No one wants to toil away at a health care Improvement effort only to see that progress disappear as systems and processes revert to the old way of doing things. Leading health care organizations recognize that improving care isn’t enough; having a systematic approach to sustaining improvement is equally important.

To learn how to build systems that sustain improvement, the Institute for Healthcare Improvement studied health care organizations that were able to achieve standout results and then build on them — organizations such as Intermountain Healthcare in Salt Lake City; Saskatoon Health Region in Saskatchewan, Canada; and Virginia Mason Health System in Seattle. These high-performing health systems offered a key insight: To sustain change, you need a strong strategy for engaging and standardizing the work of frontline managers. From their efforts, we derived four steps on how to get started with introducing new standard work processes for point-of-care staff.

1. Choose a Pilot Unit Within the Organization

Most organizations standardize work for managers by testing it on a small scale in one pilot unit. Dr. John Toussaint, CEO of the ThedaCare Center for Healthcare Value, describes the pilot unit as the “model cell,” a place for experimentation, learning, and modeling new methods for the rest of the system. It’s important to select this pilot unit carefully. Here are a few characteristics to look for:

Stability. The candidate unit should have low staff churn — the movement of staff in and out of job roles — which makes it easier to train teams. As others have described, a focus on listening to staff and helping them understand how their work is connected to the larger organization and its purpose can increase joy in work and reduce burnout and churn.

Alignment around goals. Managers in the unit should understand what’s expected of them, how their work is going to change, and why standardizing work is important to sustaining quality. (Standardizing work processes is a concept from lean management.)

Management “hygiene.” Good management practices should already be in place — for example, effective budget practices and a stable staff schedule. It’s also good to look for areas with stable processes. A manager who’s running around in a chaotic environment will have trouble focusing on the changes needed to promote sustainability and implement standard work.

Engagement. The unit should have a respected local champion who can build excitement for change, encourage participation, coach the team, and celebrate success.

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In addition, organizations working to sustain their improvements may find that standardized work processes are easier to introduce in service units with more-easily definable and predictable clinical processes. For example, a surgical unit, an endoscopy suite, or a radiology service might be a good initial candidate for the pilot unit, rather than a general medical unit, which sees patients with widely divergent needs.

In addition to such clinical units, you might select support services that are critical to effective patient care. Efficiencies gained in human resources and housekeeping can free frontline unit managers and clinical staff to spend more time at the patient’s bedside. Some systems that we studied have focused on these support departments to introduce their pilots and build goodwill among caregivers.

2. Start with the Immediate Supervisor at the Point of Care

Many leaders think “frontline manager” and turn to the administrative manager, the patient care director, or unit supervisor. But successful organizations have told us that the true frontline clinical leader is the day-to-day operations manager — often the charge nurse who supervises the nursing care given to patients in the unit.

Charge nurses and others in similar roles are the leaders responsible for immediate process management before, during, and after shifts. Charge nurses and nurse managers typically lead team huddles — 10-minute all-staff meetings at the start of each shift to assign roles, identify patients in need of special attention, and anticipate issues during the shift.

During the shift, charge nurses coach frontline staffers and ensure they follow standard processes, monitor care, change course when needed, and solve problems. Finally, they escalate to the next layer of management those issues encountered during the shift that are beyond their control to resolve.

Organizations that manage and sustain change successfully build the changes into the standard, well-defined work processes of these frontline clinical leaders. Without such clearly defined standardized work for the day-to-day operations manager, two things happen. First, systems revert to previous behaviors and processes. Second, administrative supervisors, noting this regression, feel obligated to get involved in the routine management of the clinical unit. This kind of micromanagement often causes confusion, fear, and resentment of the change, further diminishing the likelihood that it will stick.

3. Use Early Wins to Build Momentum

Once the pilot unit is established, think about what goals the unit can accomplish in the short term. For example, leaders of the improvement project — such as a quality manager working together with an administrator or nurse manager — may decide to conduct a daily huddle to monitor processes introduced through improvement initiatives, along with creating visual management boards with simple metrics for easier tracking. These processes are relatively easy to test and implement over a few weeks.

Especially in the early stages, be cautious about asking pilot units to achieve complex, hard-to-achieve goals that require significant interdepartmental teamwork — like medication reconciliation or staff onboarding. Doing so may demoralize the team and even set them up for failure.

Several successful organizations stressed the importance of early wins to boost staff motivation. For example, Greater Baltimore Medical Center introduces managers to its frontline management system by asking them to select one simple metric to track, which aligns with the organization’s overall strategic framework.

4. Motivate Frontline Clinical Managers by Tackling What Irks Them

The key to standardizing work for managers is motivating the managers themselves. No matter how well you define roles and tasks, if managers haven’t bought into the change, the system won’t work. Managers should know that their participation in standardized work is one way to earn good performance reviews and promotions.

Beyond extrinsic motivators, managers really do want clinical improvements to stick, especially those that benefit their patients. So what does it take to help them commit to the work of sustaining quality through the introduction of formalized management systems?

Health system leaders told IHI that they succeeded by focusing on problems that frontline clinical managers really cared about. Virginia Mason calls these problems “rocks in your shoes” — the daily irritants that frontline managers want eliminated. Implement changes that eliminate these daily hassles, reduce chaos and confusion, and streamline operations and workflows, and you’ll find that the managers will begin to believe in the improvement methods and make them last. From there, you’ll build momentum to tackle other problems.

Many health care systems struggle with understanding the initial steps to build standardized work at all levels and reinforce management systems. Small tests of change at the unit level — starting with existing standard work and building basic management practices like daily huddles and clear escalation protocols for problems that arise at the point of care — can help set the stage for broader changes in systems that lead to sustained improvement.