How to Sustain Change and Support Continuous Quality Improvement

Abstract

To achieve sustainable change, quality improvement initiatives must become the new way of working rather than something added on to routine clinical care. However, most organizational change is not maintained. In this next article in this Moving Points in Nephrology feature on quality improvement, we provide health care professionals with strategies to sustain and support quality improvement. Threats to sustainability may be identified both at the beginning of a project and when it is ready for implementation. The National Health Service Sustainability Model is reviewed as one example to help identify issues that affect long-term success of quality improvement projects. Tools to help sustain improvement include process control boards, performance boards, standard work, and improvement huddles. Process control and performance boards are methods to communicate improvement results to staff and leadership. Standard work is a written or visual outline of current best practices for a task and provides a framework to ensure that changes that have improved patient care are consistently and reliably applied to every patient encounter. Improvement huddles are short, regular meetings among staff to anticipate problems, review performance, and support a culture of improvement. Many of these tools rely on principles of visual management, which are systems transparent and simple so that every staff member can rapidly distinguish normal from abnormal working conditions. Even when quality improvement methods are properly applied, the success of a project still depends on contextual factors. Context refers to aspects of the local setting in which the project operates. Context affects resources, leadership support, data infrastructure, team motivation, and team performance. For these reasons, the same project may thrive in a supportive context and fail in a different context. To demonstrate the practical applications of these quality improvement principles, these principles are applied to a hypothetical quality improvement initiative that aims to promote home dialysis (home hemodialysis and peritoneal dialysis).Clin J Am Soc Nephrol 11: 916-924, 2016. doi: 10.2215/CJN.11501015 Clinical ScenarioIn 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 a...

Evaluating implementation and impact of a provincial quality improvement collaborative for the management of chronic diseases in primary care: the COMPAS+ study protocol

“…3) QI project follow-up phase After the workshop, the local implementation committee will meet with an INESSS QI team a minimum of four times over the next 18 months to finalize or refine local QI action plans and review progress with the implementation of QI projects. These meetings will actively engage local committees in the appropriate use of the Model for Improvement and use (a) active facilitation strategies to clarify QI objectives and activities and facilitate repeated small-scale improvement cycles, and (b) process control charts -a visual tool that displays objectives, indicators, activities and responsibilities -are used to support the team [45].…”

A Practical Guide to Performance Improvement: Tools and Tips to Sustain and Control Project Improvements

“… be aligned with the organization's goals and strategic plan; have a substantial effect on patient care or work processes and not be too narrowly focused; address any operational challenges, including the need for additional resources to complete the project so that competing priorities do not cause delays; have the appropriate leaders available for engagement and support; identify the strategic payoff or “quick wins” that could drive momentum for a larger project; have the necessary resources available to support the work required (eg, funding, time, personnel, culture supportive of the improvement); and result in a sustainable transformation …”

“…The visual management or PI board is a tool that allows all staff members to see the current PI project's positive and negative progress . The board should be concise so the casual observer can quickly discern when to act.…”

“…Although departmental and PI team leaders should ensure the PI board is kept current, the organization may benefit from involving frontline staff members in the updates because they may be the ones responsible for the processes and maintaining the improvements. When displaying data, personnel should use a consistent format and style that coincide with the data display methods employed elsewhere in the facility.…”

How to Measure and Interpret Quality Improvement Data

“…This expected improvement in the patient-level outcome measure needs to be verified over the longer term, by constructing another run chart documenting dialysis modality at 6 months after initiation (the outcome measure). If independent dialysis numbers do not, in fact, increase, this may suggest a failing in the root cause analysis or factors in the local environment that are impacting success (12).…”