Skip to 0 minutes and 5 secondsHello Lynne! I'd like to just ask you a little bit about the topic of sustainability because a lot of people talk about health improvements, healthcare improvement. We understand a lot about the tools and techniques of how to do it, but the recurring problem that everybody notes is this problem of sustainability. How you can sustain changes. Successful changes in health systems. Perhaps you could reflect a little bit on that. Yeah. You're absolutely right. And we keep making the same mistakes. But it's critical to healthcare improvement, because we put a lot of time and effort into it. And we want to be able to hold those gains.

Skip to 0 minutes and 45 secondsI think the major consideration that we need to make is when we start thinking about sustainability. Now in my experience, people who are running improvement projects tend to think about it right at the end. 'Oh and how are we going to keep this going?' You know, that's too late. Sustainability has to be planned for. We need to think of it in the same way as we think about all of the set up of our improvement initiatives. So start with sustainability in your mind right from the beginning. Yeah. I mean, that's a good point because it's usually very low on people's list of things to do on their agenda. Isn't it? Generally, why is sustainability so difficult in health systems?

Skip to 1 minute and 35 secondsWhy were so many intelligent people and so much resource put into change. And so many great ideas. Why do changes just dissipate or fade away over time? Even the most successful ones. Yeah I think there's a number of reasons. And I think one of the core reasons is because when we're setting up improvement projects, we tend to have quite small core teams. And we don't bring in other people who might be impacted by the change. What we need to do is involve as many people as possible, understanding their experiences, understanding their ideas, and linking those into other change ideas that an improvement team may have. I think by not involving people we start to get resistance.

Skip to 2 minutes and 26 secondsWe start to not understand why they might be unhappy about the proposed changes. And while they might go along with it during the improvement project, as soon as the formal improvement project has come to an end they start backsliding into their older way of working because that's the comfortable way. I think if we involved people in all the way along, we also know what support or additional training they might need. And often this is another thing that we don't consider enough. We think if we're taking something, we've got to make sure everybody's capable of doing and acting, in the changed way. And that's often thought of right at the end.

Skip to 3 minutes and 18 secondsSo we've implemented the change and then say, 'oh now we need to do training'. That's a little bit late really. The other important element is remembering to not cut off all the measures that we do during our improvement cycle. Because we need to think about one or two key measures to help people understand that they're still on track. Because otherwise how do they know what they're doing. And we have a plethora of measures, while we're undertaking improvements, and then they seem to stop. How do people know where they are? So it's really about planning isn't it almost? It's having a sustainability plan. It's part of the whole change... part of any change project isn't it? Built-in from the start.

Skip to 4 minutes and 15 secondsIt's one of the core factors. As we set up our projects, sustainability needs to be on that task plan. We need to think about how we involve people, how we're continuing to measure, how we continue to communicate widely. And also leaders need to be able to continually support people all the way through as they have challenges. Because that's another element that often means change is not implemented as well as it could be and then it backslides. The other critical thing about sustainability, I think, is making a really explicit link with why we're undertaking this project and how it's going to improve the organisation's strategic aims.

Skip to 5 minutes and 5 secondsIf you can link improvement very specifically to strategic goals, it tends to gain more attention from senior leaders and less likely to be disrupted when other things happen. As always does. There's always something that comes in. But if we can tie it very clearly to strategic goals, that's great. So it's not loosely coupled or lots of parallel initiatives that nobody can see the point of. Yeah. And again, narrative comes in here. What is it we're hoping to achieve? Why are we doing that? So people can buy into it? 'Ah yeah, I can see why we need to make that change and why that change is going to make a big difference'.

Skip to 5 minutes and 53 secondsInherently, we need to tap into the rational reason and the emotional reason for change. 'This is going to make things a lot better for me as a staff member and for the consumers I'm serving'. It's almost we need a completely different mindset, isn't it? People have to think sustainability. I suppose the most exciting bit of it is the change process, isn't it? People find managing sustainability far less appealing or exciting or thrilling to them. It's getting beyond that though, from what you're saying. And actually, if we consider it right at the beginning we're not going to have to manage it because it'll happen. If we get it right at the beginning there won't be this need to manage it.

Skip to 6 minutes and 41 secondsWhat will happen is, we'll get to that plateau and say, 'we're doing really well here, but how could we do better?' Because we'll enjoy the change rather than things not sustaining and then in a couple of years, we go 'oh let's have another improvement project around here'. And healthcare staff say, 'oh gosh we've done that before'. And we get fatigued staff. And a lot of that is because we've not sustained the previous improvement and we're having to do it again. Let's get it right first time. We're spending a lot of time and effort on this, quite rightly, but let's get it right first time so that we can continually improve. Not continually redo improvements that have not sustained.

Healthcare innovation and the challenge of sustainability

Here we turn to the question of how innovations in healthcare service provision are sustained over time. While considerable attention is given to the front end of innovation, less attention is given to the question of how successful changes, once introduced, are maintained and supported. This is a significant challenge in health organisations, especially in the case of new innovations in the design of work and processes which seem to challenge the status quo (see Week 2).

In the literature on this topic various factors have been identified as important for sustainability. These include planning for the future beyond the initial introductory period, as well as stability of staff and effective training. Some studies suggest that evidence of efficacy of the innovation is important, with rigorous evaluation associated with sustained service provision. In some cases, fidelity to the original design has also been found to increase the likelihood of sustainability. Perhaps unsurprisingly, many studies find that the wider organisational context can make a difference to the sustainability of innovations. A number of studies highlight organisational fit (i.e. the degree to which the innovation is compatible with existing norms and practices) as a crucial factor. Implied here is that new practices which fail to be integrated into routines, pathways and protocols progressively lose momentum over time. However, whilst organisational fit may increase the chances of sustainability, there may sometimes be a need to support more disruptive innovations if radical change is needed, even if this is challenging.

Please watch the short interview above, with Dr Lynne Maher, Director for Innovation Ko Awatea, New Zealand, in which Sr Maher explores some of these concerns about sustainability in greater detail.

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Leadership for Healthcare Improvement and Innovation

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