The best time to begin thinking about sustaining project gains is at the beginning of your project implementation. Start thinking early on about how your team can make your patient safety processes part of your routine, day-to-day work. For example, include evidence-based best practices for prevention of SSIs and other surgical complications in the policies and procedures related to the care of patients. Consider the types of resources that will be needed for long-term maintenance of your improvement efforts, and start to identify who will be accountable for sustaining the work and how they might incorporate the work into existing processes. Embedding competency testing into new hire orientation and annual skills updates for existing staff are examples of ways to ensure patient safety interventions become part of standard work. Identifying physician or nursing champions for your project to prevent SSIs and other surgical complications will also aid in sustaining improvement over time. See the section below on sustainability from IHI on planning for sustaining improvements.
IHI: Sustaining Improvements in Ambulatory Surgical Safety
The current thinking around sustainability of quality and safety improvement initiatives emphasizes the following four steps to improving sustainability in your ASC: selecting changes that have achieved performance thresholds that should be sustained, predicting their "stickiness," developing the infrastructure for sustainability, and making changes to support systems that will improve your likelihood of sustaining the gains.
Step One: Determine Change Has Achieved Acceptable Levels of Capability and Reliability
The desired changes are those that have reached adequate levels of capability and reliability. Capability means that the change is producing the desired impact on patients or populations, and reliability means that the change is consistently producing this level of impact. If a change has not succeeded in reaching the levels of performance that you hope for your system, focusing on sustainability will result in sustaining subpar performance. Conversely, when you have succeeded in optimizing your system through a series of tests to adapt the changes, and these are reliably being performed, a focus on sustainability will be important. This first step will identify the changes that are ready to be sustained.
Step Two: Develop and Use a Sustainability Prediction Tool To Understand Nature of Change and Context
Once the changes for sustaining are identified, work to apply a sustainability prediction tool. Predicting sustainability yields quantifiable, actionable information on the likelihood that a change will stick in the system. Identify opportunities to improve its "stickiness" or to improve the receptivity of the context. The NHS Sustainability Model is the most widely known and used sustainability prediction tool.6 This tool captures the essence of the key attributes of both the change and its context. Your team can use the tool and the information it yields to strengthen areas of weakness in the change or context that are diagnosed through this process. This tool is really meant as a way of beginning an important dialogue among the teams at the surgery center about the likelihood of sustainability.
Step Three: Develop Infrastructure for Sustainability
Sustainability is the province of leaders at all levels in an organization. Developing the infrastructure for sustainability requires developing standard work for leaders, particularly those leading frontline service delivery units, such as a nurse manager or charge nurse. Effective standard work for leaders includes the following six elements:
- Standardization. Processes to define and disseminate standard work—what to do and how to do it. Having well-defined daily, weekly, monthly, quarterly, and annual tasks related to the particular change at hand is important. An ASC manager should have a clear sense of these tasks, regardless of how they are outlined (in a daily checklist, a huddle board, huddle agenda, etc.).
- Accountability. Processes to review execution of standard work. The organization should have systems to monitor whether staff are implementing standard work. For example, routine observation of surgery timeouts and of other standard practices like huddles can help ensure accountability. Accountability is crucial to maintaining process control, identifying training needs, or uncovering processes that do not work well. Managers can use this information as the basis for improvement of the work unit; evaluation of individual staff performance for promotion or separation is secondary.
- Visual Management. Your organization should have systems that provide information to regulate current period performance in a visual way with an attendant daily communication system to ensure that all key staff are aware of mission critical issues and can take appropriate action. Most often, clinical units track such information using visual metric boards, displayed publicly or semi-publicly, that show key indicators which in turn align with system-wide strategic goals. These visual metric boards are usually accompanied by some form of daily communication process, often in the form of a daily huddle with all team members, to ensure everyone understands the mission of the unit and the key points of vulnerability to heighten awareness and sensitivity of all staff.
- Methods for Problem-Solving. Methods for problems solvable at the front line and skill in improvement methods. Supervisors and frontline staff should have methods available to solve problems as they arise. For example, they can use versions of root cause analysis and Plan-Do-Study-Act cycles to solve problems.7 A3 is also a popular Lean tool for this driver.8 Frontline supervisors and staff should be skilled in these tools and methods, with experts available to provide support as necessary. Without skill in problem-solving methods, other tools to support sustainability like visual boards do not have optimal impact.
- Channels for Escalation. Frontline staff identify and escalate issues that require management intervention to resolve, either directly or through commission of a formal improvement project. Not all problems are readily solvable at the front line. A well-functioning management system includes clear protocols to distinguish problems that should be escalated to higher tiers, and those that might require dedicated improvement initiatives, and also protocols that clarify the appropriate time line for resolving problems that arise at the front line.
- Integration of Standard Work. Goals and standard work are integrated across organizational levels. Frontline leader standard work must be well integrated with frontline clinical standard work. Sustainability practices like huddles and visual boards must also be nested and well integrated up and down the leadership chain within an organization to be continuously reinforced and supported.
Step Four: Change Relevant Support Systems
To sustain, some changes will require changes to human resources including workforce composition or role definition (job descriptions), information systems (how they are used, what data and reports are produced, review procedures, etc.), and potentially to long-term financing. During the steps described above, these changes will hopefully become evident and can be built into the sustainability plan and approach.
More Sustainability Resources
Sustainability Module
The Sustainability module helps an organization maintain and sustain a process that has worked well at a unit level. This module begins by defining sustainability and its importance in quality improvement, linking sustainability and spread, and discussing barriers and solutions to sustainability. The module goes through the steps of developing, implementing, and measuring a sustainability plan.
This module has several objectives:
- Define sustainability and understand the importance of maintaining positive change.
- Understand the link between sustainability and spread.
- Learn how to create and implement a plan for sustainability, including identifying barriers to sustainability, developing solutions, and creating a sustainability plan.
- Establish a sustainability measurement plan to track progress in holding the gains from a successful improvement project.
- Learn from examples of sustainability success across multiple settings.
Management Practices for Sustainability
Through research in multiple health care organizations in the United States and Canada, IHI found that a coherent, interlocking management system was crucial to sustaining standardized practices and promoting a culture of improvement. As part of the AHRQ Safety Program for Ambulatory Surgery, IHI developed a series of online modules as well as accompanying "component kits" to help you introduce these management practices in your center through small tests of change.
6For additional information, see, e.g., National Health Service Institute for Innovation and Improvement. "Sustainability: Ensuring continuity in improvement." [Guide.] http://www.institute.nhs.uk/sustainability_model/general/welcome_to_sustainability.html.
7Go to, e.g., JP Womack et al. Going Lean in Health Care. Institute for Healthcare Improvement [White paper]. 2005.
8Go to, e.g., Shook J. "Toyota's Secret: The A3 Report." MIT Sloan Management Review. 2009. http://sloanreview.mit.edu/article/toyotas-secret-the-a3-report/.
