Module 6: Sustainability

AHRQ Safety Program for Long-Term Care: HAIs/CAUTI

Slide 1: Module 6: Sustainability

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Slide 2: Objectives

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  • Define sustainability and understand the importance of maintaining positive change.
  • Describe the link between sustainability and spread.
  • Develop a plan for sustainability.
  • Discuss the steps needed to sustain efforts.
  • Describe lessons learned from examples of success across multiple settings.

Slide 3: Definition of Sustainability1-4

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  • Ensuring gains are maintained beyond the life of the project, or the institutionalization or integration of programs into ongoing organizational systems.
  • Sustaining the ideas, beliefs, principles, or values underlying an initiative, or "when new ways of working and improved outcomes become the norm".

1. Clinical Excellence Commission (CEC); Enhancing Project Spread and Sustainability – A Companion to the Easy Guide to Clinical Practice Improvement. Sydney: CEC: 2008.
2. Scheirer MA. Is Sustainability Possible? A Review and Commentary on Empirical Studies of Program Sustainability. American Journal of Evaluation. 2005 Sep;26(3):320-347.
3. Weiss H, Coffman J, Bohan-Baker M. Evaluation's Role in Supporting Initiative Sustainability. Cambridge, MA: Harvard Family Research Project; 2002. Accessed March 22, 2014.
4. NHS Modernisation Agency. Improvement Leader's Guide to Sustainability and Spread. NHS Modernisation Agency. Ipswich, England: Ancient House Printing Group; 2002.

Slide 4: Importance of Sustainability5

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  • Variability in health care.
  • Continuous high-quality care and reliable safe practices.
  • Measureable outcomes.
  • Prevent project fatigue.
  • Control processes.
  • Monitor progress.
  • Engage senior leaders.
  • Establish improvement culture and engaged staff.
  • Create cultural legacy.

Image: A team of staff

5. Kotter J. Leading Change. Harvard Business School Press, Boston, MA, 1996, as cited in TeamSTEPPS Fundamentals Course: Module 8. Change Management: Instructor's Slides: TeamSTEPPS Fundamentals Course. November 2008. Agency for Healthcare Research and Quality, Rockville, MD.

Slide 5: Sustainable Change After Project End?1

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Image: Graph showing sustainability is about the change after a project ends. One line shows that if improvement is not sustained, performance can return to the original rate or potentially worse. Another line shows that if improvement is sustained, performance can even surpass the improvements made during the project. It is this potential that makes sustainability so important.

1. Clinical Excellence Commission (CEC); Enhancing Project Spread and Sustainability – A Companion to the Easy Guide to Clinical Practice Improvement. Sydney: CEC: 2008.

Slide 6: What Does Sustainability Mean for Your Facility?

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  • How do you see other projects sustained in your facility?
  • Are values, beliefs, and practices incorporated into the mission of your organization and/or are they incorporated into existing processes?
  • Are other quality assurance and performance improvement (QAPI) initiatives aligned?

Slide 7: Facilitators of Sustainable Change5

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Image: Illustration from the TeamSTEPPS program of Kotter's 8 Steps of Change, showing penguins climbing up ledges of an iceberg to reach the top step.

The eight steps are:

Create a new culture
Don't let up- be relentless
Short-term wins
Empower others
Understanding and buy-in
Develop a change vision and strategy
Build the guiding team
Creat sense of urgency

5. Kotter J. Leading Change. Harvard Business School Press, Boston, MA, 1996, as cited in TeamSTEPPS Fundamentals Course: Module 8. Change Management: Instructor's Slides: TeamSTEPPS Fundamentals Course. November 2008. Agency for Healthcare Research and Quality, Rockville, MD.

Slide 8: Sustainability and Spread6

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Sustainability

Embedding a successful improvement into the culture and norms of a facility.

Spread

Implementing a successful improvement across multiple settings and/or facilities.

Spread is covered in detail in the Spread module of the AHRQ CUSP Toolkit available on the AHRQ Web site.

6. Spread module, CUSP Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; December 2012. Accessed March 22, 2014.

Slide 9: Planning for Sustainability

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  • Plan early for sustainability and spread.
  • Implement essential steps to create a sustainability plan.

Slide 10: Planning Early

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  • Develop plan for financial, staffing, and other resources.
  • Identify leaders and program champion(s).
  • Learn how to create a sustainable plan.
  • Educate staff.
  • Build a measurement system.

Image: Staff around a table

Slide 11: Steps to Creating a Sustainability Plan

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  1. Identify and develop program champion(s).
  2. Build the implementation team.
  3. Empower frontline staff.
  4. Establish a sustainability measurement plan.
  5. Identify and Address Barriers to Sustainability.
  6. Engage staff with stories.
  7. Recognize and celebrate success.

Slide 12: 1. Identify and Develop Program Champion(s)

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  • Program champion(s) will—
    • Communicate and reinforce resident safety and program goals as a priority.
    • Have physician, nursing, and administrative support.
    • Be motivational and inspiring.
    • Have influence.
    • Be able to communicate the vision.
    • Serve as a coach.
  • For more information on coaching, please see the Role of the Nurse Manager module within the AHRQ CUSP toolkit

Slide 13: 2. Build the Implementation Team

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  • This team will ideally include the following members:
    • Facility team lead.
    • Administrator.
    • Data coordinator.
    • Survey coordinator.
  • Identify a team leader to address team member concerns throughout the project.
  • Include your program champion to persuade and motivate.
  • Understand the program goals and components.

Image: A group of staff walking

Slide 14: 3. Empower Frontline Staff

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Frontline staff should—

  • Feel comfortable bringing up resident safety concerns to other team members or team leaders.
  • Speak up when a potential break in resident safety protocol may occur or actually occurs.
  • Be commended, and not punished, for speaking up about resident safety.

Slide 15: The Sustainability Team

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Image: Indicating a video on the slide

PLAY VIDEO:
Video 2.3: A Collaborative Effort

Slide 16: 4. Establish a Sustainability Measurement Plan

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  • Assess readiness for sustainability.
  • Build measurement system for collecting process, outcomes, and quality improvement data.
  • Determine what, when, and how to measure performance and who will collect the data.
  • Establish robust followup and transparent feedback system that uses data to continuously improve performance.

Slide 17: 5. Identify and Address Barriers to Sustainability

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  • Active involvement of administrative and clinical champions can address barriers by—
    • Motivating team members to support program interventions.
    • Highlighting positive staff experiences as a result of new procedures.
    • Dedicating time and resources to help carry out the interventions.

Slide 18: 6. Engage Staff With Stories

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  • Stories are a powerful way to engage staff in ways that numbers cannot.
  • Encourage your team leaders to discuss actual resident stories to drive home important lessons.

Image: Staff next to a resident in a wheelchair

Slide 19: 7. Recognize and Celebrate Success

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  • Recognizing success, large and small and both early on and long term, is important to sustainability.

Image: A nurse standing with an administrator.

Slide 20: Steps for Sustaining Efforts7

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  • Collect, review and share data with facility administration and frontline staff.
  • Communicate and engage
    • How is staff reminded of the project on an ongoing basis?  Posters with CAUTI rates? Announcements such as "100 days since the last CAUTI"?
  • Align with other QAPI efforts.
  • Celebrate successes.
  • Incorporate into orientation and training.
  • Address barriers to sustainability with workable solutions.

7. Swerissen H. Understanding the Sustainability of Health Programs and Organisational Change. A Paper for the Victorian Quality Council. June 2007.

Slide 21: Potential Barriers to Sustainability

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  • Lack of organizational infrastructure and resources.
  • Staff turnover.
  • Organizational skepticism.
  • Individual resistance to change.

Image: A group of staff with arrows pointing in opposite directions

Slide 22: Workable Solutions to Sustainability Barriers

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  • Lack of organizational infrastructure and resources
    • Develop strategies and flexibility to account for resource fluctuation.
    • Plan financial resources for maintaining improvements beyond the project end.
  • Staff turnover
    • Embed newly developed processes into new staff orientation and organizational policies.
    • Train staff continuously, including train-the-trainer education.
    • Develop volunteer network to assist in case of staffing fluctuations and/or shortage (funding, staff turnover).

Slide 23: Workable Solutions to Sustainability Barriers1

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  • Managing skepticism
    • Present ongoing evidence that the new process is a better one.
    • Show staff and stakeholders real data.
    • Reserve staff time away from normal duties to work on proposed improvements.
    • Encourage active senior leader engagement
      • Consider measuring how frequently senior leaders/administrators review sustainability data/outcomes as indicator of engagement at this level.

1. Clinical Excellence Commission (CEC); Enhancing Project Spread and Sustainability – A Companion to the Easy Guide to Clinical Practice Improvement. Sydney: CEC: 2008.

Slide 24: Assessing your Sustainability Plan

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  • What is your sustainability measurement plan?
    • What data will be acceptable?
    • How often will it be reviewed?
  • How will you make this as part of daily operations? 
    • Included in orientation of new staff?
    • Included in competency of existing staff? 
    • How will you make sure excitement will be the same in a year or two as it is today?

Slide 25: Sustainability Examples: Data8

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  • Baptist Memorial Health Care created a measurement system including—
    • An appointed facilitator.
    • A process for collecting, reporting and inputting data into system database.
    • Generation of graphics to show performance trends .
    • Communication to senior leadership and medical staff.
    • Data-based refinement of the improvement plan.

Image: Staff looking at a table.

8. 5 Million Lives Campaign. Getting Started Kit: Rapid Response Teams. Cambridge, MA: Institute for Healthcare Improvement; 2008. www.ihi.org. Accessed March 22, 2014.

Slide 26: Sustainability Examples: Ongoing Training9

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  • Partners in Care in New York City utilized a train-the-trainer model to deliver communication training to all staff on an ongoing basis.
  • Incorporating training into ongoing training and orientation assures that that all staff have consistent information and expectations.

9. Ozga M. Partners in Care: How the nation's largest home health agency is transforming its culture. Chicago, IL: Pioneer Network: January 2012. Accessed November 20, 2014.

Slide 27: Key Concepts Review

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  • Sustainability helps organizations embed processes into their organizational culture.
  • Organizations must be prepared to address barriers that can hinder sustainability.
  • An effective sustainability plan includes –
    • Planning early in the improvement process.
    • Easy to reach goals.
    • Program champion.
    • Fit within organizational mission.
    • Ongoing evaluation and transparency of measures.

Slide 28: References

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  1. Clinical Excellence Commission (CEC); Enhancing Project Spread and Sustainability – A Companion to the Easy Guide to Clinical Practice Improvement. Sydney: CEC: 2008.
  2. Scheirer MA. Is Sustainability Possible? A Review and Commentary on Empirical Studies of Program Sustainability. American Journal of Evaluation. 2005 Sep;26(3):320-347.
  3. Weiss H, Coffman J, Bohan-Baker M. Evaluation's Role in Supporting Initiative Sustainability. Cambridge, MA: Harvard Family Research Project; 2002. Accessed March 22, 2014.
  4. NHS Modernisation Agency. Improvement Leader's Guide to Sustainability and Spread. NHS Modernisation Agency. Ipswich, England: Ancient House Printing Group; 2002.
  5. Kotter J. Leading Change. Harvard Business School Press, Boston, MA, 1996, as cited in TeamSTEPPS Fundamentals Course: Module 8. Change Management: Instructor's Slides: TeamSTEPPS Fundamentals Course. November 2008. Agency for Healthcare Research and Quality, Rockville, MD.

Slide 29: References

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  1. Spread module, CUSP Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; December 2012. Accessed March 22, 2014.
  2. Swerissen H. Understanding the Sustainability of Health Programs and Organisational Change. A Paper for the Victorian Quality Council. June 2007.
  3. 5 Million Lives Campaign. Getting Started Kit: Rapid Response Teams. Cambridge, MA: Institute for Healthcare Improvement; 2008. www.ihi.org. Accessed March 22, 2014.
  4. Ozga M. Partners in Care: How the nation's largest home health agency is transforming its culture. Chicago, IL: Pioneer Network: January 2012. Accessed November 20, 2014.
  5. Tool 6A: Sustainability Tool: Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. January 2013. Agency for Healthcare Research and Quality, Rockville, MD.
Page last reviewed March 2017
Page originally created March 2017
Internet Citation: Module 6: Sustainability. Content last reviewed March 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module6/mod6-slides.html