Table 3.

Key findings from grey literature publications

Authors/title/method	Research question/aim	Main process(es)	Definitions	Mechanisms involved in spread/scale-up/sustainability	Factors that facilitate or impede spread/scale-up/sustainability
Massoud et al., Framework for spread: From local improvements to system-wide change (United States of America) [72]	Provide a snapshot of the Institute for Healthcare Improvement’s latest thinking and work on spread	Spread	None mentioned	Preparing for spread involves acknowledgement by leadership that the improvement project is a key strategic initiative of the organisation, and designation of both executive sponsorship and day-to-day leadership. The existence of successful sites that are the source of the specific ideas to be spread, as well as evidence that the ideas result in the desired outcomes are important Establishing an aim for spread involves identifying the target population, specific goals and improvements, and a time frame for the effort Developing, executing and refining a spread plan includes communication methods and channels to reach and engage the target population, a measurement system to assess progress in meeting the spread aims, and anticipation of actions needed to embed the changes into the organisation’s operational systems	Characteristics of the innovation Willingness or ability of those making the adoption to try the new ideas Characteristics of the culture and infrastructure of the organisation to support change
Clinical Excellence Commission (2008) Enhancing project spread and sustainability: a companion to the ‘easy guide to clinical practice improvement’ (Australia) [73] The Spread and Sustainability Wheel	Provide helpful tips and practical advice to clinicians and health managers on how to improve and asses the spread and sustainability of clinical practice improvement projects	Spread Sustainability	Spread and sustainability: ensure that recognised improvements are maintained beyond the life of the project, and are extended to other areas of healthcare that would also benefit	None mentioned	Nature of initiative Ownership of initiative: leadership and support at senior level Readiness for improvement Effective relationships Integration into practice Evidence of improvements Local context Staff engagement Incentives Processes of implementation Dedicated resources People with influence
Lomas, Formalised informality: an action plan to spread proven health innovations (New Zealand) [74] Summary of the Action Plan to Improve Innovation Spread	Identify gaps and highlight the actions and actors needed to address these gaps for improved spread of innovation in New Zealand’s health sector	Spread	None mentioned	Coordinating, supporting and integrating the three phases of the innovation chain: production/evaluation, dissemination and adoption Interacting interorganisationally is more effective to spread innovations than focussing on structures	Dedicated resources for innovation exploration and development Focused and coordinated evaluation capacity to identify which innovations are worthwhile Commitment from senior leadership Alignment with policy and political priorities Attention to potential adopters’ needs and their balance of costs and benefits Training programmes on innovation-driven change management for managers and clinicians Time set aside specifically for reflection and experimentation by the workforce Slack resources for new projects Relational capital, networks and face-to-face exchanges between stakeholders: Investment in social interaction, not just structures and technology Historical, cultural and economic (dis)incentives for interorganisational collaboration Porous boundaries between the ideas and action communities Boundary-crossing intra- and interorganisational interaction, reflective time: Incentives and networks for ongoing interaction between innovators, evaluators and implementers Targeted persuasive communication, tailored to different audiences Differentiated and decentralised decision-making Specialised focus of professional knowledge in a teamwork environment Because innovations are characterised by novelty and problem orientation, a barrier to spread is their challenge to the status quo
Health Quality Ontario, Spread Primer (Canada) [7]	Spread in the quality improvement framework	Spread	Spread: the active dissemination of best practices and knowledge about interventions, and the implementation of interventions in every applicable care setting Improvement knowledge generated anywhere in the system becomes common knowledge across the system, leading to improvement action	Developing strategies for spreading improvements from the beginning of the improvement project and start small Sharing accountability for spread and empowering others to lead spread builds commitment to common goals as well as the infrastructure to sustain change Ensuring that improvements and the renewed energy and satisfaction that innovations generate reach all parts of the organisation Using a variety of approaches makes it easy for staff to be receptive and adopt change	Nature of the change induced by the innovation Organisational readiness for change Awareness of change concepts and ideas Applicability of potential changes to new environments Belief that change ideas will result in improvement Taking action to adopt the change Sense of urgency and understanding of unmet needs Team collaboration in designing spread plan Regular review of data on defects and performance
Quality Improvement Hub, The spread and sustainability of quality improvement in healthcare (United Kingdom) [75] Literature review	Increase understanding of the 10 key factors underpinning successful spread and sustainability of quality improvement in NHS Scotland	Spread Sustainability	Spread: when best practice is disseminated consistently and reliably across a whole system and involves the implementation of proven interventions in each applicable care setting Sustainability: when new ways of working and improved outcomes become the norm	Disseminating why the change is needed Ensuring that those involved have a desire to support and participate in the change as well as knowledge of how to bring about the change Implementing new skills and behaviours and redesigning processes to sustain the change	Clarity of benefit Real time data to drive improvement Human factors: understanding of why common errors are happening and then redesigning, with steps to prevent the errors Culture: understand the role of culture on behaviours and ability to deliver improvements Change management: support for people to understand the problem a change is attempting to fix and involve them in designing and testing the solutions Leadership combining technical quality improvement skills with effective interpersonal and relational skills Accessibility, use and sharing of knowledge and resources Engagement of everyone with a vested interest, across all levels and roles, in the improvement team Evaluation to understand how activities, outputs and outcomes link and ensure learning and feedback loops are in place Empowerment of staff, patients and carers
Healthcare Improvement Scotland, Guide on spread and sustainability (United Kingdom) [76] Literature review	Summarise existing resources and key pieces of research around spread and sustainability Propose spread and sustainability framework	Spread Sustainability	Spread: the process of communicating new ideas or innovations outside the original system Sustainability: when new ways of working and improved outcomes become the norm	Increasing awareness of the need for greater attention and activity in scale-up, including research, practice and policy activity Expand capacity for scale-up policy, practice and research Facilitating information exchange, collaboration and use of existing knowledge Developing and applying new approaches for evaluation	Attributes of innovation Attributes of adopters Internal and external contextual factors System readiness Evaluation, adaptation, embeddedness and institutionalisation of innovation
What Works Scotland, Evidence review: scaling-up innovations (United Kingdom) [77]	How can small scale innovation be effectively scaled up to create large scale transformational change? Provide actionable messages on how to scale-up healthcare innovations	Scale-up	Scale-up: Delivering or enacting an innovation in a way that increases the number of people benefiting from it while ensuring the original design and measures are maintained	There is no agreement on which approaches to use or on what constitutes success of scaling-up healthcare innovations Considering both ‘hard’ components like metrics, and ‘soft’ components like sociocultural factors when thinking about scalability Scaling is emotionally, mentally and physically demanding Influencing and advocating for innovation enable buy-in to the innovation and scaling process, as opposed to position and authority Collaborating and networking play pivotal roles in spreading innovations by increasing buy-in from stakeholders and increasing the sharing of resources, knowledge and experience Planning for spread while considering that the non-linear nature of spread means that not all dynamics and consequences of an innovation can be planned for in advance Implementing an innovation should use sufficient flexibility while retaining fidelity to the core components Having multiple and creative ways to assess and evaluate the adoption and implementation of an innovation helps to embed it within the larger system Composing teams to scale innovations should be considered carefully to meet needs and team composition should be reviewed regularly to ensure required skills and competencies	Adequate time and planning Adaptation of strategy to the complexity of the innovation Agreement between stakeholders regarding the intentions and goals of the scale-up process Infrastructure and administrative and technical support Distributed leadership across levels and partners: cross-scale interplay and sharing of power through combining top-down and bottom-up approaches Size and complexity of the innovation and scaling goals Collaboration and networking The innovation narrative Encouragement for change Facility of information exchange, collaboration and use of existing knowledge
NHS Institute for Innovation and Improvement, Sustainability model and guide (United Kingdom) [78] Action research	The NHS Sustainability Model and Guide were developed for use by individuals and teams involved in local improvement initiatives	Sustainability	Sustainability: when new ways of working and improved outcomes become the norm	Using the NHS Sustainability Model and Guide (scoring sheets) to support and monitor sustainability of healthcare innovations	Innovation fit with goals and structure Progress monitoring Adaptability Credibility of evidence Benefits beyond helping patients Staff training, involvement and attitudes Leadership: senior and clinical Organisational infrastructure
Gabriel, Making it big: strategies for scaling social innovations, Nesta (United Kingdom) [79] Stages in developing a scaling strategy	How can social innovators spread their innovations? Help social innovators think through their scaling strategies, reflect on the benefits and challenges of different options, and show how others have tackled these issues	Scale-up	Scale-up: increasing the number of people who benefit from a social innovation	Clarifying social, organisational and personal goals for scaling Establishing what to scale up Choosing a route to scale-up (influence and advise, build a delivery network, form strategic partnerships, grow an organisation to deliver) and gearing up to deliver a scaling strategy	None mentioned