How to sustain a quality improvement effort
Innovation
The nature of the change greatly influences its likelihood of being sustained. In addition, one must consider the process of the intervention as well as those who will be impacted by the change. Core qualities that predispose to success include the following:7
1. Clear advantage compared with current ways
2. Compatibility/integration with current systems and values
3. Simplicity of the change and its implementation
4. Ease of testing
5. Observability of the change and its impact
This list highlights the point that the plan to sustain an intervention needs to start at the design phase and not once the change has been proven successful. Support among users also influences long-term success. Early adopters are those who embrace the intervention or change. Identifying the early adopters and using their support for positive publicity and momentum are integral in any sustainability effort.
ACTION PLAN: In our example, components of the intervention that would predispose to sustainability include choosing an outcome that is aligned with the hospital’s strategic focus (for example, cancer screening and prevention). ADR is already a measurable outcome at the hospital, which facilitates dissemination of results. Alternatively, some of the resistance to change may be due to the increased work to compile and distribute the scorecards monthly.
Organizational culture
Culture has been most simply defined as “the way we do things around here”.7 The approach of an organization toward QI will clearly impact its long-term viability. On a macrosystem level, interventions should ideally fit within strategic goals and priorities of organizations to garner maximum support. When promoting the intervention, it may be appropriate to focus on the benefits to the individual group (that is, cost savings to senior administration, time saved to front-line staff). Studies have shown that teams that demonstrate a strong teamwork ethic, have a positive attitude toward the intervention, and where all members know and understand their role on the team were more likely to have sustained success.8 In addition, engagement of all key stakeholders early in the process has been correlated with improved long-term outcomes. In a microsystem level, providers can choose to implement the intervention among a well-established team that works well together, ideally where there is a history or prior QI work.
Factors that may make sustaining a QI effort more challenging include interventions that increase time or costs to the organization. Many healthcare organizations may have specific targets set out from their regulatory body. If the intervention lowers the result of one of the targeted outcomes (or does not address those targets at all), it may be met with increased resistance within a system. In cases like this it is integral to use data to demonstrate to senior leadership why this still has tangible benefit to the organization.
ACTION PLAN: In our example, culture can promote sustainability on a microsystem level through reinforcing local success stories. This can be through posting of visual aids in the unit such as posters that display performance or progress boards that chart the status of the intervention. In addition, QI projects can be a regular agenda item at unit meetings, reinforcing their importance to team members.
Leadership
One key component of organizational culture is the influence of leadership. An effective leader will have both technical QI skills and strong interpersonal skills.7 Teams where all members feel comfortable making suggestions or voicing concerns are far more likely to succeed, and it is incumbent on leadership to create this environment. This concept is often termed psychological safety and has been directly linked to the inclusiveness of the leader. Team members with psychological safety are more likely to feel like active participants in the process, and this improves their long-term engagement.7,8 In addition, effective leaders create accountability systems to ensure gains are maintained. These may include regular performance reviews, reminders about the intervention, and assigning responsibility to senior level team members. Finally, celebration of accomplishments reinforces the positive impact of the time and energy invested by members of the team.9 The concept of distributed leadership is another key concept. This acknowledges that for any one intervention, there are a number of formal and informal leadership roles, and these can be filled by a number of different individuals.7
ACTION PLAN: For our ADR example, sustainability can be promoted through effective leadership. On a microsystem level, one option is the implementation of a weekly Improvement Huddle. This is a 10- to 15-minute meeting within the microsystem that is designed to review current performance and anticipate problems. All team members are encouraged to voice any concerns. On the macrosystem level, quarterly reports to senior administration and presentation of process and results at Grand Rounds may contribute to this goal.
