HLTH 5633 Module 6 Sustainability Plan Example

After the Project Team Goes Home: Holding a 96 Percent Critical Result Acknowledgment Rate Once the Hospital's Attention Moves Elsewhere

Student Name

American College of Education

HLTH5633: Advanced Quality Management for Healthcare Administrators

Module 6 Assignment

Instructor Name

August 7, 2028

The Result and Why It Is at Risk

The improvement work that began with an unacted-on potassium of 6.9 mmol/L has reached its aim. From April through June, the six adult inpatient wards acknowledged 95.8, 96.4 and 96.1 percent of critical laboratory results through the responsible nurse or physician inside 30 minutes, and the share waiting longer than an hour fell from 9 percent at baseline to under 1 percent in each of those months. The patient safety committee has declared the aim met. On July 31 the improvement team will disband, the project analyst will return to other reporting and the director of medical-surgical nursing, one of the two executive owners, has accepted a position at another hospital.

This is the point at which gains are usually lost. Wiltsey Stirman et al. (2012) reviewed 125 studies of what happened to health care programs after their initial implementation and found that few used rigorous methods to assess it; among those that did, only a small number reported full sustainment or high fidelity. Partial continuation was far more common than full continuation. The day an aim is declared met is the day the forces that produced the improvement begin to withdraw. The plan that follows assumes that nobody will be paying special attention in six months and asks what must be true for the result to hold anyway.

Sorting the Changes by How Much They Depend on Memory

The event analysis in Module 1 distinguished stronger actions, which change the system, from weaker ones that rely on people remembering. The same distinction predicts which changes will last. Three of the changes are built into systems and will continue unless someone actively removes them. The laboratory's call-tracking module now routes each critical call to the assigned nurse's unit phone using the staffing feed, and escalation to the charge nurse after ten minutes is automatic. The hard-stop alert for the highest-risk results, a potassium over 6.0 among them, must be acknowledged before the chart can be closed. The monthly report runs on schedule without anyone requesting it.

Two changes depend on people. Nurses must carry the unit phone and hand it to a covering colleague during breaks, and charge nurses must complete the three-minute assignment check at the start of each shift. These are the parts of the process most likely to decay, and they receive most of the plan's attention. Silver et al. (2016) describe standard work, a written or visual outline of the current best way to perform a task, as a tool for making improved practice reliable for every patient; both human-dependent steps have been written as standard work and added to the unit orientation checklist so that new nurses learn them as the normal way the unit operates rather than as a project.

Handing Ownership to the Line

During the project, ownership sat with two executives and an improvement team. After July 31, ownership moves to the people who run the wards and the laboratory every day. Each unit manager owns their unit's acknowledgment rate as one of the standing measures on the unit's performance board, reviewed at the existing monthly staff meeting. The laboratory's day-shift supervisor owns the call-tracking configuration and the escalation rule, and must approve any change to either. The hospitalist medical director continues to own the physician response at night. The replacement director of medical-surgical nursing will inherit the executive role, and the handover packet for that position now includes a one-page summary of the aim, the measures and the reasons for each change.

The written reasons matter more than they might seem. A process whose purpose nobody remembers is easy to simplify away; the phone rule, for example, looks like an inconvenience to a new manager who never heard about the patient who arrested. Silver et al. (2016) note that the success of an improvement depends on context, including leadership support and team motivation, and a new leader who understands why the process exists is part of the context that keeps it running.

Monitoring Without a Project Team

Monitoring continues through the automated report designed in Module 4, but its frequency and audience change. Each unit sees a control chart of its own acknowledgment rate monthly. The patient safety committee, which reviewed the measure every month during the project, will now review it quarterly as part of its regular dashboard. The validation sample drops from ten charts a month to ten a quarter, since the data sources have now been stable for a year. The balancing measure for alert volume per nurse stays monthly, because alert fatigue is the most likely way the gain could be undone from the inside.

The control chart is what makes infrequent review safe. Provost and Murray (2011) describe rules for detecting special cause variation on a control chart, among them any one value that falls beyond a control limit and a long run of values that all sit above, or all sit below, the center line. Without those rules, a quiet month at 93 percent will be read either as a crisis or as nothing, depending on who is looking. With them, the committee can treat an ordinary dip as ordinary and respond quickly to a genuine shift.

Triggers That Require a Response

The plan names the signals that require action and who acts on each. A special cause signal showing a decline on any unit's control chart requires the unit manager to review the ten most recent late acknowledgments within two weeks and report the cause to the laboratory supervisor and the executive owner. Any critical result not acknowledged within 60 minutes that is followed by a rapid response call, arrest or unplanned transfer to intensive care goes to the patient safety office for review as a potential event, as in Module 1. A median of more than three critical alerts and calls per nurse per shift on any unit prompts a review of which values trigger the alert.

The plan also treats certain organizational events as triggers, whether or not the data have moved. A change of unit manager, an upgrade to the laboratory or electronic record software, a change of phone vendor or a change to the staffing system each triggers a one-month check of the full measure set and a review of the standard work with the incoming staff. These are the moments when latent conditions are most likely to be created again, often by someone making a reasonable decision without knowing what it will break.

What the Plan Stops Doing

A sustainability plan that keeps every project activity running will not be kept. The weekly improvement huddle ends on July 31. The quarterly nurse survey question on alert burden will run twice more and then be retired unless the alert volume measure shows a problem. The charge nurse assignment check will move from every shift to a random selection of shifts once six consecutive months pass without a failed check. The harm outcome review, adding one field to the safety office's existing event review, continues indefinitely because it costs almost nothing and would detect the most serious failure.

Each of these decisions reduces the total burden of the process, which is itself a sustainability measure. Wiltsey Stirman et al. (2012) identified organizational capacity among the influences on whether programs last, and a process that asks less of busy staff is more likely to fit within that capacity. The plan will be reviewed in full after one year, at which point the committee will decide whether the acknowledgment rate should remain a standing measure or move to annual audit.

Conclusion

The critical result gain will hold if the parts built into systems stay in place and the parts that depend on people are made routine, owned by line managers and checked by a report that runs without a project team. The plan gives each unit a control chart with rules for telling signal from noise, names the events that require a response and who owns it and deliberately retires the activities that were needed only to create the improvement. When the next priority draws the hospital's attention, as it will within months, the wards should keep calling the right nurse because that has become the way the work is done.

References

Provost, L. P., & Murray, S. K. (2011). The health care data guide: Learning from data for improvement. Jossey-Bass.

Silver, S. A., McQuillan, R., Harel, Z., Weizman, A. V., Thomas, A., Nesrallah, G., Bell, C. M., Chan, C. T., & Chertow, G. M. (2016). How to sustain change and support continuous quality improvement. Clinical Journal of the American Society of Nephrology, 11(5), 916-924. https://doi.org/10.2215/CJN.11501015

Wiltsey Stirman, S., Kimberly, J., Cook, N., Calloway, A., Castro, F., & Charns, M. (2012). The sustainability of new programs and innovations: A review of the empirical literature and recommendations for future research. Implementation Science, 7, Article 17. https://doi.org/10.1186/1748-5908-7-17