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The AHRQ Health Care Innovations Exchange: Moving to Scale (Text Version)

Slide presentation from the AHRQ 2011 conference.

On September 19, 2011, Veronica Nieva made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (1.1 MB). Plugin Software Help.

Slide 1


The AHRQ Health Care Innovations Exchange: Moving to Scale

Veronica F. Nieva, PhD
Rockville, MD

AHRQ 2011 Annual Conference
Leading Through Innovation & Collaboration
September 19, 2011
Bethesda, MD

Slide 2


After Innovation Scale Up and Spread

  • Over 600 evidence-based Innovations.
  • How to bridge the gap between these innovations and potential adopters?
  • How to accelerate the rate of spread?

Slide 3


Innovation Scaling

"Deliberate efforts to increase the impact of health service innovations locally tested in pilot or experimental projects, so as to benefit more people and to foster policy and program development on a lasting basis."

Simmons R, Fajans P, Ghiron L (2007)

Slide 4


Image of a flowchart with the following text:

Dissemination: the targeted distribution of information and intervention materials to specific audiences + Implementation: the use of strategies to adopt and implement interventions within specific settings → Scaling

Slide 5


Key Concepts

  • Types of Scaling.
  • Factors Affecting Scaling.

Slide 6


Types of Scaling


  • Hierarchical.
  • Centralized.


  • Led by inspired individuals.


  • Network based.
  • Participatory.

Slide 7


Types of Scaling

A diagram of scaling is shown. The types of scaling are horizontal, vertical, and functional.

Slide 8


Factors Affecting Scale Up

  • The Innovation.
  • Adopting Organizations.
  • Scaling Organizations.
  • Stakeholder Organizations.
  • Policy and Market Environments.
  • Methods for Scaling.
  • The Innovator.

Slide 9


Is the Innovation Ready for Scaling?

The Innovation:

  • Credibility.
  • Relevance and Compatibility.
  • "Trialability" / Testable.
  • Evidence.
  • Clear benefits for each stakeholder group.
  • Well-defined core components.
  • Cost efficiency.
  • Return on investment (ROI).

Slide 10


Is the Adopting Organization Ready for the Innovation?

Adopting Organizations:

  • Internal Change Champions.
  • "Learning Organization".
  • Innovation-specific capacity:
    • Space?
    • Professional role changes?
    • Technology?
    • Work flow impact? Patient role changes?
  • Beware of innovation fatigue!

Slide 11


Is the Innovator Ready to Scale?

The Innovator:

  • Innovator and Spread roles differ:
    • Innovators vs. Entrepreneurs.
  • Many innovators are not interested in spread:
    • Academic research.
    • Specific problem solving.
  • Interested innovators need to learn spread skills:
    • "Marketing" is not a dirty word.

Slide 12


What Roles Might Scaling Organizations Have?

Scaling Organizations:

  • Visioning and planning.
  • Stakeholder assessment.
  • Coalition and partnership building.
  • Process documentation.
  • Project evaluation.
  • Fundraising.

Slide 13


What Methods can be Used to Scale?

Methods for Scaling:

  • "Campaigns"
    • Top-down.
    • National, state or community levels.
    • Public or private initiatives.
    • Often with supportive regulations.
    • Across sectors and involving many organizations.

Slide 14


Methods for Scaling

  • More "Top-Down" Methods:
    • Executive Mandates—top down, within system.
    • Wave sequence—unfolding within system.
    • Extension Agents—agricultural model.

Slide 15


Methods for Scaling

  • Technical Assistance.
  • Consulting.
  • Collaborative Learning.
  • Licensing/Franchising.
  • Credentialing.

Slide 16


How Can Stakeholder Organizations be Engaged?

Scaling requires developing relationships and aligning incentives among stakeholders.

Images: Logos for professional organizations, insurers, foundations, and other types of stakeholders are shown.

Slide 17


Does the Policy Environment Support the Innovation?

Policy and Market Environments:

  • Supportive legislation and regulations:
    • Affordable Care Act.
    • Medicare Shared Savings Program (ACOs).
  • Policy barriers:
    • E.g., Volume based reimbursement policies.

Slide 18


Is the Market Environment Supportive?

Policy and Market Environments:

  • Competitive advantage of the innovation, vis-à-vis comparables.
  • Readiness of the potential adopter "markets"—organizations, providers, patients.

Slide 19


Some Questions

  • Who should lead Scale Up and Spread efforts?
  • What would an effective Scale Up and Spread infrastructure look like?
  • How should individual behaviors change to support spread?

Slide 20



  • Cooley L, Kohl R. Scaling Up: From Vision to Large Scale Change—A Management Framework for Practitioners. Management Science International. Washington DC, March 2006.
  • Going to Scale: Can we bring more benefits to more people more quickly? Workshop Highlights (draft) presented by the CGIAR-NGO Committee and The Global Forum for Agricultural Research (with other organizations), April 2000.
  • Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Quarterly 82(4), 581-629.
  • Hartmann A, Linn JF. Scaling Up: A Framework and Lessons for Development Effectiveness from Literature and Practice. Brookings Institute (Wolfensohn Center for Development) Working Paper 5, Oct 2008.
  • Massoud MR, Donohue KL, McCannon CJ. Options for Large-scale Spread of Simple, High-impact Interventions. Technical Report, Sept 2010 for USAID.

Slide 21



  • McCannon CJ, Berwick D, Massoud MR. The Science of Large Scale Change. JAMA 2007; 298(16):1937-1939.
  • Norton WE, Mittman BS. Scaling Up Health Promotion/Disease Prevention Programs in Community Settings: Barriers, Facilitators, and Initial Recommendations. Jan 2010, Report submitted to Patrick and Catherine Weldon Donaghue Medical Research Foundation (available on
  • Rogers, E. M. (2003). Diffusions of Innovations. New York: Free Press. Fifth Edition.
  • Simmons R, Shiffman, J. Scaling-up health service innovations: A framework for action. In Simmons R, Fajans P, Ghiron L (Eds.), Scaling-up health delivery: From pilot innovations to policies and programmes. Geneva, Switzerland: World Heath Organization, 2007.
  • Uvin, P (1995). "Fighting Hunger at the Grassroots: Paths to Scaling Up," World Development 23(6): 927-939.
  • Yuan CT, Nembhard IM, Stern AF, Brush JE, Krumholz HM, Bradley EH. Blueprint for the Dissemination of Evidence-Based Practices in Health Care. The Commonwealth Fund. Issue Brief, May 2010.
Page last reviewed October 2014
Internet Citation: The AHRQ Health Care Innovations Exchange: Moving to Scale (Text Version). October 2014. Agency for Healthcare Research and Quality, Rockville, MD.


The information on this page is archived and provided for reference purposes only.


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