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

3. 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.

4. 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.

5. Small tests secret sauce

6. 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

7. 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

8. Case Studies 5 million lives Denver Health Kolter
IHI Sustaining Improvement

9. 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 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

10. 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

11. Denver Health Medical Center

13. 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%

14. 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%

15. 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.

16. 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

17. 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

18. 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 why is that? Increased c/s rate in 2014.

19. Change: It is the Only Constant
Discussion