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MAKING IT STICK: PLANNING FOR SUSTAINABILITY
Andrew Wray
Quality Forum 2017
Presenter Disclosure
Presenter: Andrew Wray
Relationships with commercial interests:– Nothing to disclose
What sorts of things have prevented you from sustaining improvements?
Speed Networking
Definitions
• Spread - When best practice is disseminated consistently and reliably across a whole system, and involves the implementation of proven interventions1
• Sustainability - When new ways of working and improved outcomes become the norm2
• Scale – Delivering improvement across an entire organization or system simultaneously3
“Adoption, adaptation, scale-up, spread, and sustainability are ill-defined, undertheorised, and little-researched implementation science concepts”5
“…near absence of studies focusing primarily on the sustainability of complex service innovations”6
ASSUMPTION
• Looking for a permanent new way of working
Perspective
• Sustainability is not a post-implementation activity.
• We should be addressing sustainability:
1) Planning the change
2) Change process
3) Embedding and ensuring success
Three key factors
• Context
• Intervention
• People
1) Planning for Sustainability
• Efforts planned without strategies for making the changes permanent are unlikely to stick by chance.
• The un-sustainable change may temporarily help – but can do damage in the long term
• Consideration to sustainability should be included at the outset of any initiative.
NHS Sustainability Model
• A diagnostic tool
• 10 factors critical to sustainability
– People
– Process
– Organization
• Versatile in application
©NHS Institute for Innovation and Improvement 2006
• In addition to helping patients, are there other benefits?
• Does the change reduce waste, duplication and added effort?
• Will it make things run more smoothly?
• Will staff notice a difference in their daily working lives?
Benefits beyond helping patients
©NHS Institute for Innovation and Improvement 2006
• Are benefits to patients, staff and the organisation visible?
• Do staff believe in the benefits?
• Can all staff describe the benefits clearly?
• Is there evidence that this type of change has been
achieved elsewhere?
Credibility of the benefits
©NHS Institute for Innovation and Improvement 2006
• Can the process overcome internal pressures and continually improve?
• Does the change continue to meet ongoing needs effectively?
• Does the change rely on an individual or group of people, technology,
finance etc to keep it going?
• Can it keep going when these are removed?
Adaptability of improved process
©NHS Institute for Innovation and Improvement 2006
• Does the change require special monitoring systems to identify
improvement?
• Is this data already collected and is it easily accessible?
• Is there a feedback system to reinforce benefits and progress
and initiate action?
• Are the results of the change communicated to patients, staff,
and the organisation?
Effectiveness of the system
to monitor progress
©NHS Institute for Innovation and Improvement 2006
• Do staff play a part in innovation, design & implementation of change?
• Have they used their ideas to inform the change process from
the very beginning?
• Is there a training & dev infrastructure to identify gaps in skills &
knowledge and are staff educated and trained to take change forward?
Staff involvement and training
to sustain the process
©NHS Institute for Innovation and Improvement 2006
• Are staff encouraged to express their ideas and is their input taken
on board?
• Are staff able to run small-scale tests (PDSA) based on their ideas,
to see if additional improvements should be recommended?
• Do staff think that the change is a better way of doing things that
they want to preserve for the future?
Staff attitudes towards sustaining the change
©NHS Institute for Innovation and Improvement 2006
• Are the senior leaders trustworthy, influential, respected
and believable?
• Are they involved in the initiative, do they understand it and do they
promote it?
• Are they respected by their peers and can they influence others to get
on board?
• Are they taking personal responsibility & giving time to help ensure
the change is sustained?
Senior leadership engagement
©NHS Institute for Innovation and Improvement 2006
• Are the clinical leaders trustworthy, influential, respected
and believable?
• Are they involved in the initiative, do they understand it and do they
promote it?
• Are they respected by their peers and can they influence others to get
on board?
• Are they taking personal responsibility & giving time to help ensure
the change is sustained?
Clinical leadership engagement
©NHS Institute for Innovation and Improvement 2006
• Has the organisation successfully sustained improvement in the past?
• Are the goals of the change clear and shared?
• Is it contributing to the overall organisational aims.
• Is change important to the organisation and its leadership?
• Does your organisation have a ‘can do’ culture?
Fit with the organisation’s strategic aims
and culture
©NHS Institute for Innovation and Improvement 2006
• Do you have enough good quality, trained staff?
• Are there enough facilities and equipment to support the
new process?
• Are new requirements built into job descriptions?
• Are there policies and procedures supporting the new
way of working?
• Is there a communication system in place?
Infrastructure for sustainability
©NHS Institute for Innovation and Improvement 2006
Scoring the Sustainability Model
• Some general guidance on overall scores
– > 35: Re-evaluate project
– 35-55: Some concerns to be addressed
– 55 +: Cause for optimism
• Nothing is inherently unsustainable – It provides opportunities for improvement
2) The Change Process
• After planning an improvement project, we must test the interventions
• Sustainability is a key consideration to the way interventions are designed and introduced
Reference: The Improvement Guide, 2nd ed. Langley,
Moen, Nolan, Nolan, Norman & Provost, p. 24
The Change Process
• How we work with people
• The nature of the changes
• The context in which the change occurs
3) Making it Stick
• Once we have a successful intervention(s) in place, we need to transition from a new way of working to THE way of working.
• Same three factors at play
– People
– Context
– Change
Key Considerations
• Resource
• Embedding
• Fidelity
• Monitoring for sustainability
Resources
• Often need extra resources for the improvement process
• Financial and human
• Key is to distinguish between the change process and the intervention
Impact of Change on Workload/ Capacity
Wo
rkload
Time
Baseline
Zone of change
Post implementation
of change
Unchanged
More workload/less capacity
Less workload/ more capacity
Cumulative Impact of Change
Time
Wo
rkload
Unsustainable
Acceptable
Ideal
34
Embedding the Change
• Change job descriptions
• Integrate into orientations
• Document procedures
• Include in patient education
• Transition from project lead to operational lead
Fidelity
• To avoid “drift” – we need to ensure that the key components of the change are maintained.
• We need to have learned what the key features are.
Monitoring for Sustainability
• Ongoing measurement of the improvement process
– Frequency and sample may reduce
• Integrate into electronic systems