••Fall 2005/Vol. 9, No. 4
A Focus on Innovation and Transfer

Health Systems

Practical Steps for Practice Transfer: The Four A's of Adoption to pdf >>

By Hannah King, MPH; Karen Tallman, PhD; Arthur K Huberman, MD

The Four A's of Adoption are practical and easy steps for transferring a successful practice from one location to another. The A's are based on the work of Rogers,¹ Szulanski,² Plsek,³ and a recent Kaiser Permanente (KP) study of transfer success factors conducted by the Care Experience Council (CEC).⁴ (See "Stealing Shamelessly," page 52.) In order to improve the likelihood of successful adoption, the Four A's were created to help leaders:

• Raise awareness in their facility/Region that a better practice exists
• Assess the probability of acceptance of the new practice
• Develop alignment and support for the practice
• Take action to implement the practice.

Awareness

Better practices and sound innovations exist across KP. Finding and implementing these practices is an important part of leadership. Potential means of discovering sound ideas includes learning about practices through:

• Conferences, meetings, and peer networks
• Documents prepared by KP groups, such as the Care Management Institute (CMI) or CEC
• Journals and internal Web sites of white papers, conference sessions, quality briefings, etc.

However, one person learning about a practice isn't enough. The next step is building awareness among a group of people. In the past few years, in order to encourage people at KP to bring successful practices and ideas back to their regions, many KP conference and meeting organizers are incorporating tools to help people share information back home. This work is being supported by regional and local sponsors who are setting the expectation that conference/meeting participants share successful practices with others in their region upon their return. When information is gathered at a conference or peer meeting, the important next steps are:

• Hold meetings to describe the practice and answer questions
• Share written materials and evidence with the team
• Arrange a follow-up call with the presenter(s) so that the team can learn about the practice directly from the "champion."

Do not hesitate to call the "source champion" who has the good idea/successful practice. These innovators or early adopters are almost always willing to discuss their practice with others who are interested in it.

Assessment

The next step is to determine how receptive people are to the new practice. Everett Rogers, an authority on the diffusion of innovations, suggests that several factors contribute to the likelihood of successfully transferring a practice.¹ To easily remember them, some refer to the factors as TACOS (acronym borrowed from William Marsh, MD, of the Colorado Permanente Medical Group)^a (Table 1).

It is a good idea to run this quick TACOS test with multiple stakeholders to understand how much support there is for the new practice. People may have different assessments of the value or feasibility of a given innovation and it is important to know this up front in planning an implementation strategy. As is widely known in the change literature, a change has both a technical and a social component.³
Ignoring the social component can doom the project. Therefore, make sure that all stakeholder groups are involved in assessing and implementing the practice. Furthermore, when trying to gain acceptance of the new idea, look for attractors to the new practice and publicize them. Attractors are characteristics of the change that people will find appealing such as a decrease in the time it takes to do something, an improvement in a quality or safety outcome, or an increase in professional autonomy.³

One of the best methods to learn about a practice is to make a visit to the facility with the successful practice and/or invite the champion to visit your facility. ^2,4 The KP study showed that source champions were willing to host visits or visit other locations. During a site visit, the source champion helped the team understand how to tailor the practice to local needs and provided implementation advice.⁴ The exchange of tacit knowledge (understanding that is typically not documented) is a key ingredient in building broad understanding of the practice needed for a smooth adoption.

Alignment

At this stage, a small group of people in your organization is aware of the new practice and an assessment shows that many of these people are interested in adopting the new practice. Before implementation can begin, key players must be aligned. Have a sponsor, physician champion, and lead implementer (project manager) been identified? Has a planning or steering committee, with influential stakeholders, been formed?

Sponsors are critical to implementation success. In the KP study, it was found that sponsors did a lot of the "behind-the-scenes" work by providing resources, giving physicians' administrative time to be the champions, selecting a strong department lead or project manager, and stepping in when barriers arose. In public, the sponsors were essential in endorsing the practice transfer and the project team. The physician champion and lead implementer must be visible and active throughout the project, but especially during implementation.

Another learning from Rogers, and corroborated in the KP study, is the importance of social networks in implementing a change.^1,4 A planning or steering committee of well-respected stakeholders from multiple disciplines is needed to address the concerns of different stakeholder groups and get their buy-in for the new practice.

Action

Once there is alignment, the implementation work begins. Again, based on Rogers' factors of trialability and observability, and validated in the KP study, there is often an advantage to phasing in a project slowly, rather than overnight.^1,4 This allows the "early adopters" to try the practice first and allows others to observe the outcomes. Also, the process of phasing in allows for reinvention of the practice, as needed for local circumstances. There is one caution, however, regarding reinvention: When there is uncertainty regarding the essential elements of a successful practice, the project team should copy as closely as possible and then make modifications once the practice is functioning.² As the difficult work of implementation gets underway, it is important to document progress to know the level of success. If the implementation results in better outcomes, people will want to know what modifications yielded better results, thus becoming the next successful practice!

The Four A's of Adoption provide a framework for transferring a practice within KP. First, heighten awareness of innovations and successful practices that exist. Once a potentially useful innovation or successful practice is located, carefully assess its viability for the facility. Next, insure that there is alignment by addressing an urgent problem, creating high-level sponsorship for the work and placing the right people on the team. Finally, the greatest challenge is to take action. A solid implementation strategy with broad support can help deliver the desired results.

^a Presentation to National Operations Leaders, October 4, 2004, Portland, OR.

References

1. Rogers EM. Diffusion of innovations. 4th ed. New York: Free Press; 1995.
2. Szulanski G, Winter S. Getting it right the second time. Harv Bus Rev 2002 Jan;80(1):62-9, 125.
3. Plsek P. Spreading good ideas for better health care: a practical toolkit: tools, perspectives, and information for health care providers [monograph on the Internet]. Irving (TX): VHA; 2000 [cited 2005 Oct 17]. Available from: www.tachc.org/HDC/Tools/Organization/Docs/Spreading_Good_Ideas_for_Better_
   Health_Care.pdf.
4. Huberman A, King H, Tallman K. Successful transfer of practices in Kaiser Permanente: findings from interviews with transfer participants. [monograph on the Intranet]. Oakland (CA): Kaiser Permanente Care Experience Council; 2004 [cited 2005 Aug 25]. Available from: http://cl.kp.org/pkc/national/operations/cec (password protected).