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Open Access Highly Accessed Research article

Rapid spread of complex change: a case study in inpatient palliative care

Richard Della Penna1, Helene Martel2, Esther B Neuwirth2*, Jennifer Rice3, Marta I Filipski2, Jennifer Green4 and Jim Bellows2

Author Affiliations

1 Kaiser Permanente Aging Network, One Kaiser Plaza, 16th Floor, Oakland, CA 94612, USA

2 Care Management Institute, Kaiser Permanente, One Kaiser Plaza, 16th Floor, Oakland, CA 94612, USA

3 School of Public Health, University of California, 50 University Hall #7360, Berkeley, CA 94712, USA

4 Caduceus Strategies, 1735 High Street SE, Salem, OR 97302, USA

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BMC Health Services Research 2009, 9:245  doi:10.1186/1472-6963-9-245

Published: 29 December 2009



Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one year, the number of IPC consultations program-wide increased almost tenfold from baseline, and the number of teams nearly doubled. We report here results from a qualitative evaluation of the IPC initiative after a year of implementation; our purpose was to understand factors supporting or impeding the rapid and consistent spread of a complex program.


Quality improvement study using a case study design and qualitative analysis of in-depth semi-structured interviews with 36 national, regional, and local leaders.


Compelling evidence of impacts on patient satisfaction and quality of care generated 'pull' among adopters, expressed as a remarkably high degree of conviction about the value of the model. Broad leadership agreement gave rise to sponsorship and support that permeated the organization. A robust social network promoted knowledge exchange and built on an existing network with a strong interest in palliative care. Resource constraints, pre-existing programs of a different model, and ambiguous accountability for implementation impeded spread.


A complex, hospital-based, interdisciplinary intervention in a large health care organization spread rapidly due to a synergy between organizational 'push' strategies and grassroots-level pull. The combination of push and pull may be especially important when the organizational context or the practice to be spread is complex.