Public health’s next frontier: Overcoming Barriers to Health System Innovations at Scale
By Evan M Benjamin, MD, MS, FACP
Health System Innovations are novel approaches that may improve the quality, safety or efficiency of health care delivery. One of the issues that plagues health system improvement is the frustrating fact that diffusion of innovation takes a long time and is often fraught with failures to spread.
Throughout my career I have worked on health care quality improvement (QI) with individual health systems. In 2017 I joined Ariadne Labs, where my focus is spreading improvement innovations at a global scale. The shift from implementation at a system level to diffusing these innovations at scale has been very exciting and also challenging. One of the biggest challenges to QI is our inability to get to massive scale.
Ariadne Labs, a joint center for health system innovation at Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health has been working on health system innovations for more than six years. Along the way, the experts here have learned a lot about what works and what does not when it comes to spreading innovations. With our partners, we designed and spread the WHO Safe Surgery Checklist, the WHO Safe Childbirth Checklist and the Serious Illness Conversation Guide. These tools promote teamwork and the adherence to evidence-based best practices to improve outcomes and have been tested in controlled settings to demonstrate improvement in care.
The next frontier of public health innovation will be to understand and overcome these barriers so that lifesaving tools can reach every patient, everywhere.
Yet, in spite of the evidence behind the tools, spreading innovations such as these at scale remains a challenge. The next frontier of public health innovation will be to understand and overcome these barriers so that lifesaving tools can reach every patient, everywhere.
The scaling of health system innovations is a process that occurs among users to learn about and employ the use of the innovation in clinical practice. Everett Rodgers’ groundbreaking Diffusion of Innovation first published in 1961, laid the groundwork for thinking about how innovations spread. Rodgers’ framework postulates that the rate of diffusion is related to
- The attitudes by the adopters about the innovation,
- The characteristics of the adopters themselves (e.g. early or late adopters) and
- The contextual factors of the organization or system where the innovation is to be spread.
Through our work at Ariadne to design, test and spread health system innovations, we have learned to create implementation packages that enable early adopters in various settings to succeed in improving the quality of health care. At the same time, we have found that there are unmeasured and unknown contextual barriers specific to health care that must be understood in order for an innovation to be utilized by all adopters. These include:
- Readiness for change
- Culture of improvement and teamwork
- Other unmeasured social, societal and organizational contextual items such as incentives and social pressures
A few of these are worth highlighting as I believe they are critically important for spread. The readiness for change of an organization includes:
- the level of leadership and frontline commitment to adopting an improvement solution,
- the capabilities and skills of the staff to use the tools of the innovation, and
- the capacity of the organization to adopt it, including supplies, technologies and bandwidth.
The culture of an organization is another predictor of successful adoption of innovation. In health care, it is the extent to which an organizational culture can foster improvement and teamwork. Organizations that strive for improvement, demonstrate an understanding of processes, and allow for the organization to learn from error are often more successful at adopting innovations.
In addition, our work in disseminating health system innovation has shown that when clinicians have more experience working in teams, when there is a shared common mental model, and when there is shared data and shared goals, innovation is more easily adopted.
Organizations that strive for improvement, demonstrate an understanding of processes, and allow the organization to learn from error are often more successful at adopting innovations.
Finally, we have observed that other contextual factors such as societal standards, social mores, and financial incentives all play a role in understanding if an innovation will be adopted. Innovations spread through social systems. The way independent actors work in a social setting determine the influence and acceptance of a new innovation. The social system helps to establish the opinion of the innovation itself and the collective desire to adopt it. Subtle incentives for the individuals in the social sector can influence the diffusion of an innovation and the proper understanding of these incentives and social pressures is necessary to facilitate the spread of innovation.
Ariadne Labs will be seeking to improve this understanding of readiness for change, the culture of an organization, and the social, societal and organizational influences on behavior. We believe this understanding will determine the success we have in scaling health system innovations.
Evan Benjamin is the Chief Medical Officer at Ariadne Labs.
Illustrations by Courtney Staples.