The Voltage Effect – Scaling Best Practice

Posted by: Diane Ketley - Posted on:

Five Traits Are Important for Best Practice to Scale

Best practice must possess five traits to be scalable. Ruth Tyrrell, GIRFT Academy Director (@tyrrell_ruth), ​recently spoke on ‘The Voltage Effect – Scaling Best Practice’ based on the book by John A List, book summary here. The recording of the presentation is here.

Ruth explained that great ideas are not guaranteed to be adopted or to succeed and that the route from ‘good idea’ to ‘widespread adoption’ requires the idea to be scalable, adopted in a way that is meaningful and promotes ownership to produce the ‘Voltage Effect’ (super-charged idea that is capable of scaling).

To set the scene, Ruth shared both her main insight gained from behavioural science, that humans are not rational, and the definition of best practice used by the GIRFT Academy, ‘a procedure that has been shown by research and experience to produce optimal results’ selected because it talks about evidence and optimal results.

An outline, with great examples, of the five traits that best practice must possess to be able to scale ‘The Voltage Effect’ are:

1. Avoid dupers and false positives – Importance of getting real evidence

Chrysler (car manufacturer) had a high staff absence problem – they did a pilot staff health programme, paying staff to engage in healthy behaviours. The pilot was good, and they wanted to roll it out, but instead they were forced (against their judgement) to try it in another sample of workers from the same car plant first. This time the results were bad. Was the initial data too good? They piloted it two more times, the results were also bad, so they abandoned it.

2. Know your audience – Replicability in different settings

A Kmart store manager invented a ‘blue light flash special’ where they bought a blue siren light & lit it next to goods that the manager wanted to shift. When corporate HQ got hold of the idea, they instructed stores a month in advance what goods would be on flash sale and when. This ignored the unique differences of customers (what sells in Alaska is not the same as in California). The idea would have scaled had they allowed local management to own it – but they didn’t.

3. Is it the chef or the ingredients? – People don’t scale  

An early learning pilot programme in Chicago recruited and trained up 30 teachers to support families and their children. With support, coaching & incentive payments they became exceptional individuals, but when scaling up to the entire state, 30,000 exceptional teachers would be needed. Rather than try to replicate thousands of brilliant teachers, a curriculum was designed that assumed teachers had average ability and the roll out was successful.

4. Spill overs – Avoiding unintended consequences

Uber drivers were given an increase in their basic pay to incentivise more people to drive for Uber. Initially, earnings rose, but by week six, overall earnings had dropped,  Why? Because not only did new drivers join Uber but existing ones drove more. As a result the supply of drivers was more competitive which meant that on average, each individual driver got fewer fares.

5. The cost trap – Financial implications

Investment in a drug rehabilitation programme with 100% success represents best practice but it is costly at £50k per person. Understanding the real cost of the programme and the low number of people who can be helped (assuming the programme can be replicated) means that funding a programme with 85% success at a reduced cost of £3k per person would deliver better outcomes.

Do these traits resonate with your experience?

I can recognise all five traits and particularly relate to the statement ‘people don’t scale’. I can think of a number of impressive pieces of work that have not scaled in part because the pilot relied on exceptional, motivated individuals who didn’t readily exist in other sites.

GIRFT and their Best Practice Scale

These five traits can be used to recognise best practice and they inform the GIRFT Best Practice Scale. The scale indicates the level of evidence and readiness for scale and has three levels (early success, good practice, best practice) and is used by GIRFT internally when identifying best practice and to help decide what is worth putting energy into, and what is more likely to scale.

GIRFT (, @NHSGIRFT) is a national programme designed to improve the treatment and care of patients through peer review of services, benchmarking, and presenting a data-driven evidence base to support change. GIRFT Academy codifies best practice and produces clinical resources and guidance.

More information on spread, scale and adoption, including many previous blogs and videos, available on the NHS Horizons website.

Details of the Leading the Spread and Adoption of Innovation and Improvement: A Practical Guide are in the blog here.

Please follow @HorizonsNHS#NHSSpread.