title: Rapid spread of complex change: a case study in inpatient palliative care.
abstract: BACKGROUND
  Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one year, the number of IPC consultations program-wide increased almost tenfold from baseline, and the number of teams nearly doubled. We report here results from a qualitative evaluation of the IPC initiative after a year of implementation; our purpose was to understand factors supporting or impeding the rapid and consistent spread of a complex program.
  
  
  METHODS
  Quality improvement study using a case study design and qualitative analysis of in-depth semi-structured interviews with 36 national, regional, and local leaders.
  
  
  RESULTS
  Compelling evidence of impacts on patient satisfaction and quality of care generated 'pull' among adopters, expressed as a remarkably high degree of conviction about the value of the model. Broad leadership agreement gave rise to sponsorship and support that permeated the organization. A robust social network promoted knowledge exchange and built on an existing network with a strong interest in palliative care. Resource constraints, pre-existing programs of a different model, and ambiguous accountability for implementation impeded spread.
  
  
  CONCLUSIONS
  A complex, hospital-based, interdisciplinary intervention in a large health care organization spread rapidly due to a synergy between organizational 'push' strategies and grassroots-level pull. The combination of push and pull may be especially important when the organizational context or the practice to be spread is complex.
authors.affiliation: Care Management Institute, Kaiser Permanente, One Kaiser Plaza, 16th Floor, Oakland, CA 94612, USA. richard.d.dellapenna@kp.org
authors.forename: Richard
authors.initials: R
authors.lastname: Della Penna
authors.forename: Helene
authors.initials: H
authors.lastname: Martel
authors.forename: Esther B
authors.initials: EB
authors.lastname: Neuwirth
authors.forename: Jennifer
authors.initials: J
authors.lastname: Rice
authors.forename: Marta I
authors.initials: MI
authors.lastname: Filipski
authors.forename: Jennifer
authors.initials: J
authors.lastname: Green
authors.forename: Jim
authors.initials: J
authors.lastname: Bellows
mesh_terms: D004059:Diffusion of Innovation; D006279:Health Maintenance Organizations / Q000458:organization & administration*; D006760:Hospitalization; D006801:Humans; D007407:Interviews as Topic; D019982:Organizational Case Studies; D009936:Organizational Innovation; D010166:Palliative Care / Q000458:organization & administration*; D017060:Patient Satisfaction; D015397:Program Evaluation; D014481:United States