Sustainability Planning 1 Sustainability Planning Key Questions Who

Sustainability Planning 1

Sustainability Planning: Key Questions • Who will take responsibility for your sustainability efforts? • How will you know if relapse occurs? • What would relapse look like? • How would relapse influence the project or organizational goals/aims? • What is happening NOW to threaten success? • How can you influence these threats NOW? Sustainability Planning 2

What is a Sustain Plan? v. A sustainability plan represents steps that an organization will undertake when the impact of a change has returned to its prior state and improvements are no longer being achieved. v. Attributes of a Sustain Plan v. Formalize infrastructure changes v. Continually assess outcomes v. Incorporate new processes into policies and procedures v. Address issues related to staff retention and, v. Identify resources to support sustainability v. When should a sustain plan be developed? Sustainability Planning 3

What items should be in a Sustain Plan? v. Organizational structure for sustainability v. Name of the plan ‘owner’, sustain leader and team v. Develop clear communication channels to share progress. v. Establish procedures and process to support sustainment v. Create a method for collecting & monitoring data v. Revisit goals on a regular basis (sustainment is the new norm) v. Identify red flags or triggers – what might threaten success v. Establish checklists to address red flags/triggers as/when they arise v For example, if key personnel leave, here’s what we will do… Sustainability Planning 4

When should a Sustain Plan be developed? v. A sustain plan should be developed at the beginning of a project. v. A sustain plan should be developed for each implementation or change effort. v. A sustain plan should be simple, concise, thoughtful and focused around the change to be sustained. v. A sustain plan should be shared and communication with staff. v. A sustain plan should be approved by leadership. Sustainability Planning 5

Sustain Plan: Anticipate, Plan and React v. Potential organizational triggers to anticipate include: v. True benefits of the change haven’t been clearly assessed & communicated v. Changes in staff workloads or staffing patterns v. Inadequate resources available to sustain the change v. Feedback on progress not routinely offered to stakeholders v. Lack of understanding about the purpose/aims of change v. Senior Leaders do not invest any time/energy into the change Sustainability Planning 6

Sustain Plan: Anticipate, Plan and React v. Potential staff related triggers to anticipate include: v. Staff turnover, especially change leaders v. Staff feelings that something is being ‘done to them’ v. Staff misperceptions or beliefs about their role in the change v. Staff do not feel like they were included in the change v. Staff do not feel they have the knowledge/skills to make it work v. Senior Leaders do not invest any time/energy into the change Sustainability Planning 7

Sustain Plan: Anticipate, Plan and React v. Potential solutions to address triggers: v. Assign one person to monitor the progress of the change v. Share data reports/graphs with staff at regular meetings v. Increase motivation– reallocate staff in line with interests & skills v. Emphasize the business case of keeping clients in the organization v. Develop a written protocol/procedures related to the change v. Have supportive senior leaders personally congratulate staff v. Have senior leaders communicate benefits & goals of change Sustainability Planning 8

Example of a Sustain Plan 9

Antibiotic Stewardship Intervention Purpose: Delay testing and treatment of residents with low probability of infection Implement antibiotic review to identify opportunities for de-escalation Intervention External clinical coaching Feedback reports Outcomes Reduced antibiotic starts and days of treatment per 1, 000 resident days Intervention period July 2015 to June 2016 in two nursing homes 10

Elements of Sustain Plan in All NH • Identified clinical champion, sustain champion • Obtained leadership sign-off on the sustain plan • Anticipated and planned for potential challenges • Identified trigger threshold for action • (Days of Treatment/1, 000 resident days above intervention period mean for two or more consecutive quarters). 11

Elements of Sustain Plan in All NH • Documented implemented interventions • Integrated protocols into organizational policies and procedures • Developed staff training around protocols • Incorporated training into ongoing staff training/new staff training • Communicated new protocols to all prescribers • Integrated outcome feedback into quarterly QAPI and monthly leadership meeting 12

Days of Treatment for Urinary Tract Infections/1000 Resident Days 15. 00 14. 00 13. 00 12. 00 11. 00 10. 00 9. 00 8. 00 7. 00 6. 00 5. 00 4. 00 3. 00 2. 00 1. 00 0. 00 13. 84 11. 38 11. 59 12. 12 10. 74 10. 01 9. 56 10. 58 9. 92 1 Q 2015 2 Q 2015 3 Q 2015 11. 26 10. 89 9. 28 10. 09 4 Q 2015 11. 44 11. 69 9. 36 9. 17 4 Q 2014 10. 70 8. 97 1 Q 2016 NH One (Mean=10. 54) 2 Q 2016 3 Q 2016 8. 66 9. 52 9. 44 8. 32 4 Q 2016 1 Q 2017 7. 86 2 Q 2017 3 Q 2017 NH Two (Mean=10. 71) 13

Implementing Sustain Plan in NH Two • Convene sustain team (e. g. , ICP, DON, Unit Nurse etc. ) • Analyze reasons (via root cause analysis) for not sustaining changes • Staff Turnover • Onboarding training of new staff not completed • New Prescriber • Initial prescribing decision protocol documentation not complete • De-escalation protocol not followed • Data feedback on days of treatment/1, 000 resident days for UTIs with antibiotics not routinely discussed or shared • Changes in patient acuity • Decision to talk with staff at NH ALL to learn how they are sustaining changes 14

Sustainability Plan: Key Take Away Messages v. Anticipate, plan and react to potential challenges v. Appoint sustain champion and data champion v. Develop system to continuously track outcome(s) v. Identify target for action (measure and # of months) v. Develop a sustainability plan v. Plan process steps to implement sustain plan Sustainability Planning 15

What did this module accomplish? • Learned about the importance of sustainability • Defined sustainability versus sustainment of change • Identified key lessons learned from previous research • Learned about organizational, staff, and innovation influencers of sustainability and how they intersect to impact sustainment of organizational change • Discussed the importance of sustainability planning • Learned about how to develop a sustainability plan 16