1. Sustaining and Spreading Change Mike Davies, MD Chief of Staff VA Black Hills

2. Access and Redesign Planning Group Participants Pre-work S S Ongoing Supports Email; Online Collaboration Tools Phone Conferences; Monthly Team Reports Dissemination Holding the Gains Final Reports S AP1AP2AP3 P A D P A D AD P LS1 LS2 LS3

3. Executing Improvement

4. Repeated Use of the PDSA Cycle Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Very Small Scale Test Follow- up Tests Wide-Scale Tests of Change Implementation of Change What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement

5. Old System New System Some inhibitors: “We met our goals” “We assumed the improvement would hold” Other priorities took all resources away –(not on senior management’s radar screen) Did not learn how to hold the gains Infrastructure not in place Strategies to Hold the Gains After Implementation

6. Sustain – What does it Mean?

7. Sustain means… FIX in place Retain Save Keep doing it Don’t relapse Hold the gain To keep going To lock in place

8. Sustain ALSO Means…. Continue to move forward Co-evolve “Progress” Improve Pursue excellence Renewable ambition

9. Sustains 2 Parts Don’t slide back! Continue to move forward!

10. “At some stage, the work we’re doing is no longer a project, but it is the WAY we operate.” - Sarah Fraser Transition

11. WHAT are We Sustaining? Outcomes –Access FOR and AT appointments Processes –Phones, messages, Rx renewal, etc Skills –Teamwork, measurement, feedback Attitudes/perceptions –Delay is bad for everything and everyone

12. Not everything should be sustained What to stop? What to prune? What to let die? What to sustain?

13. Understanding natural variation Upper process limit Mean Lower process limit

14. Special cause variation

15. “Soft Stuff” of Sustainability People Communication Recognition “70% of projects fail or are not sustained. The most common reason is they do not take into account the people parts of sustainability.”

16. Will it be sustained? Function of will Function of “way” improvement is carried out Function of ability of team to continue to co-evolve Function of maintaining focus and aim

17. Team Exercise 1. Select one of the specific improvement changes you have implemented in your experience. 2. Assume your team all retire: –Will this change continue to be used? –What could make your clinic revert to the old system without this change?

18. Sustainability Ideas Make aims clear Assign ownership Measure Provide feedback Design it in from the start Force function (mistake proof) Test under a wide range of conditions

19. Sustainability Ideas Establish memory Continue to meet as a team Purposefully train new staff Change written job descriptions Change proficiencies and performance evals Change policies and procedures

20. Sustainability Ideas Map processes Standardize crucial steps of process Define simple rules Use periodic self audits

21. Sustainability Ideas Map processes Standardize crucial steps of process Define simple rules Use periodic self audits

22. Now the Most Important Step… “The Paradox of Control in Organizations” –Philip J. Streatfield Being in charge but not in control Guiding Light: Measurement Focus on the key indicators [Hint: Delay] and measure that one thing periodically forever. Put it in the department and system overall measures. Care.

23. Three Kinds of Measurement: Improvement; Accountability; Research Improvement (Access Team Measures) –Intended for internal staff –Intended to help understand process and customers –Specific to individual process –Easy; Approximate; Samples; Current –Repeated over time

24. Three Kinds of Measurement Cont. Accountability (System Performance Measures) –Intended for system leaders & outsiders –Measure key outcomes –Intended to reassure and spur change –Fewer; Precise; Valid; –Large sample; externally verified; moderate effort

25. Discipline: The Two Month Rule Some of the best organizations Focus on key measures (accountability) as an index of performance Have 2 months to either improve or meet goal –Use improvement skills to improve –Use measures of improvement to test changes

26. Sustainability Action Plan What is your plan? As a Team? As a Department? As an Organization?