How to ensure the spread and sustainability of Quality Improvement in healthcare

Maintaining momentum to continue new ways of working and, when appropriate, spreading Quality Improvement projects across other teams or departments is crucial. This not only embeds emerging practices into everyday routines but also ensures the spread and sustainability of Quality Improvement in healthcare, allowing for continuous enhancement across the entire organisation. In this article we explore ways to ensure Quality Improvement initiatives last the test of time.

Sustaining Quality Improvement

Stakeholder feedback is essential in improvement. We need to bring everyone along the journey of change – not least so that we fully understand the context of existing processes and the challenges faced so that an effective and sustainable intervention can be created. 

Improvement is not something to do for team members, it is to be done with them, and it is important to communicate this from the outset. Every member of the team must understand the role they play and feel empowered and accountable. In addition, expert patients, families, and caregivers are all key partners in designing sustainable Quality Improvement interventions.

As well as involving stakeholders, formal Quality Improvement tools such as Plan-Do-Study-Act (PDSA) cycles assist in ensuring that solutions are sustainable. In the case of PDSA cycles, by adding or removing one component at a time, this tool allows for careful isolation and refinement of the different aspects of an intervention.

It’s also imperative to continue communications consistently and on an ongoing basis to drive engagement in new processes ultimately to demonstrate success and impact. This might include:

1. Robust feedback mechanisms: ensure there is a way to capture insights and feed them back to participants. With staff, this might be in team huddles or on notice boards in staff breakrooms; whereas it may be more appropriate to feedback to service users via a different channel, such as email or a generic newsletter.
2. Structures to foolproof change: from training materials and standard work documentation(simple written or visual descriptions of current best practices in a particular process) to hospital “kits” which contain everything required for a particular intervention; these structures minimise the risk of non-adherence. 
3. Formal capacity building: ensuring staff are trained in and understand new processes is vital.
4. Performance boards & process control boards: performance boards communicate the outcome of Quality Improvement efforts to staff, and process control boards display how much work is required versus how much is completed in real time. Both of these visual management methods provide simple and transparent representation for staff.
5. Communicate early and often: communications don’t need to be complicated or sophisticated, but frequent check-ins and updates go a long way to maintaining momentum.
6. Supportive management structure:  ensure senior leaders are involved. As we have seen, successful change happens with input from the frontline and senior management: management needs to set the vision that change, innovation and continuous improvement is welcome and encouraged; plus they need to provide the infrastructure for this to happen.
7. Add to the agenda of recurring staff meetings:  this shows a commitment to improve and ensures ongoing touch points.

Always remember to communicate that there is no such thing as a bad idea. It’s crucial that stakeholders feel comfortable sharing all ideas, no matter how small or novel it might appear. This is where a digital platform such as ImproveWell can really play an important role.

The NHS Sustainability Model can be used to help identify factors that may increase or decrease the likelihood of continued project success post launch.  Developed by frontline staff, improvement experts, and organisational leaders it is a checklist of ten factors related to process, staff and organisational issues and uses a weighted scoring system to derive an overall score and outlines sustainability strengths and weaknesses across each factor.

Spreading Quality Improvement

Spread means replicating an initiative in a different environment, for example a different team, department, organisation or locality. More often than not, it will involve identification of the unique facets of the environment (e.g. related to resources, infrastructure, leadership support, or culture) and possibly adaptation of the initiative accordingly.  As management consultant Peter Drucker famously said, “context eats strategy for breakfast”.

Spreading an innovation is no easy feat – there is no simple or universally replicable way of implementing change at scale across complex systems. In their paper,  Spreading and scaling up innovation and improvement, Greenhalgh & Papoutsi discuss three theories of innovation spread:

• implementation science which takes a structured and phased approach to developing, replicating, and evaluating an intervention in multiple sites;
• complexity science which encourages a flexible and adaptive approach to change in a dynamic, self-organising system; and
• social science approaches which consider why people act in the way they do, especially the organisational and wider social forces that shape and constrain people’s actions.

In reality, these approaches may be used in combination to tackle the challenges of spread.  Either way, laying the foundation of successful spread is crucial for sure. But how? Here are seven factors to consider:

1. Leadership support: ensure you have leadership buy-in to ensure the vision is supported both in terms of culture and resource.
2. Bring people on the journey: no initiative can be lifted whole scale from one environment to another. Ensure you learn from the frontline and customise the initiative accordingly.
3. Share results of pilots: demonstrating success in terms of initial pilots goes a long way to building confidence and trust in new environments.
4. Develop the plan: think about the four Ws of your initiative – what, who, where and why? 
5. Use your organisational structure: embedding new ways of working into existing structures makes adoption much more seamless.
6. Build a communications plan: from posters to emails and social media, a new programme will never take off if no one knows about it.
7. Track and measure: what does success look like? How will you measure change and impact?

An example of the spread and sustainability of Quality Improvement in healthcare

An example of spread and sustainability of quality improvement in healthcare can be seen in the use of the ImproveWell digital solution to support the implementation of the Institute for Healthcare Improvement’s (IHI) Framework for Improving Joy in Work, which started as an initiative at East London NHS Foundation Trust before being adopted at a national level by Royal College of Psychiatrists and subsequently globally by the IHI themselves.

• Back