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. Sustainability of Change

10. Does Change Complexity Influence Perceptions about Sustainability

11. Change Complexity

12. Staff Perceptions on Sustainability (VA)

13. VA IntegrationVA MHSRDPolytrauma Benefits3.575.384.72 Credibility4.695.666.08 Adaptability4.635.184.66 Effectiveness4.154.293.65 Staff Involvement6.266.587.02 Staff Attitudes4.585.537.26 Senior Leadership8.579.9110.55 Clinical Leadership10.5910.9612.15 Organizational Fit4.164.574.63 Infrastructure4.264.907.23

14. VA Sustainability Scores by Category Significant difference between the two categories at p < 0.049

15. Do Staff Agree on their Perceptions about Sustainability

16. Staff Perceptions – VA vs. NIATx200

17. Staff Differences within VA

18. Influence of Process Improvement Intervention

19. Changes in Total Sustainability Score by Survey Round for N200 Providers Notes: No significant differences in baseline total SI score by intervention * indicates a significant difference from previous round (p < 0.05)

20. Change in SI Factor Scores (Round 1 vs. Round 2) Notes: All difference for Learning Session are Significant at p < 0.05 except Senior Leadership All differences for Coaching are significant at p < 0.05 except for Infrastructure No significant differences between the Learning Session and Coaching Arms in Terms of Improvement Coaching also shows significant increases from Round 2 to Round 3 for Benefits, Credibility, Infrastructure and Clinical Leadership

21. 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

22. Facilitators, barriers and predictors Facilitators –Commitment to the customer –Strong leadership –Use of QI tools –Strong communication & collaboration –Learning organization –Institutional structural changes Barriers –Staff resistance –Institutional resistance –Non supportive leadership Predictors –Track outcomes –Regular reporting –Use of PDSA cycles Sources: Ford et al, 2011

23. Sustainability Planning

24. Three Questions  How do you introduce the concept of sustainability in organizations that you coach?  What resources do you utilize when discussing sustainability?  What are the greatest challenges faced by organizations that you are coaching as it relates to sustainability?

25. Question 1  Early and often. I tie it into the Charter and the business case and again with the questions that will be answered at the end of the Change Project Form, emphasizing the importance of thinking and working on ways that adopted changes will be sustained.  Talk about stickiness and how we can assure that positive changes stick  Honestly, I don't talk about it. They are so focused on solutions, and my time with them is so short, we never seem to get around to talking about sustainability.  I begin mentioning sustainability from the first time I meet with the change team, but focus more specifically on the topic once they have come close to meeting (or exceeding) their target objective for their change project/chosen aim.

26. Question 1  Through the sustainability tools on the NIATx website. Further, through emphasizing that, without a sustainability focus, the good work programs/agencies do on change projects simply fade away in many cases  I like to talk about sustaining use of PI as well as sustaining any innovation or successful change of process that the agency may have discovered

27. Question 2  Mostly the Change Project Form but I also use the British Nat'l Health Org. model, if not formally at least in talking about what we know about successful change.  Sustainability tool provided by NIATX, last page of Change Project Form, PP about sustainability or Case examples  The sustainability worksheet. General discussions around "integration"... that doing one NIATx change project doesn't change a culture, but rather, a program's culture needs to change to think about change on a regular basis … Change is good, but without sustaining the change(s), the effort is for naught.

28. Question 3  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 recieved 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)

29. Question 3  They are ready to be done with the particular change team and don't want to finish things up!  Realizing that they need to pay attention to sustainability  I don't know. I never get around to it. I'm gone before it becomes a concern.  Getting them to shift from actively experimenting with change cycles to thinking more in lines of long term maintenance/monitoring  Fluid attention based on shifting priorities, funding, and environmental "fires".

30. Question 3  Greatest challenge in my view is - frequent turnover of staff. When an agency loses one or two key people, the organization often retreats into "survival" mode. It's all they can do to hire a new person or two new people, keep the bills paid, and keep seeing clients. NIATx PDSAs are back-burnered until things "quiet down". Furthermore, the focus on sustaining a recent change, or more than one recent change, is lost, again because survival is the first and second and third priority and slightly longer, wider view matters, fade behind the survival focus.

31. Sustainability Model

32. Sustainability PDSA

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

34. 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…

35. 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?

36. Anticipate, Plan, React  Potential triggers to anticipate include:  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

37. Anticipate, Plan, React  Potential solutions to address triggers:  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 with interests & skills  Emphasize the fiscal importance of keeping clients in the organization

38. 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