Sustainment of Change: Planning for Sustainability Jay Ford, PhD Assistant Scientist

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.

How do we define sustainability? When new ways of working and improved outcomes become the norm. (NHS, 2002) The extent to which newly implemented intervention is maintained or institutionalized within a service setting’s ongoing stable operations (Proctor and Brownson 2012 p. 268) Sustainability is the continuation of activities or benefits for target recipients after an initial period of funding ends or following the initial implementation of a new program or procedure (Scheirer, 2013)

Sustainability  Understand the essential attributes associated with maintaining a change process.  Environment  Organization  Innovation  Evaluate if the improvements are maintained or improve over a extended time period.

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 tipping point of better practice is the goal

What do we know about Sustainability?  Significant heterogeneity exists across organizations  Clinicians and managers have different opinions  Leadership support is a facilitator and barrier  Change complexity appears to influence sustainability  Change linked to the underlying organizational culture is more likely to be sustained.  Participation in a given QI intervention appears to influence staff perceptions about sustainability  Short term sustainability is possible but long term is not certain.

Sustainability Challenges  Staff turn-over; leadership & funding changes that drive competing initiatives and new agendas that diminish resources for on-going projects.  Tough to find the balance between keeping them focused on the implementation details of the present, while also setting the project up for sustainability. I think the window for effective sustainability planning is right after they have received some positive reinforcement from data that shows success (thus the need to sustain). This celebration moment has energy than can be directed toward establishing the sustain plan. Waiting until later (which is common), results in them no longer being as interested in the project, or having already moved on to something else, Then it's like polishing shoes that are no longer in style. (easy to neglect)

Sustaining Interventions 8 Adapted from Scheirer MA and Dearing JW. An Agenda for Research on the Sustainability of Public Health Programs. Am J Public Health. 2011; 101:

Six Types of Interventions 1  Implemented by Individual Providers  Requiring coordination among multiple staff  New policies, procedures and technologies  Capacity or Infrastructure Building  Collaborative Partnerships or Coalitions  Broad scale system change 9 1. Scheirer MA, Linking sustainability research to intervention types Am J Public Health Apr;103(4):e73-80

Sustainability Planning Framework Sustainability Plan PDSA Environmental Factors Organizational Factors Innovation Attributes

Two Sustainability Readiness Tools  Britisth National Health Service Sustainability Index (  Program Sustainability Assessment Tool (

10 Key Factors for Sustaining Change

Program Sustainability Assessment Tool Sustainability Planning Funding StabilityPartnerships Organizational Capacity Program Evaluation Program Adoption CommunicationsPolitical Support

Bringing it all together EnvironmentalOrganizationalInnovation Political SupportOrganizational CapacityStaff Attitudes Funding StabilitySenior LeadershipBenefits PartnershipsClinical LeadershipCredibility Staff InvolvementAdaptability Program Evaluation/Effectiveness of Systems Communications Program Adaptation Strategic Planning/Organizational Fit Resources

What Next?  Identify 3 to 8 staff in your agency and ask them to complete one or both of the sustainability tools  Follow-up calls will focus on  Barriers and Facilitators  Development of sustain plans

Sustainability PDSA A: Assess Readiness D: Develop a sustain plan I: Implement the plan E: Evaluate M: Modify the sustain plan

Sustainability Planning Sustainability Plans should be:  Simple  Concise  Thoughtful  Focused on a particular aim

Sustain Plan Process  Assemble the planning team.  Envision your program’s future.  Review your PSAT results.  Decide where to start.  Prioritize.  Develop a sustain plan  Implement the sustain plan  Reassess your sustainability capacity each year

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…

Key Take-Away Messages  Integrate change into infrastructure  Monitor and evaluate impact of change  Make system simple and useful  Communicate and act on knowledge  Develop and implement a sustain plan

Questions 21

References 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): PMC Ford II JH, Krahn D, Oliver K and Kirchner JA. Sustainability in Primary Care and Mental Health Integration Projects in Veterans Health Administration (2012). Quality Management in Healthcare 21(4): Johnson K, Hays C, Center H, Daley C. Building capacity and sustainable prevention innovations: a sustainability planning model. Eval Program Plann. 2004; 27(2): Scheirer MA. Is Sustainability Possible? A Review and Commentary on Empirical Studies of Program Sustainability. American Journal of Evaluation. 2005; 26(3): Scheirer MA and Dearing JW. An Agenda for Research on the Sustainability of Public Health Programs. Am J Public Health. 2011; 101: Scheirer MA. Linking Sustainability Research to Intervention Types. American Journal of Public Health (In press).