How to ensure the spread and sustainability of quality improvement

Quality Improvement (QI) initiatives are crucial for enhancing patient care, streamlining processes, and ultimately creating a more efficient and effective healthcare system. However, successfully launching a QI project is only half the battle. The real challenge lies in ensuring its spread and sustainability – making sure the improvements stick, scale, and become embedded in the organisation's culture.

In this article, we will delve into practical strategies for ensuring the spread and long-term viability of QI initiatives, drawing on established frameworks, research, and real-world examples like the NHS sustainability model.

Sustainability in QI

When you work in quality improvement, thinking about how your work can both continue after implementation and develop further is essential. And this is exactly what sustainability is all about: embedding the QI initiative into your organisation's DNA so that it becomes a routine part of the daily operations.

However, according to different studies, in the healthcare space a staggering one-third of improvement initiatives fall short of their intended goals. And the cost implication is not just financial - it can negatively impact patient care, lead to staff dissatisfaction, and hinder the adoption of future beneficial changes.

Indeed, these sustainability initiatives are often undermined by two major problems. The first is the “improvement evaporation effect” or “initiative decay”, meaning that the hard-won gains gradually disappear, and the organisation reverts to its previous state. The second is the “isolated improvements” or the creation of “improvement islands” where successful changes remain confined to specific areas and fail to drive broader organisational change.

To sustain your improvement, you need to address these issues with a proper strategy, but there are also specific elements that exist within organisations that support changes, like supportive management or transparent feedback cycles. We explore them more in detail in our “Key factors in sustainability” blog article.

It’s important to note that these factors are connected to each other to support sustainability and are underpinned by engagement and clinical leadership to be more effective.

You can also read more about this in the NHS “Improvement Leader’s Guide: Sustainability and its relationship with spread and adoption” guide.

10 practical tips to achieve sustainability

We gathered 10 practical tips to help you achieve sustainability in your quality improvement initiatives.

1. Ensure that your QI initiative aligns with your organisation's overall strategic goals and priorities.
2. Formalise your QI initiative by incorporating it into existing procedures and workflows.
3. Regularly monitor key performance indicators (KPIs) to track progress and identify areas for improvement.
4. Establish feedback loops to gather input from staff and patients on the effectiveness of the QI initiative. This can be team huddles or notice boards in staff breakrooms, or via email for service users.
5. Be prepared to adapt and refine your QI project based on data and feedback. Continuous evaluation is critical.
6. Secure strong leadership support for QI at all levels of the organisation.
7. Recognise and reward staff who actively participate in QI initiatives.
8. Ensure staff are trained in and understand the new processes.
9. Create a safe environment where staff feel comfortable sharing their experiences, including failures, so that others can learn from them.
10. Leverage technology to automate processes, track data, and facilitate communication and collaboration. And this is where a software solution like Life QI can be very handy.

The NHS Sustainability Model

The NHS developed their Sustainability Model to give improvers a guidance on how to implement and sustain effective improvement initiatives. The Sustainability Model is a diagnostic tool that identifies strengths and weaknesses in your implementation plan and predict the likelihood of sustainability for your improvement initiative.

The Sustainability Model is designed to help sustain positive changes within healthcare, focusing on ten key factors related to process, staff, and organisational structure. This model was collaboratively developed with the NHS, utilising a co-production approach involving front-line teams, improvement specialists, senior leaders, and academic experts. The core principle behind the model's development is to support improvements that ultimately enhance the patient experience.

Furthermore, the Sustainability Model aims to ensure that change initiatives are effectively implemented and maintained, establishing a foundation for continuous improvement. By preventing reversion to old processes, the model helps to optimise resource utilisation, including both financial and human capital.

It’s a very practical and easy-to-follow guide and model, so we strongly advise you to learn more about it and then implement it in your improvement work.

Spreading quality improvement

As we’ve seen earlier, one of the reasons why improvements fail to sustain is that they are isolated, meaning that the improvement doesn’t go beyond the initial environment – the improvement does not spread. As the NHS states, “you will know you have succeeded when knowledge for improvement developed anywhere in the system rapidly becomes common knowledge and is actually used.”

But the journey from a successful pilot project to widespread implementation requires a strategic and phased approach.

In the NHS “Improvement Leader’s Guide: Sustainability and its relationship with spread and adoption” guide the authors discuss some potential reasons why spreading improvement is not successful. These are:

• a ‘not invented here’ organisational culture which immediately rejects ideas that come from elsewhere
• the absence of a clear organisational strategy that seeks to learn from other places
• the change itself may be too complicated or not seen as a good fit to the local context
• there may be competing priorities that divert attention away from implementing changes, especially if these were originally developed elsewhere and are not seen as solving the pressing problem of the moment
• a lack of communication about the new idea may mean that other parts of the organisation do not even know about the change
• a lack of vision and plan of how to adapt for the local area or service.

The above clearly shows that you can work hard as much as you want to spread your improvement, the ultimate success is always determined by whether the others adopt your changes or not. This means that you need to find a well-thought strategy to ensure your QI initiative takes root and flourishes.

There are many frameworks for spread out there to help you with spreading your improvement, so you don’t have to reinvent the wheel. But let’s take a closer look at what the IHI suggest.

The IHI advise to start with developing a spread plan. They identified three steps:

Step 1: Laying the foundation for spread

Successful spread hinges on the initial success of testing, implementing, and sustaining improvements within your organisation. To lay a solid foundation for widespread adoption, you should integrate the following actions with the infrastructure and activities designed to maintain existing gains:

• You should clearly communicate the goals and rationale behind the improvement efforts.
• You should identify an influential individual (a so called “champion”) who will lead the spread efforts.
• Assign a leader to oversee the spread and effectively communicate, motivate, and direct organisational resources to support the spread.
• Leverage the results of successful pilot programs to engage others through data and success stories.

Step 2: Consider how successful spread may be achieved

Before launching your spread efforts, you should establish specific and measurable (SMART) aims. This involves answering the following questions:

• What are you spreading?
• What is your target level of performance?
• Who is your target population?
• What is the timeframe?

We suggest creating SMART goals that include both process and outcome measures and adding specific deadlines. It’s always recommended to avoid vague terms.

An example of a good SMART aim might be: “Reduce waiting times for every patient needing an X-ray or MRI, impacting 2,500 patients, in 10 months.”

Now that you have your aim, you can focus on how you'll achieve it. Consider these points:

• Spread can happen more quickly and more easily if the new area is connected somehow to the one where the idea was tested and proved to be effective. Utilise reporting relationships, medical staff committees, and line responsibility to engage staff and ensure accountability.
• Identify any differences between departments that might impact implementation. Look for opportunities to make new processes as easy as possible to facilitate adoption. Integrate improvement into daily workflows, rather than treating it as a special project.
• Identify your target audiences for the interventions that you’re spreading and tailor your messages accordingly. We recommend sharing information about the improvement with staff in new units and creating methods to provide feedback to adopters to ensure accountability. It’s also essential that you provide ongoing encouragement and support to the teams.

Step 3: Refining the proposal for spread

To accelerate the adoption of interventions, the initial spread plan may require adjustments. The spread team should continuously monitor process and outcome measures, along with adoption rates, to identify areas for improvement. The spread leader can gather further insights from frontline staff and departments through formal reports, surveys, informal discussions, or other appropriate channels.

And remember that while a well-defined spread plan is important, the ideas often spread through informal conversations and interactions within trusted networks like "opinion leaders" – individuals whose views are respected and followed by their peers. Understanding their awareness and stance on the proposed interventions can significantly predict the speed and direction of dissemination.

Furthermore, studies made by Everett Rogers (2003) and Greenhalgh et al (2004) indicate that ideas with certain attractive qualities spread more rapidly. These are:

• a clear advantage compared with current ways
• compatibility with current systems and values
• simplicity of change and its implementation
• ease of testing before making a full commitment
• observability of the change and its impact.

Conclusion

Spreading and sustaining QI initiatives are always challenging. But implementing these tips can help you make your improvement stick and spread across your whole organisation. Remember, lasting changes require a commitment to both the science of improvement and the art of implementation. By focusing on engagement, communication, and continuous learning, you can ensure that QI initiatives take root and deliver sustained benefits for patients and healthcare professionals alike.