Sustaining%20Change%20How%20to%20make%20lasting%20changes%20in%20your%20primary%20care%20practice

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Sustaining ChangeHow to make lasting changes
in your primary care practice

• Sue Butts-Dion
• Improvement Advisor
• Institute for Healthcare Improvement

This project was supported by grant number
R18HS019508 from the Agency for Healthcare
Research and Quality (AHRQ). The content is
solely the responsibility of the authors and does
not necessarily represent the official view of
the AHRQ.
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Learning Objectives

• By the end of this module you will be able to
• Identify characteristics that make it easier
• to sustain change and improvement
• Utilize a checklist of considerations when
• working to sustain change
• Describe gaps in your practice as it relates
• to sustaining change
• List something that you could test immediately
• in your organization

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Your ImprovementsAre They Sustainable?
SUSTAINABLE?
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Persistence

• Sustaining change is as hard as making it

Never, never, never give up.
--Winston Churchill
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Practice Exercise

• Think of a change that was sustained
• What characteristics were present?
• List them
• Then
• Think of a change that was not sustained
• What characteristics were absent?
• List them

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Were these items on your list?
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Were these items on your list?

• New way was better than old way

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Were these items on your list?

• New way was better than old way
• Desire to want to change (urgency)

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Were these items on your list?

• New way was better than old way
• Desire to want to change (urgency)
• Had a clear visionwe knew why we were doing it

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Were these items on your list?

• New way was better than old way
• Desire to want to change (urgency)
• Had a clear visionwe knew why we were doing it
• Had a way to measure that we were holding our
  gains

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Were these items on your list?

• New way was better than old way
• Desire to want to change (urgency)
• Had a clear visionwe knew why we were doing it
• Had a way to measure that we were holding our
  gains
• Someone took ownership

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Were these items on your list?

• New way was better than old way
• Desire to want to change (urgency)
• Had a clear visionwe knew why we were doing it
• Had a way to measure that we were holding our
  gains
• Someone took ownership
• Had a coach

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Were these items on your list?

• New way was better than old way
• Desire to want to change (urgency)
• Had a clear visionwe knew why we were doing it
• Had a way to measure that we were holding our
  gains
• Someone took ownership
• Had a coach
• Support for the change (people, resources, etc.)

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Were these items on your list?

• New way was better than old way
• Desire to want to change (urgency)
• Had a clear visionwe knew why we were doing it
• Had a way to measure that we were holding our
  gains
• Someone took ownership
• Had a coach
• Support for the change (people, resources, etc.)
• Recognized and understood competing commitments

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Characteristics Present in Organizations Able to
Sustain Change

• Support from management
• Robust, transparent feedback systems
• Shared sense of the systems to be improved
• Culture of improvement deeply engaged staff
• Formal capacity-building programs
• Built-in structures to foolproof change

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Helpful 7-Question Checklist

• Do we have process owners (a home) and
  leadership support?
• Do we have a consensus understanding of whats
  being improved?
• Do we have built-in structures to foolproof
  the change?
• Do we have a way to measure that the change is
  still working?
• Do we have transparent communication/feedback
  systems in place?
• Do we celebrate (even the small things)?
• Do we engage/involve patients, families,
  clients, and customers?

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Example Damian Folch, MD

• Problem 45,000 open orders in EMR
• Solution Staff closed all open lab orders!
• How can Dr. Folch now sustain and
• continuously improve this change?

Hear Dr. Folch describe his improvement journey
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Checklist Question 1

• Consideration
• Do we have a process owners
• and management support?
• Examples
• Practice Manager
• Office Manager
• Supervisor

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Checklist Question 2

• Consideration
• Does everyone have the same understanding of the
  processes and systems we are trying to improve or
  have improved?
• Examples
• Communication
• Tool Flow map

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Checklist Question 3

• Consideration
• Have we built in structures to foolproof the
  change?
• Examples
• Checklists
• Standardized processes, protocols, guidelines
• Information technology (IT)
• Job/descriptions/policies
• Training

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Checklist Question 4

• Consideration
• Do we have a way to measure that the change is
  still working (or not)?
• Examples
• Measurements
• Charts, graphs

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Checklist Question 5

• Consideration
• Do we have transparent communication and feedback
  systems in place?
• Examples
• Communication plan
• Six times, six different ways
• Huddles (only 10-15 min.)

6 TIMES
6 WAYS

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Checklist Question 6

• Consideration
• Do we celebrateeven the seemingly small wins?
• Examples
• Lunch time party
• Celebration
• Acknowledgements

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Checklist Question 7

• Consideration
• Do we engage patient, families, customers,
  clients?
• Examples
• Inquiry (simple surveys)
• Focus groups
• Improvement meetings

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Importance of Sustainability Strategies Throughout
Phases of Work
Improvement
Test Implement
HOLD GAINS and SUSTAIN
I. During testing
II. During implementation
III. After implementation
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In Summary

• As they say

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In Summary

• As they say
• Improvement work is never completed
• and takes planning and time.

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In Summary

• As they say
• Improvement work is never completed
• and takes planning and time.
• Systems degrade,
  situations change. 
•  

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In Summary

• As they say
• Improvement work is never completed
• and takes planning and time.
• Systems degrade,
  situations change. 
•  
• You must create a system of improvement to
• be on top of the situation.

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What Could You Do Today?

• A place to startIn the past year
• Note one improvement in your practice
• Decide if the improvement was sustained
• Determine why it was, or was not
• Check if a step in the checklist was missed

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Thank You!

• Thank you
• for your time
• and attention today

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Want to learn more?

• Refer to the NSPG Beverly video

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References

• Improvement leaders guide to sustainability and
  spread. NHS Modernisation Agency. Ipswich,
  England Ancient House Printing Group 2002.
  Available www.modern.nhs.uk/improvementguides/sus
  tainability/fw.html
• Spread and sustainability of service improvement
  Factors identified by staff leading modernisation
  programmes. London, England NHS Modernisation
  Agency February 2003. Research into Practice,
  Report No. 4 Overview of early research
  findings.
• Teamworking for improvement Planning for spread
  and sustainability. London, England NHS
  Modernisation Agency August 2003. Research into
  Practice, Report No. 5.
• Øvretveit J, Bate P, Cleary P, et al. Quality
  Collaboratives Lessons from research. Qual Saf
  Health Care. Dec 200211345-351.
• Juran J, Godfrey B. Jurans Quality Handbook (5th
  Edition). New York McGraw-Hill, 1998. (Chapter
  4)

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References
The NHS Institute for Innovation and Improvement
offers spread and sustainability resources,
including a model to assess likelihood of holding
gains. See their website for more information
http//www.institute.nhs.uk/sustainability_model/
general/welcome_to_sustainability.html http//www.
institute.nhs.uk/sustainability_model/introduction
/find_out_more_about_the_model.html