QI 201: Planning for Spread: From Local Improvements to System-Wide Change
Bob has been a part of the implementation team and is excited about the new system. He read about it in a patient safety newsletter and encouraged the organization to consider implementing the system. He is well respected by others on the unit as someone who is knowledgeable about new technology and makes good decisions. Which type of adopter is Bob? (A) Early adopter (B) Early majority (C) Late majority (D) Laggard
Answer: A Bob is an early adopter because he is eager to try the new system, he is well respected among his peers, and he's known for making smart decisions. He has done the research on the system, and he is pretty confident it will work.
Recently, your organization decided to try a new process for nurses to receive medication orders over the phone. The improvement team researched the best methods for accepting telephone orders and conducted several staff trainingss to show why the change was necessary and explain how it would work. Then, the team pilot-tested the new process on one unit of the hospital. The test went well, and the team shared information with the hospital on the pilot test experience. As a next step, the team began implementing the process throughout the hospital. Once the process was implemented hospital-wide, the team monitored the use of the process by individual staff persons and recorded observational information on a specific form. Based on the data collected, the team followed up with people who were still struggling with the new process and provided further training and encouragement. After six months, data showed that the new process was being used 98 percent of the time and that medication errors had decreased by 15 percent hospital-wide. In this scenario, which action or actions represent Lewin's "unfreezing" step? (A) The team researched the best methods, conducted training sessions, and pilot-tested the process. (B) The team began implementing the process throughout the hospital. (C) The team monitored the use of the process. (D) The team followed up with people still struggling with the process.
Answer: A The unfreezing step is the preparation step: To prepare for implementing the new telephone medication ordering process, the team researched the process, trained people to use it, and pilot-tested it.
When adapting to new change, most people fall into which of the following two categories? (A) Innovators and early majority (B) Early adopters and innovators (C) Early majority and early adopters (D) Early majority and late majority
Correct Answer: Early majority and late majority For any given change, the bulk of the population will fall into the early majority and late majority.
Which of the following communications strategies did the TCAB spread team use at Seton? (A) Regular meetings (B) One-to-one calls (C) A website (D) All of the above
Correct Answer: All of the above The best answer is "all of the above." Because communication is at the heart of spread, the spread initiative needs an organized communication campaign. It's helpful to use many types of communication.
Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient's earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult. To help Dave adopt the new change, Rose should consider which of the following actions? (A) Call Dave's boss (B) Provide Dave with literature, including statistics, on the benefits of patient-centered care (C) Provide Dave with patient testimonials from the pilot test of the new process, showing how much patients value the bedside change-of-shift report (D) B and C
Correct Answer: B and C By providing Dave with literature and patient testimonials, Rose can help address some of his barriers to change.
When attempting to spread a change that you feel is valuable but is not spreading naturally, if possible, it's a good idea to: (A) Move on to something else that does spread naturally. (B) Use IHI's Framework for Spread. (C) Use the New Idea Scorecard. (D) B and C
Correct Answer: B and C Changes that do not spread naturally might benefit from IHI's Framework for Spread and from brainstorming with the New Idea Scorecard. You could switch to a different innovation that's easier to spread, but it would be wiser to use the tools available to you before abandoning a potentially valuable innovation.
According to sociologist Everett Rogers' attributes of spreadable ideas, ideas that spread naturally are: (A) Complex (B) Comprehensive (C) Compatible (D) Conceivable
Correct Answer: Compatible One characteristic of ideas that spread naturally is compatibility — that is, they are consistent with the existing values, experiences, beliefs, and needs of potential adopters. The other four characteristics, according to Everett Rogers, are relative advantage, trialability, simplicity, and observability.
Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient's earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult. In this scenario: (A) Rose is right; Dave is just being difficult. (B) Dave is probably too busy and that is why he is throwing up roadblocks. (C) Dave's behavior is normal; everyone has some challenges when adapting to new things.
Correct Answer: Dave's behavior is normal; everyone has some challenges when adapting to new things. In this scenario Dave's behavior is perfectly normal. Everyone struggles with change to some extent.
Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient's earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult. Using Rogers' theory of adoption of innovation, which category of adopter best describes Joan? (A) Innovator (B) Early adopter (C) Early majority (D) Late majority (E) Laggard (F) Not enough information to tell
Correct Answer: Early adopter Joan is an early adopter because she wants her unit to be the first to pilot test the program.
ABC Medical Center has implemented Rapid Response Teams very successfully in their Neonatal Intensive Care Unit. Their data show that the hospital is saving lives. The pilot results are so successful that ABC wants to spread Rapid Response Teams to every unit in the hospital. The hospital CEO has hired an administrator to manage the spread project and write a project plan detailing how the spread of Rapid Response Teams will take place. The administrator writes the report, puts together the project plan, and emails it to the managers of each applicable department. As soon as the plan hits their inboxes, rumors start flying: "What does she know about my department?" "She didn't even talk to me; why should she be making decisions about what we are going to do?" "This plan makes no sense!" People begin to criticize every detail of the project plan. Which of the following would have been a better way to help communicate the plan for initiating Rapid Response Teams? (A) Posting signage on the units to explain that the new process is mandatory. (B) Sharing a video to raise awareness about the benefits of the new process. (C) Emailing an instructional guide to teach the technical aspects of the new process. (D) All of the above
Answer: B Creating a video to describe the new idea and the evidence behind it is a great way to spread awareness and make the case to others. On the other hand, spread leaders should plan to teach technical information through face-to-face instruction whenever possible, as it's the best way to ensure that staff members understand the new process and receive real-time answers to their questions or concerns. Simply stating that a new system is "mandatory" is not an effective way to win people over to a change.
Recently, your organization decided to try a new process for nurses to receive medication orders over the phone. The improvement team researched the best methods for accepting telephone orders and conducted several staff trainingss to show why the change was necessary and explain how it would work. Then, the team pilot-tested the new process on one unit of the hospital. The test went well, and the team shared information with the hospital on the pilot test experience. As a next step, the team began implementing the process throughout the hospital. Once the process was implemented hospital-wide, the team monitored the use of the process by individual staff persons and recorded observational information on a specific form. Based on the data collected, the team followed up with people who were still struggling with the new process and provided further training and encouragement. After six months, data showed that the new process was being used 98 percent of the time and that medication errors had decreased by 15 percent hospital-wide. Which actions represent Lewin's "change" step? (A) The team researched the best methods, conducted training sessions, and pilot-tested the process. (B) The team began implementing the process throughout the hospital. (C) The team monitored the use of the process. (D) The team followed up with people still struggling with the process.
Answer: B During the change step, the change actually occurs and people begin to use the new process and adjust to it on a daily basis, as would occur during implementation.
You yourself are somewhere between Bob and Susan. You're participating in testing the new system, but cautiously — you still want to do more research. What type of adopter are you? (A) Early adopter (B) Early majority (C) Late majority (D) Laggard
Answer: B The best answer is early majority. You've agreed to participate in the project, but you're relying on Bob's good opinion and some of your own research.
ABC Medical Center has implemented Rapid Response Teams very successfully in their Neonatal Intensive Care Unit. Their data show that the hospital is saving lives. The pilot results are so successful that ABC wants to spread Rapid Response Teams to every unit in the hospital. The hospital CEO has hired an administrator to manage the spread project and write a project plan detailing how the spread of Rapid Response Teams will take place. The administrator writes the report, puts together the project plan, and emails it to the managers of each applicable department. As soon as the plan hits their inboxes, rumors start flying: "What does she know about my department?" "She didn't even talk to me; why should she be making decisions about what we are going to do?" "This plan makes no sense!" People begin to criticize every detail of the project plan. At this point, which of the following spread components is still left to consider? (A) Better ideas (B) Setup (C) Measurement and feedback (D) None of the above
Answer: C ABC still needs to figure out a plan for measurement and how to provide feedback to those involved. But, you've helped them begin to think about how to make the case for the better ideas (through a video) and how to set up for the spread effort (through an initial planning meeting, in which they discuss target populations and how to reach them).
ABC Medical Center has implemented Rapid Response Teams very successfully in their Neonatal Intensive Care Unit. Their data show that the hospital is saving lives. The pilot results are so successful that ABC wants to spread Rapid Response Teams to every unit in the hospital. The hospital CEO has hired an administrator to manage the spread project and write a project plan detailing how the spread of Rapid Response Teams will take place. The administrator writes the report, puts together the project plan, and emails it to the managers of each applicable department. As soon as the plan hits their inboxes, rumors start flying: "What does she know about my department?" "She didn't even talk to me; why should she be making decisions about what we are going to do?" "This plan makes no sense!" People begin to criticize every detail of the project plan. Which of the following did ABC neglect to do at the beginning of their spread effort? (A) Make Rapid Response Teams an organizational priority. (B) Designate someone to lead the spread effort. (C) Collect feedback on the new idea. (D) All of the above
Answer: C ABC was on the right track by prioritizing the establishment of Rapid Response Teams and designating a spread administrator for the effort; however, it could have benefitted from collecting feedback on the idea upfront — for example, with the New Idea Scorecard. ABC should convene a team of managers from each of the applicable departments, and ask the group to assess Rapid Response Teams relative to Everett Rogers' five characteristics of ideas that spread. This would help them determine what populations to target first and develop an initial strategy to reach those groups.
Susan is resistant to implementing the new electronic medical record. She says it's complicated and confusing, and she much prefers the paper medical records. She's heard about the advantages of the electronic medical record, but she claims she is more efficient when jotting things down on sticky notes and then copying this information into the paper medical record later. Which type of adopter is Susan? (A) Innovator (B) Early adopter (C) Early majority (D) Laggard
Answer: D Susan appears to be a laggard. She is very resistant to the change and very attached to her current process.
Recently, your organization decided to try a new process for nurses to receive medication orders over the phone. The improvement team researched the best methods for accepting telephone orders and conducted several staff trainingss to show why the change was necessary and explain how it would work. Then, the team pilot-tested the new process on one unit of the hospital. The test went well, and the team shared information with the hospital on the pilot test experience. As a next step, the team began implementing the process throughout the hospital. Once the process was implemented hospital-wide, the team monitored the use of the process by individual staff persons and recorded observational information on a specific form. Based on the data collected, the team followed up with people who were still struggling with the new process and provided further training and encouragement. After six months, data showed that the new process was being used 98 percent of the time and that medication errors had decreased by 15 percent hospital-wide. Which actions represent Lewin's "refreezing" step? (A) The team began implementing the process throughout the hospital. (B) The team monitored the use of the process. (C) The team followed up with people still struggling with the process. (D) B and C
Answer: D The refreezing step involves ways in which the team can "cement" the change by supporting others in adopting it, such as monitoring continued use of the process and helping anyone still struggling with it.
For people to accept change, you MUST address which of the following in change efforts? (A) Technology (B) Funding (C) Human behavior (D) A, B (E) B, C
Correct Answer: Human behavior Although technology and funding may be necessary for some people to accept change, human behavior is present in any change effort and must be addressed for the change to be effective.
The "setup" component of IHI's Framework for Spread is best defined as: (A) Tracking and monitoring spread progress (B) Identifying the target population and the initial strategy to reach all sites in the target population with the new idea (C) Understanding the relationships within the system (D) Assessing innovations and identifying those that are of value
Correct Answer: Identifying the target population and the initial strategy to reach all sites in the target population with the new idea The best answer is "identifying the target population and the initial strategy to reach all sites in the target population with the new idea." Understanding the relationships within the system falls under the "social" component of IHI's Framework for Spread, and tracking and monitoring progress falls under "measurement and feedback." The identification and piloting of worthwhile innovations should occur before leaders attempt to spread those innovations throughout a system.
IHI's Framework for Spread: (A) Identifies 12 components to consider when developing a spread strategy (B) Helps you assess the financial implications of spreading change (C) Is not meant to be prescriptive, but a guide (D) A and B
Correct Answer: Is not meant to be prescriptive, but a guide IHI's Framework for Spread, which identifies seven key steps to help an innovation spread through a social system, is not meant to be prescriptive, but a guide. It does not focus specifically on the financial implications of the change.
Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient's earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult. Using Rogers' theory of adoption of innovation, which category of adopter best describes Dave? (A) Innovator (B) Early adopter (C) Early majority (D) Late majority (E) Laggard (F) Not enough information to tell
Correct Answer: Laggard Dave is a laggard with respect to this particular change because he clings to the old way of doing things, and he likely will not change unless he has no other option.
Seton's Chief Nursing Officer was a key supporter of the TCAB spread effort. Which component of IHI's Framework for Spread does this fact best represent? (A) Communication (B) Leadership (C) Setup (D) Measurement
Correct Answer: Leadership The best answer is "leadership." Executive leaders in an organization play an important role in spread initiatives by supporting and facilitating the efforts. The ultimate success and sustainability of TCAB depended on leadership commitment at all levels: from the senior executives who set strategic priorities and ensured that good changes spread, to midlevel clinical leaders who empowered staff and orchestrated change, to local leaders and staff who redesigned care processes to achieve unprecedented patient outcomes.
When attempting to spread a change that you feel is valuable but is not spreading naturally, if possible, it's a good idea to: (A) Move on to something else that does spread naturally (B) Make the change an organizational priority. (C) Implement the change in each new location exactly the same way as in the previous location. (D) None of the above
Correct Answer: Make the change an organizational priority. Changes that do not spread naturally might benefit from IHI's Framework for Spread; the "leadership" component of this framework states that changes spread more easily when they are key strategic initiatives. While you could switch to a different innovation that's easier to spread, it would be wiser to try to use the Framework for Spread before abandoning a potentially valuable innovation. Remember that every location is different, so you must monitor feedback and adapt as necessary.
An innovation in the United States that is spreading is the concept of a "medical home." Medical homes are meant to be a comprehensive, integrated approach to primary care. The people developing medical homes believe that providing care this way will improve access, patient satisfaction, and patient-centeredness — and improve clinical outcomes. Implementing a medical home involves redesigning the clinic system on a large scale and changing many behaviors of the staff and providers. As of yet, there is limited and conflicting data about whether medical homes lead to improved clinical outcomes. Which of the following is an accurate statement about the spread of this innovation? (A) This innovation has a high degree of simplicity, so it is likely to spread quickly. (B) Because the relative advantage of this new care model is highly apparent, it is likely to spread quickly. (C) There are obvious and low-cost ways to make this innovation more "observable," which might help it spread more quickly. (D) None of the above
Correct Answer: None of the above The best answer is "none of the above." Implementing an entirely new clinic system is quite complex, making this a difficult innovation to spread. Improved outcomes may take time to appear and may not be easily observable, which could also slow spread. Finally, because this innovation involves a large-scale system change in most cases, it is difficult to test this easily and in a safe setting. This analysis does not imply that the medical home is not an improvement — only that it may be more difficult to spread than less complicated innovations.
Which of the following is NOT one of the key components of IHI's Framework for Spread? (A) Leadership (B) Communication (C) Testing a change concept (D) Social system
Correct Answer: Testing a change concept The testing phase of an improvement project occurs before the spread effort, as a prerequisite. Only if the pilot is successful will the improvement team initiate a spread plan.
An innovation in the United States that is spreading is the concept of a "medical home." Medical homes are meant to be a comprehensive, integrated approach to primary care. The people developing medical homes believe that providing care this way will improve access, patient satisfaction, and patient-centeredness — and improve clinical outcomes. Implementing a medical home involves redesigning the clinic system on a large scale and changing many behaviors of the staff and providers. As of yet, there is limited and conflicting data about whether medical homes lead to improved clinical outcomes. Which of the following is an accurate statement about the spread of this innovation? (A) This innovation has a high degree of simplicity, so it is likely to spread quickly. (B) Because the relative advantage of this new care model is highly apparent, it is likely to spread quickly. (C) The complexity of the change involved will likely slow the spread of this innovation. (D) There are obvious and low-cost ways to make this innovation more "trialable," which might help it spread more quickly.
Correct Answer: The complexity of the change involved will likely slow the spread of this innovation. Implementing an entirely new clinic system is quite complex, making this a difficult innovation to spread. Improved outcomes may take time to appear and may not be easily observable, which could also slow spread. Finally, because this innovation involves a large-scale system change in most cases, it is difficult to test this easily and in a safe setting. This analysis does not imply that the medical home is not an improvement — only that it may be more difficult to spread than less complicated innovations.
What is the purpose of IHI's Framework for Spread? (A) To spread health education to underserved communities (B) To spread improvements across health systems (C) To eliminate the spread of disease (D) To ensure accurate spread of information
Correct Answer: To spread improvements across health systems IHI's Framework for Spread is a useful way to think about the most important components to consider when developing and executing a strategy to spread improvements across health systems.
Which of the following is a summary of Kurt Lewin's model of change? (A) Introduction, testing, implementation (B) Research, communication, measurement (C) Unfreezing, changing, re-freezing (D) Collaboration, integration, standardization
Correct Answer: Unfreezing, changing, re-freezing Kurt Lewin wrote that successful change efforts involve preparing people for the change ("unfreezing"), helping them transition ("changing"), and ensuring that the new process becomes the norm ("re-freezing").
Regarding Seton's plan for measurement in the TCAB spread initiative, which of the following is true? (A) The spread team tracked their progress in terms of both coverage and completeness. (B) The spread team had a goal to reach a certain number of units by a certain time. (C) The spread team tracked outcomes measures related to quality and safety. (D) All of the above
Your Answer: All of the above The best answer is "all of the above." The Seton Family of Hospitals set an overall spread aim to introduce 15 medical-surgical units to TCAB by June 2007. They tracked their progress in terms of both coverage and completion, and they also tracked clinical outcome measures related to quality and safety.
An innovation in the United States that is spreading is the concept of a "medical home." Medical homes are meant to be a comprehensive, integrated approach to primary care. The people developing medical homes believe that providing care this way will improve access, patient satisfaction, and patient-centeredness — and improve clinical outcomes. Implementing a medical home involves redesigning the clinic system on a large scale and changing many behaviors of the staff and providers. As of yet, there is limited and conflicting data about whether medical homes lead to improved clinical outcomes. ABC Medical Center's leadership team has implemented the medical home model in one pilot site. Now the team wants to spread the innovation to other sites, and it is using IHI's Framework for Spread. Which of the following should the spread team do? (A) Ask staff to give daily feedback, to assess progress along the way. (B) Avoid asking staff for feedback at any point, to convey that the new system is mandatory. (C) Ask staff for feedback on the idea prior to implementation only, to encourage and then enforce staff buy-in. (D) Ask staff to try the new system for a year before giving feedback, so they have time to adjust to the new system before critiquing it.
Your Answer: Ask staff to give daily feedback, to assess progress along the way. The best answer is to solicit daily feedback. One key factor in IHI's Framework for Spread is knowledge management, which includes gathering information about the spread process as it unfolds. Waiting a year to gather feedback is too long.
The TCAB spread team use at Seton relied on regular meetings, one-to-one calls, and a website to support their spread effort. Which component of IHI's Framework for Spread does this best represent? (A) Communication (B) Leadership (C) Setup (D) Measurement
Your Answer: Communication The best answer is "communication." Because communication is at the heart of spread, the spread initiative needs an organized communication campaign. It's helpful to use many types of communication.
A well-known tech company is releasing a new phone/computer/printer/food processor combo, and your neighbor has already signed up to beta test the device. Nothing like it is on the market, and the media hype about the product is huge — although the news is the product still has some problems. What type of adopter is your neighbor? (A) Innovator (B) Early majority (C) Late majority (D) Laggard
Your Answer: Innovator Because she needs to be the first to use the technology, even before the distributor has had a chance to work out all the kinks, your neighbor is showing characteristics of an innovator.
Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient's earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult. Using Everett Rogers' theory of adoption of innovation, which category of adopter best describes Rose? (A) Innovator (B) Early adopter (C) Early majority (D) Late majority (E) Laggard (F) Not enough information to tell
Your Answer: Innovator Rose is considered an innovator because she was involved and committed to the new process before it had even come to the hospital.
Regarding the Seton network goal for spread, which of the following is true? (A) They met it exactly. (B) They failed to meet it. (C) The goal was unclear, so it was unclear whether they met it. (D) None of the above
Your Answer: None of the above The Seton Family of Hospitals set a spread goal to introduce 15 medical-surgical units to TCAB by June 2007; at project completion, they had exceeded the initial goal. With 18 months, 17 units were using the TCAB process.
Which of the following is NOT one of the key components of the IHI Framework for Spread? (A) Piloting innovation (B) Better ideas (C) Setup (D) Social system
Your Answer: Piloting innovation The pilot phase of an improvement project occurs before the spread effort, as a prerequisite. The improvement team will initiate a spread plan only if the pilot is successful.
Regarding the Seton network goal for spread, which of the following is true? (A) They surpassed it. (B) They met it exactly. (C) They failed to meet it. (D) The goal was unclear, so it was unclear whether they met it.
Your Answer: They surpassed it. The Seton Family of Hospitals set a spread goal to introduce 15 medical-surgical units to TCAB by June 2007. At project completion, they had exceeded the initial goal: 17 units were using the TCAB process within 18 months.
According to sociologist Everett Rogers' attributes of spreadable ideas, ideas that spread naturally are: (A) Trialable (B) Complex (C) Intriguing (D) Groundbreaking
Your Answer: Trialable One characteristic of ideas that spread naturally is trialability — that is, there is the opportunity for people to test the idea in a safe setting. The other four characteristics, according to Everett Rogers, are relative advantage, compatibility, simplicity, and observability.
The "Social System" component of IHI's Framework for Spread is best defined as: (A) Understanding the relationships within the system (B) Identifying a target population for the spread project (C) Assessing and identifying worthwhile innovations (D) A method of tracking and monitoring progress
Your Answer: Understanding the relationships within the system The best answer is "understanding the relationships within the system." When leaders of a spread project understand the relationships within their social system, they can identify people who can help persuade others to adopt a change. Identifying a target population falls into the "setup" component of IHI's Framework for Spread, and tracking and monitoring progress falls under "measurement and feedback." The identification and piloting of worthwhile innovations should occur before leaders attempt to spread those innovations throughout a system.