Sustaining Improvement: Beyond the QI Project Closure

Why this topic matters

Many QI projects deliver impressive results during their active phase. However, without a deliberate strategy for sustainment, these gains can be ephemeral. Hospital Episode Statistics (HES) data, national audits, and local reviews frequently highlight variations in practice and outcomes, even for well-established guidelines, underscoring the challenge of maintaining consistent high-quality care. For junior doctors and trainees involved in QI, seeing their efforts dissipate can be demotivating, hindering future engagement with improvement work.

Effective sustainment of QI initiatives translates directly into continued benefits for patients, such as improved safety, better clinical outcomes, and enhanced patient experience. For staff, it means more efficient processes, reduced frustration, and better use of resources. From an organisational perspective, sustained improvement contributes to meeting CQC standards, achieving national targets, and fostering a culture of continuous learning and excellence. Neglecting sustainment is akin to investing in a new building without a maintenance plan – it will inevitably fall into disrepair.

Practical explanation: What does sustainment involve?

Sustainment is not a post-project afterthought; it's an integral part of the QI journey, ideally considered from the project's inception. It encompasses deliberate actions to embed changes, monitor their effectiveness, and adapt as necessary, long after the immediate project team has disbanded.

Key elements of sustainment include:

• Embedding changes into routine workflows: Making the improved process the default, rather than an optional extra.
• Standardisation: Developing clear, accessible, and agreed-upon procedures, guidelines, or pathways.
• Leadership support and ownership: Securing ongoing commitment from senior staff and departmental leads.
• Training and education: Continuously educating new staff and reinforcing practices for existing staff.
• Monitoring and feedback loops: Establishing clear metrics to track performance and providing regular feedback.
• Celebrating success and communication: Regularly acknowledging progress and communicating the benefits of the sustained change.
• Integration with organisational systems: Ensuring changes are supported by IT systems, HR processes, and governance frameworks.

Common pitfalls in sustaining improvement

Recognising common challenges can help in proactive planning:

• Lack of ownership beyond the project team: If the responsibility for the new process doesn't transfer to clinical leads or service managers, it often founders.
• Insufficient integration into daily work: If the change requires extra steps or is not aligned with established routines, it's easily abandoned under pressure.
• High staff turnover: New staff may not be aware of the improvement, and existing staff may revert to old habits without reinforcement.
• "Project fatigue" and shift in priorities: Once a project closes, focus can quickly shift to other pressing issues, leaving sustained maintenance overlooked.
• Absence of ongoing monitoring: Without regular data collection and feedback, gradual decay can go unnoticed until problems resurface.
• Inadequate training cascade: New staff, or those returning from leave, may miss crucial training on the updated process.
• Resistance to change: Even beneficial changes can be met with inertia, especially if the 'why' is not continually reinforced.
• Lack of demonstrable ongoing benefit: If the positive impact isn't regularly communicated or visible, motivation to adhere to new practices can wane.

Step-by-step approach to sustaining improvement

Step 1: Design for sustainment from the outset

When planning your QI project, include sustainment as a key objective. Ask:

• Who will own this process after the project officially closes?
• How will this change be integrated into existing clinical pathways and job plans?
• What training will be required for new staff and how will it be delivered repeatedly?
• What data will we continue to collect to monitor the change, and who will review it?

Step 2: Standardise the new process

Once improvements are proved effective and reliable during the PDSA cycles, formalise them:

• Develop clear guidelines or Standard Operating Procedures (SOPs): These should be concise, accessible (e.g., via intranet, laminated cards), and reviewed regularly.
• Update relevant policy documents: Ensure the new practice is reflected in departmental or trust-wide policies.
• Incorporate into routine forms/checklists: Make the correct action part of existing documentation.

Step 3: Secure leadership and staff ownership

Sustainment requires broad engagement and accountability:

• Identify a 'process owner': A designated clinical lead or manager who takes ongoing responsibility for the improved process.
• Engage key stakeholders: Ensure departmental leads, ward managers, and senior clinicians are actively involved and championing the change.
• Empower frontline staff: Encourage individual and team ownership, providing autonomy where appropriate.

Step 4: Institute continuous monitoring and feedback

Measure to know if the improvement is holding:

• Select robust process and outcome measures: Use the same or similar metrics from your QI project baseline and intervention phases.
• Establish a frequency for data collection and review: This could be weekly, monthly, or quarterly, depending on the process.
• Create feedback loops: Share performance data regularly with the teams involved. Visual dashboards or simple team meetings can be effective.
• Build into existing governance structures: Integrate monitoring into existing departmental audits, clinical governance meetings, or safety huddles.

Step 5: Embed training and communication

Avoid knowledge decay:

• New starter induction: Incorporate training on the new process into the induction programme for all new clinical staff.
• Regular refreshers: Schedule periodic brief training sessions or awareness campaigns.
• Ongoing communication: Use newsletters, team meetings, and digital platforms to remind staff of the importance and benefits of the change.
• Celebrate successes: Acknowledge and reward teams or individuals who consistently demonstrate adherence and contribute to sustained improvement.

Step 6: Identify and address barriers to sustainment

Be prepared to troubleshoot:

• Conduct periodic 'check-ups': Revisit the process after a few months to identify any emerging issues or deviations.
• Review and adapt: Be open to making minor adjustments to the process if new barriers emerge or circumstances change. Use small PDSA cycles to refine.
• Resource allocation: Ensure that the sustained process has appropriate staffing, IT support, and equipment.

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

A junior doctor and anaesthetic registrar team identify a high incidence of PONV in patients undergoing orthopaedic surgery, leading to prolonged hospital stays and patient dissatisfaction. Their QI project successfully implemented a bundle of prophylactic antiemetics and a clear pre-operative risk assessment tool, reducing PONV rates by 30% over three months. To sustain this:

1. Standardisation: The antiemetic bundle and risk assessment are incorporated into the departmental pre-operative assessment and anaesthetic charts as mandatory fields. A laminated algorithm is placed in anaesthetic rooms.
2. Ownership: The departmental clinical lead for anaesthesia takes ownership of the PONV reduction pathway, with the lead anaesthetic nurse co-ordinating implementation on the ward.
3. Monitoring: The pre-operative assessment team continues to audit adherence to the risk assessment tool fortnightly. Post-operative recovery nurses track PONV incidence daily on a ward dashboard. These data are reviewed monthly at the departmental governance meeting.
4. Training & Communication: The new pathway is integrated into the induction for all new anaesthetic registrars and ODPs. Weekly 'Safety Huddles' on the ward include a regular reminder about the importance of the PONV bundle. Success stories from patients experiencing reduced PONV are shared.
5. Adaptation: After six months, an increase in PONV rates is noted. A mini-PDSA cycle identifies that a new batch of pre-filled syringes for one antiemetic brand has led to confusion over dosing. The team clarifies the guidance, updates the laminated algorithm, and re-educates staff, bringing rates back down.

How Lazomis can help

Lazomis provides a structured environment that inherently supports the sustainment of improvement initiatives beyond the initial project phase. Our tools can help you embed and monitor changes effectively:

• Project Documentation and Standardisation: Use Lazomis to store finalised SOPs, guidelines, and training materials in an easily accessible digital library. This central repository ensures that all staff, including new starters, can quickly find and understand the established best practices, preventing knowledge decay.
• Ongoing Data Collection and Visualisation: Our integrated data collection features allow you to continue monitoring your key performance indicators (KPIs) long after your project has 'closed'. Customisable dashboards provide real-time visual feedback on adherence to the new process and its outcomes. This continuous monitoring is crucial for identifying 'drift' and for demonstrating ongoing benefits.
• Automated Reminders and Feedback Loops: Set up automated alerts or email notifications based on your chosen metrics to prompt reviews or generate reports. This helps maintain momentum and ensures that the process owner is regularly informed about performance.
• Sharing and Learning: Lazomis facilitates the sharing of sustained improvements across different teams or departments, fostering a culture of continuous learning and preventing the reinvention of the wheel. This can help embed the change more widely and encourage others to adopt proven practices.
• Audit and Re-audit Support: For recurring audits, Lazomis provides templates and data fields that make repeated data collection and comparison straightforward, essential for demonstrating long-term compliance and the enduring impact of your QI work.

Key takeaways