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Patient Safety Tip
of the Week
July
27, 2021 Sustainability
We’ve all seen it. We implement a quality improvement or
patient safety project and get the results we desire. But 6 months later, we’ve fallen back to old practices and our gains are lost.
This failure to sustain improvement is frustrating, since a lot of work, people
resources, and often political capital usually went into the project(s).
Silver
et al. (Silver 2016) cited one study which noted about 70% of
all change initiatives fail (Nohria 2000) and another which reported that 33% of QI
projects are not sustained upon evaluation 1 year after completion (Maher 2010).
From
our perspective, there are 5 keys to any change management project:
- The
goal(s) must be meaningful
- Communication,
communication, communication…
- Having
enthusiastic champions
- Involvement
of frontline staff
- Buy-in
from those stakeholders most affected
Some might ask “Aren’t the last 2 items the same?”. The
answer is no. In many change projects the overall intended effect is positive,
but there may well be specific groups that are impacted negatively, and those
groups can scuttle the whole project. We’ve always stressed that you must encounter “noise” during
your planning stages prior to implementation. Silence during these stages
usually means you are likely to encounter resistance and barriers once you
begin roll out your project implementation. That silent resistance is also a
major reason that initial success of such projects fails to be sustained.
Note
also our comment about
the meaningfulness of the goals. In our June 8, 2021 Patient Safety Tip of the Week “Cut OR Traffic to Cut
Surgical Site Infections” we emphasized that point. Reduction in OR
traffic is not a meaningful goal in itself. Rather,
the meaningful goal is reduction of surgical site infections. (Reduction in OR
traffic might also produce a desirable reduction in interruptions and
distractions, but even that is an intermediary goal. The ultimate
goal from that would be a reduction in errors that impact the patient.)
The same reasoning may explain why hand hygiene rates are abysmally low in most
facilities and why initial improvement in those rates with QI projects fails to
be sustained. Handwashing rate is not itself the meaningful goal. The
meaningful goal is a reduction in infections. Unless clinicians (and other
healthcare workers) can visually see that infection
rates are improving, they don’t make the connection that their individual hand
hygiene practices are important.
Add
to those factors above the importance of adequate support and resources from
senior leadership and a culture of safety and continuous learning.
Silver
et al. (Silver 2016) used the NHS (UK) Sustainability Model (Maher 2010) in a quality improvement project aimed at
increasing the number of dialysis patients on home dialysis. Silver et al. note
that the NHS model has also informed several other sustainability models,
including the Institute for Healthcare Improvement model (Scoville 2016).
- Process factors
o Benefits beyond helping patients
o Credibility of the benefits
o Adaptability of the improved process
o Effectiveness of the system to monitor progress
- Staff factors
- Staff involvement and training to
sustain the process
- Staff behaviors toward sustaining
change
- Senior leadership engagement and
support
- Clinical leadership engagement and
support
- Organizational factors
- Alignment with strategic aim and
culture
- Infrastructure
Recognizing
when a quality improvement project is ready to be sustained or implemented can
be challenging, but they point out that several signs exist, including the
following:
- The
changes have been tested in different conditions with different staff,
each providing feedback on performance.
- The
necessary infrastructure (personnel, supplies, equipment) exists to
support the project long-term.
- The
project has achieved a high level of performance for several weeks/months,
as indicated on run charts.
- Measures
have been identified to monitor performance over time, along with
responsibility assigned for performance measurement and reporting.
Silver
et al. note the importance of “visual management”. While they note use of process control boards
and performance boards, our take on it is that you need to make the progress
toward and sustenance of your goals readily visible to all relevant
stakeholders.
They
also stress use of “improvement huddles”. These are regular (daily to
weekly) 10- to 15-minute meetings among all unit staff to anticipate problems
and review current performance. These allow for problems to be corrected
quickly, which shifts efforts from problem troubleshooting to problem
prevention.
In a
section “Context Eats Strategy for Breakfast”, Silver et al. note that the
success of the same improvement intervention may differ on
the basis of the local environment in which it is applied. Contextual
factors occur at all levels, including the external environment, macrosystem, mesosystem,
and microsystem.
The type of interventions in your QI project are also
important for ensuring sustainability. In our March 27, 2012 Patient Safety Tip of the Week “Action Plan Strength in RCA’s” we discuss the hierarchy of strength
of interventions. We also provide a Power
Point presentation to
visually show the relative strengths of various interventions. Though these
were discussed in the context of root cause analyses, they also apply to
interventions in any form of quality improvement process. Education and
training always rank low in our hierarchy of effective interventions. The
strongest actions are forcing functions and constraints. For
example, educational or training sessions on avoiding CLABSI’s (central
line–associated bloodstream infections) will get you only so far. But, if you
force staff to do a time out to complete a checklist before they can open a
central line kit, you’ll likely get better results.
One
barrier to sustaining improvement is staff turnover. It is especially important
when bringing new staff into a system that they fully understand the reasons
for your project and the importance of maintaining the improvements you’ve made.
Another barrier to sustainability is failure to identify
what elements in a QI project are actually important.
That’s particularly relevant since we often implement
“bundles” containing multiple interventions at the same time. When we can’t separate out the impact of individual components in
those bundles, it’s pretty easy for staff to begin slacking off on compliance
with some of those components.
Burke
and Marang-van de Mheen (Burke 2021) recently did an editorial on sustaining
quality improvement efforts to accompany a study (Schechter
2021) that showed an initial improvement in pediatric asthma
guideline adherence across 43 community hospitals was associated with
concerning declines in guideline adherence over time.
They
note that QI interventions are more likely to be sustainable if if they simplify clinical workflows. Alexander et al.
(Alexander 2021) also note that changes in work processes
must be “hard-wired” into the day-to-day work including ongoing surveillance to
ensure sustained improvement.
Burke
and Marang-van de Mheen also discuss a barrier we
mentioned above – identifying which components of a QI project are important.
They stress the importance of using PDSA cycles to allow for careful isolation
and refinement of the ‘active ingredient(s)’ and the resources necessary for
the intervention to be effective. The PDSA cycles also are important in
identifying barriers. In our August 2021 What's New in the Patient Safety World
column “Antibiotic Stewardship in Pediatrics” discusses a study by Frost et al. (Frost 2021) on improving delayed antibiotic prescribing
for acute otitis media. You should read the Frost study to see the multiple
barriers that were encountered and identified in the reiterative PDSA cycles.
Burke
and Marang-van de Mheen suggest 3 keys to sustainability:
- Leverage
the role of family and caregivers to design and sustain interventions.
- Avoid
‘low-value’ quality improvement interventions, understanding the problem
may direct to novel tools to solve it. Make it easier to do the right
thing.
- If
common QI tools are the best fit, make them count twice by aligning them
with existing workflows and engaging additional members of the
healthcare team.
The very successful Michigan Keystone ICU Project significantly
reduced central line–associated bloodstream infection (CLABSI) rates and was
able to sustain these improvements. Pronovost et al. (Pronovost 2016) found several factors that aided the
sustainability of the project. The QI teams integrated the intervention into
staff orientation, and active involvement of hospital leaders and the Keystone
Center as well as ongoing monitoring and feedback of performance were important
in sustaining results. And we will add another real key to the sustainability –
the goal was incredibly meaningful to all.
We mentioned above that many (or most) hand hygiene improvement
programs fail to produce sustained results because the “meaningful” focus should
be on infections rather than on hand hygiene per se. Well, we know of at least
one hand hygiene program that got sustained results when the focus was on hand
hygiene itself. McLean et al at Duke University Medical Center (Mclean
2017)
implemented their program on 2 inpatient pediatric units that already had quite
impressive hand hygiene rates. Hand hygiene compliance rates improved from an
average of 87% to ≥95% within 9 months, and this improvement has been
sustained for >2 years on both pediatric inpatient units. They progressively
added interventions in multiple iterations of the PDSA cycle to achieve these
amazing results. Interventions included: (1) increasing awareness, (2)
providing timely feedback, (3) empowering patients and families to participate
in mitigation, (4) providing focused education, and (5) developing interdisciplinary
HH champions. Obviously, those units already had a high culture of safety that
facilitated sustainability. But the fact that each successive PDSA iteration
further improved their outcomes reinforces the importance of not becoming
complacent once you’ve achieved good results.
Sometimes
you need to keep plugging away over the long haul to achieve desired goals
and sustain them. Alexander et al. (Alexander 2021) conducted a quality improvement initiative
over a 36-month period to improve the efficiency and reduce the variation in
the patient handoff process during high-risk, low-volume transfers from the
outpatient setting. The most significant improvement effect occurred in the
third year with a 50% reduction in transfer time. We encourage you to read the
Alexander article for details of the important components that went into their
successful program. And in our August 2021 What's New in the Patient Safety
World column “Antibiotic Stewardship in Pediatrics” we describe a study (Frost 2021) that required a total of 27 PDSA (plan-do-study-act)
cycles to overcome barriers and improve delayed antibiotic prescribing for
acute otitis media.
Achieving
an improvement in a quality improvement project is the easy part. Sustaining it
is the hard part.
Some of our prior columns on RCA’s, FMEA’s,
response to serious incidents, etc:
July
24, 2007 “Serious Incident Response Checklist”
March 30, 2010 “Publicly
Released RCA’s: Everyone Learns from Them”
April
2010 “RCA: Epidural Solution Infused Intravenously”
March 27, 2012 “Action
Plan Strength in RCA’s”
March 2014 “FMEA
to Avoid Breastmilk Mixups”
July 14, 2015
“NPSF’s
RCA2 Guidelines”
July 12, 2016
“Forget Brexit – Brits Bash the RCA!”
May 23, 2017
“Trolling the RCA”
October
2019 “Human Error in Surgical Adverse Events”
January
2020 “ISMP Canada: Change Management to Prevent
Recurrences”
October
2020 “Common Cause Analysis”
References:
Silver
SA, McQuillan R,Weizman AV,
et al. How to sustain change and support continuous quality improvement. Clin J
Am Soc Nephrol 2016; 11(5): 916-924
https://cjasn.asnjournals.org/content/clinjasn/11/5/916.full.pdf
Nohria N, Beer M. Cracking the Code of Change. Harvard
Business Review 2000 ; May-June 2000
https://hbr.org/2000/05/cracking-the-code-of-change
Maher
L, Gustafson D, Evans A: Sustainability model and guide. NHS Institute for
Innovation and Improvement 2010
https://ktpathways.ca/system/files/resources/2019-11/nhs_sustainability_model_-_february_2010_1_.pdf
Scoville
R, Little K, Rakover J, Luther K, Mate K. Sustaining
Improvement. IHI White Paper. Cambridge, Massachusetts: Institute for
Healthcare Improvement; 2016
http://www.ihi.org/resources/Pages/IHIWhitePapers/Sustaining-Improvement.aspx
Burke
RE, Marang-van de Mheen PJ. Sustaining quality
improvement efforts: emerging principles and practice. BMJ Quality & Safety
2021; Published Online First: 17 May 2021
https://qualitysafety.bmj.com/content/early/2021/05/16/bmjqs-2021-013016
Schechter
S, Jaladanki S, Rodean J,
et al. Sustainability of paediatric asthma care
quality in community hospitals after ending a national quality improvement
collaborative. BMJ Quality & Safety 2021; Published Online First: 19
January 2021
https://qualitysafety.bmj.com/content/early/2021/01/18/bmjqs-2020-012292
Alexander
C; Rovinski-Wagner C, Wagner
S, et al. Building a Reliable Health Care System: A Lean Six Sigma Quality Improvement
Initiative on Patient Handoff. Journal of Nursing Care Quality 2021; 36(3):
195-201
Frost,
HM, Monti JD, Andersen LM, et al. Improving Delayed Antibiotic Prescribing for
Acute Otitis Media. Pediatrics 2021; 147(6): e2020026062
https://pediatrics.aappublications.org/content/147/6/e2020026062
Pronovost
PJ, Watson SR, Goeschel CA, et al. Sustaining reductions
in central line-associated bloodstream infections in Michigan intensive care
units: a 10-year analysis. Am J Med Qual 2016; 31: 197-202
https://journals.sagepub.com/doi/10.1177/1062860614568647
Mclean
HS, Carriker C, Bordley WC.
Good to great: quality improvement initiative increases and sustains pediatric health
care worker hand hygiene compliance. Hosp Pediatr 2017;
7(4): 189-196
https://hosppeds.aappublications.org/content/7/4/189.long
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