Table 1

Methods to improve sustainability of common QI interventions, illustrated by published case examples

Methods to improve sustainabilityPublished case examples
Leverage the role of family and caregivers to design and sustain interventionsFrontline staff engagement was identified as a common variable in non-compliant central-line bundle audits, revealing knowledge gaps about bundle components, inadequate dressing changes and documentation gaps for line necessity. Involving a Patient and Family Advisory Board led to a completely different shape of random central line maintenance bundle audits, moving from checklists to directly observed kamishibai card (K-card) audits. The results were displayed on the unit-based kamishibai board in green or red, visible for staff and families in a central location, with failed bundle elements used as coaching opportunities in real-time. Families were also more actively involved to improve compliance (see below), leading to sustained CLABSI reductions and a 97% compliance rate even 2 years following the intervention.25
Patients with implanted cardiac devices (such as pacemakers) requested a ‘one stop shop’ for MRIs where devices could be reprogrammed and scans acquired at a single location and visit. This led to a complete service redesign that increased throughput to 20 times the national average in England, a wait time reduction from 60 to 15 days, and results that were sustained for 2 years.30
Involving patients and caregivers in bedside huddles as part of an intervention to reduce readmissions in patients transferred to the floor from the intensive care unit, led to a doubling in number of days between readmissions and 94% of patients receiving the intervention in 2 years of follow-up.31
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
QI practitioners discovered that legal and institutional barriers were the principal cause of not adhering to revised guidelines and low rates of timely neonatal HBV.27 They worked to change these barriers by formalising the revised HBV recommendations in a HBV hospital guideline, to allow verbal consent (instead of the previously required written consent) and from the other parent than the biological mother (whose medical condition could otherwise induce delay) which greatly improved timely HBV rates in infants in the neonatal ICU. An educational intervention about the importance of HBV or EHR alerts to flag that an infant had not received their vaccine would not have addressed the root problem or created a sustainable fix. After understanding the problem, they were able to create Best Practice Alerts that were supportive of the revised guidelines and fired at the appropriate time depending on birth weight, with a possibility to directly place a HBV order (with administration instructions covering verbal consent from a parent) and thereby greatly facilitated timely vaccination as it was aligned with their workflows.
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 teamIn an intervention seeking to reduce sedative-hypnotic prescriptions in the hospital often used to treat insomnia, ‘education’ of students and housestaff was not effective. Involving pharmacists as additional team members to review new orders for sedative-hypnotics and providing ‘just-in-time teachable moments’ for trainees made it much more effective, combining education and just-in-time audit and feedback.28 Pharmacists also worked with nurses to minimise interruptions to patients’ sleep by rescheduling medication administration times and dimming lights. (education & audit-feedback & workflow)
In a QI project involving families to sustain compliance with central line maintenance to reduce CLABSI, random audits presented an opportunity to educate patients and caregivers using a ‘key card’, to explain what healthcare providers were doing every day to reduce harm, to help them understand these safety practices. Patients and caregivers then served as ‘extended memory’ that shared responsibility for ongoing central line maintenance and felt empowered to speak up.25 (education & audits)
A single hospital system seeking to implement I-PASS to improve handoffs conducted educational and training sessions across more than 6000 staff. They found surgical staff were least likely to use the intervention and explained that the time required did not seem appropriate given their large, relatively healthy elective postsurgical patients. The hospital system decided to use a scaled down version of the I-PASS tool for these patients in the hopes of promoting sustainability32 (adapted intervention and alignment workflow)
  • CLABSI, central-line associated blood stream infection; EHR, electronic health record; HBV, hepatitis B vaccination; ICU, intensive care unit; QI, quality improvement.