1. Introduce the concept of sustainability as a critical element of quality improvement (QI) projects.

  2. Share Nyaho Medical Center’s experience in sustaining the gains made from QI projects.

  3. Describe key elements of sustaining improvement projects.

According to the Institute for Healthcare Improvement, sustainability is the act of locking in progress and continuously building upon it.[1] Sustaining improvement is not a project that has an endpoint.[2] Integrating a change into the fabric of daily work requires constant effort.

Continuing quality improvement (QI) interventions after a formal QI project ends is crucial. The improvement methodology encourages testing new ideas locally and on a small scale to establish their effectiveness. Testing should be the initial step in establishing high-impact change ideas across the broader system for ideas that demonstrate improvement. It is common for QIs to face the challenge of maintaining changes over time.[3,4]

Improvement and change require effort.[5] After testing and implementing ideas contributing to improvement, it is demoralizing to see a return to old performance levels. To maintain the improvements, it is necessary to take some simple but necessary steps to ensure that the system and performance do not return to old patterns.[1,4,6,7]

In May 2021, Nyaho Medical Center (NMC) recorded an incident regarding a hospital-acquired pressure ulcer (HAPU) of a patient. A facility-based assessment of the incident was conducted. A fishbone diagram was carried out to determine the factors contributing to the HAPU incident.[8,9] The plan-do-study-act (PDSA)[10] cycles (Fig. 1) were used to test the identified change ideas, and run charts were used to analyze and evaluate the improvements made over time. A total of 83 patients were assessed with the pressure ulcer assessment tool during the study period. There was a significant improvement in the number of HAPUs reported (decreased from five to one) during the study period. Complete (100%) adherence to pressure ulcer assessment and standard operating procedures (SOPs) was achieved for all patients, facilitating the improvement in HAPUs.[8]

Figure 1

Sustaining the gains of the hospital-acquired pressure ulcer (HAPU) quality improvement project at Nyaho Medical Center.

Figure 1

Sustaining the gains of the hospital-acquired pressure ulcer (HAPU) quality improvement project at Nyaho Medical Center.

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We took the following practical steps to ensure that improvements were sustained.

  1. Celebrate staff: NMC understands the importance of celebrating individuals to reinforce successful, positive behavior. When we celebrate staff, it makes us know that the change or the process we have now is better than what we had before; that’s why we’re celebrating.

  2. Remove the old systems: To prevent people from resorting to the old system, we eliminated any possibility of using the previous one.

  3. Keep measuring: We developed a metrics dashboard to track whether we still achieve our original aim (outcome measure). This helped us to investigate any deterioration in the system of performance immediately.

  4. Put the approach into practice: We embedded the measurement systems permanently and developed SOPs to reflect the changes in practice. This involved training staff on the new approaches, systems, and SOPs and onboarding newly appointed staff on these approaches.

  5. Create limitations within the system: We created limitations to encourage employees to adhere to the new process.

  6. Continually strive for improvement: At NMC, we understand that our work environment is constantly changing. It is easy for new processes to become outdated and not meet the expected level of performance. We, therefore, ensure a culture of continual improvement to ensure that the gains made are sustained.

QI improvement sustainability involves maintaining the gains of the implemented changes to become the new norm or process. Understanding how to ensure sustainability is of fundamental importance to prevent wasted effort. Table 1 describes key elements of sustainability that should be incorporated into the QI project design at the earliest stage of its development.

Table 1

Key elements of sustainability

Key elements of sustainability
Key elements of sustainability

Maintaining the gains of an improvement project is considered sustainability, even when there is staff and organizational turnover. To prevent wasted effort, it is crucial to understand how to ensure sustainability and the factors that affect it. Including these in the QI project design at the onset of the project’s development is essential.

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Competing Interests

Source of Support: None. Conflict of Interest: None.

This work is published under a CC-BY-NC-ND 4.0 International License.