Making It Stick: Planning for Sustainability

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


• 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


• 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


• 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


• 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


• 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


• 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


• 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


• 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


• 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


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

Healthcare

Making It Stick: Planning for Sustainability