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Sustaining and Spreading Change
Mike Davies, MDChief of Staff
VA Black Hills
Access and Redesign
Planning Group
Participants
Pre-work
S S
Ongoing Supports
Email; Online Collaboration Tools
Phone Conferences; Monthly Team Reports
Dissemination
Holding the Gains
Final Reports
S
AP1 AP2 AP3
P
A D
PA D A D
P
LS1 LS2 LS3
Executing Improvement
Repeated Use of the PDSA Cycle
Hunches Theories
Ideas
Changes That Result in
Improvement
A P
S D
APS
D
A P
S D
D SP A
DATA
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Old System New System
Some inhibitors:• “We met our goals”• “We assumed the improvement would hold”• Other priorities took all resources away
– (not on senior management’s radar screen)• Did not learn how to hold the gains• Infrastructure not in place
Strategies to Hold the Gains
After Implementation
Sustain – What does it Mean?
Sustain means…
• FIX in place• Retain• Save• Keep doing it• Don’t relapse• Hold the gain• To keep going• To lock in place
Sustain ALSO Means….
• Continue to move forward
• Co-evolve
• “Progress”
• Improve
• Pursue excellence
• Renewable ambition
Sustains 2 Parts
Don’t slide back!
Continue to move forward!
“At some stage, the work we’re doing is no longer a project, but it is the WAY we
operate.”
- Sarah Fraser
Transition
WHAT are We Sustaining?
• Outcomes– Access FOR and AT appointments
• Processes– Phones, messages, Rx renewal, etc
• Skills– Teamwork, measurement, feedback
• Attitudes/perceptions– Delay is bad for everything and everyone
Not everything should be sustained
• What to stop?
• What to prune?
• What to let die?
• What to sustain?
Understanding natural variation
Upper process
limit
Mean
Lower process
limit
0
10
20
30
40
50
60
70
80
F M A M J J A S O N D J F M A M J J A S O N D
Special cause variation
0
10
20
30
40
50
60
70
80
90
F M A M J J A S O N D J F M A M J J A S O N D
“Soft Stuff” of Sustainability
• People
• Communication
• Recognition
• “70% of projects fail or are not sustained. The most common reason is they do not take into account the people parts of sustainability.”
Will it be sustained?
• Function of will
• Function of “way” improvement is carried out
• Function of ability of team to continue to co-evolve
• Function of maintaining focus and aim
Team Exercise1. Select one of the specific
improvement changes you have implemented in your experience.
2. Assume your team all retire:– Will this change continue to be
used?
– What could make your clinic revert to the old system without this change?
Sustainability Ideas
• Make aims clear
• Assign ownership
• Measure
• Provide feedback
• Design it in from the start
• Force function (mistake proof)
• Test under a wide range of conditions
Sustainability Ideas
• Establish memory
• Continue to meet as a team
• Purposefully train new staff
• Change written job descriptions
• Change proficiencies and performance evals
• Change policies and procedures
Sustainability Ideas
• Map processes
• Standardize crucial steps of process
• Define simple rules
• Use periodic self audits
Sustainability Ideas
• Map processes
• Standardize crucial steps of process
• Define simple rules
• Use periodic self audits
Now the Most Important Step…
• “The Paradox of Control in Organizations”– Philip J. Streatfield
• Being in charge but not in control
• Guiding Light: Measurement
• Focus on the key indicators [Hint: Delay] and measure that one thing periodically forever. Put it in the department and system overall measures. Care.
Three Kinds of Measurement: Improvement; Accountability; Research
• Improvement (Access Team Measures)– Intended for internal staff– Intended to help understand process and
customers– Specific to individual process– Easy; Approximate; Samples; Current – Repeated over time
Three Kinds of Measurement Cont.
• Accountability (System Performance Measures)– Intended for system leaders & outsiders– Measure key outcomes– Intended to reassure and spur change– Fewer; Precise; Valid; – Large sample; externally verified; moderate
effort
Discipline: The Two Month Rule
• Some of the best organizations
• Focus on key measures (accountability) as an index of performance
• Have 2 months to either improve or meet goal– Use improvement skills to improve– Use measures of improvement to test
changes
Sustainability Action Plan
• What is your plan?
• As a Team?
• As a Department?
• As an Organization?