Sustainment of Change:
Planning for Sustainability
Jay Ford, PhD
Assistant Scientist
Statements about Sustainability
• Implementation of change does not guarantee that it will
be sustained.
• Most changes are sustained at least briefly,1,2 these
efforts are often more difficult than implementation of a
change.
• Studies indicate that up to 70% of changes are not
sustained.3,4
• Change not sustained is a direct waste of invested
resources, has costs associated with missed
opportunities, and affects an organization’s ability to
implement change in the future.
How do we define sustainability?
When new ways of working and improved outcomes
become the norm. (NHS, 2002)
The extent to which newly implemented intervention is
maintained or institutionalized within a service setting’s
ongoing stable operations (Proctor and Brownson 2012
p. 268)
Sustainability is the continuation of activities or benefits for
target recipients after an initial period of funding ends or
following the initial implementation of a new program or
procedure (Scheirer, 2013)
Sustainability
 Understand the essential attributes associated with
maintaining a change process.
 Environment
 Organization
 Innovation
 Evaluate if the improvements are maintained or improve
over a extended time period.
Sustaining Change
 Focus on creating a culture of change vs. making
the measures
 Recognize that sustainment is only good for so long.
 Over time sustainment becomes the new norm.
 Address the need for continuous improvement.
 Reach a point where the tipping point of better
practice is the goal
What do we know about Sustainability?
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Significant heterogeneity exists across organizations
Clinicians and managers have different opinions
Leadership support is a facilitator and barrier
Change complexity appears to influence sustainability
Change linked to the underlying organizational culture is
more likely to be sustained.
 Participation in a given QI intervention appears to influence
staff perceptions about sustainability
 Short term sustainability is possible but long term is not
certain.
Sustainability Challenges
 Staff turn-over; leadership & funding changes that drive
competing initiatives and new agendas that diminish resources
for on-going projects.
 Tough to find the balance between keeping them focused on the
implementation details of the present, while also setting the
project up for sustainability. I think the window for effective
sustainability planning is right after they have received some
positive reinforcement from data that shows success (thus the
need to sustain). This celebration moment has energy than can
be directed toward establishing the sustain plan. Waiting until
later (which is common), results in them no longer being as
interested in the project, or having already moved on to
something else, Then it's like polishing shoes that are no longer
in style. (easy to neglect)
Sustaining Interventions
Adapted from Scheirer MA and Dearing JW. An Agenda for Research on the Sustainability of
Public Health Programs. Am J Public Health. 2011; 101:2059-2067
8
Six Types of Interventions 1
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Implemented by Individual Providers
Requiring coordination among multiple staff
New policies, procedures and technologies
Capacity or Infrastructure Building
Collaborative Partnerships or Coalitions
Broad scale system change
1. Scheirer MA, 2013. Linking sustainability research to intervention types Am J Public Health. 2013 Apr;103(4):e73-80
9
Sustainability Planning Framework
Organizational
Factors
Environmental
Factors
Innovation
Attributes
Sustainability
Plan PDSA
Two Sustainability Readiness Tools
 Britisth National Health Service Sustainability Index
(http://networkofpractice.org/?q=node/13)
 Program Sustainability Assessment Tool
(https://sustaintool.org/assess)
10 Key Factors for
Sustaining Change
Program Sustainability Assessment Tool
Funding Stability
Political Support
Partnerships
Sustainability
Planning
Organizational
Capacity
Communications
Program
Adoption
Program
Evaluation
Bringing it all together
Environmental
Organizational
Innovation
Political Support
Organizational Capacity
Staff Attitudes
Funding Stability
Senior Leadership
Benefits
Partnerships
Clinical Leadership
Credibility
Staff Involvement
Adaptability
Program
Evaluation/Effectiveness
of Systems
Communications
Program Adaptation
Strategic
Planning/Organizational
Fit
Resources
What Next?
 Identify 3 to 8 staff in your agency and ask them to
complete one or both of the sustainability tools
 Follow-up calls will focus on
 Barriers and Facilitators
 Development of sustain plans
Sustainability PDSA
M: Modify
the sustain
plan
A: Assess
Readiness
D: Develop
a sustain
plan
E: Evaluate
I:
Implement
the plan
Sustainability Planning
Sustainability Plans should be:
Simple
Concise
Thoughtful
Focused on a particular aim
Sustain Plan Process
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Assemble the planning team.
Envision your program’s future.
Review your PSAT results.
Decide where to start.
Prioritize.
Develop a sustain plan
Implement the sustain plan
Reassess your sustainability capacity each year
Items to include in a Sustainability Plan
What should be included in the plan?
Organizational structure for sustainability
Name of the plan ‘owner’, sustain leader and team
Develop clear communication channels to share progress.
Establish procedures and process to support sustainment
Create a method for collecting & monitoring data
Revisit goals on a regular basis (sustainment is the new norm)
Identify red flags or triggers – what might threaten success
Establish checklists to address red flags/triggers as/when they arise,
i.e. if key personnel leave, here’s what we will do…
Key Take-Away Messages
Integrate change into infrastructure
Monitor and evaluate impact of change
Make system simple and useful
Communicate and act on knowledge
Develop and implement a sustain plan
Questions
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References
Ford II, JH, Krahn, D., Wise, M., and Oliver, KA. Measuring Sustainability within the
Veterans Administration Mental Health Systems Redesign Initiative. Quality
Management in Healthcare, 2011; 20(4): 263-279. PMC3188394
Ford II JH, Krahn D, Oliver K and Kirchner JA. Sustainability in Primary Care and Mental
Health Integration Projects in Veterans Health Administration (2012). Quality
Management in Healthcare 21(4): 240-251.
Johnson K, Hays C, Center H, Daley C. Building capacity and sustainable prevention
innovations: a sustainability planning model. Eval Program Plann. 2004; 27(2): 135149.
Scheirer MA. Is Sustainability Possible? A Review and Commentary on Empirical Studies
of Program Sustainability. American Journal of Evaluation. 2005; 26(3): 320-347.
Scheirer MA and Dearing JW. An Agenda for Research on the Sustainability of Public
Health Programs. Am J Public Health. 2011; 101:2059-2067
Scheirer MA. Linking Sustainability Research to Intervention Types. American Journal of
Public Health (In press).