Diana R. Jolles CNM, PhD (c) Faculty Frontier Nursing University Sustaining Change Diana R. Jolles CNM, PhD (c) Faculty Frontier Nursing University

Objectives Sustainability, Standardization, Spread and Scale Distinguish clearly how testing, implementing, and spreading a change are all different steps in the sequence of improvement Build communication strategies that foster and support spread How do you hardwire the new processes, methods, systems to create the "new norm"?   Explore next steps in sustainability, standardization, and spread.

The Juran Trilogy1 consists of three key quality-related functions for managers: Quality Planning, Quality Control, and Quality Improvement. Together these functions constitute an active, integrated system for pervasive organizational attention to customers’ (i.e., patients’) needs, the design and delivery of products and services consistent with the best technical specifications to consistently meet those needs, and the ongoing management and continuous improvement of the systems of production.

Small tests secret sauce

SEVEN SPREADLY SINS Expect huge improvements and spread right away Don’t bother testing- do a large pilot Check huge mountains of data just once every quarter

SEVEN SPREADLY SINS Give one person the responsibility to do it all Rely solely on vigilance and hard work Spread success unchanged Require the person and team who drove initial improvements to be responsible for spread

Case Studies 5 million lives Denver Health Kolter IHI Sustaining Improvement

Case Study: 5 Million Lives Sustainability: Locking in the progress that hospitals have made already and continually building upon it; and Spread: Actively disseminating best practice and knowledge about every intervention and implementing each intervention in every available care setting. A national initiative led by IHI, the 5 Million Lives Campaign aims to dramatically improve the quality of American health care by protecting patients from five million incidents of medical harm between December 2006 and December 2008. The How-to Guides associated with this Campaign are designed to share best practice knowledge on areas of focus for participating organizations. For more information and materials, go to www.ihi.org/IHI/Programs/Campaign.

Sustainability: Holding the Gains Supportive Management Structure Structures to “Foolproof” Change Robust, Transparent Feedback Systems Shared Sense of the Systems to Be Improved Culture of Improvement and a Deeply Engaged Staff Formal Capacity-Building Programs

Denver Health Medical Center

DHMC Holding the Gains National Rates N=1,573 Denver Health 2005 N=269 2010 N=1,064 2015 N=1253 Continuous labor support ------- 2% 67% 55% Ambulation 24% 12% 75% 64% Hydrotherapy 6% 3% 61% 38% Intermittent auscultation 15% 58% Intermittent auscultation only 0% 29% 21%

DHMC Holding the Gains National Rates N=1,573 Denver Health 2005 N=269 2010 N=1,064 2015 N=1253 Success with pain relief intention ------- 50% 76% 75% Physiologic pushing 21% ….. 59% 79% Non-lithotomy birth position 43% 1% 98% Delayed cord clamping ------ ……. 58% 67% Breastfeeding initiation in the birth room 45% 74%

Maintaining Transformation HARDWIRE TEAM Extremely important looking to the future - strong physician support moving forward. Strong support throughout hospital administration and with other departments. Participation in executive committees - i.e. medical staff. What happens when there is new physician leadership? Ensure strength of the service - (many things involved in this - trust, integrity, credibility, stable staff, excellent outcomes) Be very active when interviewing/selecting new physician leadership Develop reliable, trusting relationships beyond the OB service - director of ambulatory care, etc.

Maintaining Transformation HARDWIRE TEAM How to maintain a happy team that is adhering to the mission and providing quality care. work/life balance Fostering strenths Building trust, credibility Developing leaders Formal Informal

Maintaining Transformation HARDWIRE TEAM : Constant vigilance to maintain highly-functioning collaborative team. Building and maintaining Trust, credibility, integrity vital Continuing to learn from each other - MDs, RNs, etc. Supporting our differences and similarities. Participating in collaborative groups - QI, P&P Being a voice in broader hospital groups and initiatives - Priv/cred, MSEC, community health

Maintaining Transformation HARDWIRE ACCOUNTABILITY AND DATA DRIVEN DECISIONS Ongoing self-assessment, data collection and analysis Data collection over 10 years. Peer review - chart audits, formal CNM review of cases, QI IPE - informal to formal - constant education despite formality. OBs, FPs, med students, RNs talk about projects we are doing example - labor support, ambulation, ia are all down in 2015 - why is that? Increased c/s rate in 2014.

Change: It is the Only Constant Discussion