Step 9: Spread Improvements

“The tipping point is that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire.”

– Malcolm Gladwell


Step 9 is about spreading successful changes to other departments or areas of your institution, other colleges and universities, and/or even other sectors or disciplines.  After a change has been reliably implemented (and is consistently achieving the desired outcome) in one context, the goal is to replicate the outcome of this change in a new context or setting.

By the end of Step 9, you will be able to:

    1. to assess whether a change is ready to spread to other contexts or settings
    2. develop and implement a plan for spreading changes

Is a Change Ready to Spread?

Developed by the East London NHS Foundation Trust, the checklist below can help your team assess whether a change is ready to spread to other contexts.  If you can answer “Yes” to all 5 questions, consider pursing a plan for replicating the gains of your change(s) in another context:

Are you seeing sustained improvement in your test unit?
(improvement in your outcome measure that has been sustained, the changes have become "business as usual" and no further tweaks are being made)
Can you clearly describe the components of the change package that you have implementedYesNo
Does the change represent doing something differently, rather than just doing something better?YesNo
Can the changes be packed in a way that can be easily understood and tested by adopters?YesNo
Do you have the relevant documentation to support the work undertaken?
(driver diagram, measures and data as time series analysis, PDSA documentation, flow charts, policies and procedures to support implementation, etc)

Why do Some Innovations Catch on Quickly and Others Don’t?

Sociologist Everett Rogers, in his 1962 book, Diffusion of Innovations, identified five characteristics of an innovation that is likely to spread :

Attributes of ChangeDefinition
Relative AdvantageThe degree to which an innovation is perceived as better than the idea it supersedes
SimplicityThe degree to which an innovation is perceived as simple to understand and use
CompatibilityThe Degree to which an innovation is perceived as being consistent with the existing values, experiences, beliefs, and needs of potential adopters
TrialabilityThe degree to which an innovation can be tested on a small scale
ObservabilityThe degree to which the use of an innovation and the results it produces are visible to those who should consider it

Developing a Plan for Spread

During implementation, teams learn valuable lessons necessary for successful spread, including key infrastructure issues, optimal sequencing of tasks and working with people to help them adopt and then adapt a change.

Keep in mind that what worked in one area or environment may not work in another.  As such, spread efforts will benefit from the continued use of the PDSA cycle. Units adopting the change need to plan how best to adapt the change to their unit and to determine if the change resulted in the desired and predicted improvement.  Spread requires as much planning as your testing and implementation phases.  The Institute for Healthcare Improvement has developed a framework for spread that includes:

Step 9 IHI Framework for Spread


  1. Complete the “Is a Change Ready to Spread” Checklist  to determine whether a change is ready to spread to other contexts or settings
  2. Develop and implement a plan for spreading changes using the Spread Planner Worksheet