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PATHWAY TO CHANGING AND IMPROVING HEALTH CARE Dr Rajeev Kashyap. Sr. Dental Surgeon 14/08/2010 Dr Rajeev Kashyap
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Pathway to changing and improving health care

Nov 07, 2014

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Health & Medicine

Health Care improvement in Developing nations
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Page 1: Pathway to changing and improving health care

PATHWAY TO CHANGING

AND

IMPROVING HEALTH CARE

Dr Rajeev Kashyap.

Sr. Dental Surgeon

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Page 2: Pathway to changing and improving health care

OBJECTIVES

1. An effective pathway to changing and improving health care practices in developing countries.

2. Core eight principles for supporting a change in health care practices.

3. Identify success factors that build local capacity and smooth the way for effective change in health care practices.

4. Steps to support a change in practices, from initiation through widespread use.

5. The process for building scale-up into the change process from the beginning.

6.The principles for effectively communicating change to varied audiences and generating long-term commitment throughout the process.

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FOCUS

Focuses on changes in

Clinical practices,

Behavioral practices of providers,

and

Management practices at service delivery sites.

Changes in management systems and

organizational structures and strategies are

equally important in supporting and reinforcing

the service delivery changes

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Page 4: Pathway to changing and improving health care

THE CHALLENGE – INCREASE THE

IMPACT OF EACH CHANGE

Ministries of Health,

Nongovernmental organizations (NGOs),

Donors

Cooperating agencies

All want to improve the health of populations.

As a representative of one of these entities, you

share responsibility for making or supporting

sustainable changes in health services that will

impact the lives of impoverished families

throughout the countries in which you work.

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Page 5: Pathway to changing and improving health care

IMPROVEMENTS YOU SEEK FACE

FORMIDABLE ODDS

A high percentage of change efforts fail.

A high percentage of scale-up efforts fall short.

A small percentage of these health improvements

meet expectations.

Can help you understand what is missing from

many change efforts and how to supply these

elements so your efforts can achieve sustainable

results.

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RESEARCH STUDIES

Studies have shown that despite extensive

funding, many changes in health care

practices are not sufficiently scaled up.

They don’t reach the point where they

influence national health indicators.

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Page 7: Pathway to changing and improving health care

THE MISSING PATHWAY FOR CHANGE14/0

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Page 8: Pathway to changing and improving health care

MISSING PATHWAY FOR CHANGE

In improving service delivery practices, people

often involve stakeholders. Together, they

develop and strive to implement plans for

improvement.

Yet these plans and their implementation often

leave out a critical process for change and long-

term commitment.

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CHANGE PROCESS

An effective change process is a recipe for

Selecting, Adapting, Implementing, and

Scaling up effective practices in a way that will

achieve health results and sustain those results

over the years.

When we understand the change process, we are

less likely to underestimate the time and effort it

takes to make change stick.

To ensure that people carry out the change

process, you need to generate their long-term

commitment.

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COMMITMENT

Commitment to change is the determination to

carry the process to the end.

The change is complete when all program levels,

working together, continually produce desired

results as they implement, or support, the

changed practices.

When stakeholders are committed to change,

they don’t give up when they encounter barriers –

nor do they stop when donors turn their

resources toward other needs.

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ROLES IN CHANGING HEALTH SERVICES14/0

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WHAT DO WE MEAN BY HEALTH DELIVERY

PRACTICES?

Health delivery practices In health programs, changes can be made in:

Clinical practices

Providers' behaviours and attitudes

Management practices

Management systems

Organizational structures and strategies

Changes in the first three elements often have the most direct influence on services. But broader changes in systems, structures, and strategies are important factors in bolstering, maintaining, and expanding the more direct changes.

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LOCAL CHANGE AGENTS

WHO?

Clinicians, Local managers and Health Services

WHAT ?

With local change teams initiatives and carry out

change in the service delivery practice.

WHERE ?

Service delivery sites.

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Page 14: Pathway to changing and improving health care

MID-LEVEL CHANGE AGENTS AND

CHAMPIONS OF CHANGE

WHO?

Mid level managers of public or private sector

organizations.

WHAT ?

Can either act as change agents themselves or as

champions to support local support agents.

WHERE ?

District or Provincial headquarters or with the

central or national NGO`s organization.

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SUPPORTERS OF CHANGE: INDIVIDUALS

AND CHANGE COORDINATION TEAM

WHO?

National, regional or international leaders decision

matter or donors.

WHAT ?

Foster change and support change agents and

change teams at all levels

WHERE ?

National or Regional ministries of health , NGO`s

or USAID mission or other international

agencies.

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ROLES IN THE CHANGE PROCESS

(CONTINUED)

Clinicians apply effective practices in their

delivery sites to save lives and reduce illness.

They can make substantial improvements in

maternal health, child health, reproductive

health, family planning, and infectious diseases.

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ROLES IN THE CHANGE PROCESS

(CONTINUED

Mid-level managers can lead and champion

changes in health delivery practices.

Senior management needs to visibly support

the changes and those who are leading the

change process.

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ROLES IN THE CHANGE PROCESS

(CONTINUED)

National, regional, and international decision

makers support these changes in health delivery

practices.

They act as matchmakers, creating a marriage between:

Effective practices for clinical and programmatic work

and

Successful practices for change and scale-up

As a member of the last group, you can learn how to

support the change process and gain the ongoing

commitment of the implementers and managers.

Your contribution can significantly increase the

chances of producing long-term improvements in

health

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DIFFUSION OF INNOVATIONS

The change process you will learn in this session includes elements from an approach known as the diffusion of innovations.

The approach was developed to speed up a "natural" progression where new, often more effective practices replace older practices over time. But it can take decades or even centuries for the old practices to die out. Agents can help this progression by working with others to "diffuse" the new practices.

The diffusion is the process by which an innovation is simplified and communicated through certain channels over time among members of a social system.

Originating through the work of agricultural extension agents, this approach has been applied in a broad range of areas, from business and education to public health. In public health, it has been used to bring about small-scale behavior change in communities, and more recently, to change management practices in health care programs.

The diffusion approach is especially useful for helping ministries of health and NGOs adopt and sp new practices in health care. Source: Rogers 2003

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RESULTS OF DIFFUSION

Diffusion of innovations is central to

everything we do to improve health.

Diffusion often begins by simplifying and

adapting an innovation that has succeeded

on a small scale.

Improvements spread faster when you

strategically communicate while supporting

a change in practices.

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EVIDENCE & HISTORY

In 1601, a simple experiment yielded

convincing evidence that a small amount of

lemon juice each day could prevent scurvy.

The results were reported but generally

ignored. It wasn't until 193 years later,

when a young naval physician documented

convincing evidence about the effects of

lemon juice and made it known to political

decision makers, that life-saving lemon

juice was provided to the crews of all

sailing ships

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SUPPORTING AND LEADING CHANGE

There are some widely accepted principles

for change that offer a grounding for those

who play all three roles in the

change process:

Local change agents,

Mid-level change agents and champions,

and

Supporters of change

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PRINCIPLES FOR CHANGE

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PRINCIPLE 1: CHANGE MUST MATTER

TO THOSE MAKING THE CHANGE.

Align staff responsibilities, environment, and

resources, and set the stage for sustained

commitment to implementation.

Change must offer clear benefits to those who

must implement the new practice at the hospital,

clinic, community, or family level, and to their

clients.

The change will offer great advantages to these

groups, but the potential implementers may have

a very different perception. They may see a

different set of benefits, no benefit, or actual

disadvantages that will result from the change.

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EXPECTED RESULTS OF THE CHANGE

Informal discussions or focus groups are a good way to learn what they think the benefits can be.

Taking views into account will help you think through all the implications of the change.

The clear benefits for clients

The clear benefits for service providers in: Work environment

Job satisfaction

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CHANGE AGENTS

Principle 2: A credible, committed change agent is critical for change in health care practices.

Change agents are people who lead groups in developing, applying, and advocating for new practices. They transmit their commitment and enthusiasm to those who do the day-to-day implementation that ultimately translates new practices into norms.

Examples of change agents

A hospital director who improves linkages and referrals among facilities

A district health officer who secures matching grants and uses them to improve local health services

An experienced, effective clinic nurse who teaches mothers to use local ingredients for effective oral rehydration therapy

An engineer who finds a locally appropriate way to improve water filtration

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EARLY ADOPTERS

People known as "early adopters" have the

characteristics and credibility to influence others.

These people can be the most effective internal

change agents. Scaling up change often requires

recruiting change agents from among early

adopters at various levels in large programs

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CHANGE AGENTS AND EARLY

ADOPTERS

Early adopters are opinion leaders in their

work or social settings.

Often well respected and connected, they

tend to be chosen as leaders or

representatives in their work or social

groups.

They are more willing to take risks and try

new things than later adopters.

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PRINCIPLE 3: SUPPORTING THE CHANGE

AGENT GIVES THE AGENT THE CREDIBILITY

AND CONFIDENCE TO LEAD.

Motivation and support for change agents and

their teams throughout implementation and

scale-up significantly increases the chances of

institutionalizing the change.

Provide ongoing positive reinforcement,

appreciation, encouragement, recognition, and

legitimacy to change agents.

Share knowledge about pathways to successful

change and assist change agents to develop

leadership skills, so that they can engage the

commitment of their staff and sustain it over the

long term, assessments of anticipated benefit.

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COMMIT TO A CHANGE

Of particular importance are skills

to plan for implementation,

scale-up, and

sustainability right from the beginning of the

change process.

This can help to develop these skills in change

agents and their supervisors by giving feedback

and support as they plan and address their

ongoing challenges.

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PRINCIPLE 4: CHANGE IS MORE LIKELY TO SUCCEED WHEN

LEADERSHIP AT EACH ORGANIZATIONAL LEVEL SUPPORTS IT

AND WHEN IT IS INTRODUCED INTO AN ENVIRONMENT

WHERE CHANGE IS AN ONGOING PRACTICE.

Supportive leadership: Because change agents are usually working at organizational levels closest to the delivery of services, they often need an influential senior manager as their sponsor or champion in the change process.

This person uses his or her influence to open doors for the change agent, to be the agent's intermediary with senior management, and to help improve the environment for change.

In some instances, the champion selects the change agent. In other situations the change agent is in place before the champion is recruited. In either case, the champion may be your most direct contact with a change agent at the service delivery or district level.

Source: Management Sciences for Health 2004

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PRINCIPLE 4 (CONTINUED)

Supportive Environment: Studies and experience show that successful adaptation and adoption of new practices occurs most often in programs or work groups where the environment is marked by the following characteristics:

Knowledge sharing happens at all levels. Top leaders and leaders at all levels readily share information and knowledge, and encourage their staff to do the same. They send a clear message: This change is important and I stand behind it.

Making changes is routine. Leading change is part of ongoing organizational practice. Staff are encouraged to make small, practical improvements routinely, not just to undertake big changes in a crisis.

Work teams are cross-functional. Work teams are designed to bring together people with varied perspectives who can build on one another's ideas.

Prudent risk taking is rewarded. Staff are rewarded or acknowledged for asking questions, taking risks, and challenging the status quo to fulfill their program's mission more effectively.

Sources of change are trustworthy. Staff members trust the honesty and credibility of the people who are promoting change.

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PRINCIPLE 5: CLARITY IS NEEDED ON THE

PURPOSE, BENEFITS, AND ANTICIPATED

RESULTS OF THE CHANGE

You can help the change agent to communicate

clearly to all staff the reasons for the change,

what results are likely to ensue, and the ways in

which each staff member will benefit from the

change.

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PRINCIPLE 6: PROVIDING ONGOING SUPPORT TO THOSE WHO

WILL IMPLEMENT THE CHANGE HELPS MAINTAIN THEIR

DEDICATION AND CREATES A SUPPORTIVE NETWORK FOR

THE CHANGE AGENT.

The change agent can encourage continuous staff

involvement and generate the enthusiasm

needed to carry the change through to results

and incorporation into standard procedures.

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PRINCIPLE 7: CLEARLY ASSIGNED AND ACCEPTED

RESPONSIBILITY FOR IMPLEMENTING THE CHANGE

INCREASES THE CHANCES OF SUSTAINING THE CHANGE AS A

PART OF ONGOING WORK

Unless every staff member understands and agrees to her/his specific responsibilities, critical elements can fall through the cracks, reducing the likelihood of achieving the desired results

If staff are held accountable for making the change happen, the change agent needs to:

Encourage staff to recognize the necessity and priority of the proposed change

Provide them with the information, resources, and skills they need to take on new responsibilities

Integrate new responsibilities into their performance plan and hold them accountable

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PRINCIPLE 8: START WHERE YOU CAN

AND START NOW.

In some ways, this is the most important principle. If you wait for ideal conditions and a perfect environment in which all the principles are manifested, no changes will ever be initiated. The perfect is the enemy of the good.

As a supporter of change, you can help to create the best possible environment for change, and then move the process forward. With your support, a capable, motivated change agent and champion can work with the principles to make the best of imperfect conditions.

Together, you can make impressive improvements in health delivery practices and bring the benefits of change to providers and clients alike.

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SELECT A SITE FOR TESTING

Criteria for Choosing the Site

Size and client load: The demonstration site should be small enough to try the practice rapidly and inexpensively, but typical of the settings that will be using the new practice. The change coordination team could analyze caseloads to choose a facility with enough clients to show the impact of the new practice.

Staff cooperation: The best demonstration sites will have some key staff who are early adopters, who are likely to want to cooperate in testing a new, promising practice. In some instances, it may be appropriate to test the practice at the change agent's own site first, building on his or her rapport with staff.

While selecting the initial testing site(s), the change coordination team can identify other sites where the practice will likely be implemented if the first tests are successful.

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WHY TEST?

A small-scale demonstration lessens the risk of costly mistakes.

It facilitates future adoption and support, especially if the change agent is an opinion leader.

Early success reinforces stakeholders' motivation for continued energy and investment.

If accurately measured and clearly communicated, evidence of improvement will persuade staff of the value of the new practice and encourage its incorporation into day-to-day practices.

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DEVELOP THE TEST PLAN

To complete this plan, the change agent and your

change coordination team can:

Develop indicators to monitor progress, and

ultimately, evaluate whether the change has

succeeded in meeting the challenge

Clarify roles and responsibilities for the change

coordination team, the champion, the change

agent, and his/her local change team

Identify tools that have proven useful in carrying

out comparable changes

Plan for linkages to other sectors, systems, and

programs.

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ESTABLISH GUIDELINES

Planning together gives the change agent

guidelines to lead the demonstration process.

These guidelines allow every player to know what

s/he should do, and to be held accountable

throughout the process.

Guidelines establish a framework for scheduling

and help to set priorities and mobilize resources

needed for the test.

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REVIEW PAST CHANGE EFFORTS

Before embarking on the demonstration, your

change coordination team can suggest that the

program assess past change efforts – those that

succeeded as well as those clouded by failure.

An honest appraisal will reveal which approaches

and activities to repeat and which to do

differently in this new demonstration

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COMMITMENT TO SUPPORT

One of the most valuable things your change

coordination team can do is to publicly commit to

provide support for testing the new practice. The

plan should incorporate offers from members for

a variety of services, including:

Technical support in adapting, testing, and

evaluating

Financial resources

Support in setting up a system and defining

criteria for acknowledging individual staff efforts

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TRANSITION TO MORE SITES

From one test site, your change coordination

team can help move to new sites to test the new

practice under different conditions (rural versus

urban, hospital versus health center, application

by less professional staff, etc.).

Often the change agent becomes a facilitator for

managers who implement the change at other

sites under his or her direction.

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THINKING ABOUT SCALE-UP FROM THE

START

Preliminary planning is essential to anticipate and lay the groundwork for the complexities of scaling up.

Start with the action plan you developed when defining a challenge and flesh out the details concerning:

Roles

Sites

Resources

Partners

Communication

Review of past change efforts

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PLANNING FOR SCALE-UP

This step should always be included in

planning for demonstration projects.

Purposeful change can create faster

transformation than normal program

expansion that has predictable periods of

stagnation.

Given the rapid effect of many planned

changes, it is wise to be prepared for

success and scale-up.

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SUBJECT OF SCALING UP

A question of change: How do w e know when we have

achieved scale?

A question of capacity: What management, technological, and

human competencies are necessary to bring programs to scale?

A question of strategy: What strategies most effectively produce

the desired leap?

A question of impact: How should the desired impact be

measured?

A question of sustainability: How do we maintain the gains of

an expanded and comprehensive program?

A question of access: What kind of coverage is enough to qualify

as “scaled up”?

A question of supply and demand: What is being scaled up?

A question of cost: How much will it cost to scale up?

A question of resources: What resources are needed and how

can they be mobilized?

A question of timing: When is the right time to scale up?

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PLANNING FOR SCALE-UP

Roles: Clearly divide roles and responsibilities along technical and, if appropriate, geographical lines. This will foster efficient use of support and resources.

Research: Set a research agenda to supply the data needed to guide the change, including such methods as focus group discussions, document review, and operations research. The goal is to use the simplest, least expensive, least burdensome research method that will yield the information you need.

Sites: Identify the types of sites where successful new practices should be introduced, and the units that will need to support these sites in carrying out the practices.

Resources: Estimate the costs of introducing the new practices at each potential site. Consider staff, supplies, information, and funding needed to roll out the practices regionally or countrywide. Identify likely sources that can meet these needs.

Partners: Identify potential partners to help attain the needed resources and broaden the reach of the new practices. Identify other stakeholders who will need to be on board.

Communication: Analyze potential obstacles that may hinder the successful implementation of the practices and determine where advocacy and dissemination of results may help to reduce these obstacles.

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PHASE 2: PLAN FOR DEMONSTRATION

AND SCALE-UP

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COMMUNICATION IS SO CRITICAL

To communicate change, begin by knowing your audience.

For both internal and external audiences, you will want to convey the answers to these questions:

Why are we making this change?

How will it affect this audience?

How will our program and our clients benefit from the change?

At internal organizational meetings, you might also encourage discussion of two additional questions:

What may make the change hard to achieve?

What can we all do to help?

For external audiences, public discussions, notices, interviews, and news reports are all ways to raise awareness and acceptance of coming changes.

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ENCOURAGE TRUST AND COOPERATION

Manage expectations. A critical role of the change coordination team and senior management is to manage the expectations of those who will be affected by the coming change. You can anticipate that most people will have one of four reactions:

Be satisfied just to know what is going on

or

Greet the new practice with enthusiasm

or

Recommend modifications to the approach

or

Be skeptical that meaningful change will happen

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PRACTICES THAT MAINTAIN TRUST

Consistent and honest messages

Effective performance of the change agent

and local change team

Solicitation of and response to feedback

Free flow of information on

progress throughout the demonstration

Availability to staff and community leaders

Open discussion of important issues that

arise during the demonstration

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AGREE ON ADAPTATIONS

Adapting: To fit the set of effective practices to the program and test setting, the change agent and local change team analyze similarities and differences between their setting and the ones where the practice has been used before. They can then make needed adaptations, drawing on elements in the organizational culture that will support the change.

Adapting a practice for testing in a new setting may involve simplifying it.

Fewer and less complex components will speed implementers' understanding of the content and purpose of a change, and make them more willing to try it.

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MONITOR FOR TEST RESULTS

One valuable contribution could be to collaborate in developing indicators to monitor changes in such areas as:

Health problems among the population being served

Quality and use of services

Performance of service providers

Capacity to deal with constraints

Implementation of the change process

Monitoring also supports a dynamic change environment by:

Encouraging honest feedback

Making objective determinants of success visible to all players

Enabling the change agent and local change team to identify and address barriers to change

Honesty is critical. It will seriously undermine the change effort if those doing the test feel compelled to come up with positive results no matter what they actually find.

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MARK THE CONCLUSION OF THE TEST

A public event is a good way to celebrate the end of a demonstration and reward the efforts of the many people involved.

This is a good way to share findings from the demonstration, describe successes, and acknowledge the contributions of each person who implemented the demonstration and all who supported them.

If the demonstration did not fully succeed, it is still important to publicly acknowledge everyone's efforts, to ask participants for the lessons they learned, and to analyze the reasons for failure that could be counteracted in future efforts.

This event will encourage a positive mindset among stakeholders. It will motivate the change agent and local change team to persist into the next phase, even if they encounter roadblocks.

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PHASE 4: GO TO SCALE

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SUCCESS

Success: Your change coordination team can help to evaluate the results at all demonstration sites and decide whether or not to go with scale-up. If the change effort at these sites has been successful, your team can work with the champion and change agent to prepare a dissemination package for scale-up.

A typical package would describe the progression of the innovation, identify barriers and potential solutions, and extract lessons from the demonstrations.

At this point, the change agent often hands off the leadership role to another well-connected person who will manage the expansion to new settings.

The champion and change coordination team can work with the change agent to bring his or her experience to bear on a vision and plan for scaling up.

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SCALE-UP STRATEGIES

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ENGAGE BROADER COMMITMENT

Shared vision: When you and your change coordination team helped to initiate the change, you joined with counterparts and colleagues to envision a better future. Now, you can repeat the activity on a much larger scale with organizational managers at different levels, partners, and donors.

One way to create a shared vision is to encourage participants to imagine a future where they have successfully addressed the challenge, as described in Session 3, Define the Need for Change.

First, they individually frame their answers to three questions.

What can you visualize that represents that accomplishment? What will this success look like?

What obstacles will you have encountered on the way to this success?

How will you have worked together to overcome the obstacles?

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MONITORING AND EVALUATION (M&E)

Monitoring and Evaluation (M&E) is an essential

component of any intervention, project, or

program

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QUESTIONS

?

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THANK YOUREF: AS PERCEIVED FROM MANAGEMENT SCIENCES FOR

HEALTH & USAID PROGRAM

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