PATHWAY TO CHANGING AND IMPROVING HEALTH CARE Dr Rajeev Kashyap. Sr. Dental Surgeon 14/08/2010 Dr Rajeev Kashyap
Nov 07, 2014
PATHWAY TO CHANGING
AND
IMPROVING HEALTH CARE
Dr Rajeev Kashyap.
Sr. Dental Surgeon
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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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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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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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THE MISSING PATHWAY FOR CHANGE14/0
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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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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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