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

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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

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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?