Sustainment of Change: Planning for Sustainability

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Sustainment of Change Planning for Sustainability

• Jay Ford, PhD
• Assistant Scientist

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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
  organizations ability to implement change in the
  future.

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How 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 settings 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)

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Sustainability

• 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.

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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 tipping point of better
  practice is the goal

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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.

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Sustainability 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)

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Sustaining Interventions
Adapted from Scheirer MA and Dearing JW. An
Agenda for Research on the Sustainability of
Public Health Programs. Am J Public Health. 2011
1012059-2067
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Six Types of Interventions 1

• 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

1. Scheirer MA, 2013. Linking sustainability
research to intervention types Am J Public
Health. 2013 Apr103(4)e73-80
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Sustainability Planning Framework
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Two Sustainability Readiness Tools

• Britisth National Health Service Sustainability
  Index (http//networkofpractice.org/?qnode/13)
• Program Sustainability Assessment Tool
  (https//sustaintool.org/assess)

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10 Key Factors for Sustaining Change
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Program Sustainability Assessment Tool
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Bringing it all together
Environmental 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
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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

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Sustainability PDSA
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Sustainability Planning

• Sustainability Plans should be
• Simple
• Concise
• Thoughtful
• Focused on a particular aim

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Sustain Plan Process

• Assemble the planning team.
• Envision your programs future.
• Review your PSAT results.
• Decide where to start.
• Prioritize.
• Develop a sustain plan
• Implement the sustain plan
• Reassess your sustainability capacity each year

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Items to include in a Sustainability Plan

• What 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, heres what we will do

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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

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Questions
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References

• 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
• 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 1012059-2067
• Scheirer MA. Linking Sustainability Research to
  Intervention Types. American Journal of Public
  Health (In press).