2.2.1 Spread, Scale-Up, and Sustainability – in Sequence or in Parallel?

Spread, scale-up, and sustainability are sometimes depicted as three distinct and sequential phases in a linear improvement process. Spread is presented as taking place first when there is interest to adopt improvements beyond their original setting. Scale-up follows as it becomes clear what infrastructure will be needed in other settings for spread to be successful. Sustainability only receives attention after the first two processes are deemed complete during the initial (often poorly defined) implementation period.

However, as our overview of definitions in Section 2.1 suggests, it is more helpful to view spread, scale-up, and sustainability as inherently overlapping and interdependent processes.Reference Scheirer²⁶ For example, when an improvement effort achieves spread across an organisation or within the health service, it may be more likely to be sustained locally. Scale-up helps to ensure that the necessary infrastructure to support spread becomes available, while also increasing the chances of sustainability. A non-linear perspective recognises that spread, scale-up, and sustainability need to be pursued concurrently to be able to deal with the complexity of improvement efforts in contemporary health systems. Section 4 sets out two contrasting cases illustrating these points. NHS Scotland’s video consulting service provides an additional example of spread being enabled by the early development of relevant infrastructure (e.g. technical equipment, organisational resources) and by considering sustainability from the outset.Reference Papoutsi, Wherton, Shaw, Morrison and Greenhalgh^31, Reference Wherton and Greenhalgh³²

Rather than viewing spread, scale-up, and sustainability processes in mechanistic terms, we need to apply methods suitable for understanding complex adaptive systems that don’t operate in a predictable and planned manner.Reference Greenhalgh and Papoutsi^17, Reference Norton, McCannon, Schall and Mittman^20, Reference Shaw, Shaw, Wherton, Hughes and Greenhalgh^33, Reference Greene, Huang and Giusto³⁴ Viewing these translational processes as non-linear and mutually reinforcing also points to a different way of understanding improvement efforts and interventions – that is, as programmes formed by and interdependent with the context they are trying to influence, rather than something independent and optimised prior to widespread implementation. In short, we need to consider how to grow improvement efforts organically within the contexts of their implementation rather than try to build them mechanistically regardless of context. Organic growth perspectives are more attuned to local contexts and circumstances in all their social, cultural, and organisational complexity: they allow for local adaptation, contingency, negotiation, and dialogue, instead of rule-driven inflexible approaches and rigid patterns.

2.2.2 How to Balance Fidelity and Adaptability?

The academic literature features ongoing debate about the extent to which improvement interventions and their implementation strategies should adapt to local contexts and evolve over time.Reference Slaughter, Hill and Snelgrove-Clarke³⁵ Few studies describe how improvement programmes evolve and how implementation strategies are adapted to work at scale.Reference Braithwaite, Ludlow and Testa^13, Reference Moore, Mascarenhas, Bain and Straus²⁸ The terms implementation ‘fidelity’ or ‘integrity’ denote the extent to which an intervention or programme has been delivered as intended and in a more or less uniform way across all sites involved; the assumption is that high fidelity is more likely to lead to improvement.Reference Carroll, Patterson and Wood³⁶ Various ways of measuring and tracking fidelity have been devised (e.g. see the conceptual framework for implementation fidelityReference Carroll, Patterson and Wood³⁶), and checklists have been recommended to improve the description and replicability of interventions (e.g. see the TIDieR checklistReference Hoffmann, Glasziou and Boutron³⁷).

If unwarranted variations of process exist between different settings, this does impose learning overheads and creates risks at the system level.Reference Dixon-Woods and Martin³⁸ However, there are tensions between standardisation and flexibility: How can spread and scale-up succeed if adaptation to local structures and a sense of local ownership are not encouraged?Reference Papoutsi, Boaden, Foy, Grimshaw, Rycroft-Malone, Raine, Fitzpatrick and Barratt³⁹ But then, as Scheirer asks: ‘If the adaptation of components is viewed as desirable at the local level, at what point is it no longer the “same” program?’Reference Scheirer²⁶ Are there essential components of a programme that need to be maintained and others that can be modified in different settings?

Some authors distinguish between the ‘hard core’ of an intervention (the features of an intervention that are deemed to be critical in leading to desired outcomes) and its ‘soft periphery’ (the wrap-around features that can and should be adapted to context).Reference Greenhalgh, Robert, Macfarlane, Bate and Kyriakidoy^14, Reference Denis, Hébert, Langley, Lozeau and Trottier⁴⁰ For example, Denis et al. suggest that when introducing a new pharmaceutical treatment, the new drug formulation constitutes the hard core of the intervention, and the soft periphery refers to the organisational arrangements that enable changes to patient monitoring and follow-up, including decisions on who should be treated.Reference Denis, Hébert, Langley, Lozeau and Trottier⁴⁰ Yet, depending on the type of intervention, distinguishing between hard and soft components may be challenging, and what constitutes an irreducible feature in one context may need to become an adaptable feature in another.

Other authors suggest that instead of attempting to reproduce an intervention (or its implementation strategy) in the same format across settings, the emphasis should be on achieving the same function.Reference Hawe, Shiell and Riley⁴¹ This focuses attention on understanding the principles by which an intervention is expected to generate change in one or more contexts (rather than its components or ingredients) – for example, through more informed use of programme theory.Reference Dixon-Woods, Leslie, Tarrant and Bion^9, Reference Hawe, Shiell and Riley^41, Reference Davidoff, Dixon-Woods, Leviton and Michie⁴² Hawe et al. discuss the contrasting ways in which the same principle (e.g. educating patients about depression) can be standardised by format (e.g. all implementation sites need to distribute the same information leaflet for patients) or by function (e.g. sites need to develop their own ways of devising tailored information materials based on local population characteristics).Reference Hawe, Shiell and Riley⁴³ When it comes to spread, scale-up, and sustainability in complex systems, local adaptations and pragmatic adjustments become important to better adapt to local needs and continue meeting the intended function of improvement interventions over time (e.g. see Horton et al.Reference Horton, Illingworth and Warburton⁴⁴ for survey evidence on how frequently adopters have to adapt interventions to context).

2.2.3 Sustainability of What?

Sustainability is an inherently ambiguous term since it embodies a tension between, on the one hand, an improvement intervention enduring in its current form (and hence potentially becoming obsolete over time as organisations adapt to accommodate it while perhaps overlooking new products and practices emerging elsewhere) and, on the other, the intervention changing over time or even being replaced by something more fit for purpose (as the organisation responds to a changing context).Reference Greenhalgh, Macfarlane, Barton-Sweeney and Woodard¹¹ Whereas the literature tends to assume that it is the innovation itself that should be sustained, the term ‘sustainability’ may also be used to mean sustainability of the service or health system. Increasingly, the term is also used to refer to sustainability of the planet and hence to considerations of reducing waste and pollution and working towards a greener future. Moreover, sustainability and scale-up may not always be desirable; de-implementation or scaling back in the sense of actively stopping obsolete practices may become an equally valuable goal towards improved safety, quality, and efficiency.Reference Øvretveit, Garofalo and Mittman^16, Reference Norton and Chambers⁴⁵

Views in the literature vary on which aspects of sustainability to assess and at which level, for example, programme or system level. Some have called for tighter definitions of sustainability to ensure that all studies are using the term in the same way.Reference Braithwaite, Ludlow and Testa¹³ But perhaps it is more important to clarify, for any particular study, how the term is being used. Many studies take a relatively narrow view of sustainability as related only to the continuation of programme activities,Reference Moore, Mascarenhas, Bain and Straus²⁸ with some authors questioning what proportion and intensity of activities would establish a programme as sustained (especially after withdrawal of specific implementation support and capacity).Reference Scheirer²⁶ Others extend sustainability to encompass continued provision of beneficial outcomes for clients or service users, maintaining community attention to the problem addressed by the programme (e.g. after those who originally led implementation have moved on), sustaining community-level partnerships and coalitions (e.g. in relation to public health), or replicating the programme in other sites.Reference Scheirer^26, Reference Shediac-Rizkallah and Bone^46, Reference Scheirer and Dearing⁴⁷ Different stakeholders will have different priorities and approaches to measuring sustainability – for example, commissioners may focus on savings, patients may view sustainability as related to continuation through their own treatment pathway, and providers may prioritise feasibility within staffing capacity and resources.

Øvretveit distinguishes between sustainability of impacts, projects, methods, and the capacity to improve quality.²¹ This distinction is echoed by Greenhalgh et al., who discuss sustainability of the original vision and of the capacity for quality improvement so as to be able to balance emergent tensions.Reference Greenhalgh, Macfarlane, Barton-Sweeney and Woodard¹¹ They suggest that models of sustainability may be:

• ‘intervention-focused (What if anything has been sustained?)’. Here, the focus is on the original programme and its components (studied using theoretical concepts such as fidelity and a more or less conventional logic model); or

• ‘system-dynamic (How and why did change unfold as it did?)’. Here, the focus is on the innovation and its interacting and evolving context, including the interdependencies and uncertainties in a complex system (studied using mixed methods oriented to producing a rich and meaningful case study narrative).Reference Greenhalgh, Macfarlane, Barton-Sweeney and Woodard¹¹

Greenhalgh et al. make the point that these seemingly incommensurable approaches may be fruitfully combined to depict how an innovation has to some extent been sustained as planned but has also changed for good reason to adapt to a changing context. Whereas basic logic-model evaluation of sustainability may involve a relatively simple check of whether original aims have been achieved, case studies of system-dynamic sustainability consider how both the innovation and the organisation have adapted dynamically, including an analysis of both intended and unintended consequences (which may be valued differently by different stakeholders).

2.2.4 What Are the Time Frames for Sustainability?

Beyond asking what counts as sustained improvement, it is also important to understand when an improvement might count as having been sustained. Research studies vary in the time frames they use to assess sustainability, but commonly limit measurement of outcomes to one or two years after implementation, depending on the type of intervention.Reference Braithwaite, Ludlow and Testa^13, Reference Scheirer²⁶ Funding may dictate how long it is possible for researchers to measure sustainability, as many healthcare improvement projects are carried out through time-limited, external collaborations. Healthcare organisations often have little internal capacity to continue measuring improvement sustainability (quantitatively and qualitatively) beyond standard performance targets mandated at system level.Reference Braithwaite, Ludlow and Testa¹³ So, to assess sustainability, a more strategic approach to medium-term and long-term measurement is needed, with appropriate justification for different types of interventions and adequate flexibility to capture changes over time. For example, Van de Ven describes how the Minnesota Innovation Research Programme coordinated longitudinal research across several innovation projects spanning almost two decades to develop process theory (i.e. explanations for how innovation unfolds over time). This was enabled by combining research grants and financial support from a range of sources (e.g. see Van de Ven and PooleReference de Ven AH and Poole⁴⁸ and Van de VenReference de Ven AH⁴⁹).

3.3.1 The Dynamic Sustainability Framework

Chambers et al.’s Dynamic Sustainability Framework aims to help overcome challenges in spreading interventions beyond experimental settings. The framework cautions against over-reliance on fidelity and protocols when it comes to the success and sustainment of complex improvement efforts. Instead, the authors emphasise ongoing adaptations of improvement interventions over time in their implementation contexts.Reference Chambers, Glasgow and Stange¹⁵

The framework has three key components:

• Intervention: interventions are primarily seen as being characterised by distinct components (e.g. clinical guidelines) which are intended to be delivered by designated individuals (e.g. clinicians) through specific delivery platforms (e.g. face-to-face, telephone) to achieve specific (often patient-based) outcomes.

• Practice setting or implementation context: the clinical or community context in which implementation happens is largely characterised by its human resources, organisational and technical infrastructures, and approaches to organisational learning and supervision (the framework places significant emphasis on learning healthcare systems).

• Ecological system: the broader ecological system comprises other clinical settings (where the intervention is not being implemented), the legislative and regulatory environment, market forces, and population characteristics.Reference Chambers, Glasgow and Stange¹⁵

None of the three components is deemed static; rather, they are continuously evolving and changing in relation to external influences and each other (see Figure 1). Constant alignment or dynamic fit is needed based on learning and experimentation over time (see Box 2 for key principles). Because the framework focuses primarily on particular single interventions, it is best used in an organic way by teams looking to implement a guideline or protocol, for example.

Figure 1 The Dynamic Sustainability Framework. The framework seeks to establish ‘optimal’ but dynamic ‘fit’ between the intervention, its implementation context and the broader system, in a balance that changes over time as each of the three components evolve (i.e. T0, T1, Tn).

Reproduced from Chambers et al.Reference Chambers, Glasgow and Stange¹⁵ in accordance with the terms of the Creative Commons Attribution Licence (http://creativecommons.org/licenses/by/4.0).

Chambers et al. provide illustrative examples of how the framework could be applied in the areas of chronic care management, clinical guidelines, and psychotherapy implementation.Reference Chambers, Glasgow and Stange¹⁵ Urquhart et al. have used the framework in their qualitative study of influences on the sustainability of innovations in cancer survivorship care.Reference Urquhart, Kendell and Cornelissen⁵⁸ Others have built on its principles to develop the foundations for their realist evaluationReference Flynn, Mrklas, Campbell, Wasylak and Scott⁷⁴ and to extend research in cognitive work analysis.Reference Austin, Blakely, Salmon, Braithwaite and Clay-Williams⁷⁵

3.3.2 The 3S Scale-Up Infrastructure Approach

The crucial role of context, which is at the heart of the Dynamic Sustainability Framework, is also emphasised in Øvretveit et al.’s approach to developing a 3S (structure, strategy, supports) scale-up infrastructure.Reference Øvretveit, Garofalo and Mittman¹⁶ Building on several years of research in this area,Reference Øvretveit and Staines^76, Reference Øvretveit⁷⁷ the 3S approach distinguishes between the internal contexts (e.g. management support, leadership continuity) and external contexts (e.g. financing opportunities, favourable regulation) that influence improvement in practice. The authors argue that without a supportive organisational culture, strategic leadership, and accountability structures in place to drive improvement efforts, widespread change becomes difficult to achieve.Reference Øvretveit, Garofalo and Mittman¹⁶ But instead of simply identifying contextual characteristics that may determine strong ‘fit’ with the intervention (as in the Dynamic Sustainability Framework), Øvretveit et al. encourage ‘actions to increase readiness for change’ and ‘preparing contexts’ so that the chances for successful scale-up are maximised.Reference Øvretveit, Garofalo and Mittman¹⁶ Practitioners can draw on this approach when seeking to create and sustain an enabling infrastructure and environment for any improvement intervention.

The 3S approach proposes that three infrastructural components are necessary to support large-scale implementation:

• Structure: organisational teams and individuals at different levels with capacity and accountability to deliver scale-up, supported by a reporting process.

• Strategy: an organised scale-up plan with actions, milestones, and allocated responsible individuals.

• Support: high-quality and trustworthy data monitoring systems for periodic reviews, and expertise in adaptive facilitation to drive scale-up.

The approach includes a practical checklist for improvers to help guide 3S infrastructure development. The checklist provides a series of improvement-related questions about process for prioritisation, structure of accountability, flexibility for adaptation, and support available from leaders, facilitators, and researchers. It suggests asking informed observers to attribute scores of 0–5 for how much of each element is present in the development context. Low scores for some elements can suggest areas where attention is needed to improve the chances of success of the scale-up programme.Reference Øvretveit, Garofalo and Mittman¹⁶

Given its applied focus, there are few published examples of this approach, but those leading improvement efforts may find the explanation provided by Øvretveit et al. on care transitions across large health systems in the USA helpful.Reference Øvretveit, Garofalo and Mittman¹⁶

3.3.3 The NASSS Framework

Instead of treating improvement efforts as linear and simplistic, the NASSS framework aims to understand and explain unpredictability, uncertainty, dynamic interactions, and interdependencies. Drawing on complexity theory and social science for its dominant underpinning theoretical lens, Greenhalgh and her team developed the framework in 2017 to address persistent problems related to technological but also other types of innovation projects in health and care.Reference Greenhalgh, Wherton and Papoutsi⁸

NASSS includes seven domains (with associated sub-domains) in which complexity manifests to varying degrees in technology projects (see Figure 2):

• the nature of the health condition or illness

• the type of technology (or intervention)

• the value proposition (both financial, e.g. return on investment, and non-financial, e.g. benefits to patients)

• the role of intended adopters

• organisational capacity and other support structures

• the complexity of the wider system

• the potential for continuous embedding and adaptation over time.

Figure 2 The NASSS framework for studying non-adoption, abandonment, and challenges to spread, scale-up, and sustainability of technology projects in health and care organisations

Reproduced from Greenhalgh et al.Reference Greenhalgh, Maylor and Shaw⁷⁸ in accordance with the terms of the Creative Commons Attribution Licence (http://creativecommons.org/licenses/by/4.0).

Each domain can be characterised as simple, complicated, or complex. For example, a simple illness or condition (e.g. a sprained ankle) has clear diagnostic criteria and its management can be predictable; a complicated illness (e.g. some types of cancer) may be more challenging to manage but would still follow a clinically predictable path; a complex illness (e.g. psychosis) is more likely to require ongoing care that takes into account comorbidities and other social factors.

Programmes where multiple domains are characterised as complicated (there are multiple interacting components or issues) may encounter more spread and scale-up challenges. Programmes where multiple domains are complex (dynamic, unpredictable, not easily disaggregated into constituent components) will be less likely to become sustained without significant effort.Reference Greenhalgh, Wherton and Papoutsi⁶¹ What matters is not just complexity within the domains themselves, but also the interactions and interdependencies between the domains over time, as the arrows in Figure 2 illustrate.

The NASSS framework aims to:

• inform the design of technology

• support planning for implementation, spread, or scale-up

• contribute to early identification of innovations where increased complexity is likely to limit success

• increase learning by explaining programme failures.

The framework is not intended as a checklist, but as a sensitising device to facilitate construction of a rich narrative synthesising different perspectives in unfolding technology programmes. Several researchers and policymakers have used the NASSS framework to understand, plan, and explain the journeys of technology projects, including video consultations, remote monitoring, and decision support (e.g. see Abimbola et al.Reference Abimbola, Patel and Peiris⁷⁹). A series of practical tools for improvement teams based on NASSS is described in Box 3.

4.1.1 How Was the Intervention Developed, Spread, and Scaled Up?

PRactical Obstetric Multi-Professional Training (PROMPT) is a multi-professional training package for obstetric emergencies in maternity units. Based on a local course that was originally developed in 2000 to address local training needs at Southmead Hospital in Bristol, the training package aims to help midwives, obstetricians, anaesthetists, and other members of multi-professional maternity teams deliver safe and effective maternity care.Reference Papoutsi, A’Court, Wherton, Shaw and Greenhalgh^{62, 81}

Following early evidence of organisational and system-level benefits from delivery of the training package in both real-world and simulation settings,Reference Crofts, Ellis and Draycott^82, Reference Draycott and Winter⁸³ a clinical effectiveness study identified improvements in staff knowledge, teamwork, and outcomes for mothers and babies.Reference Draycott^84–87 In 2008, the Bristol team developed a ‘train the trainer’ (T3) model for PROMPT, whereby a multi-professional team attend training and learn how to deliver courses in their own maternity unit. Key to this training model was the ‘course in a box’ concept. It sought to ensure that after being trained themselves, the maternity unit teams are provided with wide-ranging training resources (course and trainers’ manuals, scenarios, videos, clinical algorithms, and emergency boxes) that they can adapt and use to deliver training at local sites. Initial course materials were published with the support of the Royal College of Obstetricians and Gynaecologists,Reference Draycott and Winter⁸³ until the PROMPT Maternity Foundation (a registered charity in England and Wales) was set up in 2012. Second and third editions of the ‘course in a box’ were published in 2012 (PROMPT 2) and 2017 (PROMPT 3), and its continued local use has been associated with sustained improvements in outcomes.Reference Crofts, Lenguerrand and Bentham⁸⁸

In 2014, the PROMPT Maternity Foundation ran a stepped-wedge rollout of PROMPT across 12 maternity units in Scotland (the THISTLE Study).Reference Lenguerrand, Winter and Innes⁸⁹ And in 2017, Welsh Risk Pool funded the rollout and evaluation of PROMPT in 12 maternity units in Wales (PROMPT Wales).Reference Renwick, Hookes and Draycott⁹⁰ In 2018, the PROMPT Maternity Foundation was awarded funding to work with a social franchising team, Spring Impact, to understand how to sustain PROMPT use and best practices at local level. An enhanced implementation support package, the PROMPT Partnership Programme, was developed in 2018 and piloted at five sites in the UK.⁸⁷ Evaluation of this enhanced support package demonstrated that scaling up was possible and learnings from the programme have been included in the fourth PROMPT training package, the PROMPT Annual Update.

Most maternity units across the UK have either attended a PROMPT T3 programme or downloaded the more recent PROMPT digital training resources and integrated implementation programme. Based on data held by the PROMPT Maternity Foundation, the PROMPT Annual Update package has been accessed by 104 maternity units across the UK as of May 2023. In addition, PROMPT has also been introduced (in its original or adapted format) in 15 countries around the world, and a further 10 countries have sent maternity teams to receive training, although the actual scale of local implementation is not actively monitored (data until May 2023).

4.1.2 What Influenced Spread and Scale-Up?

Achieving this degree of scale-up and spread took many years with diverse influences from multiple contributors. In the UK, pump-prime funding from the Royal College of Obstetricians and Gynaecologists was important for initial rollout.Reference Draycott and Winter⁸³ There has been a plethora of published evidence describing the positive impacts of PROMPT training on safety and effectiveness of maternity care and this has justified both initial uptake and later spread, nationally and internationally, by providing a compelling value proposition for adoption.Reference Draycott and Winter⁸³

Spread and scale-up were also strongly influenced by the external landscape, in particular the policy environment. For example, NHS Resolution had recommended local multi-professional training for those delivering maternity care. The Clinical Negligence Scheme for Trusts Maternity Incentive Scheme in England and, in Australia, the Victorian Managed Insurance Authority incentivise providers to meet safety actions to improve maternity care.Reference Draycott and Winter⁸³ This type of policy and regulatory infrastructure has been key for sustainability to date.

Those behind the development of PROMPT also played a key role in encouraging demand and facilitating spread, both through their own leadership and by identifying local champions for adoption in maternity units.Reference Draycott and Winter⁸³ This core, multi-professional PROMPT team of clinicians helped build supportive relationships and networks for spread, for example by talking about PROMPT training at professional events and within formal and informal networks. This helped to raise awareness and stimulate interest and demand. The team behind the intervention also worked with academics to understand the social and relational nature of interventions and how this can impact on successful implementation and spread. Although initial spread was mainly organic and not grounded in an explicit strategy, understanding social and relational influences helped codify success factors and informed approaches to spread later on.Reference Draycott and Winter⁸³

Various features of the intervention itself have also supported spread and sustainability at some sites. They include the user-friendly, localised training model, meaning that healthcare staff are not required to travel to simulation centres, more staff from a single unit can benefit at the same time, and locally delivered training is more cost-effective than training in a simulation centre.Reference Draycott and Winter⁸³ A train the trainer model also supports both spread and sustainability as the training effort is not dependent on external trainers and the course materials can be adapted to support local implementation.Reference Draycott and Winter⁸³ And the option of external implementation support (part of the PROMPT Partnership Programme) can help sites which might otherwise struggle to deliver and sustain the training fully autonomously and over time – for example, because of difficulty in securing management buy-in and commitment to release staff time to attend training, or delays in implementation of local training following initial attendance at the PROMPT train the trainer session.⁸⁷

The PROMPT core team have identified some key influences that are important in ensuring future sustainability, including:

• sustaining policy-level support

• being able to nurture communities of practice around the training package

• ensuring implementation fidelity of core components (while recognising the importance of adaptability to a local context as well)

• nurturing receptive organisational environments, including organisational support for staff to attend and deliver training

• conducive team relationships in the settings that are implementing the improvement effort

• local champions

• ongoing trouble-shooting support from the PROMPT Maternity Foundation.Reference Draycott and Winter⁸³

4.2.1 How Was the Intervention Developed, Spread, and Scaled Up?

Older patients may suffer disproportionate levels of harm due to inconsistent implementation of accepted clinical standards in non-specialist settings.Reference Offord, Wyrko and Downes⁹¹ The Frailsafe collaborative sought to address this challenge by spreading implementation of a patient safety checklist in 12 acute hospitals across the UK. The idea behind the checklist was to ensure that a number of evidence-based interventions were completed as soon as possible after admission. The checklist, which was refined and eventually standardised during the programme, consisted of two parts: a screening phase to identify older patients in need of specialist assessment; and confirmation (where appropriate) that key assessments (e.g. dementia, delirium, mobility, among others) had been completed.Reference Offord, Wyrko and Downes⁹¹

Checklist use was expected to result in more reliable clinical assessment to prevent harm, in improved communication between clinical teams (especially frailty and acute care teams), and in less hierarchical ways of working. Clinical staff were encouraged to use the checklist to ‘challenge’ each other around appropriate and timely completion of assessments.Reference Offord, Wyrko and Downes⁹¹ The spread and scale-up effort was supported by the Frailsafe collaborative (based on the Breakthrough Series model⁹²), which brought together the 12 hospital teams alongside a team of geriatricians and quality improvement experts.Reference Offord, Wyrko and Downes⁹¹ The project was also supported by a professional organisation for geriatricians in the UK and received significant attention at the time.

4.2.2 What Influenced Spread and Scale-Up?

Despite the initiative’s highly structured quality improvement approach and enthusiasm among participating sites, a mixed-methods evaluation across the 12 UK sites identified challenges in spreading and scaling up use of the checklist within (and beyond) the collaborative.Reference Papoutsi, Poots and Clements⁹³ Hospital teams did perceive value in adopting a quick shorthand approach to identifying older people in need of additional assessment, and they found the checklist useful for highlighting gaps in the ways assessments were carried out locally. However, they also recognised that the checklist’s contribution to patient safety was limited because completion of assessments did not always lead to better patient care. And even when use of the checklist identified that an assessment had not been done, this did not always lead to further action. Use of the checklist was often at odds with the reality of admission routines and already established, culturally complex ways of working and communicating in different clinical settings.Reference Papoutsi, Poots and Clements⁹³

To our knowledge, checklist adoption remained limited to improvement teams participating in the Frailsafe collaborative and rarely extended to other hospital teams. Its introduction was not sufficient to broker new ways of working across geriatric medicine and acute care, nor to change communication patterns in hierarchical multidisciplinary teams. In contrast to the original programme design, the checklist was often completed by clinicians independently rather than in the context of a clinical discussion with other team members, or it was used by senior doctors to check whether more junior members of staff had completed their duties. Such dynamics were more visible in clinical settings where isolated working and strong hierarchies were prevalent. The checklist appeared to be used more meaningfully by teams that already had well-developed and positive collaboration styles. Although leadership at programme level was strong, the extent to which local champions were able to promote change in their settings and to garner organisational support varied.Reference Papoutsi, Poots and Clements⁹³

Spread and scale-up were limited because they were perceived as primarily technical and mechanistic processes; less attention was paid to the practical everyday accomplishment of clinical work in different settings, to established routines and interprofessional dynamics, norms, and values, and to dynamically changing local organisational contexts. Adapting the patient safety intervention locally to respond to specific needs and align with pre-existing processes might have enabled further spread. Identifying ways to link with accountability structures, support established teamwork patterns and relationships, as well as involve other stakeholders, such as patients and carers, could also have supported more widespread adoption.Reference Papoutsi, Poots and Clements⁹³