In the previous article in this Moving Points in Nephrology feature (1), the new dialysis nurse educator helped increase the percentage of predialysis patients who were assessed for home dialysis (home hemodialysis and peritoneal dialysis). The percentage of patients started on a home dialysis modality also increased in the subsequent months. The Nephrology Division leadership and clinic staff are thrilled with these results, but you have observed that home dialysis assessments and new starts on home dialysis have not continued at this rate over the last several months. Now that your improvement team has finally experienced success, you want to be able to sustain these improvements rather than devolve toward past performance. You begin to review different sustainability frameworks and tools and recognize several factors that serve as barriers to successful quality improvement. However, you are unsure how to apply sustainability tools to your quality improvement project or how to recognize factors from the local environment and setting that promote a supportive context for future quality improvement initiatives.
Plan for Sustainability Early
Sustainability refers to holding the gains of an improvement project, even in the face of staff and organizational turnover. Unfortunately, up to 70% of organizational change is not sustained (2); the National Health Service (NHS) in the United Kingdom found that 33% of quality improvement projects are not sustained upon evaluation 1 year after completion (3). Some improvement leaders believe that the challenge is not starting improvement work but rather continuing the work after the initial enthusiasm has dissipated (4). We have already observed that quality improvement requires a significant investment in time and effort to achieve results, and this improvement will succeed only if the same effort is applied to project sustainability.
Because sustainability will not happen by chance, we require strategies to plan for sustainability. Similar to our approach to quality improvement, this process starts by diagnosing sustainability problems. The NHS Sustainability Model can help identify factors that may increase or decrease the likelihood of continued project success (3). The NHS model was developed by frontline staff, improvement experts, and organizational leaders. It is the most comprehensive of the existing sustainability frameworks and is organized in a checklist format to facilitate knowledge translation. The NHS model has also informed several other sustainability models, including the Institute for Healthcare Improvement, Agency for Healthcare Research and Quality, and Health Quality Ontario (5–7). Therefore, discussion of the NHS model will encompass the components of the other aforementioned sustainability frameworks.
The NHS model consists of ten factors related to process, staff, and organizational issues (Table 1). For each factor, an improvement team selects the description that best represents the improvement project. The NHS model uses a weighted scoring system to derive an overall score and outlines sustainability strengths and weaknesses across each sustainability factor. Preliminary evidence suggests that a quality improvement project with a score ≥55 has a high probability of sustained success, whereas a score <35 requires significant effort to address sustainability limitations (3).
Table 1. -
National Health Service Sustainability Model and its application to the home
dialysis clinical scenario
||Factor Rating (Weighted Score)
||Rationale for the Home Dialysis Score
| Benefits beyond helping patients
||The change has a wide range of benefits (8.5)
||Score=4.7: Adding a new dialysis nurse educator improves patient modality education
Are jobs now easier?
||The change has some benefits (4.7)
||Other staff can now spend less time on modality education, but clinic appointments may take longer
Is waste reduced?
||The change has one or two benefits (4.0)
|The benefits are only related to patients (0)
| Credibility of the benefits Does evidence support the change?
||Benefits of the change are widely communicated, immediately obvious, and supported by evidence (9.1)
||Score=6.3: Modality education is a necessary step to increase the use of home dialysis
Are benefits visible?
Can staff describe the benefits?
||Benefits of the change are not widely communicated or immediately obvious, but are supported by evidence (6.3)
||Home dialysis is supported by local physicians, patients, and health care leaders
||Benefits of the change are not widely communicated, immediately obvious, or believed in by stakeholders. They are supported by evidence (3.1)
||Improved modality education does not immediately or necessarily translate into increased use of home dialysis
||Benefits of the change are not obvious, believed in by stakeholders, or supported by evidence (0)
| Adaptability of the improved process Does the change rely on a specific individual or group?
||The improved process can be adapted to support wider organizational change. The change will not be disrupted if specific individuals or groups leave (7.0)The improved process can be adapted to support wider organizational change. The change will be disrupted if others leave (3.4)
||Score=3.4: The change relies on adding a dedicated dialysis nurse educator to a predialysis clinicThis change will be disrupted if the nurse educator leaves or other staff are not familiar with the new clinic processes
||The change is difficult to adapt and will be difficult to continue if others leave (2.4)
||However, this is a relatively simple change that could be adapted to account for staff turnover (e.g., by training multiple staff in the delivery of dialysis modality education to ensure redundancy)
|The change depends entirely on a specific individual or group (0)
| Effectiveness of the system to monitor progress
||The monitoring system is supported beyond the life of the project (6.5)
||Score=2.4: The current monitoring system is local only and based upon Plan-Do-Study-Act cycles
|No formal monitoring system exists to measure ongoing performance long-term
Are there monitoring systems to communicate results?
||The monitoring system is temporary (3.3)
|The monitoring system is temporary, and results are not communicated beyond the improvement team (2.4)
|There is no reliable monitoring system (0)
| Staff involvement and training to sustain the process
||Staff were involved in all phases of the project and trained in the new process (11.4)
||Score=6.3: Frontline staff were heavily involved in all aspects of the improvement project from start to finish
Were staff involved in the change?
Are staff trained in the new process?
||Staff were heavily involved in the project but have not been trained in the new process (6.3)
||All staff have yet to be trained in the new home dialysis process
||Staff were consulted near the end of the project and trained in the new process (4.9)
|Staff have not been involved or trained in the new process (0)
| Staff behaviors toward sustaining change
||Staff ideas are frequently tested to strengthen the change (11.0)
||Score=11.0: Frontline staff were heavily involved in all aspects of the improvement project from start to finish
Are staff encouraged to express ideas?
||Staff suggest ideas, and they are sometimes tested (5.1)
||Staff ideas and experiences helped inform change ideas and Plan-Do-Study-Act cycles
Are staff ideas tested?
||Staff sometimes suggest ideas, but they are rarely tested (5.1)
|Staff do not feel comfortable sharing their ideas to sustain change (0)
| Senior leadership engagement and support Are leaders involved?
Are leaders able to break down barriers?
||Senior leaders are involved, respected, and effective at supporting improvement (15.0)
||Score=6.2: Senior leaders helped to identify the improvement opportunity and attended some of the initial improvement team meetings
||Senior leaders are involved and effective, but staff usually do not seek their input (6.2)
||Frontline staff did not have much contact with senior leaders after the first few Plan-Do-Study-Act cycles
||Senior leaders are somewhat involved and cannot break down major barriers (5.7)
|Senior leaders are minimally involved (0)
| Clinical leadership engagement and support
||Clinical leaders are involved, respected, and effective at supporting improvement (15.0)
||Score=5.5: Clinical leader involvement was similar to senior leadership
|Clinical leaders are involved and effective, but staff usually do not seek their input (6.7)
||Clinical leaders were not visible in their support of the project either to frontline staff or at hospital/divisional meetings
|Clinical leaders are somewhat involved, but not visible in their support (5.5)
|Clinical leaders are minimally involved (0)
| Alignment with strategic aim and culture Is there a record of improvement success?
||The change is consistent with strategic aims, and the organization supports a culture of improvement (7.0)
||Score=3.5: Home dialysis was identified as a local strategic priority by physicians, patients, and healthcare leaders
||The change is consistent with strategic aims, but the organization does not have a record of quality improvement (3.5)
||Your local organization is just beginning to gain experience in quality improvement
|The change has been shared within the organization, but it is not aligned with the strategic aims (3.3)
|The change is not supported by the organization (0)
| Infrastructure Is there space and equipment to support the change?
Do policies support the change?
||Staff are trained, and resources are sufficient to sustain the new process (9.5)Training and resources support the new process, but job descriptions and policies have not been updated (4.4)
||Score=4.4: Plan-Do-Study-Act cycles include details on staff trainingAll staff have yet to be trained in the new home dialysis process
||Training exists, but policies and resources do not support the new process (3.3)
||The new role of dialysis nurse educator has not been formalized as a permanent position by the organization
|No organizational infrastructure has been dedicated to support the new process (0)
A maximum process score is 31.1, a maximum staff score is 52.4, and a maximum organization score is 16.5. An overall score ≥55 has a high probability of sustained success, an overall score <45 is reason for concern, and an overall score <35 requires significant effort to address sustainability limitations. Adapted from Maher et al.
The NHS model is intended to be used longitudinally, but in our experience critical moments are also evident at project planning and implementation. At the project planning stage, any serious issues that threaten sustainability can be addressed prior to dedicating resources and time to a project with little chance for long-term success. At the implementation stage, a sustainability reassessment allows the improvement team to use tools (described below) targeted at the most significant threats to long-term success.
Recognizing when a quality improvement project is ready to be sustained or implemented can be challenging, but several signs exist (5). These include the following:
When a project exhibits these elements, it suggests that the initial phase of improvement work is complete. The next step involves the application of specific tools to sustain improvement.
- (1) The changes have been tested in different conditions with different staff, each providing feedback on performance.
- (2) The necessary infrastructure (personnel, supplies, equipment) exists to support the project long-term.
- (3) The project has achieved a high level of performance for several weeks/months, as indicated on run charts.
- (4) Measures have been identified to monitor performance over time, along with responsibility assigned for performance measurement and reporting.
Quality Improvement Methods to Sustain Improvement
Visual management is a quality improvement principle that allows for the rapid differentiation of normal from abnormal working conditions (8). Its key attributes are transparency, simplicity, and being actionable. A visual management system should be transparent and simple so that every staff member can distinguish normal from abnormal in under 5 seconds (8). Printing yearly reports from a database should not be required to determine whether an improvement project is sustained because at this point results may have already reverted to their prior performance. An actionable system means that once a problem is identified, work is assigned to correct the issue. Two common sustainability tools that use visual management are process control and performance boards.
A process control board displays how much work is required versus how much work is completed in real time. For example, a nephrologist who has 16 patients booked into her 4-hour clinic is required to see four patients every hour. The number of patients actually seen each hour is updated in real time on the process control board, along with the reasons for above- or below-expected performance (i.e., four patients every hour). Tracking the sources of variation allows staff members to visualize problems (e.g., too many new patients scheduled) and address them immediately or at subsequent clinics. Process control boards should be simple to use and interpret and require no more than 5 minutes to complete. In most cases, administrative staff are willing to enter data provided the results are actually used for improvement activities (8).
Based on similar visual management principles, a performance board communicates the outcome of quality improvement efforts to staff. It displays the aim or strategic priority at the top of the board, and the rows depict monthly/quarterly and daily/weekly results (using run charts), along with sources of variation and the current improvement activities to address them. The exact time intervals on the performance board should be tailored to the quality improvement project, with high-volume processes (e.g., target weight attainment) requiring more frequent time intervals than lower-volume processes (e.g., home dialysis training).
Performance boards also represent an organization’s commitment to sustained quality improvement (5). Management and senior leadership are responsible for updating monthly/quarterly results, which provides transparent feedback to staff on both the project’s progress and reasons for achieving or falling short of improvement aims. Performance boards are often reviewed at improvement huddles (discussed later in this article) and also help sustain improvement by creating accountability for results among organizations and staff (5).
Standard work is a simple written or visual description of current best practices to complete a specific process. Standard work often elicits negative reactions in health care but is a fundamental concept for sustained improvement (9). Rather than approach standard work as “cookbook” medicine, it should be perceived as a method to ensure that changes that have improved patient care are consistently and reliably applied to every patient encounter (10). When standard work is in place, it is easier for staff to sustain an improvement process and recognize when a process is no longer completed as intended (8).
Standard work includes a written narrative of the improvement activity that describes the process steps, their sequence, the approximate amount of time required, and personnel responsibilities (10). These principles could be applied to arteriovenous fistula insertion, in-center hemodialysis rounds, and patient flow in predialysis clinics. To increase the likelihood that standard work is followed, some organizations use visual management and place examples of standard work near the location where the process is completed (11). Other institutions design structures to promote standard work, such as order sets and information technology constraints (12). Combining standard work with these change ideas helps sustain improvement by making it more difficult to revert to old habits.
Standard work also helps sustain quality improvement results through other mechanisms. These include the following (8,11):
This final point emphasizes that standard work is not intended to constrain creativity or limit continual improvement (10). Rather, it is meant to establish a new and improved baseline that can be used to reach even higher levels of performance.
- Training goals for new staff so that improvement can be sustained despite staff turnover.
- A transparent method to audit and measure staff performance.
- Another visual management tool to distinguish normal from abnormal work.
- A clear starting point for ongoing improvements.
Improvement huddles are regular 10- to 15-minute meetings among all unit staff to anticipate problems and review current performance (9). Regular meetings should occur daily to weekly, which is necessary to maintain the rhythm and momentum for sustained improvement (13). While the busy health care environment can make meeting attendance challenging, short and consistently scheduled meetings are usually easier for health care staff to attend than conventional hour-long meetings (14). This structure also allows for problems to be corrected quickly, which shifts efforts from problem troubleshooting to problem prevention. In this way, improvement huddles may save more staff time than they consume (9,11).
Huddles are typically held in front of a performance board, which guides the discussion. One staff member facilitates the meeting; the facilitator can be a manager or frontline staff, and the role may alternate according to staff experience and comfort. Another team member should update the performance board to document the ideas that are generated. Performance results should be populated in advance to maximize meeting time (8). The agenda proceeds as follows:
One important pitfall to avoid is penalizing employees for anticipating or recognizing quality-of-care problems. With practice, similar agendas are completed by hospitals in the United States and Canada in 10–15 minutes (7,8). Improvement huddles not only allow frontline staff to solve quality-of-care problems and sustain improvements on a regular basis; they also create engaged staff members and a culture of improvement (5,15). These factors help create an environment or context supportive of quality improvement, which is the next step in understanding why some projects succeed and others fail.
- (1) Review monthly or quarterly performance (1–2 minutes).
- (2) Review daily or weekly performance (1–2 minutes).
- (3) Review current quality improvement projects and Plan-Do-Study-Act (PDSA) cycles (1–2 minutes).
- (4) Discuss reasons for high or low performance (2 minutes).
- (5) Brainstorm change ideas to sustain high performance or address low performance (2 minutes).
- (6) Assign responsibility for the new improvement projects, including the senior leadership support needed to remove barriers (1–2 minutes).
Context Eats Strategy for Breakfast
It is well documented that some quality improvement initiatives result in substantial improvements (16); some, modest improvements (17); and others, no improvement (18). In addition, the success of the same improvement intervention may differ on the basis of the local environment in which it is applied (19). This variation in success has led to skepticism about the effectiveness of quality improvement methods in health care (20). However, this pattern should be familiar to clinicians. Similar to how disease severity and the characteristics of individual patients affect the effectiveness of medical interventions, the characteristics of a quality improvement team and organization can affect the success of quality improvement initiatives. The factors that affect quality improvement work, but that are separate from the technical quality improvement methods described throughout this Moving Points feature, are referred to as context (21,22). To understand context, we must shift our focus from the application of quality improvement methods to the settings, processes, habits, and traditions in which a project operates.
These are several different models to explain context (19,23,24), and it is helpful to organize the factors according to the health care system level affected. The different levels include the external environment, macrosystem, mesosystem, and microsystem (25). Table 2 summarizes contextual factors, stratified by these health system levels. It is important note that the same factors may exert their effects at different levels.
Table 2. -
Contextual factors that influence quality improvement
|Health Care System Level
||Community motivation for change
|Government pressures and incentives
|Project sponsorship by third-party organizations
||Senior management improvement expertise
|Senior management support and leadership
|Organizational culture supportive of improvement
|Organizational improvement experience
|Alignment of improvement work with strategic goals
|Health information technology
|Dedicated improvement office and resources
|Training programs to build improvement capacity
|Presence of a triggering event
|Unit culture supportive of improvement
|Knowledge of improvement methods
|Motivation to change
|Subject matter expertise
|Team familiarity and experience
The external environment refers to community and society, including socioeconomic and political forces. These forces may heighten expectations that can motivate organizations and individuals to improve. In addition, the external environment can incentivize quality-of-care agendas by setting new goals and potentially offering resources to support specific projects. Therefore, aligning a quality improvement project with external forces may increase the likelihood of long-term success (19). For example, a government agency with lower 30-day hospital readmission rates as a strategic priority will be more likely to contribute resources to a quality improvement project targeted at preventing readmissions in hemodialysis patients than a project on the prevention of contrast-induced nephropathy in hospitalized patients.
The macrosystem refers to the organization or hospital in which improvement work occurs. Important contextual factors are related to senior leadership and organizational experience with quality improvement. Senior management help shape the values and norms of an organization, including a culture that is supportive of continuous improvement (19). Management also controls project resources. Without the support of senior leaders, quality improvement risks being perceived by staff as a short-term project rather than the new way to approach a task. Strategies to strengthen one’s macrosystem include involving senior leaders on improvement teams and creating competition between organizations to achieve quality of care targets (21). For example, a single kidney transplant center may have more success with increasing rates of living donation if they join a group of other centers to stimulate competition and shared ideas (often referred to as a quality improvement collaborative), rather than pursuing the initiative independently without senior leader support.
The mesosystem refers to major divisions and interactions within a macrosystem, such as the Department of Medicine, physicians, laboratory services, and health information technology. Patients interact with several of these groups during a single clinical encounter, and so failure to involve a key group can make it impossible to address certain quality-of-care problems. In addition, the mesosystem includes quality improvement infrastructure in the form of data support and training programs. As health information technology improves and becomes more widespread, access to performance and process data will be simpler. These data are critical to successful improvement, and robust data infrastructures facilitated by health information technology can save the improvement team time and illustrate organizational support for a project (21). The importance of health information technology to quality improvement was illustrated in a recent systematic review, in which the presence of data systems was associated with improved team motivation and success (21). Outside of health information technology and data infrastructure, mesosystem factors can be addressed by promoting physician involvement (26), partnering with senior leadership to share data collection responsibilities, and referring to a trigger event (a positive or negative local event that stimulates shared interest in a quality-of-care problem) (19). For example, a team interested in medication reconciliation may enhance collaboration among nephrology, intensive care, and pharmacy by describing a transplant recipient who accidentally had all of his immunosuppressant medications discontinued after a hospital admission for sepsis.
The microsystem represents the frontline clinical units where care is provided and quality improvement projects are introduced. Microsystem contextual factors involve local leadership, the motivation to change, and improvement team dynamics. These factors all directly influence how a team will apply quality improvement methods and implement changes (19). Microsystems are also partly a function of the larger organizations in which they reside. Strategies to strengthen microsystems have been mentioned throughout this Moving Points feature on quality improvement, including physician engagement, interdisciplinary involvement, quality improvement expertise, and leadership support. To increase the likelihood of success, one option is to initiate projects in microsystems with favorable local factors and experience, but this can lead to improvement fatigue if the same microsystem is always used (27). With less experienced microsystems, planning for short-term wins is important to maintain enthusiasm and momentum (28). For example, a hemodialysis unit that is trying to increase the use of advance directives should plan to recognize staff each time such a discussion occurs, as well as the unit when the use of advance directives increases above a small predetermined threshold.
In summary, the success of quality improvement depends not only on the components of the intervention but also contextual factors (29). Even the most well designed project can be rendered ineffective if applied in the wrong setting at the wrong time. As a result, context should be assessed at the start of every project to identify strengths and weaknesses. Furthermore, context should be reassessed whenever an intervention fails to achieve the desired results or cannot be sustained (19).
While your improvement team did not plan for sustainability at the start of the project, the NHS Sustainability Model will still help identify factors that may explain why the initial home dialysis improvements were not sustained (Table 1). At an improvement team meeting, the group completes the NHS tool. Several project strengths and weaknesses become apparent across each of the process, staff, and organization factors. Project strengths include that staff and patients view home dialysis as beneficial, were involved throughout the project, and influenced the new changes and processes. Project weaknesses include that the project may be threatened through staff turnover if new staff are unfamiliar with the processes, there is no formal system to monitor the new home dialysis assessment process, a feeling exists among frontline staff that senior and clinical leaders could be more effective at supporting quality improvement, and the organization in which the project took place lacks experience in sustaining and supporting quality improvement.
Adding up the different sustainability factors in the NHS tool (Table 1), your quality improvement project receives an overall score of 53.7 (a score of 55 or higher indicates a high probability of sustained success). Therefore, the improvement team should address some of the identified project weaknesses to increase the probability that their improvements in the home dialysis process are sustained. To address these issues, the improvement team tests the following sustainability tools using PDSA cycles:
- (1) Standard work for each predialysis clinic staff to help with staff turnover, training of new staff, and existing staff roles
- (2) Process control boards for staff to monitor the number of home dialysis assessments at each predialysis clinic (Figure 1) (these boards could be reviewed at the end of each clinic to ensure that sources of variation are quickly addressed so that current processes and performance are sustained)
- (3) Manager-led improvement huddles at the beginning or end of each weekly predialysis clinic, with management responsible for creating and updating a performance board that is prominently displayed in the predialysis clinic (Figure 2) (this exercise will not only help frontline staff to monitor their performance but also demonstrate to frontline staff the dedication of leadership and the organization to their ongoing efforts to improve healthcare quality).
You realize that many of these changes also address contextual factors (Table 2) and wonder whether some of the success of the quality improvement project is related to the alignment of the project with the priorities of local physicians, patients, and health care leaders. Certainly, this alignment helped the improvement team secure resources and management support that are usually difficult to obtain. A colleague at another facility wants to replicate your team’s project and success, and you suggest they first review their local context to determine whether home dialysis is an appropriate quality-of-care problem for their facility to address at this time. You intend to use this strategy to select the next improvement target so that your project is supported at multiple health system levels to optimize the application of the quality improvement methods that you have learned.
What Are the Next Steps?
Now that sustainability tools are in place, you are ready to begin another quality improvement project. This step involves all of the skills that have been demonstrated throughout this Moving Points feature on quality improvement: improvement team formation, root cause analysis, PDSA cycles, and measurement with run charts. These skills are not a comprehensive list, and we encourage nephrology health care professionals to advance their quality improvement expertise through practice and experiential learning. We all want to provide our patients with the right care at the right place at the right time. This Moving Points feature on quality improvement has provided nephrology health care professionals with the skills to translate their experience into effective system changes for patients. This transformation involves everyone in health care having two jobs every day: to do their work and to improve it (30).
S.S. is supported by a Kidney Research Scientist Core Education and National Training Program Postdoctoral Fellowship (cofunded by the Kidney Foundation of Canada, Canadian Society of Nephrology, and Canadian Institutes of Health Research). G.M.C. is supported by a K24 midcareer mentoring award from the National Institute of Diabetes and Digestive and Kidney Disease.
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