Innovation in service delivery and organisation was defined by Greenhalgh as: a novel set of behaviours, routines, and ways of working that are directed at improving health outcomes, administrative efficiency, cost effectiveness, or users’ experience and that are implemented by planned and coordinated actions.

Fundamental to change is the management of people: an understanding of how they will react is invaluable.

We can spread innovation using passive approaches (diffusion), active efforts directed at a target group (dissemination), wider efforts covering entire organisations (implementation) and finally achieving normalisation where an innovation is so embedded that it is no longer an innovation but routinised into practice.

The model of spread developed by Greenhalgh and based on Rogers’ seminal work on diffusion of innovations (as represented in the diffusion curve above) provides a comprehensive model of how spread can occur. It shows how innovations can spread depending on the innovation itself, the organisational system(s), the external context, individual actors, the interactions between these (communication, influence and linkages) and the consequences of adoption or assimilation.

Change agents affect the early stages of diffusion through three modes of influence: (1) they can be a direct source of advice, (2) they can seek to actively persuade or (3) they can provide a model to be followed. This latter is often termed ‘opinion leadership’. Opinion leaders within organisations characteristically have slightly higher status, have greater degrees of connectedness and have more personal influence than their followers or others in their network. Rather than being innovators or early adopters, they are usually found in the ‘early majority’ on the adoption curve.

Adoption is the result of a number of factors including the appeal or ‘stickiness’ of the idea itself; the effect of advice, persuasion or modelling by change agents; and the effect of external influences to overcome resistance to change. The early, slower phase of adoption is usually the result of persuasion and external influence. The more rapid, mid-phase of adoption occurs when adoption accelerates through modelling or imitation without persuasion or external influence, and this is sometimes termed the ‘tipping point’, at which innovations become adopted very widely. These ideas and principles can be used to further spread innovations including quality improvement initiatives.

Spreading improvement from a successful local initiative to wider implementation involves careful preparation, agreeing aims, developing a spread plan and implementing the plan. Preparation involves understanding the system, its context, and in particular the organisational leadership and its readiness for change. The aim for spread should include the organisations and people, the improvement goals and measures, and the time period for implementation. Implementation of spread needs consideration of the steps by which this will occur and what the facilitators and barriers may be, including existing organisational support, structures and culture for change, what changes need to be made to these to effect spread and how changes can be normalised into practice.