Presented by Sue Stableford, MPH, MSB, on September 27, 2013 at the fourth annual Center for Health Literacy Conference: Plain Talk in Complex Times.

1. What happens when communication
policies hit the ground?
Sue Stableford, MPH, MSB, Director
University of New England Health Institute
September 2013
The Diffusion of Innovation meets
Complex Adaptive Systems

2. Assumptions
• Communication focus:
Terms and 2 major strategies
• Moving strategies into practice = CHANGE
• Core issue for better health and public health
outcomes

3. What’s Ahead
1. The challenge of change
2. Context: Policy and history
3. What happens when policy
hits the ground?
4. How change happens:
Interweaving theories
5. Opportunities to improve practice

4. The Challenge of Change
[Atul Gawande. Slow Ideas. New Yorker, July 29, 2013]
• Adopted quickly: Anesthesia
– Ether introduced 1846 and universal in 7 years
• Adopted slowly: Antiseptic techniques
– Lister report 1867: Carbolic acid
– Generation(s) passed; still challenges
• Public health example: Limes on British ships
Relationship to plain language and teachback?

5. Context: Policies, Guidelines, Standards, Tools
Triple Aim

6. More Policies, Guidelines, Standards, Tools

7. Context of Change: History in 1 Slide
2013
1985 Doaks and Root publish “Teaching
Patients With Low Literacy Skills”
All major national policy and accreditation bodies
recommend/require clear health communication
1999 AMA ‘White Paper’
2003 2nd National Assessment of Adult Literacy (NAAL)
1992 1st National Adult Literacy Survey (NALS)

8. Policy hits the ground

9. Healthcare and public health:
Stormy environments
• Complex
• Many players
• Multiple stakeholders
• Limited resources
• Competing agendas

10. Competing for Attention
• External forces
– Finances
– Politics
– Regulations
– Safety & quality
• Internal agendas

11. Time pressures acute

12. Impact on improving communication?
More like this Than this
Results

13. How can we get
to better communication practice?
• Not easily!
• Change theories converge
– Public Health: Diffusion of Innovation
– Medicine: IHI Model for Improvement
– Business: Kotter’s 8 step action model
– Popular press: Switch
Tipping Point

14. Core Concepts of Change
• Establish need
– Engage head and heart
(data and stories)
• Engage trusted leaders
• Show the way/Start small
• Clear obstacles
• Measure and celebrate
• Spread, build, and anchor

15. What promotes broad-scale change?
• Relative advantage
• Compatibility
• Simplicity
• Trialability
• Observability
(visibility)
“Diffusion of Innovation” (Everett Rogers)

17. Lacks 4 of 5 key elements of easy diffusion
• Visibility
• Simplicity
• Relative advantage
• Compatibility with
‘usual care’
Barriers to Communication Change

18. Another Framework for Understanding Change
– Nonlinear
– Self organizing
– Emergent
– Dynamic
– Adaptive
Healthcare and public health as
Complex Adaptive Systems (CAS)

19. The CAS framework and communication
practice change
“Health care providers, patients, officials and the many
other stakeholders in a health system interact with
each other through a web of complicated
relationships, influenced by communities of
practice, neighborhoods, and social networks.
Scaling up health services involves intervening in
these networks and engaging in dynamic, health
system relationships.”
Paina L & Peters D. Understanding pathways for scaling up health
services through the lens of complex adaptive systems. Health
Policy and Planning, 2012: 27.

20. Diffusion of
Ideas and
Behaviors
Core
Concepts of
Change
Complex
Systems in
Complex
Environments
Common theme: Social Relationships
Policies, Guidelines,
Standards, Tools

21. Showing the way: Models of Success
• IOM Health Literacy Roundtable, April 2013
– Focused on organizational change
– Care systems using change frameworks
and systems thinking to integrate
plain language and teachback
• Public health: ecological paradigm

22. So, what does it take to change
communication practices?
1. Core concepts
– Prioritize, Invest, Measure
2. Diffusion of Innovation
–  Compatibility and
simplicity
– Emphasize advantage
3. Systems & social theory
– Flexibility and creativity
– Points of leverage

23. Support for Improved Communication Practice
• ACA payment reforms
• Links to high-profile issues
e.g. Cultural Competence
• Accreditation requirements
• Academic changes
• Links to proven programs
e.g. TeamSteps and
Choosing Wisely

24. What about technology solutions?
• Technology: A supporting player, not the star
• Change
– A social process
– Person to person
• Gawande: “People talking
to people is still how
the world’s standards change.”

25. Will it make a difference?
Yes! Evidence on communication impact:
• Patients
• Providers and care systems
• Public health

26. Finale
Atul Gwande referencing
Everett Rogers:
“Every change requires
effort, and the decision to
make that effort is a social
process.”

27. Selected Additional References
• Foster-Fishman P, Nowell B, Yang H. Putting the system back into systems
change: a framework for understanding and changing organizational and
community systems. Am J Community Psychol, 2007. 39:197-215.
• Hawe P, Shiell A, Riley T. Theorising Interventions as Events in Systems. Am J
Community Psychol, 2009. 43:267-276.
• Hibbard JH and Greene J. What the Evidence Shows About Patient
Activation: Better Health Outcomes and Care Experiences; Fewer Data on
Costs. Health Affairs, 2013. 32(2):207-214.
• Langley GJ et al. The Improvement Guide: A Practical Approach to Enhancing
Organizational Performance, 2nd ed. San Francisco: Jossey-Bass, 2009.
• Meadows D. Thinking in Systems. Vermont: Chelsea Green Publishing, 2008.
• Patton MQ. Developmental Evaluation: Applying Complexity Concepts to
Enhance Innovation and Use. New York: The Guilford Press, 2011.
• Rogers E. The Diffusion of Innovation. New York: Simon & Schuster, 1962.
• Sterman JD. Learning from Evidence in a Complex World. Am J Public
Health, 2006. 96(3):505-514.
• Trickett EJ et al. Advancing the Science of Community-Level Interventions.
Am J Public Health, 2011. 101(8):1410-1419.