Module 7
Spread means taking a successful change from one unit, team, or location and implementing it in others, without losing the quality of the original.
- Formal accountability: Embed the change in policy, performance metrics, and reporting structures.
- Champions at every level: A nurse champion on the floor, a physician champion in the department, and a leadership champion in the C-suite.
- Ongoing visibility: Keep the data in front of the team, not just at launch, but months and years later.
Audience-Specific Sustainability and Spread Examples
| Audience | Scenario / Application | Key Takeaway |
|---|---|---|
Emergency Physician |
Embeds the behavioral health screening protocol into the department’s standard triage order set. Ensures it is reviewed in annual nursing competency assessment. Includes screening compliance as a provider performance metric. |
Structural embedding sustains compliance even with staff turnover. Policy + training + accountability = sustainability. |
EMS Team / EMS Medical Director |
Adds the pediatric behavioral health transport protocol to the regional EMS training curriculum and quarterly protocol updates. Designates a QI lead to track compliance. Reviews data at medical director advisory meetings. |
Formal integration into training and governance sustains the change across crew rotations. |
PECC |
Creates a shared QI dashboard across ED shifts that displays screening compliance in real time. Presents results at monthly department meetings. Advocates for PECC representation on the hospital QI committee. |
Visibility, leadership support, and institutional representation drive sustained accountability. |
School Clinician |
Implements the shared referral tracking tool across all school buildings in the district after a successful pilot at one site. Holds a learning session for counselors from all buildings. Creates a district-level coordinator role. |
Peer learning accelerates spread. A coordinator role provides ongoing support and accountability. |
Primary Care Team |
A primary care practice that successfully piloted a warm handoff model, where the PCP personally introduces the care manager to the family before they leave, embeds it as standard workflow for all behavioral health referrals. The protocol is added to new provider orientation, included in the annual quality review, and tracked monthly by the care manager. The practice shares the model with two neighboring practices in the network through a peer learning session, providing the tracking spreadsheet and introduction script as ready-to-use tools. |
Sustainability requires workflow embedding, not just good intentions. Peer sharing with practical tools accelerates spread without requiring each site to rebuild the model from scratch. |
Behavioral Health Staff |
The behavioral health team embeds the safety plan delivery protocol into the formal ED behavioral health evaluation workflow, documented in department policy and included in annual competency review for social workers and behavioral health clinicians. A monthly audit of 10 randomly selected charts tracks compliance and is reported at the department QI meeting. When compliance dips below 90%, the charge social worker conducts a brief team check-in to identify barriers. A behavioral health champion is designated to support peer coaching for new staff. |
Sustainability depends on making compliance visible and building peer accountability into the culture. An audit, not just a policy, is what keeps the improvement alive over time. |
Hospital Leadership / CMO |
Establishes a PMHCA QI committee that meets monthly, reviews data across sites, and champions spread of successful interventions. Aligns QI work with Magnet designation or accreditation goals. |
Executive sponsorship creates organizational accountability for improvement across the system. |