Change is easy. Staying changed? Not so much

July 28, 2014

Director of Research
Center for Health Enhancement Systems Studies/NIATx 
University of Wisconsin-Madison

But staying changed can be a challenge.   

Maybe you’ve seen it happen in your own organization: an improvement project has an initial success…then fades into improvement project oblivion a few months later.

Just as losing weight doesn't mean that it will stay lost, implementing an organizational change doesn’t guarantee that it will be sustained. Studies indicate that only 40 to 70% of changes are sustained[i].A change not sustained is a direct waste of invested resources, creates costs associated with missed opportunities, and affects your organization’s ability to implement change in the future.

Despite these challenges, we are learning more about what makes change “stick,” or the attributes that influence sustainability of organizational change. But before I tell you about these attributes, I want to clarify two important related concepts: maintenance of change and organizational capacity to maintain the benefits of a change.  How do they differ? 

I like to define maintenance of change as “the extent an evidence-based intervention can deliver its intended benefits over an extended period of time.[ii]” 

Take a look at weight loss. For a dieter, maintenance of change might be the ability of reduced calories and increased activity to deliver the intended benefit (a healthy weight) over time. For an organizational improvement project to reduce appointment no-shows, maintenance of change might be the extent to which using reminder phone calls reduces no-shows, once that practice is adopted as standard procedure.  

Organizational capacity to maintain the benefits of change refers to the existence of structures and processes that allow a program to leverage resources to effectively implement and maintain evidence-based policies and activities.[iii]” In other words, how does the organization’s environment support sustaining the improvements made?  Creating a culture of change can make all the difference in sustaining a new business process or an evidence-based practice.

Long-term success

What I do know is that the longer your organization maintains the benefits of a change, the more likely those benefits to become the “new normal.”   

 Let’s say you make changes to reduce waiting time for first appointments from 28 to 7 days. After testing a few promising practices such as reminder phone calls, double booking appointments, and offering same-day service, you successfully reducing waiting time to 7 days.  Even better, you maintain that improvement over a 12-month period! Admissions are up, and more clients are continuing in treatment. The increase in billable hours has boosted revenue, and your board of directors is pleased. The expected appointment wait time of 7 days is now the new normal for your organization, and you would measure any efforts to improve wait time further against this internal benchmark.

A sustainability focus
Two aspects of sustainability do not get enough attention in quality improvement projects: lack of focus on sustainability early in the implementation process and sustainability planning.  Think of yo-yo dieting: a person might achieve a dramatic weight loss by severe restricting calories and increasing activity. But can both changes be maintained over time? Does the dieter have a plan already in place for counting calories and staying active once the weight loss goal is achieved?

Organizations need to go into implementation believing that the change will be successful and should be sustained. The ideal time to start thinking about sustainability will vary, but once the change has been implemented and appears to be successful, it’s time for an organization to assess its capacity to sustain the change. Now’s the time to identify internal barriers to sustainability. I know about two tools to help assess your organizations’ sustainability capacity: (1) the British National Health Service Sustainability Index and (2) the Program Sustainability Assessment Tool. Regardless of the tool used, recruit four to eight staff persons in your organization to complete the tool to ensure that multiple opinions are considered when assessing sustainability capacity.

A sustainability plan
Use the results from the assessment to focus on sustainability planning. A sustainability plan identifies specific actions that an organization might take to support sustainability.

In my opinion, a sustainability plan should be simple and concise. It should formalize the infrastructure and identify the resources to support sustainability. For example, the plan should identify a sustain leader and the process that will be used to regularly monitor the impact of the change over time. The sustain plan can been seen as your “relapse prevention plan” should the change begin to fail. Similar to when a fire alarm is pulled and you need to evacuate the building, the sustain plan should identify the red flags or triggers that will stimulate action.

Let’s go back to the example of the organization that reduced waiting appointment wait time to 7 days. Your organization decided that the red flag would be appointment wait time creeping up to 10 days for two consecutive weeks. Your sustain plan should clearly define immediate steps to take when that happens. These steps could include reconvening the change team in 48 hours to study the problem, identifying the source of the increase in appointment wait time, and then taking correctable actions.

These are some of my thoughts related to sustainability. Now it would be great to hear from you. Do you have a success story to share related to sustainability? What attributes influenced your organizational capacity to sustain change? How long have you been able to maintain the benefits from an implemented change? Are some changes easier to maintain than others? If so, what types of changes? Let’s start a dialogue so everyone benefits from our collective knowledge.

Dr. Jay Ford’s current research applies health systems engineering principals and techniques to improve health care delivery systems within behavioral health. Current projects involve community-based treatment providers, states, and the Veterans Administration. He serves as a coach for projects such as the Wisconsin Mental Health Learning Collaborative and BHBusiness. Previously, Dr. Ford led the research and data analysis for NIATx 200 and STAR-SI projects that focused on spreading and sustaining organizational change in addiction treatment organizations and systems. He was also a member of the team that developed and tested the NIATx model in the Robert Wood Johnson Foundation-funded and CSAT-funded Paths to Recovery and STAR projects

[i] Scheirer, M. A. and J. W. Dearing. 2011. “An agenda for research on the sustainability of public health programs.” American Journal of Public Health 101(11): 2059-67
[ii] Chambers DA, Glasgow RE Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci. 2013 Oct 2; 8:117
[iii] Schell S, Luke D, Schooley M, Elliott M, Herbers S, Mueller N, et al. Public health program capacity for sustainability: A new framework. Implement Sci., 2013 Feb 1; 8:15.

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