Sustaining Improvement


How to Cite This Paper:

Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. (Available at


This white paper presents a framework that health care organizations can use to sustain improvements in the safety, effectiveness, and efficiency of patient care. The key to sustaining improvement is to focus on the daily work of frontline managers, supported by a high-performance management system that prescribes standard tasks and responsibilities for managers at all levels of the organization.

To inform this work, we reviewed selected literature and interviewed leading organizations. The result presented in this white paper is a description of high-performance management in theory and practice, along with recommendations for organizations interested in pursuing these methods:

  • A theoretical context for high-performance management, grounded in the Juran Trilogy (Quality Planning, Quality Control, and Quality Improvement) and selected current literature;
  • An organizational framework for a high-performance management system (HPMS), illustrating standard work for each tier of management and the integrated organizational hierarchy that reinforces, supports, and improves work at all levels;
  • A driver diagram that summarizes our theory of the key factors for implementing a HPMS through standardized management tasks, pervasive Quality Control (as defined by Juran to mean monitoring the system and making necessary adjustments to ensure stability over time), coordinated Quality Improvement, and development of a culture of candid transparency that encourages and sustains these activities;
  • Case examples that describe three health care organizations’ approaches to testing and implementing management standard work; and
  • Appendices containing additional guidance for organizations seeking to implement these practices.

Why Is Sustaining Improvement So Important — and So Difficult?

What can frontline clinical managers do to sustain improvement? IHI's Kedar Mate offers guidance.

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