sustaining change how to make lasting changes in your primary care practice sue butts-dion...

Sustaining ChangeHow to make lasting changes in your

primary care practice

Sue Butts-DionImprovement 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 Improvements—Are 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

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 vision—we 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 vision—we 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 vision—we 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 vision—we 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 vision—we 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 vision—we 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 what’s 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?

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?

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Example: Damian Folch, MD

Hear Dr. Folch describe his improvement journey

Consideration: Do we have a process owners

and management support?

Examples: Practice Manager Office Manager Supervisor

Checklist: Question 1

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Checklist: Question 2

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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

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.)

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Checklist: Question 6

Consideration: Do we celebrate—even 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 StrategiesThroughout Phases of Work

Improvement

HOLD GAINS and SUSTAIN

Test Implement

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.

What Could You Do Today?

A place to start—In 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?

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Refer to the NSPG Beverly video

References

Improvement leaders’ guide to sustainability and spread. NHS Modernisation Agency. Ipswich, England: Ancient House Printing Group; 2002. Available: www.modern.nhs.uk/improvementguides/sustainability/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 2002;11:345-351.

Juran J, Godfrey B. Juran’s Quality Handbook (5th Edition). New York: McGraw-Hill, 1998. (Chapter 4)

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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.htmlhttp://www.institute.nhs.uk/sustainability_model/introduction/find_out_more_about_the_model.html

References