Attributes of innovations and approaches to scalability – lessons from a national program to extend the scope of practice of health professionals

Figures & data

Table 1 Definitions of terms

Term	Definition
Diffusion	The passive, untargeted, unplanned, and uncontrolled spread of new interventions.^Citation33
Dissemination	An active approach of spreading evidence-based interventions to the target audience via determined channels using planned strategies.^Citation33
Innovation	An idea, practice, or object that is perceived as new by an individual or other unit of adoption.^Citation12
Scaling up	Efforts to increase the impact of innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and program development on a lasting basis.^Citation34
Scaling up strategy	The means by which the innovation is communicated, transferred, or otherwise promoted.^Citation13

Figure 1 Conceptual framework for scaling up innovations.

Table 2 Innovation attributes of the ECP model

Innovation attributes	Evaluation findings
Relative advantage	A high proportion (72.5%) of patients seen by ECPs did not require transport to hospital. Cost-effectiveness depended on sufficient throughput of suitable patients identified in an efficient manner. The costs of implementing the model were met by ambulance services, but any cost savings accrued to the health system more generally, particularly hospitals (because of reduced transfers to hospital).
Compatibility	The practice of ECPs was compatible with current practice of ambulance paramedics. From an organizational perspective, the major issue of “compatibility” related to throughput. With sufficient throughput, a sole ECP can work in a specially equipped vehicle with no patient transport capability, quite separate from existing emergency response crews. If throughput is less, the ECP role has to be combined with another role (eg, the existing emergency response service).
Complexity	The ECPs managed patients with diverse, and often ill-defined, signs and symptoms. Although much of this work can be considered as “low acuity”, it can also be quite complex, requiring advanced clinical reasoning. This requires relatively in-depth training, with mentoring and supervision by medical practitioners or experienced ECPs, which may be difficult to provide adequately. The ECP role required highly experienced ambulance paramedics with appropriate qualifications.
Trialability	The model is difficult to “try out” without a significant investment of time, money, and stakeholder engagement. The cost of training each ECP was estimated at AUD30,000. In the absence of prior experience implementing the role, the results of the evaluation indicated that 12–18 months are required to establish systems, structures, and processes before any patients benefit.
Observability	The benefits of the model were “visible” to ECPs and those they treated, with strong agreement among ECPs that their role improved quality of care for specific patient groups and very high levels of consumer satisfaction with the model. Few patients refused treatment by an ECP.
Adaptability	At most sites, the caseload was too small to warrant a full-time, stand-alone position. A hybrid role was seen by most ECPs as more satisfying and efficient in rural and regional locations, with the added advantage of allowing ECPs to maintain their intensive care skills. The stand-alone ECP model may be more viable in large metropolitan locations that generate higher caseloads or in localities where the supply of other primary health practitioners is limited.
Risk	The model is low risk, with small likelihood of adverse outcomes, as long as strict clinical governance arrangements are in place, particularly supportive medical supervision. In addition to being highly experienced, carefully selected, and comprehensively trained, ECPs had a distinct set of personal characteristics and attributes that were seen to promote safe practice. Key stakeholders were satisfied that the model operated safely and offered a very high level of quality in patient care. This was reinforced by the available information from administrative data sets.

Abbreviation: ECPs, extended care paramedics.

Table 3 Innovation attributes of the PCP model

Attribute	Findings
Relative advantage	The waiting times, treatment times, and lengths of stay for MSK patients treated by PCPs were shorter than for patients treated by other clinicians. Evaluation of cost-efficiency was limited by the lack of available data. The model may help reduce resource use in the area of X-ray ordering by facilitating more prompt and expert assessment of patients with suspected fractures. On weekdays when PCPs were rostered on, ED performance improved and patient throughput was higher.
Compatibility	The practice of PCPs is compatible with current physiotherapy and ED practice. The model requires physiotherapists to change their thinking from one of accepting referrals to one of seeking out referrals. The PCP model can be introduced as a separate model, or combined with an existing secondary contact physiotherapy service.
Complexity	The practice of the PCPs was largely restricted to a well-defined group of patients with MSK conditions. The training is relatively complex, but can be broken down into smaller parts. This can include an early focus on key competencies to facilitate commencement of PCP practice and reduced need for supervision.
Trialability	The model can be “tried out” by slowly increasing the skills and expertise of existing staff to take on increasing responsibility for the patient cohort as their competencies develop.
Observability	There was strong agreement among PCPs that their role improved quality of care for MSK conditions. The PCP role was strongly endorsed by colleagues who were satisfied that the model was safe and improved quality and efficiency. Patients reported good experiences and high levels of satisfaction with the care they received.
Adaptability	The arrangements for supporting the PCP model can be adapted for local use. The available training pathways were appropriate, but there is the potential for the pathways to be more flexible so as not to limit the number of physiotherapists who are suitable for the role. Medical staff can be replaced as assessors of clinical competence by an experienced and suitably qualified PCP.
Risk	Based on limited data, re-presentations to the same ED for the same health condition were similar for PCPs and other practitioners. The number of unexpected deaths was similar for the baseline and implementation periods and decreased postimplementation. All PCPs were experienced clinicians. Stakeholders were confident that the model was safe and that PCPs were working within their scope of practice. Some senior doctors emphasized the importance of medical oversight and PCPs themselves demonstrated willingness to seek advice and refer as needed.

Abbreviations: PCP, primary contact physiotherapist; MSK, musculoskeletal; ED, emergency department.

Table 4 Questions for scalability

Questions to be answered by evidence adopters
Is the “adopting” organization likely to be receptive to the innovation?
Can the innovation deliver care that is as safe as, and of equivalent quality (or better) than, usual care?
Will the innovation lead to greater efficiency or productivity?
Is the innovation cost-effective or at least cost neutral?
Is there a critical mass of appropriately qualified and experienced personnel who can fill, or be trained to fill, the expanded role?
Are appropriately qualified personnel available to provide supervision and support when required?
Is the innovation compatible with current practice?
How will the innovation “fit” with current service provision?
Does the innovation need to be adapted to meet local circumstances (including any adaptation to ensure sufficient throughput)?
Can the innovation be “tried out” before full adoption?
Questions to be answered by evidence influencers
Are there health services that are likely to be receptive to the innovation eg, management support, support from clinical leaders, recognized need for change?
Are there health services with the necessary infrastructure (eg, resources, structures, training capability) to support the innovation?
Will the innovation lead to greater efficiency or productivity?
Is the innovation cost-effective or at least cost neutral?
Are any legislative changes required to facilitate the innovation?
Are there any potential economies of scale, eg, in the provision of training and skills development?
Does the current funding system support the innovation?
How does the innovation align with current policy priorities?
Do professional bodies support the innovation?
Are there industrial implications arising from the introduction of this innovation?

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