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

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 ANTICIPATE STAFF: Involvement & training  Empowerment & Belief  Senior Leadership Clinical Leadership PROCESS: Benefits Credibility of Benefits Adaptability Monitoring Progress ORGANIZATION: Strategic Fit & History Infrastructure/Resources Political Environment External Pressure PLAN Potential Solutions: Potential Solutions: Potential Solutions: REACT Integrate these elements into your sustainability plan so that you have a system in place to enable quick reactions. As you do this, consider some key questions: Who will take responsibility for your sustainability efforts? How will you know if relapse occurs? What would relapse look like? How would relapse influence the NIATx aims? Are things happening NOW to threaten success? How can you influence these threats NOW?

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.