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At first glance, improvement work may seem linear. It appears to have a beginning, middle, and end:

• Identify a problem that needs improvement.
• Test solutions you believe will improve the outcome.
• Hardwire changes into the processes and system.
• Sustain the new, improved level of performance.
• Spread the ideas to more people and prepare the structures to support the new process.

Easy, right? In reality, improvement is most often successful when these steps are done in an “overlapping” or parallel approach rather than sequentially.

Let’s consider sustainability, for example. The key to sustaining improvement is the possibly counterintuitive idea that you need to plan for “holding the gains” before you achieve the improvement you want to sustain.

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The following areas, when considered early in an improvement effort, may help to plan for sustainability:

• Identify one or two measures that are critical to the sustainability of your improvement effort and decide on a data collection and monitoring process. Typically, improvement efforts use a discrete set of measures to monitor improvement. Often this includes outcome, process, and balancing measures.
  
  After you see improvement, and are confident that the changes are being sustained, you can take a step back from data monitoring. However, for sustainability, you need to continue measuring outcomes data over time. The other measures can be reviewed, if needed. (You may, for example, review process measures if you see the outcome data moving in an undesirable direction.)
  
  Additionally, you may want to reduce the frequency of data collection. For example, if you were collecting the data weekly, you could move to monthly or even quarterly. Link this new timing to other periodic activities during which it makes sense to review the data (e.g., monthly or quarterly team meetings).
  
  You should also decide what signals in the data will trigger investigation. For example, three consecutive data points above the median might be reason to look more closely at what is happening.
  
• Involve the owner of the process. Members of QI teams are often from multiple departments. This should include the owner of the given process. The process owner — or person who authorizes changes and is responsible for sustaining improvements — should have oversight of the staff involved and authority to allow testing. Their input and buy-in is vital because they have subject matter expertise and will oversee how QI learnings are incorporated into future work.
• Develop a communication and training plan about improvements and learning. Consider who needs to know what, when and how often they need to know it, what method would work best, and who should be the one sharing it. For example, you may invite your senior sponsor to your team meeting once a quarter for 20 minutes. You could post your PDSA cycle learning in your waiting room every week and ask for patient feedback. Your QI team leader might periodically connect one-on-one with the neighboring department leader so they are more prepared for spread.
  
  Think creatively and with adult learning principles in mind when preparing to train current and new staff. Information retention is often more effective with “at the elbow” peer-to-peer support or “just-in-time” training that is done when the work is taking place. These options are less resource-intensive than classroom training and help move people from awareness to action. You can use PDSA cycles to determine the training method that is most effective. 
  
• Hardwire changes. There is nothing more frustrating than seeing people operate the “old way” — despite evidence of improvement — because they’re unable to incorporate the changes into their work. Make it easy to use the “new way” by preparing for infrastructure changes and the resources needed to support the improved process. For example, plan for how to update documents, tools, standard work, policies, procedures, job descriptions, information flows, the electronic record, equipment, and maintenance, etc. to align with and maintain the changes.
• Assess how change(s) may affect staff workload. Changes that add work to the system are harder to sustain. Changes that decrease workload have a higher chance of success over time. The improvement effort itself means more work because the old process and testing of a new process happen simultaneously. However, when moving to implementation, consider how to take away the “old” ways and move to the new process. Ideally, the improvement has removed work and made people’s jobs easier and more efficient.

It’s exciting to see QI efforts result in better care or more efficient processes. Use IHI’s Sustainability Planning Worksheet to help you plan for success and make sure your hard-won improvements stick.

Lauren H. Macy is an IHI Improvement Advisor and faculty for the IHI Quality Improvement Practicum.

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