Starting with the End in Mind: Planning for Sustainability

Successful project planning involves starting with the end in mind, meaning planning for sustainability from the onset. Too often as new projects come in, attention shifts, and backsliding can occur. In the Institute for Healthcare Improvement’s white paper titled “Sustaining Improvement” (2016) key lessons are summarized from high-performing healthcare organizations known for their clinical excellence. This includes a focus on sustainability through continued monitoring of data and processes implemented to ensure consistent performance is maintained at desired levels. If gaps are identified, steps are taken to address the problems. Additional measures for project sustainability include standardization, effective communication, ongoing ownership of project tasks, and celebrating successes. These topics will be explored in further detail.

Continuous Data and Process Monitoring – Keeping your eye on the ball

Visual displays of data can be used on clinical units to highlight areas of focus, prioritize work, and keep the team updated on project status. One way of doing this is through the use of a data dashboard that displays project metrics. This allows for active visibility on a daily basis and serves as a way to bring the work to the bedside and engage frontline staff. Daily discussion of metrics can be incorporated into regularly occurring team meetings or huddles (Scoville et.al., 2016). In addition, audits are often used to monitor processes and determine compliance. Ongoing monitoring of data and processes allows us to determine if goals are initially met and then sustained over the long term.

Once data goals are consistently achieved, one can determine how often to continue monitoring. For example, when conducting audits to monitor processes, once consistent results are achieved, the frequency may be moved out from monthly to quarterly. An important piece of this is determining a goal, for instance,>90% compliance for 3 consistent months, and revisiting the process when not achieving that goal versus continuing to do audits with no improvement or end in sight.

Case Example

As part of a quality improvement effort to reduce the primary cesarean delivery rate, a quality improvement program focusing on safe care during labor is implemented. The focus is on integrating measures that are protective of the fetus, facilitate rotation and descent, and overall promote safe vaginal birth: frequent maternal reposition changes, routine evaluation of progress, identification and treatment of fetal malposition, corrective measures with fetal heart rate/uterine abnormalities, and safe use of oxytocin.

The outcome measure is PC-02, term nulliparous singleton vertex cesarean delivery, and a balancing measure identified is the unexpected complications in term newborns, PC-06. Some of the process measures include audits on maternal repositioning, and corrective measures performed with fetal heart rate/uterine abnormalities. A dashboard is placed on the unit, displaying the primary cesarean and unexpected term newborn rate. This enables frontline staff to have day-to-day visibility on these metrics, thus building awareness into the everyday structure. Process measures are manually collected and shared in various forums.

Standardization

Standardization involves the development of detailed, step-by-step, processes for frontline staff and leadership. This could be in the form of checklists or algorithms. The benefit of standardizing processes is that everyone is doing it, in the same manner, each and every time, thus reducing variation. In addition, these processes should be time and resource-efficient, effective, based on best practice, and patient-centered.

The following is an example of a standardized format for a team meeting:

The charge nurse announces the daily huddle
SBAR report out by nursing staff using an SBAR tool
The team meeting checklist, verbally reviewed by the charge nurse, includes the following items to be addressed:
- Staffing concerns
- Physician/resident coverage changes
- Potential or actual upcoming cesarean deliveries or operative procedures
- Any abnormalities noted include but are not limited to prolonged labors, abnormal vital signs, or concerns for a shoulder dystocia
- HIgh-Risk patients- potential and current
- Patients with vaginal packing in place
- Newborns that require head surveillance monitoring s/p instrumental or difficult delivery
- OB emergency team members

This standardized team meeting format is built into the everyday structure of the unit and also serves as a reminder for other standardized, safety processes. Building standardized processes into the everyday structure is one way to achieve sustainability.

Effective Communication with your team

Ongoing, effective communication should occur with the core project team and with the greater multidisciplinary team involved in patient care. Using a multi-faceted approach often reaches the greatest number of staff and can include unit meetings, department meetings, emails, staff huddles, and grand rounds presentations. Sharing of data on a regular basis is another way of keeping the team updated on project status. As previously mentioned, it is ideal to have a visual data display on the unit. If this is not possible, sharing the data in the various communication methods discussed above would also be appropriate.

Ongoing Ownership

Putting plans in place for ongoing ownership is important. This involves organizing and assigning tasks to team members for both pre and post-project implementation. This structure ensures that the work is evenly distributed among the team and engages others in the process. It truly takes a village!

Project trackers are an effective tool to assist with organization and delegation. Essentially this is a document that lists out the project tasks, owners, start and end dates, and percentage completion. The idea is that owners report on these items at the project meetings. Once goals are achieved, new targets can be set with ongoing owners assigned. See the example for a basic template idea.

Celebration of Successes

Last but not least is celebrating successes and pausing to acknowledge the good work done. It’s easy to move on to the next thing, however, recognizing staff for their efforts is so important. This can be done in a variety of ways: verbal recognition at meetings and huddles, written recognition through staff emails, and celebrating with food. In addition, encouraging presenting this information at conferences or creating a publishable product is another way to highlight the work.

In summary, sustaining improvement work takes thoughtful consideration to the planning process including building in sustainability from the onset. This involves project planning with delegated task ownership, integrating standardized processes, keeping an eye on how things are working and evolving, fixing problems as they are identified, effective team communication, and lastly, celebrating the wins.

References

Scoville, R. (2017) 6 Essential Practices for Sustainable Improvement. Retrieved from http://www.ihi.org/communities/blogs/six-essential-practices-for-sustainable-improvement

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