The Institute of Medicine’s (IOM’s) Roundtable on Population Health Improvement convened a workshop on December 4, 2014. The workshop, titled Achieving Meaningful Population Health Outcomes: A Workshop on Spread and Scale, was held at Hunter College in New York City. Jennifer Raab, president of Hunter College, welcomed participants to the Silberman School of Social Work and drew attention to the workshop’s location in East Harlem, an area with significant health, social, economic, and educational challenges. Raab noted that the new building where the workshop was held was intentionally designed to engage the surrounding neighborhood. The aim of locating the school in Harlem, Raab summarized, was to be engaged in the community, be a true community partner, listen to the community’s objectives, and focus research on the needs of the community.
In her introductory comments, Debbie Chang, the vice president of policy and prevention for Nemours and co-chair of the planning committee, noted that this workshop, by building on the insights provided by previous workshops on innovations in population health, is intended
1 This workshop was organized by an independent planning committee whose role was limited to the identification of topics and speakers. This workshop summary was prepared by the rapporteurs as a factual summary of the presentations and discussion that took place at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the Institute of Medicine or the roundtable, and they should not be construed as reflecting any group consensus.
to highlight how to accelerate change by placing a particular focus on the different strategies that have been used to take successful initiatives or interventions, getting the right infrastructure and the right financial structures in place to support capacity, reach more locations and people, and increase impact. “Ultimately,” she emphasized, “if we want to get to population-level changes, we’re going to need to change the way we work.” There are pockets of innovation but they are disconnected, she continued. People are working in the same topical areas, but they are not working together. Population-level change requires that innovations first be tested and promising tools and strategies that work are spread and scaled, and refined through a continuous feedback loop. As an example, she noted that Nemours has been working to improve healthy eating and physical activity behaviors in child care centers, and has now developed a curriculum and a national technical assistance center to spread this strategy that was developed in Delaware to nine other states. To spread strategies of healthy eating and physical activity, Nemours works with partners to incorporate Nemours’ training into current educational and early care systems. This is a way of building change into a system’s infrastructure, said Chang. To accelerate change, Nemours uses open source platforms so other people can learn from what they are doing. Nemours also works to change policies, a strategy that supports and sustains change. In Delaware, for example, they worked with partners to change child care licensing rules to include healthy eating and physical activity. Taken together, these practices and policy changes create on-the-ground demand for Nemours’ interventions.
A primary activity of the IOM Roundtable on Population Health Improvement is sponsoring workshops for its members, stakeholders, and the public to discuss issues of importance to improving the nation’s health. The working definition of population health used by the roundtable is “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig and Stoddart, 2003). The roundtable understands that such population health outcomes are the result of multiple health determinants, including environmental factors, social factors, behaviors, public health, medical care, and genetics.
The topics of spread, scale, and sustainability of different strategies and practices that affect population health have emerged as significant areas of discussion in previous workshops on applying a health lens to non-health sectors, financing, the role and potential of communities, and collaboration between the health and education sectors (IOM, 2014a,c, 2015b,c). To consider the issues of spread and scale as they apply to popu-
Statement of Task
An ad hoc committee will plan and conduct a public workshop that will feature invited presentations and discussion about the spread, scale, and sustainability of practices, models, and interventions for improving health in a variety of inter-organizational and geographical contexts. Specific topics to be explored may include lessons learned and best practices from several programs that have been successfully grown, disseminated, and adapted to other settings or communities; the role of innovation, culture, and context on diffusing programs and ideas or achieving desired outcomes; and methods for evaluating the impact of these efforts on population health. The committee will define the specific topics to be addressed, develop the agenda, select and invite speakers and other participants, and moderate the discussions. An individually authored summary of the presentations and discussions at the workshop will be prepared by a designated rapporteur in accordance with institutional guidelines.
lation health, an independent planning committee, co-chaired by Debbie Chang and Jacqueline Martinez Garcel and including J. David Hawkins, Kerry Ann McGeary, Kevin Nolan, Wynne E. Norton, and Mary Pittman, was charged with developing a workshop (see Box 1-1). Chang explained that the workshop was designed with four basic goals:
- to explore the different meanings of the spread and scale of programs, policies, practices, and ideas;
- to learn about a variety of approaches to spread and scale;
- to explore how users measure whether their strategies of spread and scale have been effective; and
- to discuss how to increase the focus on spread and scale in population health.
The planning of this workshop was informed by a large, diverse body of literature produced by academics as well as by practitioners in the health and non-health sectors. The terms “spread” and “scale” are not consistently used or defined in this literature or in practice, particularly when in reference to a program, idea, skill, or policy and sometimes the terms are even used interchangeably (see, for example, GEO, 2013; Hardee et al., 2012; Ilott et al., 2013). There are also numerous frameworks, models, and theories of action of how to spread or scale up the impacts of successful programs or initiatives (see, for example, Allen et al., 2014; Dees et al., 2004; Harris et al., 2012; IHI, 2008; Massoud et al., 2010; McCannon
et al., 2009; MSI, 2012; Nolan et al., 2005; Rogers, 1995). For the purposes of this workshop, the planning committee members decided it would be most useful to learn how a selected group of practitioners actually engage in efforts to spread, scale, and sustain strategies in order to improve population health outcomes (see Box 1-2). Other than the keynote speaker, Anita McGahan of the University of Toronto, workshop participants were not asked to define these terms, nor discuss their experiences within a consistent framework. Instead, speakers were asked to provide background information on how they understand these concepts within the context of their own work (see Appendix C).
The first of two keynote speakers addressed the roundtable members and participants in the morning to set the stage for the later discussion of spread and scale (Chapter 2). Following the first keynote speaker, all participants were engaged in an interactive activity that facilitated the exchange of current perceptions and new ideas about spread and scale (Chapter 2). Next, over the course of three panel sessions, case examples of the spread and scale of evidence-based initiatives were discussed, including barriers to and facilitators for improving the health of populations. The first panel provided case examples from the health arena (Chapter 3); the second panel shared examples from other sectors (Chapter 4); and the last panel considered lessons learned from the tobacco control experience (Chapter 5). At the end of the day, a second keynote speaker discussed how best to take action, from getting started to the elements of successful spread and scale initiatives (Chapter 6). In the final discussion of the workshop, roundtable members reflected on the presentations and shared their thoughts for moving forward (Chapter 6). In order to focus discussion on the practical aspects of spread and scale, panelists were asked to provide brief background statements on their case examples to the roundtable members prior to the workshop; these are provided in Appendix C.
In accordance with the policies of the IOM, the workshop did not attempt to establish any conclusions or recommendations about needs and future directions, focusing instead on issues identified by the speakers and workshop participants. In addition, the organizing committee’s role was limited to planning the workshop. The workshop summary has been prepared by the workshop rapporteurs Theresa Wizemann and Darla Thompson as a factual summary of what occurred at the workshop.
Topics Highlighted During Presentations and Discussions
Throughout the workshop, participants shared many important insights on how to spread, scale, and sustain practices to improve outcomes. These included
- Design for success and scale. (Massoud, McCannon, McGahan)
- Start small with a demonstration project, and develop an evaluation process that demonstrates the efficacy of the intervention. (Kaufman, Kelder, Massoud, McCannon, McGahan, Sanghavi)
- Knowledgeable, committed, and passionate staff and leadership are an essential component of success from start-up through scale and spread. (Kaufman, Massoud, McCannon)
- Working as a team is crucial to performance and motivation. (McCannon, McGahan)
Implementation and Scale Up
- Finding and maintaining financial resources is a crucial component of success and a major challenge to spread, scale, and sustainability. (Dotson-Newman, Healton, Herman, Herndon, Kelder, King, Noltenius, Sanghavi)
- Innovative incentive programs and strategies increase participation and can have a significant impact on outcomes. (Kaufman, McGahan)
- Democratize the change process. (Kaufman, Massoud, McCannon)
- When evaluating scale up, measure not only the achieved outcomes but also the costs and time relative to the demonstration project. (Massoud, McCannon)
- Local context matters. Successful spread and scale is not simply replicating what worked in one place or site. (Herndon, Kaufman, Kelder, Massoud, McCannon, McGahan)
- Use data in an ongoing evaluative learning process that informs strategy on a regular basis. (Kaufman, Massoud, McCannon)
- Relevant, accurate, and disaggregated data should be collected specifically to understand the disparities within racially and ethnically diverse populations in order to achieve greater impact. (King, Noltenius)
- In order to be successful at improving outcomes for all populations, approaches should take into consideration the needs of diverse (racial, ethnic, national, geographical) subpopulations. (Dotson-Newman, Kelder, King, Larkin, McGahan, Noltenius)
- Develop monitoring and surveillance strategies that reach people in need, particularly those in remote geographic locations. (Massoud, McCannon, McGahan)
- Stories are an important method of spread. (Herndon, Kaufman, Larkin, McCannon)
- Improved and sustainable outcomes are often achieved by cultivating and spreading culture, beliefs, and values. (Healton, Herndon, Kaufman, Kelder, Larkin, Massoud, McCannon, McGahan)
- The success of spread, scale, and sustainability strategies often depends on building relationships and forming partnerships within and across multiple sectors. (Dotson-Newman, Healton, Herman, Herndon, Kaufman, Kelder, Larkin, McGahan, Noltenius, Sanghavi)
- See points above regarding contributions to sustainability, including finding knowledgeable staff and working as a team; financing; continuous learning and evaluation; and cultivating culture, beliefs, and values of change.