CHAPTER 11
Spreading Lessons Learned and Best Practices: Dissemination
KEY WORDS
Spread, lessons learned, best practices, dissemination, scaling up, distribution
OBJECTIVES
By the end of this chapter, readers will be able to:
1. Differentiate between lessons learned and best practices
2. Describe the importance and value of dissemination as it relates to professional practice models (PPMs)
3. Evaluate dissemination frameworks
4. Explain how the term scaling up can be applied to lessons learned and best practices
5. List at least three strategies for distributing lessons learned and best practices
6. Describe the role of leadership in dissemination
LESSONS LEARNED AND BEST PRACTICES
The ultimate goal of professional practice model integration is to change practice in health systems such that health outcomes are enhanced for patients and families and the disciplinary values and contributions of nursing are upheld and advanced.
Usually, such integration occurs in a single clinical site in a particular geographic location. Yet, health systems and their employees often learn important lessons through their experiences of implementing and evaluating projects (or innovations) and/or identify best practices as a result of integration processes, but many of these useful implications fade or perish when not promptly shared with others who might benefit.
Lessons learned include both positive and negative understandings gained from the experiences of integrating a professional practice model (PPM) or other large-scale innovations. For example, using a particular evaluation tool might be found to be better (or worse) than another and, if shared with others, could potentially influence decision making. Or a certain educational strategy might be assessed as more efficient at achieving important project outcomes, saving others valuable time. However, noticing and understanding the value of such lessons requires some reflection on the experiences, documentation of the learning points (positive or negative), analysis of the source or basis of the lesson, and recommendations for incorporating the “lesson” in future contexts. Formal lessons learned are typically drawn at the conclusion of projects; however, they can be developed at any time during the integration phases.
These “lessons” learned from experiences in one health system can advantage others by providing valuable insights, useful and applied processes, information about evaluation methods, and enabling strategies for adaptation and enculturation.
Best practices, on the other hand, have become known in health care from the business world, and include “methods or techniques that have consistently shown results superior to those achieved with other means, and that are used as benchmarks” (“Best practices,” 2015). In health care, the World Health Organization (WHO) defined best practice as “knowledge about what works in specific situations and contexts, without using inordinate resources to achieve the desired results, and which can be used to develop and implement solutions adapted to similar health problems in other situations and contexts” (WHO, 2008, p. 2). In this definition, “what works” signifies that results of specific processes or strategies are known and can be documented—in other words, adequate evaluation has been conducted. Such “tested” information enables additional health systems to learn how “best” to implement specific strategies, thus preventing the “reinventing the wheel” syndrome or inadvertently duplicating others’ mistakes, fostering better effectiveness and efficiency of project outcomes. Although not research per se, effective PPM integration uses implementation and evaluation approaches that require specialized strategies and assessments that consume health system resources; thus, sharing them with others may expedite efficiencies.
Nurses and nurse leaders who generate lessons learned and best practices from professional practice model integration and who promptly share them with others (even if they are negative), promote more widespread application and evaluation in a variety of new settings and populations.
Health systems that apply lessons learned and best practices to professional practice model integration at their sites may be poised to deliver more effective implementation strategies, evaluation techniques, and achieve intended successes, such as improved patient quality outcomes, while ensuring efficiencies of the integration process itself.
However, the dissemination of such information is not typically included as an important component of health systems’ PPM integration plans.
DISSEMINATION EXPLAINED
The process of spreading lessons learned and best practices is complex, protracted, and frequently left undone, limiting additional health systems and stakeholders from learning about advantages they could potentially experiment with and reducing opportunities for some health systems to showcase their successes. For example, generating and then rapidly dispersing lessons learned and best practices resulting from PPM integration that could benefit others can be hampered by time requirements and/or lack of experience with publication and presentation, the time from manuscript acceptance to publication, the characteristics of the best practices themselves, and variation in the local contexts of other health systems (e.g., the willingness or ability of others to try the new ideas, or the characteristics of the culture and infrastructure [including resources] of a health system to embrace new ideas). Although reporting about research findings, Colquhoun Aplin, Geary, Goodman, and Hatcher (2012) suggested that the diversity and inconsistency of dissemination terminology and frameworks are an additional barrier to applying findings. Thus, it can sometimes take years and many strained attempts to effectively integrate and sustain PPMs, potentially disadvantaging those patients, families, and health professionals served by additional health systems.
Understanding how to rapidly and effectively spread lessons learned and/or best practices from professional practice model integration in and across complex health systems is vital to more rapidly and pervasively improve patient outcomes and advance professional nursing over a wider range of health systems and geographic settings.
To improve dissemination of best practices, it is essential to understand the term, consider various perspectives and methods used to attain success in broadcasting superior ways of working. Dissemination refers to “the targeted distribution of information and practice change materials to a specific public health or clinical practice audience” (Glasgow et al., 2012, p. 1275), representing an active process (Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou, 2004). More recently, the Patient-Centered Outcomes Research Institute (PCORI) defined dissemination as: “the intentional, active process of identifying target audiences and tailoring communication strategies to increase awareness and understanding of evidence, and to motivate its use in policy, practice, and individual choices” (Esposito, Heeringa, Bradley, Croake, & Kimmey, 2015, p. 3). The ultimate purpose of dissemination is to increase impact (McNichol & Grimshaw, 2014), implying that the new findings, lessons learned, or best practices, are applied or used and evaluated in additional sites or with different individuals.
In the case of nursing PPMs, the clinical practice audience includes similar clinical sites beyond the original site (e.g., extension to a health system or close regional sites), clinical sites within a different context (e.g., best practices learned in acute care and applied to community-based sites [home care, extended care, primary care]), and the discipline as a whole (e.g., rapid dissemination nationally and internationally). How do lessons learned and best practices from one health system best reach others beyond the original site, in alternative contexts, or effectively and efficiently inform the discipline?
The term scaling up has been used to describe the intentional, guided processes designed to bring proven or promising health care models or practices to more people (Mangham & Hanson, 2010; Ovretveit, 2011; WHO, 2010) and often is used synonymously with dissemination and spread. Scaling up is any form of expansion of an intervention or approach, not as an end in itself, but as a means to achieve greater and more widespread benefits for the population of concern (Linn, Hartmann, Kharas, Kohl, & Massler, 2010). It signifies urgency, growth, and intention. When new and additional sites or disciplines use a lesson learned or best practice from a PPM integration project, for example, and significant changes to professional practice that go beyond verbalization to include deep processes that change practice and enable better patient outcomes that continue over time, a “shift in ownership” from the original innovator to a new adopter occurs, generating meaningful scale-up (Coburn, 2003).
Scale-up is an active process that aims to benefit more stakeholders and foster institutionalization on a lasting basis. Interest in scale-up has grown in recent years because of the increased urgency to expand successful health care innovations rapidly.
Raising awareness about lessons learned or best practices during professional practice model integration with the intention of improving implementation or integrating model components better and more widely in new contexts, such that they are embedded in new systems, is more than simply adopting a lesson learned or best practice.
In fact, Management Systems International (MSI; 2012) suggests that testing, clarifying, refining, and simplifying an innovation requires many years of evidence generation. Furthermore, the evidence produced needs to be carefully appraised by those desiring to embrace the innovation. Thus, understanding the type of evidence that exists is essential. For example, the difference between anecdotal reports in one setting and valid and reliable quantitative evidence from several sites in different settings is quite substantial.
Prior to scaling-up activities, evaluating the innovation, lessons learned, or best practices for several characteristics that might demonstrate the best chances for adoption by others has been advocated. They are as follows (WHO, 2010, p. 19):
• Credibility: Is there sound evidence or application by respected persons or institutions?
• Observability: Can potential users see the results in practice?
• Relevance: Are the lessons learned or best practices pertinent to PPM integration issues?
• Advantage: Is there a relative benefit over existing approaches?
• Simplicity: Is it easy to transfer and adopt?
• Compatibility: Do the lessons learned or best practices fit with existing users’ established values, norms, and facilities?
• Trialability: Are the lessons learned or best practices able to be tested or tried without committing the potential user to complete the adoption?
In addition, the Scalability Assessment Tool (SAT) checklist (MSI, 2012) containing 28 items is intended to stimulate dialogue and aid in decision making about scale-up activities to facilitate simplifying the scaling-up process. Once the potential viability of an innovation and its evidence base is better known, specific scale-up strategies have been documented that may facilitate the process.
In the WHO document, Nine Steps for Developing a Scaling-up Strategy (2010), several approaches for scaling up were identified: vertically (through administrative structural and policy changes), horizontally (extended geographically), functionally (adding on to an existing model), and spontaneously (scaling up without intension or naturally). In practice, these approaches often work together. For example, horizontal and functional scaling up are most likely to succeed when accompanied by vertical scaling up. Although spontaneous scaling up occurs infrequently, guided approaches, involving deliberate efforts to put a best practice or new innovation in place, help ensure that the key elements of the innovation and the context that are needed for success remain in place (Massoud, Donohue, & McCannon, 2010).
Much of what is known about scaling up comes from the international health literature on improving health services in low-income countries. Limited evidence exists for scaling-up lessons learned or best practices, particularly from integration or demonstration projects, including PPMs. Thus, there is no single best approach that can be applied, and most approaches require tailoring to the local situation. Nevertheless, there are a variety of frameworks and methods of distribution that have been reported that may facilitate the way clinicians and leaders approach dissemination.
FRAMEWORKS AND METHODS OF DISTRIBUTION
Dissemination Frameworks
Several frameworks exist for understanding dissemination and spread (Wilson, Petticrew, Calnan, & Nazareth, 2010), but only a select few will be described here. Because effective dissemination entails active strategies for reaching a wide audience, frameworks that use more passive or natural forms of spread will not be included. For example, Rogers’s Diffusion of Innovations Theory (1995; see also Chapter 8) focuses on how, why, and at what rate practices or innovations spread through defined populations and does not specifically describe active dissemination processes or outcomes. And in Malcolm Gladwell’s Tipping Point (2000), spread is viewed as a natural process that begins with a few people, a “sticky” change or innovation, and a specific context (see also Chapter 8). It does not offer specific strategies for spread or describe methods of application. A number of more active frameworks were found in the health care literature that may offer promising insights and strategies.
The Institute for Healthcare Improvement’s (IHI) evolving framework for spread (Massoud, Nielsen, Nolan, Schall, & Sevin, 2006) considers dissemination a leadership responsibility and lists several key issues necessary for successful dissemination. They are as follows (Massoud et al., 2006):
• Preparing for spread
• Establishing an aim for spread
• Developing an initial spread plan
• Establishing and refining the spread plan
This framework has been used in several IHI learning collaboratives such as the 100,000 lives campaign, the Kaiser Permanente system, the End Stage Renal Disease Network, and the California Improvement Network. It has been refined over several years and, because it involves planning and consideration during implementation processes, it is dependent on senior leadership for its success.
The University of Washington Health Promotion Research Center (HPRC) framework (Harris et al., 2012) uses social marketing principles in a practical way to encourage dissemination of research findings to real-world practice environments. It contains two key elements: the resources for disseminating evidence-based practices, which include collaborating researchers and disseminating organizations, and the user organizations that adopt and implement the practice. It requires linking to and learning from the user organization (which has fixed characteristics) to develop relevant and effective dissemination. Although referring to research, it has implications for spreading lessons learned and best practices as well.
The Value-Added Research Dissemination Framework (Macoubrie & Harrison, 2013) was developed for the Administration for Children and Families, U.S. Department of Health and Human Services, after conducting a multidisciplinary (human services, communication, and organization studies) literature review and contains six elements. The core challenges, or the persistent issues that face disseminators, lie at the heart of the framework. The challenges arising from organizations and the disseminator’s role, which is to perform or guide a series of activities that address the core challenges, are highlighted and include communication concepts and utilization issues. The framework represents a functional approach to dissemination, and shows four phases: planning, translation and packaging, strategic distribution, and follow through. The Value-Added Research Dissemination Framework emphasizes the disseminator’s role in overcoming common dissemination challenges and includes dissemination as a strategic communication process, incorporating concepts from the communication field. The framework considers the complex structure of clinical practice in the United States, strengthening the understanding of challenges inherent in dissemination and offers several solutions. Used to guide dissemination of lessons learned and best practices from professional practice integration, this framework is comprehensive and practical while emphasizing the disseminator’s role.
The Dissemination and Implementation Framework (Esposito et al., 2015) was created to enhance awareness and knowledge of useful and relevant information to help people and organizations make decisions and put them into everyday practice. To generate that information, engaging stakeholders as partners from the very beginning of a project is deemed relevant to helping target audiences make real-world choices, potentially improving the likelihood of rapid practice changes. The focus on the engagement of individuals, communities, and organizations is unique and placed at the core of this framework, enabling it to allow those using the framework to better understand the needs of audiences who will use evidence to make health care decisions. Project findings are disseminated to the practice environment where they are applied and evaluated in an iterative process that continues to inform future innovations. Little evidence exists for the effectiveness of this framework as it is relatively novel.
The ExpandNet/WHO framework for scaling up (WHO, 2010) offers a systematic way to consider scale-up guided by four key principles: systems thinking; a focus on sustainability; the need to determine scalability; and respect for gender, equity, and human rights principles. In this holistic framework, five elements (the innovation, the resource team, the user organization, the environment, and the scale-up strategy) are centered and four strategic choice areas (dissemination and advocacy, costs/resource mobilization, monitoring and evaluation, and organizational processes) are provided. The framework, created for underdeveloped nations, is considered a learning process, and changing the strategic plan as learning proceeds is constructive and necessary. Moreover, because learning requires systematic use of evidence, it is essential that data are linked to decision making. Balancing the broad range of factors for scaling up carries out what is desirable and feasible.
In summary, several frameworks exist for reflecting on, learning about, and strategizing for dissemination, spread, and scaling up of lessons learned and best practices related to PPM integration. Common themes among them include: planning dissemination into the integration project at the beginning; consideration of context; responsibility, particularly among leaders; and systematic, active strategies that maximize extension and expansion.
Methods of Distribution
Distribution includes creating networks or conduits in order to spread knowledge gained from research findings or, in this case, lessons learned and best practices resulting from the integration of a PPM, to the widest possible audience. Two primary channels, namely, direct and indirect, act in concert with various subchannels or intermediaries to transfer ideas and materials learned from integrating a PPM at one location to a wider range of existing or potential stakeholders. Distribution involves initial notification, periodic and end-of-project exposure of lessons learned and/or best practices, and ongoing communication of model components to different contexts with the goal of extension and expansion.
