Achieving Full
Implementation and
Sustaining Improvement:
Your work has just begun!
Presenter Name
Bright Futures Training Intervention
With Office Staff
Workshop II
1
Sustainability
“There will come a time when
you think you are finished.
That will be the beginning.”
-Louis L’Amour
2
Overview
 Describe strategies for moving from testing to
full implementation of Bright Futures
components.
 Describe key strategies for sustaining
improvements.
3
Implementing Improvements:
The “Ripple Effect”
4
The Inner Circle of Improvement:
Your Bright Futures Practice Team
 Group most invested in improvement
 Small size of group streamlines process of
adoption/adaptation of new ideas
 Conducts initial Plan-Do-Study-Act cycles
5
Tests of Change
Changes that
result in
improvement
Ideas
6
Moving Beyond the Inner Circle:
Beginning Implementation
 Identify larger group (10-15 staff members).
 Communicate your previously tested
improvement.
 Let larger group “own” idea and suggest further
changes.
 Test modified improvement in larger group using
Plan-Do-Study-Act cycle(s).
7
Extending the “Ripple Effect” of
Improvement: Full Implementation
 Expand group to include all staff affected by

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
improvement.
Invite further input.
Invite acceptance.
Implement improvement practice-wide.
Provide immediate and periodic feedback.
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Managing Change: Avoiding
Surprises
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Overcoming Resistance to Full
Implementation
 Provide reassurance that there is always room
for clinical judgment.
 Make your improvement the “default” option in
your system.
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Sustaining Improvement
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Why Focus on
Sustaining Improvement?
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Sustainability: Key Strategies
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Assign ownership of system.
Hardwire sustainability into the system.
Continue selected measurement.
Senior leadership.
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Ownership
 Assign Coordinator/Team to “Own” Bright Futures
Training Intervention With Office Staff

Conduct regular meetings, senior leader updates.
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Assess critical success factors.
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Review data.

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Design ongoing improvements (Plan-Do-Study-Act
cycles).
Communicate.

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Frequent and ubiquitous.
Celebrate successes and have fun!
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Critical Success Factors

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Must Dos
Must Haves
Must Results
Must Whens
Must Whos
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“Hardwire” Sustainability
 Involve all staff.

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Job descriptions.
Staff evaluations.
 Plan for turnover/absences.

Staff orientation includes training in newly
implemented Bright Futures components.
 Educate patients—create accountability.
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Sustaining—Training
 You must have a method to continually train the
entire staff.

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Introduce concepts.
Conduct orientation of new staff members.
Continue to post results.
Continue to celebrate.
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Ongoing Measurement
 Simplify measures—shift to auditing mode
when possible.


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Decrease number.
Decrease frequency.
Automate or use simple tools.
 Use it!

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Meetings, planning, day-to-day, marketing,
accreditation.
Make culture “data driven.”
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Importance of Senior Leaders

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Key to resources.
Establish level of priority.
Create accountability.
Advocacy role.
Shared vision.
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What Happened? Why Didn’t We
Sustain Our Improvement?
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The Devil Is in the Details
 We assumed that everything would keep running
as planned.
 We quit monitoring progress.
 We are now playing catch-up.
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Lessons Learned
 DON’T assume what you have done will
automatically continue.
 DON’T stop training key staff.
 DO continue to monitor and report on results.
 DO continue to modify and improve.
» And ALWAYS remember…
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It ain’t over til it’s
over….
Yogi Berra
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“And it’s never
over…”
Anonymous participant in
Quality Improvement
Collaborative
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References
Langley J, Nolan K, Nolan T, Norman C,
Provost L. The Improvement Guide. San
Francisco, CA: Jossey-Bass; 1996
Trustees of Dartmouth College. Clinical
Microsystems.
http://www.clinicalmicrosystem.org. Accessed
January 12, 2009
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Tips and Strategies for
Ongoing Bright Futures
Measurement
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Beyond the Workshop: Principles for
Ongoing Bright Futures Data Collection
 Reduce frequency of data collection
(quarterly?).
 Enter monitoring/surveillance mode.
 Transition to managing data collection and
monitoring results internally at your practice.
27
Beyond the Workshop: Principles for
Ongoing Bright Futures Data Collection
 Can continue to use same data collection
instruments (chart review forms, parent surveys)
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Monitoring Improvement:
Continuing Data
Collection Worksheet
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Sample Ongoing Data Collection:
Preventive Services Prompting System
 Proposed monitoring tool: Bright Futures Chart
Review Tool
 Suggested frequency: Quarterly
 Suggested quantity: Ten consecutive patients
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Sample Ongoing Data Collection:
Preventive Services Prompting System
 Identify questions
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Is a preventive services prompting sheet on the
chart?
Is there at least one entry on the preventive services
prompting sheet within the past 12 months?
 Count number of chart review with “yes” responses
to both questions.
 Convert number to proportion of 10 charts
reviewed (eg, If 5 have a preventive services
prompting system, then proportion is 0.5).
 Enter proportion where indicated on worksheet.
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Using an Excel Spreadsheet to
Enter Your Own Data
Date
PSPS
Nov 05
0.5
Dec 05
Jan 06
Feb 06
Mar 06
Apr 06
May 06
Jun 06
Jul 06
Aug 06
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Generating Your Own Run Charts:
It is easy using the Ongoing Data Collection Worksheet!
PSPS
100%
80%
60%
40%
20%
0%
Nov
09
Dec
09
Jan
10
Feb
10
Mar
10
Apr
10
May
10
Jun
10
Jul 10
Aug
10
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Ongoing Data Collection
 Recall and Reminder and Community Linkages:
Bright Futures Office Systems Inventory
annually
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Ongoing Measurement:
Closing Messages
Keep it simple!
Keep it going!
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