Recognizing the need for better methods to accelerate adoption of effective health practices and programs, researchers and funding agencies have expanded work in implementation science and the related disciplines of improvement science
] and health systems and delivery research
]. Generally speaking, these fields aim to identify barriers and facilitators to the adoption and use of effective practices and programs, and develop, test, and refine strategies for bridging the research-to-practice gap
To date, however, most implementation studies have been conducted in relatively small- to moderately-sized samples of institutions, delivery systems, agencies, and/or communities
]. Although studies in small samples provide useful insights regarding local barriers and facilitators to adoption, the relevance of these findings for efforts to achieve large-scale adoption (i.e.
, scale-up or spread) in hundreds or thousands of institutions or communities is limited. Numerous practice-based efforts to scale-up and spread evidence-based health programs have been documented (although primarily in developing countries), but this work often does not employ theory-based, rigorous scientific approaches for studying scale-up processes, and thus offers limited evidence and guidance for improving future scale-up efforts. The terms ‘scale-up’ and ‘spread’ lack accepted, universal definitions
]; we use the terms interchangeably and define scale-up and spread as ‘deliberate efforts to increase the impact of innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and program development on a lasting basis’ (p. viii)
]. Others use the term ‘going to scale’ when at least 60% of the target population that could potentially benefit from the program receives it
]. Development and use of the terms scale-up and spread are noted elsewhere
Although limited, research interest in scale-up and spread is increasing. Much of this work has been conceptual or descriptive: developing frameworks and models for scale-up and spread
]; discussing key issues in scale-up and spread
]; and describing strategies for achieving scale-up and spread
]. Furthermore, much of this work is narrowly focused, occurring in silos delineated by country, care setting, and/or health domain. There are few opportunities for cross-fertilization of ideas among researchers, practitioners, and policymakers engaged in scale-up and spread activities, and relatively few funding opportunities for research or practice efforts.
Responding to these challenges and the need for expanded research, practice, and policy to ensure that effective programs achieve impact on health at the population level, we launched a multi-stakeholder initiative to increase awareness and to identify specific actions needed to expand scale-up activity in health. The initiative was envisioned and launched during an informal, 30-person working dinner meeting held in junction with a panel session at the 2nd Annual National Institutes of Health Conference on the Science of Dissemination and Implementation (2009). The dinner attendees proposed a state-of-the-art/agenda-setting conference involving approximately 100 U.S. and international representatives from research, practice, and policy in healthcare and public health, which we conducted during July 2010. The conference generated specific recommendations for actions needed to facilitate enhanced interest and activity in scale-up. A follow-up activity was conducted during Fall 2011 to prioritize and operationalize the recommendations. This article describes the methods and findings from the conference and the follow-up prioritization activity.
The Conference to Advance the Science and Practice of Scale-up and Spread of Effective Health Programs in Healthcare and Public Health (hereafter noted as ‘the conference’) was held in Washington, DC from July 6-8, 2010. The conference was organized by representatives from the Institute for Healthcare Improvement (McCannon, PI), the University of Alabama at Birmingham School of Public Health (Norton), and the US Department of Veterans Affairs Quality Enhancement Research Initiative (Mittman). Approximately 100 individuals were invited to attend the conference, reflecting a purposeful mix from the research, practitioner, policymaker, public health, healthcare, U.S., and international communities (see Table
for represented agencies, organizations, and institutions). Support for the conference was provided by the U.S. Agency for Healthcare Research and Quality, The Commonwealth Fund and the Department of Veterans Affairs, with additional funding from The John A. Hartford Foundation and The Patrick and Catherine Weldon Donaghue Medical Research Foundation.
Organizations, institutions, and agencies represented at the conference
The conference format was based largely on the VA’s state-of-the-art conference model
]. The first full meeting day began with an overview presentation by the conference organizers, brief presentations by the authors of four commissioned papers
], and a summary of objectives for the working groups. Five working groups, each comprised of approximately 15-20 individuals representing a mix of researchers, practitioners, and policymakers, were created prior to the meeting. Each working group was charged with three main tasks to accomplish over the next day-and-a-half: envision and describe an ideal system for scale-up; identify gaps between the current and future envisioned state; and develop recommendations for action to close the gaps. Working groups presented summaries of their recommendations to the broader group on the second full day of the conference, followed by a discussion of next steps.
We re-engaged attendees one year after the conference to prioritize and operationalize the conference recommendations. The core conference planning group first refined and summarized the conference recommendations, producing five broad summary recommendations. We then drafted sub-recommendations describing specific actions to operationalize each of the five summary recommendations. Next, we invited 126 individuals to complete an online survey to rate the importance of each recommendation and sub-recommendation for advancing scale-up effective health programs (1
Very Important). The 126 individuals included attendees from the conference as well as approximately 25 other individuals identified by colleague referrals. Of the 126 eligible individuals, 49 (39%) completed the survey.