Whose Job to Sustain and Spread Improvement?
My IHI colleague Kelly McCutcheon-Adams and I were talking with two members of a project team a couple of weeks ago.
The project team had already changed their work to assure that each resident in their assisted care facility had clear documentation of a health care agent. They also had developed and used an interview guide to help residents describe what mattered most in their care. They had made systematic progress, testing their way to more effective care with their residents.
What did they need to do to move their project from testing and implementing changes in their pilot site to sustaining the work while beginning to spread the changes to another site in their organization?
Whose job would it be to coach and support the social workers and care managers at the sister site to understand the changes and lessons developed at the pilot site? Even the task to share lessons and help colleagues get started takes time and presents challenges.
Kelly listened to the concerns. She got right to the heart of the issue: spread of changes to the sister site is not the job of the point-of-care social workers who have tested the changes in the pilot site. To spread changes successfully, the organization’s formal leaders have to make the case for change. Those leaders also have to provide time and support for people in the sister site to adapt and integrate the change(s) into their regular operations.
Managers and executives have their own PDSA cycles to run on the upper steps to assure that useful changes are sustained and spread. For several years, I did not coach project teams with this in mind. I lost the context and contact with project executive sponsors; as a result, organizations struggled to keep the changes in place and failed to spread promising changes.
I now realize that when we charter an improvement project and name an executive sponsor, the sponsor in fact has a job: treat the project as a PDSA cycle that the executive owns. If the executive does not understand how to do that job, it is unlikely that useful changes will stick and become widely practiced.
Source of the slide image
Dr. Jafet Arriez, another colleague at IHI, shared the ‘sequence of improvement’ slide at the beginning of this post. Jafet’s picture shows PDSA cycles that start small at the left side of the stair steps and then expand. The increasing size of the circles matches the advice to start with a very small test of a change and then grow the scale and scope of tests before you implement the change.
Jafet also likes the clear distinction between stages of testing, implementing, sustaining and spreading, shown as step changes between stages of improvement.
The upper steps are owned by managers and executives; if they are not engaged in the improvement sequence, we should expect even successful changes to remain local and have inconsistent impact.