Spreading and Sustaining Quality Improvement: A Practical Guide

Why this topic matters

Many excellent QI projects achieve impressive results within a specific clinical area or team but struggle to scale or endure. This 'pilotitis' phenomenon means that valuable insights and efficiencies are often confined, limiting their potential benefit to patients and staff across the wider NHS. For junior doctors and trainees involved in QI, understanding how to spread and sustain projects is crucial for demonstrating leadership, impact, and contributing to systemic improvements, moving beyond a one-off project to create lasting change.

NHS England actively encourages the spread and adoption of innovation and good practice. Documenting your approach to spread and sustainability is often a requirement for national awards, publication, and demonstrating the long-term value of your work.

Practical explanation: Spreading vs. Sustaining

It's important to differentiate between spreading and sustaining a QI project, although they are interconnected.

• Spreading (or scaling) refers to the process of implementing a successful intervention or change across different departments, clinical units, or even other organisations. It's about replicating success in new contexts.
• Sustaining refers to embedding the new practice or process into routine operation within the original project area and any areas where it has been spread. It's about ensuring the changes persist long after the initial QI team's direct involvement.

Effective spread and sustainability require deliberate planning and a strategic approach, rather than simply hoping good ideas will catch on organically.

Common pitfalls

Several common issues can hinder the spread and sustainability of QI projects:

• Lack of early engagement with stakeholders: Failing to involve key individuals who will be impacted or are crucial for wider adoption from the outset.
• Insufficient data to prove impact: Relying on anecdotal evidence rather than robust, measurable data to demonstrate the value of the change.
• Underestimating contextual differences: Assuming what worked in one area will automatically work elsewhere without adaptation.
• Lack of a clear spread plan: No defined strategy for how and where to implement the change next.
• Inadequate training and support: Expecting new teams to adopt changes without proper guidance, education, or resources.
• No clear ownership or champions: The new process lacks an accountable person or team to champion its continued use.
• Fading enthusiasm and neglecting monitoring: Initial enthusiasm wanes, and the new process is not regularly monitored or reinforced, leading to drift back to old ways.
• Poor communication: Not effectively sharing success, lessons learned, or the rationale for the change.

A Step-By-Step Approach to Spreading and Sustaining

1. Document Your Success

Before you can spread, you need to clearly articulate what worked and why.

• Clear project aim: Reiterate your original aim and how you met it.
• Robust data: Present your baseline and post-intervention data, highlighting the measurable improvement. Use appropriate statistical process control (SPC) charts if applicable to demonstrate special cause variation.
• Process mapping: Document the 'before' and 'after' processes. What exactly changed?
• Identify key interventions: What specific changes led to the improvements? Be precise.
• Quantify benefits: Beyond clinical outcomes, consider staff satisfaction, efficiency gains, cost savings, or patient experience improvements.
• Lessons learned: Document challenges encountered and how they were overcome. This is invaluable intelligence for other teams.

2. Identify Potential Areas for Spread

Think strategically about where your project could have the most impact.

• Similarity of context: Look for areas with similar patient populations, processes, or challenges.
• Need for improvement: Prioritise areas where your intervention could address a clearly identified need or existing problem.
• Leadership buy-in: Identify potential champion clinicians or managers in those areas who are receptive to change.
• Capacity and resources: Assess if the new areas have the capacity and resources to implement and sustain the change.
• Engage with management: Discuss potential spread with departmental, directorate, or divisional leads to gain their support and identify priorities.

3. Develop a Spread Strategy

This is your plan for wider implementation.

• Pilot and learn: You may need to run a small pilot in a new area to test adaptability and make local adjustments.
• Identify champions: Secure a local champion in each new area who can drive the change and provide peer support.
• Adaptation, not replication: Be prepared to adapt your interventions to fit local context and culture. Acknowledge that a 'one-size-fits-all' approach rarely works for complex changes.
• Communication plan: How will you share your success and the rationale for the change? This could involve presentations, workshops, written reports, or 'roadshows'.
• Training and support: What training will be needed for new staff? How will ongoing support be provided?
• Monitoring and evaluation: How will you track implementation and outcomes in the new areas? Will you use the same metrics?
• Feedback loop: Establish a mechanism for new sites to provide feedback and suggest further adaptations.

4. Plan for Sustainability from the Outset

Sustainability shouldn't be an afterthought. Consider these factors throughout your project and particularly during spread.

• Embed into routine: Can the new process be integrated into standard operating procedures, policies, or care pathways?
• Ownership: Who will 'own' the ongoing monitoring and maintenance of the new process once the QI team steps back?
• Training for new staff: How will new starters be oriented to the new way of working?
• Audit and review: Schedule regular audits or reviews to ensure fidelity to the new process and sustained outcomes. This might include re-audit.
• IT system integration: Can the change be supported or hard-wired into electronic patient records or other digital systems?
• Leadership reinforcement: Ensure senior buy-in continues, and leaders regularly communicate the importance of the new practice.
• Resource allocation: Ensure necessary resources (staff, equipment, time) are allocated permanently.

5. Communicate, Celebrate, and Share

Effective communication is paramount for both spread and sustainability.

• Tell your story: Share your project journey and its impact widely. Use newsletters, internal publications, trust QI forums, and external conferences.
• Celebrate successes: Recognise the efforts of the initial team and those adopting the change. This helps build momentum and motivation.
• Publish and present: Consider writing up your project for peer-reviewed journals, national conferences, or specialist society meetings. This validates your work and disseminates learning.

Example in clinical practice: Reducing Post-Operative Nausea and Vomiting (PONV)

A junior doctor, as part of a QI project, successfully implemented a multidisciplinary, evidence-based PONV prophylaxis bundle in their general surgical ward, resulting in a 30% reduction in PONV rates and improved patient satisfaction scores.

Spread:

1. Documentation: The team presented their data in a ward meeting, clearly showing the reduction using a run chart, and outlined the specific changes made (e.g., standardisation of antiemetics, nursing care bundles).
2. Identification: They identified similar surgical wards (orthopaedics, urology) and the post-anaesthetic care unit (PACU) as potential areas for spread, noting similar patient profiles and anaesthetic practices.
3. Strategy: They secured interest from an enthusiastic consultant anaesthetist and a ward sister in orthopaedics. The project lead created a 'toolkit' including slides, data collection sheets, and an adapted protocol. They planned a 2-week pilot in orthopaedics with joint training sessions.
4. Sustainability Plan: The anaesthetist worked with their department to embed the bundle into the standard anaesthetic prescription sheet. The ward sister updated local nursing guidelines and ensured new staff received training on the bundle.

Sustaining:

• Six months later, the original general surgical ward and the orthopaedic ward continue to monitor PONV rates monthly. The ward sister in orthopaedics now champions the bundle, and the junior doctor presents the combined data at trust-wide governance meetings, advocating for spread to other surgical specialities.

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

How Lazomis can help

Lazomis offers tools that can significantly support the spread and sustainability of your QI projects:

• Project Documentation: Our structured templates within the Lazomis QI Project Setup tool help you methodically document your project's aim, interventions, and outcomes, creating a shareable record of success.
• Data Visualisation: Lazomis Dashboards can be used to track key metrics consistently across different areas as you spread your project, allowing for easy comparison and identification of sustained improvement.
• Knowledge Sharing: Use Lazomis to store and disseminate your project's 'toolkit' – protocols, training materials, and lessons learned – making it readily accessible to other teams looking to adopt your changes.
• Monitoring for Sustainability: Set up automated reminders and data feeds within Lazomis to prompt regular review and re-audit schedules, helping to ensure long-term adherence to new processes and identification of 'drift'.