Change Project 911: Unable to sustain a change

Mat Roosa, LCSW-R
NIATx Coach

“It’s easy to quit drinking. I’ve done it a thousand times.”   W.C. Fields

Change is easy. Sustaining change is not so easy. This is true for personal changes like quitting smoking, exercising more, driving slower, or keeping the house more organized. It is also true for workplace systems changes, such as implementing new policies and procedures. Too often, despite our best intention, we end up like Sisyphus, doing our best to roll the change up the hill, only to see it slide back down.  

The NIATx rapid-cycle PDSA change model emphasizes making changes that you can measure and implement quickly. Sometimes, change teams think of the process as a quick sprint to change. But sustaining a change (sustainment) is more like a long-distance run. So here are a few things you can do to pace yourself to sustain your change project gains. 

Create a sustain plan

Sustainment rarely happens without a clear sustainment plan. Just as inpatient hospital care should include discharge planning at admission, change projects should start sustainment planning at the beginning of the change. Build the sustainment conversation into the change project planning, and use the elements below to ensure sustainment success. 


Keep meeting

NIATx change teams meet frequently when developing and implementing a change project. Too often, these teams disband prematurely at the end of the change implementation. Schedule ongoing—but less frequent—change team meetings to monitor the successful change. 


Track the data

Many successful change sustainment teams develop a data dashboard for tracking key change metrics. Periodic review of the data helps decision-makers take action when the data reflects a drift from the new practice. Teams can set parameters that will trigger actions: If metric x drops below level Y, we will do Z, etc.


Engage new staff

Staff turnover poses a primary challenge to sustainment. Initial implementors leave, often replaced by staff who have no knowledge or investment in the new practice. Offset this issue and sustain the new practice by building it into your organization’s policy and procedures and new staff training. In addition, learning the history story of successful change projects helps new staff to appreciate the work that has come before them and will motivate them to sustain the improvements.


Assign a Sustain Leader

A key role in the NIATx model is the Change Leader. Teams are also encouraged to assign a data coordinator, who gathers and presents the change project data. The Sustain Leader plays another key role for Change Teams. Assigning a  Sustain Leader responsible for creating a sustainment plan is the clearest path to making sustaining the change a priority for your team.


Focus on ROI

Change teams feel frustrated when they see the progress of a successful change project fading—or worse, reverting to the old way. Backsliding leaves the team right back where they started, with little to show for their efforts. Instead, motivate teams to sustain successful gains by celebrating progress. Announcing the successful change and honoring the change team's effort in an office newsletter or other communication can also motivate the team to sustain the improvement.


Recognize the challenge of turning the new into the norm

Most people and teams are better at starting new things than they are at sustaining new things. Humans evolved to notice risk and make rapid decisions to increase safety. Appreciating this innate wiring can help us feel greater empathy for ourselves and our team members as we work to monitor changes and enhance sustainment. 

Using the strategies above can help you to succeed in turning new changes into norms of practice. However, continuous quality improvement is not just about the implementation of change. CQI also requires an ongoing effort to sustain the changes you have already made. 


About Change Project 911

Change Project 911 is a monthly blog post series covering common change project barriers and how to address them. Has your change project hit a snag that you’re not sure to tackle? Share your issue in the comments section below, or email Change Project 911 at matroosa@gmail.comWe’ll offer solutions from our team of change project experts!

About our Guest Blogger

                                                 

Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in quality improvement, organizational development and planning, and implementing evidence-based practices. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat (Change Project SOS) at matroosa@gmail.com.


AMERSA People & Passion, Episode 10: Initiating Medications for Opioid Use Disorder—There’s an App for That?!?

To support utilization of Medications for Opioid Use Disorder (MOUD), the Office Based Addiction Treatment Training and Technical Assistance (OBAT TTA) team will be releasing a mobile application that will guide healthcare providers through the initiation of buprenorphine and naltrexone for OUD (including injectable buprenorphine) and pain management for patients on these medications via interactive clinical algorithms [if already released we should include a link]. This is one of the only apps of its kind for addiction care and this podcast will interview key members leading the development of the app to learn more about its development, what gaps it is addressing, and feedback on initial utilization and impact.






Elizabeth M. Oliva, PhD, received her PhD in Developmental Psychopathology and Clinical Science from the University of Minnesota where her graduate work examining the etiology of substance use from adolescence to early adulthood was funded by a National Science Foundation Graduate Fellowship. She completed her pre-doctoral clinical psychology internship at UCSD/VA San Diego and is currently the VA National Opioid Overdose Education and Naloxone Distribution (OEND) Coordinator. Dr. Oliva also conducts research on VA OEND implementation as an Investigator at the VA Center for Innovation to Implementation (Ci2i) at the VA Palo Alto Health Care System. She is a Senior Evaluator for the VA Program Evaluation and Resource Center (PERC; one of three VA Office of Mental Health and Suicide Prevention evaluation centers) and supports implementation of VA’s Stratification Tool for Opioid Risk Mitigation (STORM). Dr. Oliva is also an Associate Editor for the Substance Abuse journal.

Andrea Caputo, DNP, FNP-BC, CARN-AP, is a Nurse Practitioner and Clinical Nurse Educator for the OBAT TTA+ program at Boston Medical Center with expertise in women's health, individuals experiencing homelessness, and chronic disease management. She is committed to serving vulnerable populations and works per diem at Boston Health Care for the Homeless Program; Andrea has also conducted international healthcare work in Haiti. She is a term lecturer and preceptor for nurse practitioner students at the MGH Institute of Health Professions (MGH IHP). Andrea received her Masters of Science in Nursing in 2011 and her Doctorate of Nursing Practice in 2018, both from the MGH IHP. She is board certified in addictions nursing through the Addictions Nursing Certification Board.


Annie Potter, MSN, MPH, NP, CARN-AP 
is a Nurse Practitioner and Clinical Nurse Educator for the OBAT TTA+ program at Boston Medical Center. Annie educates and supports health care providers on best practices in the treatment of substance use disorders and serves as Medical Director for BMC’s Massachusetts OBAT ECHO. Prior to joining BMC, Annie practiced at a community health center in Baltimore, MD, where she established and served as the clinical lead for the city's first walk-in HIV treatment and prevention program. She is board-certified in addictions and holds specialty certifications for the treatment of HIV and Hepatitis C. Annie earned her Masters of Nursing and Masters of Public Health from the Johns Hopkins School of Nursing and Bloomberg School of Public Health, respectively.

AMERSA People & Passion, Episode 9: History of AMERSA with Sid Schnoll

Sid Schnoll, one of the founders of AMERSA, discusses with Paula Lum the origin of the organization out of the Career Teacher Program of the early 1970s. The desire by the federal government to cultivate experts in substance use disorders into health professional schools has resulted in a vibrant, growing organization that helps health educators provide cutting-edge information to their students.





Sidney H. Schnoll, M.D., Ph.D.
, is an internationally recognized expert in addiction and pain management who has recently applied his experience of over 30 years in academic medicine to the issues of risk management of controlled substances. Sid was a member of the team that developed the Tramadol Independent Steering Committee (ISC), and he was the principal investigator on the health care professional surveillance project to determine rates of use of tramadol among health professionals. Sid also developed the RADARS® System to study the use and diversion of prescription opioids, which was cited by the FDA as a model risk management program. With over thirty years in academic medicine, Sid has published over 150 research papers, book chapters and educational materials. His areas of research include both addiction and pain management with special emphasis on perinatal addiction and prescription drug use.
 


Sid Schnoll on 1971 Philadelphia Magazine Cover


Paula J. Lum, MD, MPH
 is an HIV primary care physician, addiction medicine specialist, and Professor of Medicine at the University of California, San Francisco.  Board certified in internal medicine and addiction medicine, her research, clinical, and teaching activities for the last 25 years have focused on evidence-based and patient-centered care to improve the health and wellness of the urban poor.  After attending her first AMERSA conference in 2008, Dr. Lum “felt the love” and knew she had found her professional home.   She enjoyed reviewing abstracts for the conference so much, that she went on to co-chair the Abstract Committee in 2012 and 2013, and to co-chair the Conference Program Committee in 2014 and 2015.  Encouraged by AMERSA colleagues and other giants in the field, she established the first accredited Addiction Medicine Fellowship Program in the University of California.  In 2019, Dr. Lum received AMERSA’s W. Anderson Spickard, Jr. Excellence in Mentorship Award and began her current tenure as President of the AMERSA Board of Directors.  At the Annual National Conference, pestering Sid Schnoll for stories about the Summer of Love has become one of her favorite traditions. 




AMERSA People & Passion, Episode 8: Key Conversations: Dismantling Racism Against Black, Indigenous, and People of Color Across the Substance Use Continuum

The Association for Multidisciplinary Education and Research in Substance use and Addiction (AMERSA) released a solidarity statement and a position paper articulating racism’s deadly effects on persons who use alcohol, tobacco, and other drugs. This cascade of negative effects, compounded with the social determinants of health results in higher rates of incarceration, increased risk of overdose, fewer employment options, multi-generational poverty and economic disadvantages for Black, Indigenous, and People of Color (BIPoC).

The AMERSA Board of Directors (BOD) proposes an initial set of strategies to promote diversity, equity, and inclusion using a framework that speaks to four key AMERSA experiences: engagement, education, mentorship, and leadership. Please join Dr. Holly Hagle, Marlene Martin, and Miriam Komaromy in this podcast for a discussion on how AMERSA commits to promoting equity and inclusion to dismantle the individual, institutional, and structural racism that has pervaded the United States for centuries. Through these actions we stand in solidarity with BIPoC and all persons who use substances across the spectrum of harm reduction, prevention, intervention, treatment, and recovery; committing to promoting equity and inclusion. The AMERSA BOD cannot achieve this alone. We invite our members to join us in building an inclusive, multidisciplinary professional society equitable for all. Please visit us at AMERSA.org





Holly Hagle, Ph.D
. is an Assistant Research Professor at the Collaborative to Advance Health Services, at the University of Missouri-Kansas City’s School of Nursing and Health Studies. Dr. Hagle is a proven leader and educator with over 18 years’ experience developing educational programming, curricula for traditional face-to-face and online education, supervision of staff and consultants, and the management of multi-million dollar federal grant budgets. She is the Co-Director of the National Addiction Technology Transfer Center (ATTC) Network Coordinating Office (NCO) and Principal Investigator (PI) for the Prevention Technology Transfer Center (PTTC) NCO. In addition, she is the UMKC PI, and Co-Director on behalf of the ATTC Network for the Opioid State Targeted Response Technical Assistance (STR-TA) grant. Dr. Hagle has been actively working with medical and behavioral health providers for more than 20 years on the integration of behavioral health interventions, including educational programming on intercultural sensitivity. Her area of expertise is in adolescent co-occurring disorders, screening, brief intervention, and referral to treatment, and the application of evidence-based practices in community settings with a special focus on qualitative research methods.



Marlene Martin, MD
, is an Assistant Clinical Professor at UCSF and a hospitalist at San Francisco General Hospital. She is driven to improve care for populations in the safety net.

Marlene was born and raised in Los Angeles and is a first-generation college graduate. She attended college and medical school at Stanford prior to completing Internal Medicine residency at UCSF. Her bilingual and bicultural Mexican immigrant background influenced her to serve socially oppressed populations.

Marlene is board certified in addiction medicine and founded and directs the Addiction Care Team, a novel interprofessional consult service that delivers compassionate, evidence-based care for hospitalized people with unhealthy substance use. She is interested in alcohol use disorders among LatinX populations as well as eliminating the inequities faced by persons with substance use disorders.

 

Dr. Miriam Komaromy
is an addiction medicine physician who is medical director of the Grayken Center for Addiction at Boston Medical Center, where her work focuses on all aspects of substance use disorders and the intersection between addiction and health equity. In the past she led the development of the ECHO model for education of clinical teams about how to treat substance use disorders in primary care. She currently leads a federally-funded program studying the best way to treat co-occurring addiction and mental health disorders in primary care settings.

Change Project 911: Customers don’t notice improvements



Mat Roosa, LCSW-R
NIATx Coach

How do we know if a change is an improvement?

Change teams and change leaders ask this question frequently. It often refers to the measures and data they’re using to monitor change results.

But there is another and perhaps more meaningful way to ask this question: How do our customers know that a change is an improvement? 

The number one NIATx Principle asks us to understand and involve the customer. The most important way to involve customers is to make sure that they are experiencing the improvements resulting from a change.

Collecting quantitative data on the change is essential, but collecting qualitative data about the customer/client/ patient experience is also essential. For example, do the results of the change create a real impact that the customer feels? Does the change make the service process more satisfying, comfortable, or useful to the people we are trying to serve?  

Quality customer experience by design

Most of us try to gather customer feedback to help us to improve our services. Surveys and focus groups of service recipients can be excellent strategies for determining the impact of a change that we have implemented. Typically this feedback is gathered after the implementation to support efforts to improve a flawed process further. 

Wouldn’t it be better to design the process to ensure quality in the customer experience from the beginning? 

Wouldn’t it be better to gather customer experience data before developing change projects? 

The best way to ensure that the customer feels the change is to engage the customer on the front end of the change development process. So what can we do to ensure that we include the customer’s values from the beginning of the change process?

Include customers on the change team

“Nothing about us without us” has been a powerful refrain in the behavioral health peer recovery movement. These words underscore the importance of including people who are receiving services or support in all decisions related to that service. Perhaps the best way to do this in a change project is to include customers on the change team.  Many organizations that have adopted the NIATx model have found that a change team that consists of both service recipients and service providers generates change ideas with greater impact. 

Use the “So What?” test

The history of product design is filled with clever products that excited designers but left customers saying, "So what?” Again, if we return to the NIATx principle number one, we need to know and understand the customer to develop services or make service improvements that create a strong positive customer response. 

Use customer impact criteria to select a strategy

In the NIATx model, we often use Nominal Group Technique (NGT) to brainstorm change strategies to address our chosen aim. Typical NGT uses a simple return on investment criteria to select a strategy from the list generated: 

What is the level of resource required to implement the strategy, and what are the expected results? 

We can add to this criteria a question about customer impact to ensure that the selection process includes these critical elements: Which of these strategies will have the greatest desired impact on the customer's experience? As described above, including customers on the change team is a great way to ensure that the change project addresses customer values and priorities. In addition, customers participating in the NGT process will generate ideas that focus on customer experience. 

To believe that the customer is “always right” is to believe that the customer is the first and best source for improvement ideas. Regardless of the industry or service type, customers/ clients/ patients vote with their feet. If you engage customers in building and improving your service, they will keep coming back, and you will be able to deliver the services, care, and supports that will make a difference in their lives.  

About Change Project 911

Change Project 911 is a monthly blog post series covering common change project barriers and how to address them. Has your change project hit a snag that you’re not sure to tackle? Share your issue in the comments section below, or email Change Project 911 at matroosa@gmail.comWe’ll offer solutions from our team of change project experts!

About our Guest Blogger

Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in quality improvement, organizational development and planning, and implementing evidence-based practices. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat (Change Project SOS) at matroosa@gmail.com.