-designed plan. You might want to download and look at the Implementation Plan template which will enable you to work through every step of your project implementation. This plan covers aspects such as documentation, staff education and ongoing investment which will help you scale up and spread QI changes.

Good luck with spreading or scaling up your project – and introducing your QI innovation across your organisation!