Sustainment of Change: Sustainment of Change: Planning for SustainabilityPlanning for Sustainability

Jay Ford, PhD

Assistant Scientist

Statements Statements aboutabout Sustainability 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.

HowHow do we define sustainability? do we define sustainability?When new ways of working and improved outcomes

become the norm. (NHS, 2002)

The extent to which newly implemented intervention is maintained or institutionalized within a service setting’s ongoing stable operations (Proctor and Brownson 2012 p. 268)

Sustainability is the continuation of activities or benefits for target recipients after an initial period of funding ends or following the initial implementation of a new program or procedure (Scheirer, 2013)

SustainabilitySustainability Understand the essential attributes associated with

maintaining a change process. Environment Organization Innovation

Evaluate if the improvements are maintained or improve over a extended time period.

Sustaining ChangeSustaining 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 tipping point of better

practice is the goal

What do we know about Sustainability?What do we know about Sustainability? Significant heterogeneity exists across organizations Clinicians and managers have different opinions Leadership support is a facilitator and barrier Change complexity appears to influence sustainability Change linked to the underlying organizational culture is

more likely to be sustained. Participation in a given QI intervention appears to influence

staff perceptions about sustainability Short term sustainability is possible but long term is not

certain.

Sustainability ChallengesSustainability Challenges 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 received 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)

SustainingSustaining Interventions Interventions

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Adapted from Scheirer MA and Dearing JW. An Agenda for Research on the Sustainability of Public Health Programs. Am J Public Health. 2011; 101:2059-2067

Six Types of Interventions Six Types of Interventions 11

Implemented by Individual Providers Requiring coordination among multiple staff New policies, procedures and technologies Capacity or Infrastructure Building Collaborative Partnerships or Coalitions Broad scale system change

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1. Scheirer MA, 2013. Linking sustainability research to intervention types Am J Public Health. 2013 Apr;103(4):e73-80

Sustainability Planning FrameworkSustainability Planning Framework

Two Sustainability Readiness ToolsTwo Sustainability Readiness Tools Britisth National Health Service Sustainability Index (

http://networkofpractice.org/?q=node/13)

Program Sustainability Assessment Tool (https://sustaintool.org/assess)

10 Key Factors for Sustaining Change

Program Sustainability Assessment ToolProgram Sustainability Assessment Tool

Bringing it all togetherBringing it all togetherEnvironmental Organizational Innovation

Political Support Organizational Capacity Staff Attitudes

Funding Stability Senior Leadership Benefits

Partnerships Clinical Leadership Credibility

Staff Involvement Adaptability

Program Evaluation/Effectiveness of Systems

Communications

Program Adaptation

Strategic Planning/Organizational Fit

Resources

What Next?What Next? Identify 3 to 8 staff in your agency and ask them to

complete one or both of the sustainability tools Follow-up calls will focus on

Barriers and Facilitators Development of sustain plans

Sustainability PDSASustainability PDSA

Sustainability Planning

Sustainability Plans should be:

Simple

Concise

Thoughtful

Focused on a particular aim

Sustain Plan ProcessSustain Plan Process Assemble the planning team. Envision your program’s future. Review your PSAT results. Decide where to start. Prioritize. Develop a sustain plan Implement the sustain plan Reassess your sustainability capacity each year

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…

Key Take-Away Messages

Integrate change into infrastructure

Monitor and evaluate impact of change

Make system simple and useful

Communicate and act on knowledge

Develop and implement a sustain plan

QuestionsQuestions

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ReferencesReferencesFord 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

Ford II JH, Krahn D, Oliver K and Kirchner JA. Sustainability in Primary Care and Mental Health Integration Projects in Veterans Health Administration (2012). Quality Management in Healthcare 21(4): 240-251.

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.

Scheirer MA. Is Sustainability Possible? A Review and Commentary on Empirical Studies of Program Sustainability. American Journal of Evaluation. 2005; 26(3): 320-347.

Scheirer MA and Dearing JW. An Agenda for Research on the Sustainability of Public Health Programs. Am J Public Health. 2011; 101:2059-2067

Scheirer MA. Linking Sustainability Research to Intervention Types. American Journal of Public Health (In press).