BackgroundImprovement initiatives offer a valuable mechanism for delivering and testing innovations in healthcare settings. Many of these initiatives deliver meaningful and necessary changes to patient care and outcomes. However, many improvement initiatives fail to sustain to a point where their full benefits can be realised. This has led many researchers and healthcare practitioners to develop frameworks, models and tools to support and monitor sustainability. This work aimed to identify what approaches are available to assess and influence sustainability in healthcare and to describe the different perspectives, applications and constructs within these approaches to guide their future use.MethodsA systematic review was carried out following PRISMA guidelines to identify publications that reported approaches to support or influence sustainability in healthcare. Eligibility criteria were defined through an iterative process in which two reviewers independently assessed 20% of articles to test the objectivity of the selection criteria. Data were extracted from the identified articles, and a template analysis was undertaken to identify and assess the sustainability constructs within each reported approach.ResultsThe search strategy identified 1748 publications with 227 articles retrieved in full text for full documentary analysis. In total, 62 publications identifying a sustainability approach were included in this review (32 frameworks, 16 models, 8 tools, 4 strategies, 1 checklist and 1 process). Constructs across approaches were compared and 40 individual constructs for sustainability were found. Comparison across approaches demonstrated consistent constructs were seen regardless of proposed interventions, setting or level of application with 6 constructs included in 75% of the approaches. Although similarities were found, no approaches contained the same combination of the constructs nor did any single approach capture all identified constructs. From these results, a consolidated framework for sustainability constructs in healthcare was developed.ConclusionsChoosing a sustainability method can pose a challenge because of the diverse approaches reported in the literature. This review provides a valuable resource to researchers, healthcare professionals and improvement practitioners by providing a summary of available sustainability approaches and their characteristics.Trial registrationThis review was registered on the PROSPERO database: CRD42016040081 in June 2016.Electronic supplementary materialThe online version of this article (10.1186/s13012-017-0707-4) contains supplementary material, which is available to authorized users.

Healthcare systems redesign and service improvement approaches are adopting participatory tools, techniques and mindsets. Participatory methods increasingly used in healthcare improvement coalesce around the concept of coproduction, and related practices of cocreation, codesign and coinnovation. These participatory methods have become the new Zeitgeist-the spirit of our times in quality improvement. The rationale for this new spirit of participation relates to voice and engagement (those with lived experience should be engaged in processes of development, redesign and improvements), empowerment (engagement in codesign and coproduction has positive individual and societal benefits) and advancement (quality of life and other health outcomes and experiences of services for everyone involved should improve as a result). This paper introduces Mental Health Experience Co-design (MH ECO), a peer designed and led adapted form of Experience-based Co-design (EBCD) developed in Australia. MH ECO is said to facilitate empowerment, foster trust, develop autonomy, self-determination and choice for people living with mental illnesses and their carers, including staff at mental health services. Little information exists about the underlying mechanisms of change; the entities, processes and structures that underpin MH ECO and similar EBCD studies. To address this, we identified eight possible mechanisms from an assessment of the activities and outcomes of MH ECO and a review of existing published evaluations. The eight mechanisms, recognition, dialogue, cooperation, accountability, mobilisation, enactment, creativity and attainment, are discussed within an 'explanatory theoretical model of change' that details these and ideal relational transitions that might be observed or not with MH ECO or other EBCD studies. We critically appraise the sociocultural and political movement in coproduction and draw on interdisciplinary theories from the humanities-narrative theory, dialogical ethics, cooperative and empowerment theory. The model advances theoretical thinking in coproduction beyond motivations and towards identifying underlying processes and entities that might impact on process and outcome. Trial registration number The Australian and New Zealand Clinical Trials Registry, ACTRN12614000457640 (results). The new ZeiTgeisT: pArTiCipATionThe current preoccupation with methods for citizen engagement, public participation and involvement of people with lived experience in health system redesign and service improvement might be said to represent the new Zeitgeist-the spirit of our times.

This paper looks at the management of ser vice innovation. In particular it explores the challenge of public services and argues that there is a need for new approaches to the ways which engage users as more active co-creators within the innovation process. It draws on wider research on radical innovation being carried out as part of a long-term international programme and reports on a series of case studies of experiments in the health sector in the UK using tools like ethnography and prototyping to enable innovation.. The paper argues that a potentially valuable toolkit can be found in the field of design methods. By their nature design tools are used to help articulate needs and give them shape and form; as such they are critical to the 'front end' of any innovation process. Methods like ethnography allow for deep insights into user needs, including those not clearly articulated whilst prototyping provides the possibility of creating a set of 'boundary objects' around which design discussions which include users and their perspectives can be carried out.

There has been a surge in experience-based co-design (EBCD) efforts for quality improvement in health care and systems design globally. Service users together with staff are playing a far greater role than ever before in the redesign of services and systems of care. EBCD offers a systematic, bottom-up approach to improving service user and staff experiences of care. There is growing interest in the application and potential of EBCD; however, studies indicate common shared challenges, which coalesce around power, commitment to the process, methods for gathering experiences, designing improvements, implementation, and subsequent impact.

PurposeThe purpose of this paper is to describe a study which aims to provide an alternative approach to clinical governance. This involves patients in redesigning services based on their actual experiences of health services. This will be of interest to front line health care staff and public and patient involvement leads.Design/methodology/approachThe paper illustrates Experience Based Design (EBD) as a structured, formal methodology with clearly defined roles, actions and timescales. A case study approach is used to describe the implementation of this model in a District General Hospital.FindingsThis study demonstrates how three theoretical components of good design: functionality, engineering and aesthetics can be used as a framework to improve performance, safety and governance and in addition, actual experience of the service for patients and staff.Research limitations/implicationsThe case study approach used has provided a good range of learning and transferable information; however, the results are currently based on a single site.Practical implicationsThe use of the EBD approach will ensure that healthcare services truly reflect the needs of patients and carers based on their specific experience. It provides a mechanism whereby patients' views contribute fully to the change process leading to safer, more effective and reliable care. This approach will require the application of the non‐clinical competencies included in the Medical Leadership Competency Framework and specific health and wellbeing dimensions in the Knowledge and Skills Framework.Originality/valueThis paper offers a new model that can be incorporated into service redesign. The model enables greater understanding of clinical governance as described by patients through narrative of their actual experiences.

Background: Online electronic records such as patient portals and personally controlled electronic health records (PEHRs) have been widely viewed as a key component to modernising the delivery of healthcare but the uptake of such systems has been slow. Objective: The purpose of this literature review was to determine what influences consumers to engage and interact with their clinical data online. Method: A scoping literature review following PRISMA guidelines was completed. Electronic patient record research published between January 2009 and December 2018 was included. Following screening and full-text reviews, a total of 64 records were included in this review. Results: Three key areas of influence on consumer engagement with their clinical data online emerged: demographic factors affecting consumer interaction with PEHRs; consumers’ perceived benefits and detriments of PEHR use; and the influence of PEHR use on consumer empowerment and responsibility. Discussion: Consumer motivation and readiness for engaging with their clinical data online and their long-term ongoing use of these systems requires further exploration. Conclusion: As worldwide rates of consumer interactions with individual online clinical data remain low, what influences consumer engagement with a PEHR remains unknown. Further research into the consumer perspective of, and interaction with, a PEHR, needs to be undertaken to determine if factors such as frequent usage of the system by consumers leads to improved clinical outcomes.

Experience-based co-design (EBCD) is a quality improvement approach that is being used internationally to bring service users and health professionals together to improve healthcare experiences, systems and processes. Early evaluations and case studies of EBCD have shown promise in terms of improvements to experience and organisational processes, however challenges remain in participation around shared power and decision making, mobilisation for implementation, sustainment of improvements and measurement of outcomes. The objective of this case study was to explore the emergent issues in EBCD participation and implementation in six quality improvement projects conducted in mental health, rehabilitation, blood and bone marrow transplant, brain injury rehabilitation, urinary incontinence and intellectual disability settings by the Agency for Clinical Innovation (ACI), New South Wales, Australia (2015-2018). Methods: A two stage process of analysis was employed. The first stage involved a case to case synthesis using a variable-oriented approach. In this approach themes were identified within individual cases and compared across cases in workshops with all project leads. In the second stage the case themes were synthesised within an overarching thematic that was identified as the main challenge in effective participation and implementation in these EBCD projects. The results: themes identified in the first stage of analysis related to different methods for gathering experiences and the activities used for the co-design of improvements. Variability in service user participation within co-design workshops was also discussed. Four out of the six projects implemented improvements in full. The prominent thematic overarching all six EBCD cases was the need for guidance on capability development and co-design preparedness for all participants in co-design not only project leads. In conclusion, variability in EBCD implementation makes it difficult to identify which component parts are essential for improving experiences and services, and which of these lead to sustained changes and benefits for service users and health professionals. One way to address this is to develop a model for codesign capability and preparedness that is closely linked with a set of eight mechanisms that have been previously identified as essential to achieving change in healthcare improvement initiatives.

Background Numerous models, tools and frameworks have been produced to improve the sustainability of evidence-based interventions. Due to the vast number available, choosing the most appropriate one is increasingly difficult for researchers and practitioners. To understand the value of such approaches, evidence warranting their use is needed. However, there is limited understanding of how sustainability approaches have been used and how they have impacted research or practice. This review aims to consolidate evidence on the application and impact of sustainability approaches in healthcare settings. Methods A systematic scoping review was designed to search for peer-reviewed publications detailing the use of sustainability approaches in practice. A 5-stage framework for scoping reviews directed the search strategy, and quality assessment was performed using the Mixed Method Appraisal Tool. Searches were performed through electronic citation tracking and snowballing of references. Articles were obtained through Web of Science, PubMed and Google Scholar. Six outcome variables for sustainability were explored to ascertain impact of approaches. Results This review includes 68 articles demonstrating the application of sustainability approaches in practice. Results show an increase in the use of sustainability approaches in peer-reviewed studies. Approaches have been applied across a range of healthcare settings, including primary, secondary, tertiary and community healthcare. Approaches are used for five main purposes, namely analysis, evaluation, guidance, assessment and planning. Results outline benefits (e.g. improved conceptualisation of sustainability constructs and improved ability to interpret sustainability data) and challenges (e.g. issues with approach constructs and difficulty in application) associated with using a sustainability approach in practice. Few articles (14/68) reported the sustainability outcome variables explored; therefore, the impact of approaches on sustainability remains unclear. Additional sustainability outcome variables reported in retrieved articles are discussed. Conclusions This review provides practitioners and researchers with a consolidated evidence base on sustainability approaches. Findings highlight the remaining gaps in the literature and emphasise the need for improved rigour and reporting of sustainability approaches in research studies. To guide future assessment and study of sustainability in healthcare settings an updated list of sustainability outcome variables is proposed. Trial Registration This review was registered on the PROSPERO database CRD 42016040081 in June 2016.