As I mentioned before, Expand has another meaning and you can also be expanding into new projects or new topic areas in your safety efforts. So, you might say to yourself, "Why when I'm working on a project now do I need to be thinking about my next project? Isn't that going to be distracting?" But there are reasons why it's important to start thinking about spread to new projects and the sooner that you do, the better prepared you'll be. For one thing, quality can always improve and there's so many things for us to work on that we wouldn't want to get stuck in a rut of having one particular feather in our cap, one thing that we did really well back in 1964, and since then we haven't continued to improve or we haven't changed anything. So, knowing that quality can always improve means that you will be changing, you might as well, have some influence over what those changes are going to be. You also have developed some capacity to change while you were doing your first intervention. So, you want to use that new capacity and keep applying it to change care and make care continually better. It also maintains the engagement of staff. You spent a lot of time getting people interested in doing your intervention, this new project and so, don't squander that engagement, but continue it by giving new tasks, new opportunities for leadership, new opportunities to change and improve care. It's also good that if you think now about what your particular next project is going to be, you actually have a little control over what that next initiative will be. And that ultimately leads to a more rewarding work environment generally speaking, because you're deciding what you want to work on as far as your project, and you're picking something that you think is really critically needed in the area that you're working in as opposed to receiving mandates from on high about what you're specifically supposed to be working on. So, it can be really rewarding. The Institute for Healthcare Improvement put out a paper that featured a framework for Spread, they think a lot about how to get uptake of various interventions across the nation. And so, in their set of advice they offer, they suggested first you should make the project an organizational goal or strategic initiative if possible. And so, rather than just at the one level or the one unit, you have this goal you actually want to try to escalate it up to higher levels so that it's consistent with what organizational goals are. In addition, identifying the owner or the executive who's going to be responsible for Spread is important because somebody needs to be overseeing that. If there's no official responsible individual, then it's not going to get done. It's also useful to identify the person or team who are going to manage the day-to-day Spread activity because you know that executive is probably not going to be managing day-to-day activity. And it does take a certain amount of effort. So, make sure that you have some designated individuals who are going to be putting in a lot of that time for the day-to-day operations. So, it also helps to bundle changes. If you have a set of interventions or a set of things that you did to improve care, pull them together into some kind of the package that can easily be adopted, that looks comprehensive, that looks meaningful, and looks consistent, internally consistent. It will be more highly taken up by others if it looks like it was well reasoned and makes sense together. If you are trying to teach one change at a time over a long period, some of them are not going to make it in, and will be regarded as potentially superfluous so, you want to try to bundle the changes into some kind of a tested package. They also recommend that you develop a plan and you figure out your targets for your Spread initiative. That you don't just have it be haphazard, but that there's actually a goal in mind and that you've got some kind of deadlines or if not deadlines, then at least goal dates for your Spread. You want to say what the specific goals are and what are we trying to do. We want to cover 15 units in the next year, then you need to lay that out in order to have a clear goal that you're working towards. And be very specific too if you can about the improvements that are going to be made and sort of what the vision is and what you're hoping to achieve. The timeframe, as I mentioned, is really important and not to just leave it to happenstance because it will fall off the agenda since people are so busy. It will get put off and put off. So, create a time frame that people can stick to that's reasonable and yet has some internal deadlines to help people stay on task. And then, it's also great to create a template for feedback report to the sites for monitoring their progress. So, if you are asking a new site to undertake something, you should be feeding information to them about how it's going and helping them learn how to monitor their own progress at the same time. So, this little graphic is a piece of art that my son made when he was about five. And I like to end with it because we had an interesting conversation around this picture that I think in some way it can inspire people to continuously work on improving quality, improving safety, and also being concerned about the sustainment of that change at an early date. So, I said to him, "Oh honey that's pretty cute, what is that?" He said, "Well, that's a tunnel?" I said, "Oh, where does the tunnel go?" And he said, "The tunnel goes everywhere". And so here you are standing at the entrance to the tunnel to everywhere and it's up to you to decide where you're going to be when you come out the other side of that tunnel. Do you want it to be ten years down the road and there's no sign of the intervention that you were working so hard on today? Well, if you don't want to see that as the end of your tunnel, then be sure to plan for sustainability and think about engaging appropriately, and think about how you will expand into new areas so that when you get to the end of your tunnel, it's the vision of excellent patient care that you hold close to your heart.