Challenge: Systems-level Adoption and Sustainment of New Practices
Implementation science has demonstrated over the past decade that training is necessary but not sufficient to successfully implement a new practice. This holds especially true for the NIATx model as an evidence-based practice. Technical assistance in the form of coaching, mentoring, and train-the-trainer models can help increase system-wide adoption and sustainment.
Services for the Underserved (S:US) has been working with the NIATx Foundation for several years to train Program Directors on how to use the NIATx model for continual improvement and the associated core NIATx tools (i.e., walkthrough, flow chart, nominal group technique, and plan-do-study-act (PDSA) rapid cycle testing) using Change Leader Academy (CLA) training. S:US’s vision is to develop and leverage the change management skills of the agency’s three Performance Improvement (PI) Managers to ensure sustainable NIATx implementation throughout the agency.
Solution
S:US’s vision is well aligned with NIATx Foundation’s prioritization on sustained change, and so NIATx Foundation and S:US worked together to develop a plan to incorporate a robust train-the-trainer component into the CLA to help ensure sustainable implementation.
Under the supervision of the Assistant Vice President of Practice Advancement, the PI Managers work closely with quality assurance staff and other administrative services departments across S:US to support practice improvements. The NIATx Foundation implemented a train-the-trainer model focused on developing the PI Managers through strong mentoring and regular individual and group coaching sessions. The objective was to equip them to then train, coach, and support Program Directors in their practice improvements efforts across the wide array of S:US’s programs.
At the beginning of the train-the-trainer process, the PI Managers had modest familiarity with NIATx or other Continuous Quality Improvement (CQI)/PDSA change models. As such, the NIATx coach implemented an intentional coaching model to develop the PI Managers’ skills, increase their independence over time, and ensure a strong and lasting skill set:
- Initially, the NIATx expert coach heavily supported much of the PI Managers’ early coaching work with the Program Directors to introduce the NIATx model. This approach provided the PI Managers with the opportunity to build their skills with real-time support and guidance from an expert.
- The plan evolved to gradually increase the PI Managers’ independence, as they moved from providing program support with the assistance of a NIATx expert to providing independent coaching to the programs, which were subsequently reviewed with the NIATx expert to identify opportunities for continual learning.
- Team meetings continued as the PI Managers coached more independently to encourage ongoing improvement. Concurrently, the Assistant Vice President of Practice Advancement met individually with the NIATx expert to ensure that the PI Managers continued receiving the individualized support needed to advance their NIATx coaching skills.
Outcomes
The PI Managers began their NIATx journey with motivation and enthusiasm but very limited understanding of the PDSA change model. As a result of three six-month rounds of project implementation over two years across a wide array of S:US programs and services, the PI Managers have emerged with strong skill and confidence levels. The PI Managers are now able to effectively coach Program Directors in the NIATx model to sustain continual improvement. Further, they have advanced the use of the NIATx model within S:US by implementing some creative applications of the NIATx tools, including an enhancement to the nominal group technique related to choosing strategies that are easy to do and have a high impact (i.e., Ease and Impact).
This approach to developing change leader capacity is a clear demonstration of the following training principles:
- It takes time. A train-the-trainer mentoring model requires an investment over time. In this case, S:US committed to multiple rounds with a NIATx expert coach who employed an intentional model of increased independence with the PI Managers to ensure a strong and lasting skill set.
- It requires a culture committed to learning. The S:US administration demonstrated a strong commitment to the NIATx improvement model, as well as a keen awareness of the importance of sustaining practice improvement to achieve the full return on investment. The S:US team did their initial homework by exploring several PDSA models and then committed to the NIATx model. Ongoing support from senior management enabled the project to achieve strong and lasting results.
The NIATx Foundation continues to evolve toward using more e-learning and implementation coaching as critical supplements to the traditional didactic training focus. These new approaches will enable other organizations to join S:US as they build NIATx into the foundation of their quality improvement journeys.
