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

Health Systems

Stealing Shamelessly: Practice Transfer Success Factors | to pdf >>

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

Organizational leaders might expect that once a successful practice is identified, the practice will be quickly adopted within the organization. However, practice dissemination within firms can require 27 months, even in organizations committed to transferring successful practices.¹

Introduction

Success factors that improve the likelihood of deciding to transfer and effectively implementing the practice have been identified. Transfer generally occurs when potential practice recipients have a compelling problem to correct^2,3 and there is evidence of a superior practice.^1-5 Having a high level of trust in the person sharing information^2-4 (the "source champion") and clear communications with this person have been identified as transfer success factors.^1,2,4 Practice recipients who have an opportunity to observe a functioning model of the practice have an advantage.^3,5 Practice transfer has also been related to leadership support,^1,2,5 resource availability,^2,4 and the presence of a culture supportive of practice transfer.^1,3-5 Practice recipients have been urged to copy the original practice exactly if they are uncertain which practice features are essential to its effectiveness.⁴

The Value of the Visit To build a rich understanding of the practice, many potential implementers (sometimes with their team) visited the source site or invited the source champion to visit their site. These visits often influenced their decision-making process and helped with the implementation process. Advance Access Transfers Many implementers talked about how much they valued having a credible Permanente physician source champion come to their site to describe how to use the practice, answer questions, provide detailed explanations, and allay concerns. Home-Based Palliative Care Transfers Some potential implementers visited the source site and observed caregivers as they visited patients. This approach yielded important, but undocumented, information. Emergency Prospective Review Program (EPRP) Lead implementers reported that when their physicians spent a day at the source site, they overcame their initial uncertainty about the hospital repatriation practice. They were able to resolve various problems so that the practice could function in the new location.

Transfer Study by Care Experience Council

Do these principles of effective transfer apply to transfers in an integrated health care setting? To better understand how to support transfer of successful practices within Kaiser Permanente (KP), the KP Care Experience Council (CEC) sponsored a retrospective study of KP transfers.⁶ Ninety-two structured interviews with KP physicians and employees were conducted to identify factors associated with the transfer of 13 clinical and service practices within the organization. The participants included lead implementers at recipient sites who transferred a successful practice; potential implementers at sites who studied but rejected a practice; and source champions. (Source champions are practice experts and/or practice innovators who communicate about the successful practice.) Four transfer outcomes measures were used to subjectively gauge success in transferring a practice from the perspective of the lead implementer or potential implementer. These transfer outcome measures included the following:

• Did the recipient site choose to transfer the practice?
• Did the recipients achieve what they set out to accomplish?
• Was there evidence of improvement following implementation?
• Was the practice maintained over time?

Analysis

The transfer outcome measures were correlated with the presence of factors (conditions, processes, or behaviors) hypothesized to be related to these outcomes. Various hypotheses put forth in the transfer literature were examined. For example, does having a physician champion supporting the transfer improve the odds of a successful implementation? The factors having the strongest correlations with transfer outcomes are described in Table 1.

Source Champions

Having a supportive source champion was related to transfer success. Some source champions spent a great deal of time helping recipient sites with their transfers.

Source champions explained how potential recipients were persuaded to transfer. Some believed that potential recipients were persuaded to transfer by a combination of data and testimonials from peers facing comparable challenges. Typically, evidence alone was not sufficient reason to transfer.

The source champions and recipients tended to agree on the factors that supported transfer, with one exception. When explaining why a site chose not to transfer, source champions were likely to attribute a decision not to transfer to "not-invented-here" barriers. In contrast, potential recipients tended to cite competing priorities or lack of perceived value as reasons not to transfer.

Measurement Limitations

Some of the transferred practices lacked objective evidence that the practice resulted in improvements. This did not discourage some sites. Similarly, recipients who adopted practices often failed to collect measures that would permit full evaluation of the imported practice. The outcome measures used in the study were subjective assessments. Given the resources used to implement any practice, innovators and recipients are urged to work with analysts to collect baseline data and monitor outcomes over time to document the value of the transferred practices.

 

Should we Encourage Sites to "Reinvent" rather than "Transfer" Successful Practices? The assertion that transferred practices should be copied exactly4 was partially tested in this study. Although none of the recipients made an "exact copy," there were variations in the degree of conformity to the original model. Some borrowed only a concept from the practice, while others preserved most of the features of the original practice. On average, more exact copying did not appear to be related to better outcomes. It appears that operational and structural variations within KP necessitated tailoring the practice to each location. Sometimes sites needed to modify the practice to increase support for the new practice.

Summary

In general, the findings of this study are consistent with those of the transfer literature. To foster transfer of successful practices within the organization, potential recipients can overcome some commonly experienced barriers by: choosing practices that address high-priority issues; enlisting multidisciplinary participation during the planning and implementation stages; assigning lead implementers and champions who believe in the value of the practice; and verifying that sponsors will use their influence to assist with obstacles during implementation. Innovators and recipients are encouraged to verify that their practices actually improved performance, and collecting appropriate measures and tracking them at useful intervals sustains the practice.

References

1. Szulanski G, Intra-firm transfer of best practices project: Executive summary of the findings. Houston (TX): American Productivity & Quality Center. 1994.
2. Permanente Interregional Consultants and Operations Consulting and Support Services. Critical success factors for a best practice transfer. Fall 1996.
3. Rogers EM. Diffusion of innovations. 4th ed. New York: Free Press; 1995.
4. Szulanski G. The process of knowledge transfer: a diachronic analysis of stickiness. Organizational Behavior & Human Decision Processes 2000 May; 82(1):9-27.
5. Berwick DM. Disseminating innovation in health care. JAMA 2003 Apr 16:289(15):1969-75.
6. 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; July 2004 [cited 2005 Aug 25]. Available from: http://cl.kp.org/pkc/national/operations/cec (password protected).