Understanding Diffusion in Health Care: Innovations and Policy Changes, Summaries of Voice

Download Understanding Diffusion in Health Care: Innovations and Policy Changes and more Summaries Voice in PDF only on Docsity! By James W. Dearing and Jeffrey G. Cox Diffusion Of Innovations Theory, Principles, And Practice ABSTRACT Aspects of the research and practice paradigm known as the diffusion of innovations are applicable to the complex context of health care, for both explanatory and interventionist purposes. This article answers the question, “What is diffusion?” by identifying the parameters of diffusion processes: what they are, how they operate, and why worthy innovations in health care do not spread more rapidly. We clarify how the diffusion of innovations is related to processes of dissemination and implementation, sustainability, improvement activity, and scale-up, and we suggest the diffusion principles that can be readily used in the design of interventions. I n synthesizingmany studies fromdiffer- ent disciplines about how people re- spond to new ideas, Everett Rogers was answering a call set forth by the sociologist Robert K. Merton: theorize, but in empirical ways and with practical impli- cations.1 Now, fifty-six years past the first publication of Rogers’s book Diffusion of Innova- tions, we briefly review this theory, its principles, and the implications for practice as a fifteen-year update to the book’s last edition in 2003. Oneof the best documented if frustratingprin- ciples of diffusion is that it can take a long time. Consider the case of Project ECHO (Extension for Community Healthcare Outcomes), previ- ously reported inHealth Affairs.2 This innovation in how academic medical centers partner with rural primary care clinicians to extend specialty care began at one site in New Mexico in 2003. By November 2017 Project ECHO reported 158 sites across theUS, with sixtymore sites in twen- ty-four other countries.3 The programhasmoved from hepatitis C care to include HIV/AIDS, geri- atrics, psychiatric medicationmanagement, and more.4 Or consider the Green House model of nursing home care, in which “house-like” facili- ties are built that emphasize an open kitchen, residents’ control in decision making, and em- powered nursing assistants.5 Underwritten by a series of developmental, demonstration, and evaluation grants from the Robert Wood John- son Foundation beginning in 2003, more than 200 Green Houses were in operation across the US in2017with300expectedby theendof2018.6 Project ECHO and the Green House model are evidence-based innovations that are spread- ing as new ways to deliver health care, but have they diffused? To assess the diffusion of an inno- vation, one must attend to its denominator. In these examples, the number of plausible and potential adopting sites for either of them is large, with 4,134 Medicare-certified rural health clinics in 2015 and 15,583 certified nursing facilities in the US in 2016.7 In diffusion terms, even after fourteen years and like many other health care innovations, impressive innovations such as Project ECHOand theGreenHousemod- el still have not reached “takeoff” or a tipping point in time on a national diffusion curve.8 What Is Diffusion? Diffusion is a social process that occurs among people in response to learning about an innova- tion such as a new evidence-based approach for extending or improving health care. In its classi- cal formulation, diffusion involves an innova- tion that is communicated through certain chan- doi: 10.1377/hlthaff.2017.1104 HEALTH AFFAIRS 37, NO. 2 (2018): 183–190 ©2018 Project HOPE— The People-to-People Health Foundation, Inc. James W. Dearing (dearjim@ msu.edu) is a professor in the Department of Communication at Michigan State University, in East Lansing. Jeffrey G. Cox is a research associate in the Department of Communication, Michigan State University. February 2018 37 :2 Health Affairs 183 Diffusion Of Innovation Downloaded from HealthAffairs.org on June 07, 2022. Copyright Project HOPE—The People-to-People Health Foundation, Inc. For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org. nels over time among the members of a social system.9 The typical dependent variable in diffusion research is time of adoption, though when complex organizations are the adopters, subsequent implementation is a more meaning- fulmeasure of change. Diffusion can be assessed among individuals such as members of Con- gress, organizations such as health care insur- ers, or larger collectivities such as cities and states. Exhibit 1 illustrates the relationships be- tween rates of adoption and howwe characterize diffusion under different scenarios, including when innovations are introduced and do not dif- fuse. When time-of-adoption data are graphed cumulatively, an S-shaped curve is common, with an initial slow rate of adoption giving way to a rapidly accelerating rate, which then slows as fewer nonadopters remain within the social system in question. Not all instances of diffusion play out this way, especially in policy diffusion— where time to adoption can be shorter because of the occasional convergence of national attention to a problem, financial incentives, readiness for change among elected officials, motivated and organized groups, and an innovative solution that is perceived positively.10 As exhibit 1 suggests, several contextual as- pects of diffusion typically go unstudied. Com- petingorcomplementary innovations are impor- tant, since potential adopters usually have a choice in what to adopt. Failures are important, since most innovations do not diffuse. Decelera- tion is important in two ways, since the decision to adopt an innovation often means abandoning a prior one,11 and nonadopters have their deci- sion to reject an innovation socially confirmed.12 In the case of voluntary adoption decisions, acceleration in the rate of diffusion is usually the result of influential members of the social system making the decision to adopt and their decision being communicated to others, who then follow their lead. To use the example of efforts to reduce tobacco use, while a small sub- set of tobacco taxation policy experts, child wel- fare specialists, or mayors may make careful as- sessments of the evidence and other attributes of an innovation, most of their eventually adopting peers do not.When opinion-leading individuals and organizations adopt an innovation, social systems convert from one normative state (such as smoking in public being acceptable) to anoth- er (smoking being unacceptable).When opinion leaders do not adopt an innovation, systems do not change. Diffusion is an atypical outcome, since the vast majority of innovations fail to dif- fuse, never acceleratingupanS-shaped curve.13,14 This can be a wholly warranted result, since an innovation is defined simply as that which is perceived to be new—not necessarily better— by potential adopters. Unworthy innovations sometimes diffuse, and effective innovations are often stymied. Over time through waves of innovations, diffusion changes societies. Sometimes these changes manifest as differences in knowledge, disproportionate access togovernment and com- mercial services, and worsening inequality be- cause resource-rich communities tend to adopt innovations early relative to poor communities.15 In this special issue of Health Affairs, for exam- Exhibit 1 The context of diffusion SOURCE Authors’ analysis. NOTE Each curve represents a separate hypothetical innovation. Diffusion Of Innovation 184 Health Affairs February 2018 37 :2 Downloaded from HealthAffairs.org on June 07, 2022. Copyright Project HOPE—The People-to-People Health Foundation, Inc. For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org. farmers, consumers, and other autonomous de- cision makers for whom adoption served as a reasonable proxy for use. In clinics and other types of organizations, the extent and quality of implementation and the responses of clients and constituents are outcomes at least as impor- tant as initial adoption. The same can be said about the sustained use of innovations after implementation and continued outcomes for patients or other end beneficiaries. Sustainabili- ty is the subject of increasing study by implemen- tation science and organizational change scholars.31 Government Policies As Innovations Policies have been long studied as innovations in the diffusion tradition, startingwith a seminal US study about the spread of traffic-safety legislation among the states32 to hundreds of diffusion studies about policies concerning edu- cation, health, civil rights, and lotteries.33 While studies about policy diffusion among the states suggest rapid imitation once diffusion begins, the diffusion of policies sometimes demon- strates the sameS-shaped curve as do other types of innovations in their cumulative distribution over time,34 with long latency periods beforeme- dia and public attention are able to propel policy adoption—as was the case with the issue of HIV/ AIDS in the 1980s.35 Researchers often concep- tualize more or less time-ordered stages of policy consideration, adoption, and growth or scale-up,36 though such stages have become com- pressed over the past century as communication technology has enabled faster and faster aware- ness of innovations.10 Policy diffusion researchers have found that beliefs about an innovation’s effectiveness can bemore important thanknowledge of actual out- comes, again suggesting that who has previously adopted an innovation can be more important for decision makers than what was previously adopted and what effects it had.37 This type of result echoes the importance of imitation and mimicry in studies of other types of innovations in other eras and in other countries.38 Policy diffusion studies show that national policy and media attention candrivepolicy consideration at the state level,39 as a contextual effect,18 though there is evidence that policy attention and enact- ment in neighboring states and gubernatorial agenda-setting can be stronger predictors of state policy adoption.40 There is also consider- able evidence that local successes in cities and states can becomenoticed and highlighted at the federal level and then diffuse back out broadly to the states as new programs and policies, often with the incentive of funding mechanisms.33,41 Policy diffusion among the states accelerates with more federal attention to a problem area and its policy alternatives.42 Policy diffusion studies have also shown the importance of types of intermediary actors, such as professional associations, in diffusion proc- esses.43 Policy entrepreneurs are a particularly notable type of actor with the ability to pollinate political jurisdictions with innovations.44 A poli- cy entrepreneur combines the functions of a bridge who ties together disparate groups with that of a championwho represents an innovation from one city or state to high-level decisionmak- ers in other jurisdictions. Effective policy entre- preneurs are able to talk about innovations as solutions to public policy problems in ways that are politically palatable.45 Policy entrepreneurs have been state representatives, leaders of nonprofit community organizations, and well- known experts within a profession. They work to exploit political windows of opportunity; frame solutions to problems in politically palat- able ways; and join together disparate individu- als, groups, and networks to diffuse policies. Fidelity, Reinvention, And Adaptation Fidelity is the extent to which an innovation is implemented by others in the way intended by its developers. Fidelity is often measured as the correspondence between how a program is delivered in tests before scale-up and how the program is later offered by implementing part- ners in the field.46 Innovation developers differ in the degree to which they modify innovations before dissemination, and how much they seek tomaintain control over potential modifications by practice-based implementers. Although a strict adherence to the original procedures may be desirable to maximize effectiveness in the new setting, implementers often make changes—knowingly or not—to better fit an in- novation to their organization and clients. Fidelity can be affected in the process of diffu- sion in two ways: reinvention and adaptation. Reinvention refers to changes made by an inno- vation’s developer to an innovation before its dissemination or scale-up to increase its likeli- hood of being adopted and effectively imple- mented. These changes often take the form of lessening a “perfect” but costly innovation so that it produces enough benefit to justify its dis- semination to more beneficiaries. For example, the YMCA of the USA reinvented its Diabetes Prevention Program from a one-on-one counsel- ing intervention led by a medical professional to a group intervention facilitated by YMCA personnel—which lowered the program’s cost February 2018 37 :2 Health Affairs 187 Downloaded from HealthAffairs.org on June 07, 2022. Copyright Project HOPE—The People-to-People Health Foundation, Inc. For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org. and broadened its reach.47 Adaptation refers to changes made to an inno- vation by implementers who serve intended ben- eficiaries. Adaptations are made by staff in re- sponse both to the immediate context of a health care or public health organizational setting and to changes in the external environment that can make or break the sustained applicability of an innovation for improvinghealth andhealth care. Developers who share or cede control of the im- plementation of an innovation, sometimes in- sisting on fidelity to its core components while encouraging customization of peripheral com- ponents, can achieve diffusion through ongoing course corrections and allowing the implemen- tation strategy to evolve, as exhibited in the twenty-year history of Health Leads reported in this issue of Health Affairs.48 Health Leads has successfully integrated social needs into clin- ical care partly as a result of developers’ willing- ness to cede control. This result—that degrees of decentralized control can increase the rate and reach of innovation diffusion—is found in stud- ies of educational and public health innova- tions, too. Feedback from field-based implementers so that ongoing results can contribute to an evolv- ing implementation strategy need not end with developers. The sharing of real-time insights from implementers to other implementers is a key takeaway lesson from the Center for Medi- care and Medicaid Innovation’s experience, as reported in this special issue.49 Performance im- provement methodology does not suit all inno- vations, but health care services in particular seem well suited to the incorporation of stake- holders’ perspectives into service redesign.50 En- abling and supporting adaptation by stakehold- ers can produce sustained use of innovations because of a stronger sense of ownership by im- plementers,51 as long as adaptations are fidelity consistent.52 Using Diffusion Concepts To Affect Rate And Reach Purposive dissemination, or designing for diffu- sion, means taking additional steps early in the process of creating an innovation to increase its chances of being noticed, positively perceived, adopted, adapted, and implemented—and, thus, successfully crossing the research-to-practice chasm.53 First of all, one wants to be certain that an innovation should be diffused and that, in so doing, its reach is extended to those communi- ties and population segments where need is greatest and capacity is sufficient to adopt and implement the innovation to good effect. In pur- posive dissemination, external validity—the in- novation’s ability to achieve positive outcomes across a diversity of sites—needs to be assessed (ideally on the basis of theory as well as data) from the vantage points of stakeholders whowill implement the innovation.54 Other measures of readiness also shouldbe assessed, includinghow potential adopters perceive the attributes of the innovation and the availability of implementa- tion support in anticipation of demand from providers and patients.55 Formative assessment of advice-seeking net- works among potential adopters of an innova- tion is an important key to the stimulation of diffusion. Such data can statistically and visually identify which few potential adopters are partic- ularly influential when the vast majority of others are deciding whether or not to adopt, as illustrated in the work of the Translating Research in Elder Care group, based at the Uni- versity of Alberta. A recent formative study by this group assessed advice-seeking ties across 958 nursing homes in nine of Canada’s eleven provinces and territories. The results identified opinion leaders within each jurisdiction, as well as advice-seeking ties across provinces, so that future resources can be focused on intervention with small proportions of influential individuals and organizations for eventual system change.56 Getting off on the right foot in the stimulation of a diffusion process is important. Diffusion processes often exhibit path dependence,where- by initial conditions determine how rapidly and to what extent an innovation will spread.57 Relat- edly, the timing of dissemination can be critical to diffusion.58 If potential adopters are attending to a different type of problem than the innova- tion addresses, waiting to disseminate can be the right decision. Learning about and addressing barriers to dif- fusion for both end beneficiaries and the health care practitioners who serve them is important. Many health care innovations require multiple levels of adoption—for example, by a chief medi- cal officer and organizational sponsors, clinical chiefs, head nurses, and patients and families. Getting off on the right foot in the stimulation of a diffusion process is important. Diffusion Of Innovation 188 Health Affairs February 2018 37 :2 Downloaded from HealthAffairs.org on June 07, 2022. Copyright Project HOPE—The People-to-People Health Foundation, Inc. For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org. Formative evaluation along the entire supply chain that needs to coordinate for the dissemi- nation, supply, delivery, and support of an inno- vation can reduce barriers before launch.59 This includes attention to perceived incentives, both monetary and intrinsic, which can be tailored to address types of stakeholders where formative evaluation suggests that barriers to adoption are high—thus contributing to a climate for change.60 Conclusion The research and practice paradigm known as the diffusion of innovations offers a ready set of concepts and approaches that can be used to explain receptivity to health care policies and practices by individuals and organizations. Diffusion principles can also be operationalized to accelerate the rate of adoption and broaden the reach of health innovations. ▪ NOTES 1 Dearing JW, Singhal A. Communi- cation of innovations: a journey with Ev Rogers. In: Singhal A, Dearing JW, editors. Communication of innovations. 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