Well, we've talked about how to sustain and now we want to talk about expanding. So by expanding, what I mean is spread. And this is essentially either taking your intervention to other places or potentially within a unit, expanding into new topic areas, which we'll talk about in a minute. First, I want to talk about the link between spread and sustainability. These two things are not unrelated. For example, when you're starting to spread, if someone else or another unit or another practice has asked you how to do what you did, because you got good results and they want to do the same, then you're teaching another group of people how to take the same thing that you did and use it in their own environment, requires a self-study and tends to solidify your own understanding of what you did. And of course, that helps in your long term sustainability or sustainment of your specific intervention. It also lets you know about some of the unique challenges that you may see in other units or other practices, and that could give you some new ideas, and maybe some new methods that could really change your perceptions of your implementation that you did. Watching them and watching how they do theirs may give you some new thoughts and new ideas. And then that could lead, again, to better sustainability over the long run. It also uses your new capacity to change and to make care even better. By spreading it from one place to another, you are giving them skills for change at the same time that you're giving them some kind of new intervention to try and that may really improve your own intervention and therefore sustainability. It also maintains engagement of the staff and their interest and attention of management when you are moving the same successful intervention into other places or your expanding to new topic areas. This continues to grab people's attention and keep them interested in what you're doing, because it's clear that there's continuing work to be done and that they can be a key piece of that. And then finally, it results in kind of a more rewarding work environment overall when you're continually working on new things. Even though people get tired or get fatigued with too much work, when they get to use their brains, when they get to make things better, it feels very rewarding and that can be really important for recruitment and retention. So spreading to other units, and by units I might mean within an inpatient setting or to a different practices within the same network. And the first question if we were going to stick with the CLABSI example would be something along the lines of, what other parts of our hospital need to maintain lines and therefore may have an infection problem? And then, start by having a meeting with them and say, "We have this really successful intervention that we've tried, we thought you might be interested in it." And this may happen at the hospital level or at a higher level within the organization, but they say, "Okay. Unit A did a great job, but unit B and C are both having some trouble still. Let's take this intervention over there." So, as a group, try to develop a plan and work closely with a core team on the receiving end. And really, again, don't forget, go for that engagement first and let them own what they're doing. If you tell them that it has to be the way you did it, then they're not going to feel any ownership over it. So make sure that they're getting some data about their own infections and their own issues with lines that they may have placed or maintained, so that they feel ownership and engagement over this specific problem within their own level not just because the hospital management or someone told them that they needed to change. Allow whichever unit is receiving the new intervention to pick which of the tools they think are the ones they should start with. Every place has its own big concerns and problems, and so, allowing whoever is receiving a new intervention to come up with their own timeline of when they think things are feasible and what they think needs to be prioritized, will be an adaptation that will lead to better sustainability ultimately and probably better near term results as well. And so, it shouldn't be so rigid as you try to spread that it's not appealing to the place that's receiving this new intervention. And then think about building a team at the highest level of your organization, hospital level perhaps or practices might consider network level, to really talk about all of your safety interventions, to talk about all of your quality improvement efforts and to think about cultural aspects of that overall organization. This can allow for a better spread or expansion of successful things from one place to another and it can also support the sustainment of the overall intervention because there are other team members working on the same thing in other places within the same organization. And of course, if you're running into resistance, it can be important to have hospital backup or a higher level backup in order to try to encourage the receiving units to try harder or to work with you more in order to have the special intervention shared with every patient rather than withheld only for patients who are lucky enough to be in this specific unit that's doing best on, let's say, bloodstream infection reduction. You wouldn't want to be one of the folks that unfortunately ended up in a different unit and therefore didn't have the benefit of this wonderful intervention that you've developed and are trying to implement. But it is important to remember that even though you may think that it's a wonderful intervention, if you try to force your ideas on a unit that's not ready for it, then it will not go well. You can expect it to be met with lots of barriers that wouldn't be there if they had openly asked for the intervention. And so, that's something to definitely keep in mind as you try to spread to other places.
