Sustaining Change in a Changing World

1. Sustaining Change in a Changing World Jay Ford, PhD Assistant Scientist

2. Statements about Sustainability • Implementation of change does not guarantee that it will be sustained. • Most changes are sustained at least briefly,1,2 these efforts are often more difficult than implementation of a change. • Studies indicate that up to 70% of changes are not sustained.3,4 • Change not sustained is a direct waste of invested resources, has costs associated with missed opportunities, and affects an organization’s ability to implement change in the future.

3. Sustainability • Sustainability represents essential attributes associated with maintaining a change process. • Sustainment addresses if the improvements are maintained or improve over a extended time period.

4. Sustaining Change • Focus on creating a culture of change vs. making the measures • Recognize that sustainment is only good for so long. • Over time sustainment becomes the new norm. • Address the need for continuous improvement. • Reach a point where the epiphenomena of better practice is the goal

5. Sustainability Model

6. Infrastructure Capacity • Identify key stakeholders & develop plan to foster and maintain the relationship • Role & involvement of champion and leadership in the sustainment of change • Identify and strengthen resources • Assess and change policies and procedures • Build internal expertise and capacity • Empower staff as part of the change process Sources: Johnson et al, 2004; Ford et al, 2011; Scheirer and Dearing 2011

7. Attributes of a sustainable innovation • Identify & understand the benefits of the change (i.e., impact on efficiency and jobs) • Foster collaboration to support the change • Provide credible evidence about the change benefits • Ability to adapt the change to the organization • Assess the fit with organizational goals • Belief by staff that the change will be sustained Sources: Johnson et al, 2004; Ford et al, 2011; Scheirer and Dearing, 2011

8. 10 Key Factors for Sustaining Change

9. NIATx200

10. Sustainability: Change Complexity Significant difference between the two categories at p < 0.049

11. Staff Differences within VA • Administrators and clinicians differ on opinions about sustainability in regards to: • Benefits go beyond helping the patient and make jobs easier and improves efficiency • Credibility of the change in terms of the benefits being obvious and believed by stakeholders • Staff have been involved from the start and adequately trained to sustain the improvement • Staff felt empowered as part of the change process and believe that the change will be sustained.

12. Six Common Areas of Improvement • Benefits beyond helping patients • Adaptability of improved process • Effectiveness of the system • Staff involvement and training • Staff attitudes • Fit with organizational strategic aims & culture

13. Sustainability Planning

14. Sustainability Model

15. Sustainability PDSA

16. Sustainability Planning • Sustainability Plans should be: • Simple • Concise • Thoughtful • Focused on a particular aim

17. Items to include in a Sustainability Plan • What should be included in the plan? • Organizational structure for sustainability • Name of the plan ‘owner’, sustain leader and team • Develop clear communication channels to share progress. • Establish procedures and process to support sustainment • Create a method for collecting & monitoring data • Revisit goals on a regular basis (sustainment is the new norm) • Identify red flags or triggers – what might threaten success • Establish checklists to address red flags/triggers as/when they arise, i.e. if key personnel leave, here’s what we will do…

18. Anticipate, Plan and React (APR) Tool

19. Example APR

20. APR: Potential Triggers • Changes in personnel, especially change leaders • Staff feelings, e.g. that something is being ‘done to them’ • Workloads increase • Resources run low/inadequate to keep things going • Feedback on progress not routinely offered to stakeholders • Lack of understanding about the purpose/aims of change • True benefits haven’t been clearly assessed & communicated • Staff unsure about their role in the change • Staff do not feel like they were included in the change • Staff do not feel they have the knowledge/skills to make it work • Senior Leaders do not invest any time/energy into the change

21. APR: Potential Solutions • Assign one person to monitor the progress of the change • Share data reports/graphs with staff at regular meetings • Produce a written protocol for training & ongoing knowledge • Detail standard operating procedures/outline of the new process • Detail roles & responsibilities for all staff • Have supportive senior leaders personally congratulate staff • Have senior leaders communicate benefits & goals of change • Have a staff appreciation lunch • Increase motivation: reallocate staff in line w/interests & skills • Emphasize fiscal importance of keeping clients in organization

22. Key Take-Away Messages • Determine organizational readiness to sustain change • Anticipate, plan and react to potential challenges in sustaining change • Develop and implement a sustainability plan

23. References Scheirer MA. Is Sustainability Possible? A Review and Commentary on Empirical Studies of Program Sustainability. American Journal of Evaluation. 2005; 26(3): 320-347. Johnson K, Hays C, Center H, Daley C. Building capacity and sustainable prevention innovations: a sustainability planning model. Eval Program Plann. 2004; 27(2): 135-149. Ford II, JH, Krahn, D., Wise, M., and Oliver, KA. Measuring Sustainability within the Veterans Administration Mental Health Systems Redesign Initiative. Quality Management in Healthcare, 2011; 20(4): 263-279. PMC3188394 Scheirer MA and Dearing JW. An Agenda for Research on the Sustainability of Public Health Programs. Am J Public Health. 2011; 101:2059-2067.