1. Chronic Pain Management
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Chronic Pain Management
Learning Session 3
Presenter’s name here
Location here
Date here

2. Agenda Introductions & Sharing Learnings (75 mins)
Hand out evaluation forms at beginning of session
Yellow Flags & Mental Health Tools (30 mins)
Break (15 mins)
Community Resources (30 mins)
Describe local community resources and how teams can collaborate with them
How to collaborate with your community to integrate changes
Sustainability (45 mins)
Identify ways to sustain changes in practice
Wrap up and evaluations (15 mins)

3. Learning Objectives – LS 3
Use appropriate tools to assess Yellow Flags
Use appropriate Mental Health tools for patients with chronic non-cancer pain
Reflect on his/her delivery of pain tools and develop a process improvement plan

4. Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
Grants/Research Support: PharmaCorp ABC
Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
Consulting Fees: MedX Group Inc.
Other: Employee of XYZ Hospital Group
Please fill out all applicable areas (highlighted in red). One slide per speaker.

5. Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
[Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
[Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
Please fill out all applicable areas (highlighted in red).

6. Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to the College of Family Physicians of Canada’s “Quick Tips” document.
Please fill out all applicable areas (highlighted in red).
Please visit the following link for the CFPC’s “Quick Tips” document:

7. Sharing and Learning

8. Our Clinic Our team members: Physicians, MOAs, other staff
One Chronic Pain Patient:
Male/female
Age
Occupation
Main complaint
How long?

9. One chronic pain patient
Number of visits:
Assessment tools used:
Values recorded
Co-morbidities
Management tools and strategies used:
Results
Referrals to specialists, allied health professionals, community resources

10. Questions to the Group
Are there any other tools or management strategies you might consider using?
If so, which ones?
Have you had a similar patient?
Did you see improvements?

11. What would you have done differently?
Family involvement?
Physical activities?
Mental health support?
Medication?

12. Pearls and Challenges What did you learn from this case study?
What surprised you most?
What are your main challenges in your practice?
How will you address them?

13. Reflections Is there one idea that you want to try?
What is one thing you still have questions about?

14. Psychosocial Yellow Flags: Helping Someone at Risk
Suggested steps to better early behavioral management of low back pain problems
Psychosocial Yellow Flags: Helping Someone at Risk - Suggested steps to better early behavioral management of low back pain problems
Be directive in scheduling regular reviews of progress. When conducting these reviews shift the focus from the symptom (pain) to function (level of activity). Instead of asking “How much do you hurt?” ask “What have you been doing?”
Keep the individual active and at work if at all possible, even for a small part of the day. This will help to maintain work habits and work relationships.
Acknowledge difficulties with activities of daily living, but avoid making the assumption that these indicate all activity or any work must be avoided.
Help to maintain positive cooperation between the individual, an employer, the compensation system, and health professionals. Encourage collaboration wherever possible. Please refer to the template letter to employers – Return to Work as an example of collaboration.
Make a concerted effort to communicate that having more time off work will reduce the likelihood of a successful return to work. At the 12-week point consider suggesting vocational redirection, permanent job changes.
Be alert for the presence of individual beliefs that he or she should stay off work until treatment has provided a ‘total cure’. Watch out for expectations of simple ‘techno-fixes’.
Promote self-management and self-responsibility. Encourage the development of self-efficacy to return to work.
Be prepared to ask for a second opinion, provided it does not result in a long and disabling delay. Use this option especially if it may help clarify that further diagnostic work is unnecessary.
Avoid confusing the report of symptoms with the presence of emotional distress. Exclusive focus on symptom control is not likely to be successful if emotional distress is not dealt with.
Avoid suggesting (even inadvertently) that the person from a regular job may be able to work at home, or in their own business because it will be under their own control. Self employment nearly always involves more hard work.
Encourage people to recognize, from the earliest point, that pain can be controlled and managed so that a normal, active or working life can be maintained. Provide encouragement for all ‘well’ behaviors—including alternative ways of performing tasks, and focusing on transferable skills.
The information presented here is taken entirely, without any content modification from: Kendall, N A S, Linton, S J & Main, C J (1997). Guide to Assessing Psycho-social Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss. Accident Compensation Corporation and the New Zealand Guidelines Group, Wellington, New Zealand. (Oct, 2004 Edition).

15. Yellow Flags
Psychosocial indicators suggesting risk of progression to long-term distress, disability and pain
Designed for acute low back pain
Can be applied more broadly to assess development of persistent problems
Medical Practice Guidelines: Hunter Integrated Pain Services, Updated Nov. 2005, New Zealand

16. Yellow Flags
Can relate to patient’s behaviour, attitudes, emotions, beliefs, family and workplace
Behaviour of health professionals can also have a major influence

17. Yellow Flags Key Factors:
Belief that pain is harmful or severely disabling
Fear-avoidance behaviour
Low mood and social withdrawal
Expectation that passive treatment rather than active participation will help
In Low Back Pain

18. Mental Health Algorithm

19. Mood Self-Management in 5 minutes
Dan Bilsker PhD
Clinical Asst Prof, Psychiatry, UBC
Adjunct Prof., SFU
Private Practice in CBT

20. Antidepressant Skills Workbook
Free at
Languages: Chinese; Punjabi; French
Versions: Adolescent; Workplace; Chronic Health Conditions
AudioBook
Relaxation Audiofile
CBT is probably more effective than meds for relapse prevention and offers the possibility of discontinuing meds once the acute episode is in remission.(their interest will be in reducing med costs)
-there is Cochrane level evidence to support CBT

22. The Antidepressant Skills
How to set specific & achievable goals
Reactivating Your Life
How to think about yourself and your situation in a fair, realistic & helpful way
Realistic Thinking
How to systematically tackle problems
Resolving Problems
How to mentally and physically relax yourself
Relaxation

23. Benefits Low Cost Low Risk Effective
Just handed out = sig. effect (SD=.4)
Limited coaching = larger effect (SD=.8)
Assessing response to basic CBT allows a period of observation before committing patient to a course of AD

24. B.C. Family Docs (N=81) Having access to the workbook helped me treat my depressed patients

25. Prescribing the Antidepressant Skills Workbook: A 1 page handout

26. Relevance to Pain Management
Pain experience
reactivating
Increasing social & phys. activity in a paced safe way
resolving problems
Dealing with challenges like medication scheduling
relaxing
Increasing skill in releasing tension, anxiety

27. Cognitive Behavioral Interpersonal Skills (CBIS) Manual

28. Problem List

29. Resource List

30. Activation Daily activities Energize Small goals Problem solving
Chunking time
Improving mood
Self-supportive
The activation module is the beginning of the active treatment handouts for your patients.
Activation exercises are ideal for those patients with vegetative symptoms who need to becoming more active in their recovery.
We suggest you work on activation first, as it is often easier to change behaviour then it is to change thoughts or mood

31. Cognition Changing behavior Changing thinking Changing feeling
CBT is all about the inter-relationship between behaviours, thoughts, and feelings.
The cognition module contains a handout that explains the basic CBT concept and several exercises that begin to shift negative cognitions.
It also contains strategies to address worry thoughts, guilt, assertiveness and anger.

32. Relaxation Benefits Stress management Breathing Grounding Relaxation
Mindfulness
Meditation
The exercises in this module will assist with anxiety, pain and stress as well as depression.
They provide a positive benefit to overall physical and mental health.
The skills are organized sequentially, with more advanced skills building on the preceding foundation.
They are easy to learn and more effective if demonstrated in your office.

33. Lifestyle Sleep Nutrition Substances Exercise Wellness
The lifestyle module contains informational handouts on various lifestyle factors that promote mental and physical health.
It includes handouts on sleep, nutrition, substances, physical activity, and ends with a wellness wheel that looks at balancing all components of a healthy life.

34. Navigating the Skills Manual
Three ways to begin:
Problem list action plan
Symptoms
Self-assessment questionnaire
So, how might you use this CBIS manual?
Once you’ve completed the Assessment there are 3 ways to find the right handout for your patient.
Through the PROBLEM LIST ACTION PLAN
Through the SYMPTOMS
Through the SELF-ASSESSMENT QUESTIONNAIRE

35. Problem List Action Plan
ACTIVATION RELAXATION
I feel tired all the time
Irritable – tense
I don’t want to do anything
I overreact
Not interested in seeing friends
Arthritis – pain
Sleeping during the day
COGNITION LIFESTYLE
No job – I’m too old to retrain
Drinking more coffee
I overreact
Having a few beers
I feel like a failure – I’ll never get a job
Stay up late watching TV
Sleeping during the day
The Problem List Action Plan that you complete with your patient from their problem list is one way to access the handouts.
In this example, the busiest sections are Activation and Lifestyle.
So choosing Activation would be a good place to start.
MEDICATION REFERRAL
Tired all the time
No job – job coach
Bankruptcy – debt counselling
Arthritis – Bounce Back

36. Flow Chart Healthy Habits For Sleeping, pg 68
It’s True: You Are What You Eat, pg 69
Physical Activity, pg 71
The Wellness Wheel, pg 72
LIFESTYLE
Anti-Depression Activities, pg 31
Depression’s Energy Budget, pg 32
Small Goals, pg 34
Problem Solving, pg 36
Opposite Action Strategy, pg 37
Chunk The Day, pg 38
Improve The Moment, pg 39
Appreciation Exercise, pg 40
ACTIVATION
You would go to the Flow Chart, find the activation box and that would direct you to the first handout on Anti-depression Activities.

37. Flow Chart RELAXATION MODULE Abdominal Breathing, pg 57
Grounding, pg 58
Passive Relaxation, pg 61
Mindfulness, pg 64
NEGATIVE THINKING
COGNITIVE DISTORTIONS
PANICKY
COGNITION MODULE
The Circle Of Depression, pg 42
Common Thinking Errors, pg 44
Thought Change Process, pg 45
Self Talk (Mean Talk), pg 47
Thought Stopping, pg 48
Good Guilt / Bad Guilt, pg 50
Is Anger A Problem For You, pg 54
NEGATIVE THOUGHTS
A second way to access the handouts are through symptoms.
For example: If your patient presents with panic symptoms, you could check the flowchart which will direct you to the appropriate handouts. If the patient has a negative thinking pattern, the flowchart directs you towards another set of handouts.
You can begin with the first handout and over time work your way through the remainder of the skills.

38. Self-assessment Questionnaire
0 = never or rarely true to me; 1 = somewhat true; 2 = quite a bit true; 3 = very true of me
____ It’s hard for me to say no to people even if I don’t want to agree or don’t have the time or energy
____ I will do almost anything to avoid hurting people’s feelings, whatever the cost to myself
____ I do lots of things for others, even at the expense of meeting my own needs
The third way to access the handouts is through the Self-assessment Questionnaire in the Assessment section.
This Questionnaire identifies interpersonal styles of pleaser, perfectionist and over-thinker that might be contributing to your patient’s depression.
The Patient Profile section of the flowchart will then direct you to the handouts in the manual that are most helpful for these interpersonal styles.

39. Flow Chart ACTIVATION MODULE Anti-Depression Activities, pg 31
Depression’s Energy Budget, pg 32
Small Goals, pg 34
Problem Solving, pg 36
ACTIVATION
RELAXATION MODULE
Abdominal Breathing, pg 57
Grounding, pg 58
Passive Relaxation, pg 61
Mindfulness, pg 64
PANICKY
In summary:
The CBIS manual takes you step-by-step through an assessment interview, developing an action plan, and delivering practical one-page interventions.
The first 3 modules – are for you.
The remaining modules – contain those one-page, user-friendly handouts that you can prescribe as homework for your patients to engage them in self management and assist them in their recovery from depression.
Once you’ve completed the Assessment there are 3 ways to find the right handout for your patient.
Through the PROBLEM LIST ACTION PLAN
Through the SYMPTOMS
Through the SELF-ASSESSMENT QUESTIONNAIRE
Remember just 2 things:
The mnemonic SIGECAPS AGS POMP CAGES
When in doubt – go with the flow
OVER-THINKER PROFILE
ASSESSMENT MODULE
Over-thinker Profile, pg 24

40. “Is there anything you would like to do for your health in the next week or two?”
Behavioral Menu
SMART Behavioral Plan
Elicit a Commitment Statement
“How confident (on a scale from 0 to 10) do you feel about carrying out your plan?”
If Confidence <7, Problem Solve Barriers
Step through the slide, clicking through the flow chart.
Blue = three questions
5 skills are yellow and green. Yellow are skills used every time, green are skills used as needed.
“Would you like to check in with me to review how you are doing with your plan?”
Follow-up

41. Mindfulness Based Stress Reduction (MBSR)
Program started in 1979 at U Mass Medical School by Dr. Jon Kabat-Zinn.
8 week group program, usually 2.5 hour class with all-day retreat.
Trainings include breath/body awareness, developing acceptance of present moment, and understanding stress physiology.
Over 30 years of research, documenting its value in improving patient self-management and the capacity to more effectively deal with stress & illness.

42. MBSR & Chronic Pain Chronic Pain Vowles & McCracken 2005, 2008
108 & 171 patients respectively, intensive programs
demonstrated improvements pre- to post- treatment on measures of pain, depression, pain-related anxiety, disability, medical visits, work status and physical performance
Chronic Pain: Simpson & Mapel 2011
RCT with 32 people: mix of FM, arthritis, IBS, migraines etc
Significant positive changes around rumination, magnification and helplessness (better able to manage pain)

43. MBSR-Chronic Back Pain
Low Back Pain: Morone, Greco & Weiner 2008
RCT with 37 people: greater acceptance, engagement in activities and overall physical functioning
Failed Back Surgery Syndrome: Esmer et al 2010
Single-center, prospective, randomized trial with 25 people: clinically significant increase in pain acceptance, sleep & QoL measure, decrease in pain, functional limitation & frequency of use/potency of analgesics
Not resignation to pain but rather helping people cope with pain when it is an inevitable aspect of living (skillful coping of stress/suffering)
Acceptance means less resistance, which means less depression/disability/pain-related anxiety, and pain intensity…while also being directly correlated with improved work status and (acknowledgment, even if not acceptance….acknowledge what is present now, including lack of acceptance!)

44. MBSR & Fibromyalgia
Fibromyalgia: Kaplan, Goldenberg & Galvin-Nadeau 1993
Pre-post assessments with 59 people: improved sleep, pain, fatigue, well-being, coping and FM symptomatology (SCL-90- R)
51% responders (moderate to marked improvement)
Fibromyalgia: Weissbecker et al. 2002
RCT with 91 women: improved sense of coherence*, lower perceived stress and less depression
*Sense of Coherence: disposition to experience life as meaningful and manageable

45. How might you bring Mindfulness to the Clinical Encounter?
Mindful Listening (to self and patient)
Use CBIS handouts on body scan and mindfulness
Give mindfulness options for behavioral menu options (do one thing at a time, slow down, “nothing” time, breath awareness)
Suggest books
Be aware of local mindfulness programs

46. Suggested Books

47. Mindfulness Resources
CBIS handouts (body scan, mindfulness meditation, relaxation)
Mindfulness-Based Chronic Pain Management
The Mindfulness Solution to Pain (Dr. Jackie Gardner-Nix)
MBSR courses being held around BC
Pain BC
Center for Mindfulnesswww.umassmed.edu/cfm/stress/index.aspx
Make these consistent

48. Introducing mindfulness to patients
It is common for those dealing with chronic pain to focus on past issues (good or bad), future concerns or judgments about the present
Mindfulness is the capacity to BE WITH and IN the constant flow of present moment
It allows for a clearer understanding of how thoughts and emotions can impact health and quality of life
This capacity is inherent with each person, and can be cultivated through practice
Would you like to hear some options for exploring mindfulness, or do you have some ideas of your own?

49. Questions?

50. Resources
Center for Comprehensive Motivational Interventions
Patient Self-Management Module (VCH) of PSP

51. Returning to Function Part Two
Box Breathing

53. Review The purpose of pain is not to accurately tell us:
where the problem is
what the problem is
how bad the problem is
Pain’s job is to make us stop!
Our patient’s need treatment and guidance to make these protective responses less sensitive.
Wind down the nervous system

54. Setting Functional Goals

55. Advanced Family Practice Skills: to empower our patients
Mindfulness: to calm the mind and body; to encourage healthier attitudes and perspectives
Cognitive Behavioural Therapy: to replace maladaptive cognitions with adaptive cognitions about pain; to empower patients to treat anxiety and depression
Self-hypnosis: to reinforce cognitive and attitudinal changes; to alter pain perception; to visualize goals

56. Cognitive Behavioural Therapy

57. Cognitive Behavioural Therapy

61. Challenging Cognitive Cognitive Distortions
Identify the Distortion
Examine the Evidence
The Double-Standard Technique How would you judge a friend?
The Experimental Technique Let’s test the validity of your negative thought
Thinking in Shades of Grey When things don’t work out as hoped, think of them as partial successes rather than total failures. What can you learn from the situation?

62. Challenging Cognitive Cognitive Distortions
Define Terms What do you mean by the labels you give yourself?
Semantic Method Instead of saying “I shouldn’t have made that mistake,” try “It would be better if I hadn’t made that mistake.”
Reattribution Instead of blaming yourself entirely, consider other factors that may have contributed.
Cost-Benefit Analysis What are the advantages and disadvantages of thinking, feeling this way?

63. Common Cognitive Distortions: about chronic pain
Catastrophizing This pain will just get worse.
Disability Beliefs I cannot live a normal life because of pain.
Harm Beliefs Pain means that I am causing harm to my body. I must stop activity because of pain.
Medical Cure Beliefs I must find the medical cure, a medication or a procedure for my pain. It is the responsibility of healthcare providers (not me) to manage my pain.
Chemical Coping I must take painkillers (drink alcohol or use other drugs) to control my pain.
Kinesiophobia Movement causes pain. I have to lie down or sit down when I have pain.

65. Adaptive Thoughts: for chronic pain
Self-efficacy, Sense of Control I have the skills and resources to manage pain and its effects on my life.
Acceptance I accept discomfort, but I choose to remain engaged in what matters most to me.
De-emphasizing Pain This pain is no longer in the foreground of my life. It is fading to the background.
Pacing I can maintain an appropriate level of activity (not too much and not to little) even in the presence of pain.
Perseverance I will not allow pain to interfere with the essential activities of my life.
Exercise, Mobility Daily exercise helps me to remain fit and strong.

66. Cognitive Behavioural Therapy
Consider taking one of the CFP-award winning CMEs taught by Dr. Greg Dubord of CBT Canada
Accredited CMEs
In Vancouver, Whistler, major Canadian cities and sunnier vacation destinations
Medical CBT customized for 10 to 20 minute family practice visits (Only possible if you make the patient work harder than you)
Enjoyable and useful with lots of role-playing
Teaches you to teach your patients to take responsibility for their moods, thoughts and lives.

67. Break… 67

68. Community Resources LINKING PEOPLE TO COMMUNITY PROGRAMS
Only 25% of persons with chronic health conditions are referred to community self- management programs by health care professionals.
Health Council of Canada, January 2010
The probability of a person taking a community self-management program increases 18 fold if it is recommended by a health care professional.
Murphy et al., Arthritis and Rheumatism

69. A Movement to Change Pain and Change Minds
Patient Engagement and Education Overview
Maria Hudspith, Executive Director
PSP – April 30, 2014

70. Pain BC Strategies
Educating and building hope for patients and their families
Developing skills and increasing knowledge for health care providers
Facilitating health care innovation and improvement

71. Patient Education – Multiple Platforms/Goals
Foster peer support connection
Validate
Translate knowledge
Reduce stigma
Navigation of resources
Build hope
Support self management
Mobilize and activate

72. Online Education Platforms
Interactive webinars: 27,000 participants in 2013
Sleep
Medication Management
Psychological Aspects
Condition specific programs (Fibromyalgia, Arthritis etc.)
Therapeutic Yoga for People in Pain
Empowering Self Management…
“Pain Waves” Online Radio Show: 54,000 listens

74. Social Media for Knowledge Translation

75. Social Media for Validation and Peer Support

76. Results and New Directions
Facebook
“Finally! Someone that gets it. People in pain now have someone in our corner!”
“Wow! I just went through your site and learned more than I have in ten years living with chronic pain.”
Webinars
Patient activation measures high
Anecdotal evaluation responses very positive
Coming soon: New website, expanded education programs and more…

77. Bounce Back
Self-help DVD, Workbooks, and Telephone Coaching for Low Mood, Stress, and Worry
Murli Soni: Program Manager
Canadian Mental Health Association, BC Division

78. What? – BB Program Overview
Bounce Back
What? – BB Program Overview
Developed in 2008 to provide easily accessible mental health support options to the primary health care sector
Free program for patients with mild- to moderate- depression, anxiety or worry
Funded by the BC Ministry of Health to be accessible throughout the province

79. What? – Primary Components
Bounce Back (BB) offers two levels of evidence-based cognitive-behavioural self- help:
Psycho-educational DVD (over 115,000 distributed since 2008)
Workbooks + Telephone-Coaching (over 25,000 referrals since 2008)

80. What? – Participant-Selected Topics
Bounce Back
What? – Participant-Selected Topics
Choice of workbooks to address different needs
Accessible language and easily understandable concepts
Understanding why I feel as I do
Worry & stress;  Physical health
Extreme & unhelpful thinking
Reduced activity;  Avoidance
Practical problem-solving
Being assertive;  Using exercise
Sleep problems;  Antidepressants
Here is an overview of some of the topics covered, please note the wide range of topics covered.

81. How to Access Convenient and quick access to free service
Bounce Back
How to Access
Convenient and quick access to free service
Family Doctor or Nurse Practitioner can refer patient
Need to complete referral form for coaching component
Patient will be contacted by a coach within 5 working days
Referrer informed of patient’s progress
Please note – Ascertain eligibility and send fax or to BB and referring Primary Care Practitioner always retains professional responsibility for their patients. Eligibility for Coaching
Adults age 19 years & older
Mild to moderate symptoms of depression +/- anxiety
PHQ-9 score from 5 to 19
No severe symptoms or active suicidal ideation
No history of psychosis or bipolar disorder
No personality disorder
No alcohol / drug abuse
No cognitive impairment

82. Why? – Outcomes / Effectiveness
Bounce Back
Why? – Outcomes / Effectiveness
Depressive & Anxious symptoms reduced by half; All significant improvements (n = 5982)

83. Participant Feedback
Upon program completion, participants' understanding, knowledge, confidence, and health-related ‘patient activation’ are all substantially increased
Over 90% of feedback form respondents rate their experience of BB as ‘good’ or ‘very good’, and are that likely to recommend BB to a friend or family member
Participant Feedback:
"Bounce Back is such a practical program, down to earth and very helpful; It has helped me to change my life for better.“ ‐VCH Participant, March 2014
“I don’t feel lost anymore. Everything makes sense now, & the books have been incredibly helpful. I’ve been talking about them to all my friends.” ‐FHA Participant, March 2014

84. Bounce Back
How? – Contact Information
To request materials or make referrals:
Call your local Bounce Back team at our toll-free phone #: 1‐866‐639‐0522 (in BC)
To jump-start the Bounce Back process:
Pick-up a starter-pack of program info & referral resources at our display table
To find out more about Bounce Back:
Visit our Website:
Please add fax number

85. Sustaining Your Gains

86. Why focus on sustainability?
Up to 70% of change initiatives fail, impacting:
Best possible care.
Staff and provider frustration.
Reluctance to engage in future.
Implementing a change in practice does not guarantee it will sustain long term. In order to continue to reap the benefits from your hard work you need to focus on how to ensure your change will ‘stick’.
The risk of failing to sustain your changes is not just clinical, but can effect provider and staff satisfaction and future change efforts.

87. You’ve had a head start!
The involvement of families and community members in your improvement work will help you sustain:
More partners in care.
Recognition and encouragement from team mates.
Maximizing community and family support.
The good news is that teams involved in this module have had a head start because of your community approach to care.
This helps by:
Having more partners in caring for patients and their families to insure best practice care is being provided in a patient centered way
Team mates to keep you accountable and encourage you to keep going with improvements
Using the ability and willingness of patients and families to be partners in their care

88. You can all work as one to sustain changes in practice and community!
As we talk about sustainability of your changes, think about how you as a team can sustain the changes you have made.

89. What are you trying to sustain?
With your community team discuss what you would like to sustain in the practice and community, is it:
A specific change?
A measured outcome from your efforts?
An underlying culture of improvement?
Relationships established in the community?
A combination?
(5 min)
Before you focus on specific strategies to sustain your changes over time, you need to be clear on what it is you are trying to sustain. You may be trying to sustain:
A specific change you implemented
An outcome you have achieved through your work
An underlying positive culture and attitude towards improvement
Relationships you have established that contribute to your success now and into the future
Or a combination of these
In your team, discuss what your group would like to sustain.
Source: NHS Improvement leader’s Guide: Sustainability, NHS Institute for Innovation and Improvement, 2007

90. Strategies to Sustain the Changes
Be clear about the benefits (use measurement).
Establish and document standard processes and have a plan for ongoing training.
Establish an ongoing measurement processes.
Make changes to job descriptions and procedures to reflect change.
Celebrate success!
Some strategies for holding the gains once initial improvements have been made (tested and implemented):
1. To work towards sustaining a change long term patients, staff and providers need to be clear what the benefits are in terms of patient care, workplace satisfaction, and personal practice. Using measurement to show the improvements will help to support the change. When each stakeholder can explain ‘what’s in it for me’ the change is more likely to sustain.
2. The permanence of the change should not depend on specific people, but should become embedded in the work processes. One of the ways to do this is to establish and document standard processes, so that even if there are staff changes everyone will know what the new process is and be able to follow it. Additionally, a plan for training new employees will help to ensure that the new responsibilities and new processes are understood and carried out correctly, and ensues continuity in practice over time.
3. Data collection continues so that the practice has information about whether the gains are being maintained. It may be that the data collection schedule can be reduced, with data collection occurring less frequently or with a smaller sample. The objective here is to monitor the new system, and guide improvements as they are tested and implemented.
4. One suggestion for embedding the change and making it permanent is to review job descriptions so that new personnel will know immediately what is involved in their responsibilities. Additionally, make sure that any documentations of policies and procedures reflect any change in process.
5. It is important to celebrate when an achievement has been reached, but also important to celebrate when that achievement has been sustained for a period of time. Keep focus and energy up by celebrating with your team your continued best practice and reminding yourselves of the good work you have done.
Adapted from: NHS Improvement leader’s Guide: Sustainability, NHS Institute for Innovation and Improvement, 2007

91. Predictors of Sustainability
Staff, providers and patients can describe why they like the change and its impact.
Providers and staff are confident and can assist in explaining to others.
Job descriptions reflect new roles.
Measurement is part of the practice and used to monitor progress.
The change is no longer ‘new’, but ‘the way we do things around here’.
Once you have made some changes towards sustaining your gains, how will you know that your work is paying off? There are some simple ways to tell if your change is more likely to sustain over time.
When you ask staff, providers and patients about the changes you have made they will be able to describe to you why the change is a good one and the impact it will have on both patient care and staff/provider experience in the clinic.
Providers and staff are confident that they could explain the new way of working to others and help to train new staff or providers.
Any effected job description has been changed to reflect changes in roles
Measurement is ongoing even after the change has been implemented. The measures are reviewed regularly to monitor progress and any changes indicating a loss in gains results in a correction.
People effected by the change do not describe it as ‘new’ or ‘being tested’ but accept it as the ‘new way of working’.
Adapted from: NHS Improvement leader’s Guide: Sustainability, NHS Institute for Innovation and Improvement, 2007

92. Sustainability Activity
At your table, develop a plan for increasing the probability of sustaining your improvement work.
Use one or more of the strategies outlined in the previous slide, or come up with others.
Share your ideas with the group.
(Use the blank PDSA form)
At your table, develop a plan for sustainability of your improvement work
Use one or more of the strategies outlined in the previous slide
Be prepared to share your ideas with the group
Answer the questions:
What are you trying to sustain?
How will you know that your efforts are being sustained?
What changes will you try that will increase in chances of sustaining your changes?

93. Thanks to the physician facilitators for their leadership in this module.
Again, we at PSP are here to support you and coach you each step of the way.

94. Practice Support Program
For more information
Practice Support Program
West Broadway
Vancouver, BC V6J 5A4
Tel: