Statistics from Altmetric.com
Between 2014 and 2019, four key quality improvement programmes were delivered in kidney services that required a national roll out of improvement interventions that had been developed and tested at a single site. As expected, this ‘Scaling Up’ presented a set of delivery challenges as the work was extended across multiple sites that were distinct to those seen during the local development phase. Some of these were anticipated, others were not.
The programmes studied were complex interventions designed to benefit patient care and each achieved success.
‘SHAREHD’ used a quality improvement collaborative to enable and increase haemodialysis self-management support across 19 National Health Service (NHS) trusts.1
‘Tackling Acute Kidney Injury’ via a stepped wedge method, tested the delivery of a complex intervention at an organisational level in four locations, leading to improvements in the standards of care and patient outcomes.2
‘ASSIST- CKD’ (Chronic Kidney Disease) worked with 20 sites looking to spread and sustain the use of a kidney function surveillance tool (the ‘estimated glomerular filtration rate’ graph) to identify progressive CKD earlier in primary care.3 4
‘Transforming Patient participation in Chronic Kidney Disease’ established repeatable ways of working to support patients to take greater control of their health and well-being.5
By presenting themes from the learning report that examined these programmes, we have explored key differences between local project development and multisite roll-out.6 This is not a structured roadmap but seeks to provide readers with significant considerations when embarking on scaling up work. We initially review themes related to the early stages of a programme and move through to implementation and execution (summarised in figure 1).
Being honest about the intervention—is it ready to scale? To obtain funding to support these programmes, competitive bids (business cases) had to be prepared. This required evidence that the intervention was clearly defined, had been tested and had positive outcomes. Although this was time consuming, it resulted in more robust interventions that remained focused and achieved their stated aims.
Working in partnership with service users—the value of working in partnership with those who have lived experience of the clinical service is necessary for local projects and even more important for scaling up programmes. The patient voice provides a continual reminder of purpose and brings in dimensions that healthcare professionals are likely to overlook. Key messages from the patient partners reinforced their need to feel part of the team and not an ‘afterthought’. Representation requires more than a single individual, needs to be diverse, and to begin as early in the work as possible. As with professionals, clarity of role is essential, and expectations should be managed, supported by necessary training and reviewed to maintain enthusiasm and engagement.
Developing the ‘why’—meaningful delivery of an intervention at scale requires more than overcoming a local challenge that everyone knows about. For spread to be successful it was critical to win the hearts and minds of potential adopters and stakeholders within multiple contexts. The message must be clear, concise, well-rehearsed and easily shared. Even once the intervention has been adopted and incorporated into practice it is central that the rationale is bought into and understood by participants, otherwise the exercise can become procedural and lose impact.
Planning the programme and building the team—local initiatives usually draw on local resources with time often donated by staff within existing roles. The scaling-up business cases were greatly strengthened when the core teams showed a track record of working together on a local pilot; however, additional contributors with appropriate skills such as evaluation, communication and charity partners also needed to be recruited to the team. Early employment of a programme manager is recommended to define activities, monitor and coordinate effort and free up individual members to focus on their technical strengths. Generally local initiatives are less complex and do not require this level of coordination.
Securing appropriate funding—as a new idea is developed at a single site the work is exploratory and requires testing and iteration. However, when the programme is being prepared to scale-up evidence of early effectiveness is required to inform the detailed planning and secure funding which is essential since no matter how important the initiative, it is not possible to implement at scale without sufficient resources to support it. Time away from the day job for specialists including patient partners requires funding via formal cost models.
Justifying the evaluation—local evidence can be gathered via service and quality improvement measurement tools but for a local project to scale it must provide proof that it will be replicable to persuade both grant funders and partner trusts to commit. To achieve this, a formal evaluation requires to be planned from the outset such as through carefully designed research studies. This is also essential if the results of the work are to be included in clinical guidelines and embedded into routine practice.
Setting up robust governance—as interventions spread from local sites to involve additional teams and organisations who were investing their time and resources, these partners rightly expected the core team to deliver against planned commitments. External governance processes were required such as reports and programme boards, as well as the establishment of advisory groups responsible for evaluation, participation and dissemination. Where such robust management structures were in place, problems that arose during the programmes were quickly escalated and mitigations planned. A spirit of openness was also prevalent where teams were encouraged to report difficulties early and were ready to learn from failure.
Dealing with a wide degree of contextual variation—it was found that for interventions to be effectively embraced by adopting sites with differing contextual characteristics, a degree of adaptation by local teams was required. It was important, therefore, to provide clarity on which components of the intervention were fixed and which could be varied. This enabled adopting teams to use quality improvement(QI) methods to adapt aspects of the intervention to take account of local circumstances, developing ownership while remaining true to the core principles of the intervention.
Spreading via communication—even when running a local project, it is hard to ensure that all relevant staff and patients are aware of the work. Inevitably, the challenge is greater when scaling to wider teams and national bodies. A formal communication plan was essential including strategies to develop skills among team members and employ tools ranging from social media to complex infographics to reinforce key messages.
Managing project tensions—effective leadership and stakeholder engagement are critical for any initiative to succeed. As more teams join, a strong, accessible and transparent core team will allow for inevitable tensions to be openly discussed with responses agreed collaboratively.
Drawing on the themes from four successful programmes, we have highlighted key aspects including working in partnership with service users, developing the real ‘Why’ and communicating this clearly and consistently to all stakeholders while being mindful of contextual variation. It is necessary to secure appropriate funding and skills to deliver the work and simultaneously manage deliverables, tensions and challenges. Also a formalised and rigorous evaluation must be planned from the outset so that the impact of the work can be demonstrated, and results disseminated.
In conclusion, successfully setting up and executing a large-scale national programme involves similar but more structured approaches and specialist skills to those required for local initiatives. Not all locally effective projects or teams can scale beyond the pilot site. By applying good management principles and recognising the differences from the start, the programmes studied demonstrate that it is possible to effectively deliver at scale.
We acknowledge the Health Foundation in funding the full report from which this short report is derived as well as funding 3 of the 4 reviewed Renal programmes. Massive thanks are owed to all those who took part in the programmes without which this learning would not have been possible.
Contributors This short report was planned, written, reviewed and edited jointly between the two authors.
Funding This study was funded by the Health Foundation (AWD 110219).
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.