Planning for Sustainability
The best way to ensure your disparities intervention will be sustainable is to plan for sustainability from the start.
Sustainability may feel like the last step of your plan to reduce disparities: "let’s start something, then we’ll figure out how to keep it going." This is a common mistake.
In fact, you should think about sustainability throughout the process of creating a culture of equity, conducting a root cause analysis, designing an intervention, and securing buy-in. The Roadmap to Reduce Disparities includes many tips for enhancing the sustainability of your intervention. Here are some of the important take-home messages:
Build a strong culture of equity. If your organization has a general commitment to equity, and is willing to prioritize equity activities, it will be easier to get the resources you need to start and sustain your intervention, such as funding and protected time.
HOW DO WE DO THAT? Finding Answers has many tips to create a culture of equity in Step 2 of the Road Map. All of those strategies will create an environment that supports and sustains your disparities intervention for the long run.
Integrate equity into organizational values and activities. Because equity is a cross-cutting component of quality, it needs to be a cross-cutting component of quality improvement. Even the most well-intentioned equity program is less likely to succeed if it operates in isolation from the rest of the organization’s programs. The more your intervention is integrated into your organization and existing efforts, the easier it will be to sustain it.
HOW DO WE DO THAT? Add equity to your organization’s mission and value statements. Think about your existing activities and ask yourself: how can I make equity a part of these programs?
Pick the low-hanging fruit. Disparities typically have many causes, and it can be tempting to try to address all the root causes of a disparity right away with a major initiative. Consider starting with with a simple and attainable goal. When you achieve it, you’ll build momentum and help avoid staff burnout. And when you show a “quick win” to leadership, it will foster confidence in your program and in your ability to get things done as you expand your goals.
HOW DO WE DO THAT? Find a goal that is feasible but relevant to your identified disparities. A priority matrix can help you determine which goal might be a good choice. Don't discount goals that may not have an immediate impact on health outcomes-- changes at the process level are helpful too. A goals can also help your team start conversations about equity and practice Plan-Do-Study-Act (PDSA) cycles. Be sure to report back to all your stakeholders—especially leadership—to celebrate the improvements you achieve.
Get patients’ buy-in. For many ambulatory quality improvement activities, the success of the project relies on the patient’s active role in managing his or her condition: getting buy-in from patients is often critical to the intervention. Additionally, if patients buy-in to your program, it may influence their willingness to pay for services related to the initiative—and that will impact the financial feasibility of the program. For example, if patients don’t buy-in to meeting with a diabetes educator, they may not be willing to go if a co-pay is required.
HOW DO WE DO THAT? Work with patients throughout the process of creating a culture of equity, conducting a root cause analysis, and designing an intervention. By involving patients from the beginning, the intervention should be a natural fit for your priority population (making it easier to secure patient buy-in). Finding Answers has compiled several strategies to secure patients’ buy-in. These are summarized in Step 5 of the Road Map.
Collect data to make your case. A sound investment is based on sound data. Think carefully about what your leadership (or a funding agency) will want to know when you ask for resources. Design your intervention so you can collect that data, and practice collecting it when you pilot-test.
HOW DO WE DO THAT? Understanding how to collect data and measure change is covered in Step 6 of the Road Map. Be sure to talk to stakeholders about the kinds of results you expect when. For example, you’re likely to see changes in process measures before health outcomes improve. Or, you may see patient satisfaction drop temporarily as their expectations increase; this is a natural part of raising standards in an organization and satisfaction scores often improve again over time. Prepare your stakeholders for these kinds of changes so they aren't viewed as failure.
Make your team sustainable, too. Nothing stalls a project like absent staff. Secure your leadership’s commitment to protect the team’s time, and plan ahead to keep your team intact during times of change. Your aim is to ensure that even with leadership changes, staff turnover, or new organizational priorities, the team has time and permission to move forward.
HOW DO WE DO THAT? Be realistic about the time you’ll need for the project and make sure it is protected up front. It is also helpful to plan for staff turnover by cross-training staff and documenting institutional knowledge. Incorporate intervention training into staff orientation and refresher courses. When appropriate, include program responsibilities in job descriptions, and assess interest in the intervention among candidates for leadership positions.
Sustainability is possible. Planning for sustainability from the beginning makes it less daunting to get your project institutionalized. Consider sustainability with every decision you make about implementation.
Promoting Financial Sustainability
The MacColl Center for Healthcare Innovation’s recommendations and case studies provide a good model and starting point for how to design equity-focused quality improvement efforts that are financially feasible.
MacColl recommends getting a comprehensive picture of the organization’s financing structure and examining the payer mix to learn what types of practice activities generate revenue. This knowledge can then inform the design phase of the quality improvement process and maximize the potential for reimbursement.
For further reading: Integrating Chronic Care and Business Strategies in the Safety Net. AHRQ Publication No. 08-0104-EF. September 2008.