Sustaining quality improvement efforts: emerging principles and practice

Abstract

Do we care if a quality improvement (QI) innovation is effective, if it is not sustained? This uncomfortable question is increasingly important as healthcare is judged (and reimbursed) on ‘quality’ and ‘value’. Often, a sentinel safety event or dip in performance on a quality measure tied to reimbursement spurs a ‘quick fix’ mentality. However, considering how to ‘fix the problem’ in such a way that it is permanently fixed—in other words—that the ‘fix’ becomes part of everyday practice routines, is essential. This is not easy. Reviews of the extant literature point out how little we know about how to do this successfully1–4 and conceptual models drawing on this literature also vary widely in what they consider to be important key contributors to sustainability.5–9 When empirical literature does exist, it often demonstrates the lack of sustainability of QI interventions,10 11 and almost no studies describe how QI interventions became adopted in practice and why.12 13 At some point, the active implementation of a QI intervention ceases at the end of a local QI project or larger multicentre collaborative. Research that carefully describes which components of an intervention remain, which ones end and why, is essential to understanding why the effects of some QI interventions on processes or outcomes are sustained. In this context, we welcome the substantial contribution to the empirical literature that Schechter et al make in this issue of BMJ Quality & Safety .14 The authors describe how the pathway for improving paediatric asthma care (PIPA) intervention was rolled out across 45 community hospitals during the national QI collaborative, focusing on early administration of bronchodilators via metered-dose inhalers, screening for secondhand smoke exposure and caregiver referral to smoking cessation resources, if appropriate. The collaborative lasted 12 months. Prior to its end, the investigators approached …

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