How to sustain a quality improvement effort

1. The intervention was developed and finalized through iterative design among the QI team.

2. Performance has been consistently above target among all endoscopists for 4 consecutive months.

3. ADR is an important quality metric to individual endoscopists as well as hospital leadership. Moreover, because there are increasing models tying reimbursement to funding that are based on adherence to quality indicators, ADR will become more important.

4. If hospitals become mandated to provide scorecard data, the intervention may become redundant. However, the measurement and implications of the data still may be relevant to ongoing QI activities.

Interventions supporting sustainability

Sustainability planning is ideally started at the initiation phase of the project. When choosing a target for change, consideration of organizational factors such as strategic priorities, staff engagement, and leadership support are integral to long-term success. Factors influencing the type of intervention developed should include available funding (both long term and short term), existing information technology (IT) resources, and the ability to incorporate into existing workflow. Considering these factors from the outset will help improve a project’s long-term viability.

A number of toolkits have been produced to guide QI teams through the sustainability process. The National Health Service Institute for Innovation and Improvement has produced a comprehensive guide to sustainability.⁴ The guide provides advice on how to identify opportunities to increase the likelihood of sustainability for your initiative. It is accompanied by a model that can be used to predict success by dividing the factors influencing sustainability into three groups: staff, process, and organization. Each of these has a number of subcategories, and relative significance is attributed to each, with staff factors (clinical leadership engagement, senior leadership engagement, staff involvement in the change, and staff attitudes toward the change) holding the highest weighting. On the basis of the results of the model, the QI team can identify both the likelihood of success as well as opportunities for improvement.

Visual aids are another intervention that promotes sustainability. Visual cues such as posters, buttons, and magnets act as easy reminders for front-line staff. Creating a storyboard at the beginning of the project allows stakeholders to have a broad perspective on both the intervention and sustainability phases.⁵ Ongoing auditing and reporting of results also encourage long-term compliance. This can take the form of posting results of the intervention in the department on a regular basis as well as reports to senior administration. Regular check-ins with all stakeholders are also encouraged. This can be at a monthly staff meeting or a brief “improvement huddle” on a standing basis.

Factors influencing success

Any discussion of QI work must consider context. An understanding of the system one is working within will allow for optimization of system strengths and avoidance of pitfalls because of weaknesses. A lack of attention to context can lead to an unsuccessful project. This could be due to choosing a focus that is not in line with hospital priorities, a project that is asking staff to take on additional tasks without removing others, or developing a solution that requires funding or IT infrastructure that is not readily available.

Any organization has a number of different settings that need to be considered simultaneously. This is most simply divided into microsystem, mesosystem, and macrosystem. Microsystem is defined as the combination of a small team of people who work together on a regular basis. The mesosystem focuses on the integrated care needs of a particular group or population with the same diseases or conditions and provides support for individual microsystems. The macrosystem forms the infrastructure of the larger organization, providing the systems and governance that define the system.⁶ In our example, the microsystem is the endoscopy unit, including physicians, nurses, administrative support, and managers. The mesosystem is composed of the endoscopy unit in addition to the Departments of Gastroenterology and Surgery, the hospital IT team, and the Pathology Department. The macrosystem is the hospital, including senior leadership and administration. Another way of thinking about this is the microsystem is the environment most easily influenced by the individual provider, whereas the macrosystem includes the organizational-level factors that need to be taken into consideration when designing an intervention.

A great number of factors have been proposed to influence sustainability. National Health Service Scotland performed a literature review and met with subject matter experts to determine key factors that require consideration when engaging in activities to sustain and spread QI activities. They produced a guide that focused on 10 factors thought to have the greatest influence.⁶ Although a review of all 10 factors is beyond the scope of this review, we will highlight key ones to consider.