Implementing Sustainable Change: A Guide to QI Sustainability Planning

Why this topic matters

In the demanding environment of the NHS, resources are finite, and staff time is precious. Investing significant effort into a QI project only for its benefits to fade away represents a major missed opportunity. Sustainable QI ensures that improved patient outcomes, increased efficiency, and enhanced staff experience are maintained and embedded into routine practice. This not only maximises the return on investment for the organisation but also prevents the demoralising cycle of re-addressing the same problems repeatedly.

NHS England's commitment to QI principles, as well as the increasing emphasis on value-based healthcare, highlights the importance of changes that stick. Projects that demonstrate long-term sustainability are more likely to be championed, spread, and scaled across departments or even trusts, contributing to system-wide improvements.

Practical explanation: What is sustainability planning in QI?

Sustainability planning in QI is the proactive process of designing and implementing strategies to ensure that beneficial changes introduced by a QI project are maintained over time. It involves considering various factors that influence whether a change will endure, including:

• Integration into routine workflow: Making the new process the 'easy' and 'default' way of working.
• Ownership and leadership: Identifying individuals or teams responsible for the ongoing maintenance of the change.
• Monitoring and feedback: Establishing systems to track performance and provide regular feedback to maintain focus.
• Staff education and training: Ensuring new and existing staff are competent and confident with the modified process.
• Resource allocation: Confirming that necessary resources (staffing, equipment, funding, IT support) remain available.
• Cultural alignment: Ensuring the change aligns with the values and norms of the wider organisation.
• Contingency planning: Anticipating potential barriers and having strategies to address them.

Sustainability is not about doing 'more' after a project ends; it's about embedding the new way of working so successfully that it becomes indistinguishable from standard practice.

Common pitfalls

Several factors can undermine the long-term success of QI initiatives:

• Lack of early planning: Treating sustainability as an add-on rather than an integral part of the project design from the outset.
• Reliance on a 'champion': When the individual driving the change moves on, the change itself can falter without broader ownership.
• Insufficient training and communication: Staff not understanding the 'why' behind the change, or how to perform the new process correctly.
• Inadequate monitoring: Without continued measurement, it's impossible to know if the improvement is being maintained, leading to drift.
• Absence of formal integration: The improved process remains an 'extra' step rather than being codified in standard operating procedures (SOPs) or policies.
• Resource withdrawal: Reduction in staff, budget, or materials previously allocated to support the change.
• Organisational change: New leadership, departmental restructuring, or competing priorities can inadvertently destabilise previously embedded improvements.

Step-by-step approach to sustainability planning

Integrating sustainability into your QI framework will significantly increase the likelihood of lasting improvements. This approach is best initiated early in your project, ideally during the planning and implementation phases.

1. Define the 'new normal'

Clearly articulate what the sustained state will look like. What specific behaviours, processes, and outcomes will be consistently observed? Document this 'new normal' in a clear, concise manner.

2. Identify key stakeholders and assign ownership

Who will be responsible for maintaining the change once the project team steps back? This should typically be the operational team or department where the change is embedded. Identify specific individuals or roles responsible for:

• Monitoring key metrics.
• Troubleshooting issues.
• Training new staff.
• Reviewing and updating associated documentation.
• Communicating performance.

3. Embed the change into routine workflow

• Standard Operating Procedures (SOPs): Revise or create SOPs to reflect the new process. Ensure these are easily accessible.
• Job descriptions: Consider if new responsibilities need to be formally added to relevant job descriptions.
• Electronic systems: Integrate the change into electronic health records, order sets, or other digital systems where appropriate.
• Environmental cues: Use visual aids, checklists, or redesigned physical spaces to support the new behaviour.

4. Develop a robust monitoring plan

Determine how you will continue to track the performance of the sustained change. This often involves the same, or a subset of, the measures used during the active QI project.

• Metrics: Which key outcome, process, and balancing measures will you continue to track?
• Data collection: How will data be collected (e.g., automated reports, regular audits, existing dashboards)? Who will collect it?
• Frequency: How often will data be reviewed?
• Feedback loops: How will performance data be shared with the front-line staff and responsible owners to enable timely adjustments?
• Control charts: Consider using statistical process control (SPC) charts to monitor stability and detect degradation early.

5. Plan for ongoing training and communication

• New staff orientation: How will new recruits be trained on the updated process?
• Refresher training: Will periodic refresher training be necessary for existing staff?
• Communication strategy: How will changes, updates, or performance feedback be communicated to the wider team?
• Why it matters: Reinforce the benefits of the change for patients and staff.

6. Secure necessary resources

Review the resources required to sustain the improvement. This includes:

• Staffing: Is adequate staff time allocated for the new process or monitoring activities?
• Equipment/consumables: Are these budgeted for and readily available?
• IT support: Is ongoing technical support in place if the change relies on digital systems?
• Financial support: Are any specific financial allocations secured?

7. Formulate a review and adaptation strategy

Things change, and what works today might need tweaking tomorrow. Plan for periodic review of the sustained process (e.g., annually) to ensure it remains effective, efficient, and aligned with current best practice or guidance.

• Who will review? Generally, the designated owners.
• What will be reviewed? Process adherence, outcome measures, staff feedback, literature updates, national guidance.
• How will changes be made? Establish a clear pathway for minor adjustments vs. re-initiating a QI cycle for significant issues.

Example in clinical practice: Sustaining improved venous thromboembolism (VTE) prophylaxis documentation

Initial QI Project: A surgical ward team identified low rates of VTE prophylaxis documentation in patient notes leading to potential safety risks. Their QI project successfully increased completion rates from 60% to 95% using a new checklist and daily reminders.

Sustainability Plan Elements:

1. Define new normal: All adult surgical inpatients receive documented VTE risk assessment and prophylaxis plan on admission and at daily reviews, with 95%+ compliance.
2. Ownership: Ward Manager and Senior Staff Nurses responsible for daily oversight and weekly audit of 10 notes randomly selected from admissions.
3. Embedding:
   • Integrated the VTE checklist into the electronic admission pathway as a mandatory field before other fields could be completed.
   • Ward nursing documentation policy updated to reflect the mandatory nature of VTE assessment and documentation.
   • All new nurses joining the ward undergo specific training on the updated VTE documentation process during their induction.
4. Monitoring:
   • The weekly audit results are shared in the ward's daily safety huddle. Any deviation below 90% triggers a review.
   • Quarterly, the Clinical Governance Lead reviews the ward's VTE documentation compliance data via an automated report from the electronic system.
   • A control chart monitoring VTE documentation compliance is displayed in the staff room, updated weekly.
5. Training & Communication:
   • A 'VTE Champion' (a Senior Staff Nurse) provides an annual refresher training session for all ward staff.
   • The importance of VTE prevention is reiterated during mandatory annual safeguarding training.
6. Resources: The electronic system's IT support team is aware of the mandatory field and provides support for any technical issues. The trust's VTE committee provides updated guidance when required.
7. Review: Annually, the ward's multidisciplinary team reviews VTE documentation performance, incident reports related to VTE, and national guidance to identify areas for further optimisation or re-auditing.

This systematic approach ensures the hard-won improvements are not lost.

How Lazomis can help

Lazomis provides a structured framework to support your QI journey, including tools that facilitate sustainability planning:

• Project Documentation: Our templates encourage you to plan for sustainability from the outset, with explicit sections for identifying owners, review periods, and embedded processes.
• Data Dashboards: Regularly updated dashboards can display your key sustainability metrics, making it easy for nominated owners to monitor performance and spot signs of decay.
• Action Tracking: Use Lazomis to assign actions for ongoing monitoring, training updates, and policy reviews, ensuring tasks are not forgotten.
• Knowledge Repository: Store updated SOPs, training materials, and key contact information securely, making them accessible to current and future staff.

By leveraging Lazomis, you can build a robust infrastructure that supports the transition from project initiation to sustained, embedded practice, safeguarding your improvements for the long term.

This resource supports, but does not replace, clinical judgement. Local policy, formulary and specialist advice should be followed.