Sustaining Change in a Changing World

Jay Ford, PhD

Assistant Scientist

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.

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.

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

Sustainability Model

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

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

10 Key Factors for Sustaining Change

NIATx200

Sustainability: Change Complexity

PC/MHI MHSR Polytrauma0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

8.42 9.53*19.12

29.8833.00

36.99

17.03

20.50

11.86

OrganizationStaffProcess

55.50

63.7967.96

Significant difference between the two categories at p < 0.049

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.

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

Sustainability Planning

Sustainability Model

Sustainability PDSA

A: Assess Readiness

D: Develop a sustain plan

I: Implement the plan

E: Evaluate

M: Modify the sustain

plan

Sustainability PlanningSustainability Plans should be:

Simple

Concise

Thoughtful

Focused on a particular aim

Items to include in a Sustainability PlanWhat 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…

Anticipate, Plan and React (APR) ToolANTICIPATE

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?

Example APR

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

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

Key Take-Away MessagesDetermine organizational readiness to

sustain change

Anticipate, plan and react to potential

challenges in sustaining change

Develop and implement a sustainability

plan

ReferencesScheirer 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.