The sustainability of a quality improvement initiative

Abstract

Functional decline in seniors admitted to hospital is due in part to lack of mobilization. Many Quality Improvement (QI) initiatives targeting mobilization of the elderly population in acute care exist; however, their long-term effectiveness is not well-documented. Mobilization of Vulnerable Elders (MOVE) was a grant-funded initiative that started in Ontario and spread to Alberta. The primary objective of this project was to ascertain the sustainability of the MOVE project 1 year post implementation at two hospital sites in Alberta, Canada. Qualitative and quantitative cross-sectional data were gathered from multidisciplinary healthcare professionals. Our findings suggest MOVE was not well-sustained one year post implementation. Examination of specific survey questions provided an indication of strengths and weaknesses of the MOVE QI. Sustainable and cost-effective QI targeted at this elderly patient demographic could alleviate some of the demand on the healthcare system. Modifications to improve the sustainability of MOVE are summarized.

Introduction

By the year 2036, 25% of the Canadian population will be seniors, a rise from 16% in 2015.^1,2 Already this demographic accounts for nearly 50% of healthcare spending,³ and their acute care hospital admissions often result in undesired costly outcomes such as reduced physical function, cognitive impairment, hospital-acquired infections, pressure ulcers, deep vein thrombosis, longer institutional stays, and prolonged waiting for placement in long-term care. Research has linked these negative outcomes, in part, to lack of mobilization and prolonged bed rest in hospital.^4,5 Regardless, bed rest remains overprescribed and ambulation neglected in inpatient geriatric nursing care.^6
–8

To decrease strain on the healthcare system, an increasing number of elder-friendly hospital units, programs, and Quality Improvement (QI) initiatives incorporated mobilization into daily care.^9

–12 Research that concentrates on the sustainability of these QI interventions in healthcare is deficient. A group of Canadian researchers implemented an interdisciplinary early mobilization QI program for seniors called Mobilization of Vulnerable Elders (MOVE).¹³ This QI, developed in Ontario, Canada, intended to change the practices of acute care staff and shift to a unit culture where seniors would engage in progressive and scaled mobilization. Subsequently, MOVE was adopted in Alberta, Canada, by the Seniors Health Strategic Clinical Network. The research group in Ontario evaluated outcomes in 14 hospitals 20 weeks post implementation with positive results.^14,15 A plan to measure sustainability after 20 weeks was not included in the MOVE initiative in Alberta or Ontario. At a time when healthcare spending is of utmost concern, we should be monitoring the effectiveness of these new interventions, especially when funded by government grants. The purpose of this project was to ascertain whether the MOVE QI was sustained 1 year following the intervention at two Alberta hospitals and identify impediments to the sustainability of this initiative.

Methods

Both quantitative and qualitative data from a multidisciplinary group of healthcare professionals employed on three acute care units at two hospitals in Alberta were collected using a cross-sectional survey. Approval was obtained from the University of Calgary Conjoint Health Research Ethics Board (REB16-1381) and from Alberta Health Services provincial research administrators.

The project took place in the fall of 2016 in two hospitals: one urban (hospital A) and one rural (hospital B). The hospitals, separated by over 300 km, belong to Canada’s largest integrated provincial health system; they have similar staff to patient ratios and are dominated by an elderly patient demographic. A convenience sample of employees in a healthcare provider role employed on one of the three units at the time of data collection were invited to complete the survey. This project was conducted 1 year post implementation of the MOVE QI.

The MOVE Sustainability Survey consisted of 21 Likert-type scale questions and a comment box. The development of the moderate sustainability score was guided by the National Health Service’s (NHS) Sustainability Model.¹⁶ The NHS Sustainability Model provides a publicly available diagnostic tool that can identify strengths and weaknesses in an initiative, predict the likelihood that an improvement will last, and provide recommendations to increase sustainability.¹⁶ The NHS tool is spread over three subscales: (a) process, (b) staff, and (c) organization. Supplementary items were added to the moderate sustainability score to capture staff perceptions about specific aspects of MOVE, namely principles and education. Face validity and usability was established by distributing the survey to co-workers of the primary researcher at a long-term care facility within Alberta.

Statistical methods

The moderate sustainability score had a scoring range of 17-84; data were treated as interval level using SPSS version 24. For most individual survey items, a higher score indicated a greater level of sustainably achieved; four survey items (17, 18, 19, 20) used a reversed coding scheme. Nominal variables included profession, hospital, participation in initial MOVE project, and shift type. A Cronbach α was determined to be α = .88, indicating good internal consistency of the survey questions. A value of P < .05 indicated statistical significance throughout all inferential analyses.

Thematic analysis

A final survey question asked: Are there any other comments you would like to make about the MOVE initiative? Themes were derived inductively, with themes coming from the data versus the literature. Comments were organized by profession and hospital into positive, negative, or neutral categories. This sorting helped to discern staff feelings toward the MOVE initiative and provided a broad sense of sustainability.

Results

The response rate was 30.8% (n = 84) from 272 eligible participants. Forty-four percent of respondents also provided qualitative feedback data. An equal number of surveys (n = 41) came from each hospital, with 57% of participants indicating they had not participated in the MOVE initiative. A small proportion of respondents (5%) worked only night shift. Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) comprised the largest proportion of participants (38% and 30%, respectively). This was representative of overall staff mix; RNs and LPNs comprised 75% of both hospitals’ employees.

Survey scores

An overall low-moderate sustainability score of Mean (M) = 53.09 (Standard Deviation [SD] = 10.81) was achieved across both sites. An independent t test revealed a statistically significant difference between hospital mean scores t(75) = −5.57, P = .00. Hospital A had a moderate overall score (M = 59.13; SD = 9.05), while hospital B had a low score (M = 47.50; SD = 9.25).

Comparing professions

The largest proportion of employees and of survey participants was RNs, and they had the lowest average score (Figure 1). An analysis of variance revealed no statistical differences in scores when comparing the three largest groups of respondents (ie, physical and occupational therapists, RNs, and LPNs; P > .05).

Examining the moderate sustainability score subscales comparing hospitals

Independent sample t tests revealed significant differences (P < .05) in mean scores for process, staff, and organization subscales. Hospital A scored significantly higher in all three of these subscales. Hospital B scored higher in the principles and education subscales; however, these differences were not statistically significant.

Since significant differences existed between hospitals, we examined descriptive statistics to gain insight. Of the 41 participants from hospital B, 38 (92.6%), 39 (95.1%), and 36 (87.8%) responded neutral, disagree, or strongly disagree to all statements within the process, staff, and organization subscales, respectively. These were significantly higher proportions of negative responses compared to hospital A respondents (P < .05).

Lowest scoring items: Cause for concern

Overall, the lowest scoring item for both hospitals was: Getting patients up out of bed for a walk creates more work for nurses and other unit staff (M = 2.51; Median [Mdn] = 2.00). Over 58% (n = 48) of respondents from both hospitals agreed or strongly agreed with this item (Table 1). This was the lowest scoring item for hospital A (M = 2.54; Mdn = 2.0) where 23 (56.10%) participants agreed or strongly agreed (Table 1). Two items had equally poor scores for hospital B: The results of MOVE were discussed on my unit, and MOVE is still being monitored on my unit and new staff are informed about MOVE and the importance of mobilizing elderly patients. Thirty-two (78.04%) (M = 1.9; Mdn = 2.0) participants disagreed or strongly disagreed with these statements.

Table 1.

Itemized survey results: Comparing hospitals

Survey item	Hospital A		Hospital B
Survey item	M	%	M	%
I believe MOVE has benefits beyond helping patients.	4.02	80.4	3.22	64.4
I understand the benefits of MOVE and they are easy to describe.	3.97	79.4	2.87	57.4
MOVE continues to inform my practice OR changes the way I work.	3.59	71.8	2.55	51.0
The results of MOVE were discussed on my unit, and MOVE is still being monitored on my unit.	3.24	64.8	1.90	38.0
I felt included in MOVE when it started on my unit, and I feel confident in this new way of working.	3.29	65.8	2.28	45.6
I was encouraged to share my ideas about MOVE and staff listened to my suggestions.	3.35	67.0	2.08	41.6
My unit manager and/or team leader talks about why it is important for elderly patients to be active.	4.24	84.8	2.55	51.0
My unit educator talks about why it is important for elderly patients to be active.	3.56	71.2	2.63	52.6
The goals of MOVE are supported on my unit.	3.81	76.2	3.35	67.0
New staff are informed about MOVE and the importance of mobilizing elderly patients.	3.16	63.2	1.90	38.0
Patients older than 65 years old are checked by a staff member for problems with moving within 24 hours of admission.	3.97	79.4	4.03	80.6
Patients on my unit who are older than 65 years and able to walk do so at least three times per day.	2.46	61.5	2.55	63.8
Getting patients up out of bed for a walk creates more work for nurses and other unit staff.	2.54	50.8	2.50	50.0
On my unit physical and occupational therapists are the most responsible for getting patients up for a walk.	2.78	55.6	2.83	56.6
Walking increases the risk of injury and falls for frail elderly patients.	3.46	69.2	3.38	67.6
Bed rest helps elderly patients to regain their strength and health.	3.97	79.4	4.18	83.6
MOVE changed the way people work on my unit, and without MOVE patients would be less active and stay in hospital longer.	3.68	73.6	2.72	54.4

Abbreviation: MOVE, Mobilization of Vulnerable Elders.

Highest scoring items: Areas of strength

Overall, the highest scoring item from both hospitals was Bedrest helps elderly patients to regain their strength and health (M = 4.10; Mdn = 4.0). Most respondents (n = 63; 76.82%) disagreed or strongly disagreed with this item (Table 1). This received the highest score from hospital B (M = 4.18; Mdn = 4.0), with 80% of participants disagreeing or strongly disagreeing with this statement. From hospital A, My unit manager and/or team leader talks about why it is important for elderly patients to be active, scored well (M = 4.24; Mdn = 4.0), with 90% of participants agreeing or strongly agreeing with this statement (Table 1).

Thematic analysis

Themes were based on commonalities found in the participants’ optional free-text responses. Several participants left comments that indicated they had never heard of MOVE or that they were away on leave and were not oriented to MOVE when they returned. For example, one participant commented “I’ve only been working here since April, and to be entirely honest I’ve never heard of MOVE.” Another stated “I don’t remember this initiative being implemented or encouraged or discussed on my unit.” A total of 22 comments fell under this theme we titled Ignorance is Bliss. Reflecting on this, it seemed that several employees were unaware of MOVE, did not remember it, or did not believe there was enough information provided about the initiative. Other participants made comments that fell under the theme feeling left out, regarding not feeling included in the MOVE initiative. For instance, five nursing staff members indicated the QI was directed toward physical therapists. One participant stated “It rolled out strong, PT department put signs up in some patient rooms, but not all. No frontline staff education. Most staff thought it was for the PT department.” A third theme, barriers to change, indicated that barriers to MOVE existed at the time of survey collection. For example, one person indicated “The staffing cuts that are taking place—we do rely on PT [physiotherapists] or OT [occupational therapists] most often to keep the patient moving daily…but it takes a lot of time. We don’t have a lot of support, only one HCA [healthcare aide] per shift.” The final theme, mobilization as a priority, represents that some participants acknowledged the importance of mobilization, an aim of the MOVE QI (eg, “[I] have noticed a significant difference between units on willingness of nursing to assist with mobilization. The culture is starting to change but we still have a long way to go”).

Discussion

The findings of this project are consistent with literature that shows QI projects are often met with resistance and can have high failure rates.^16,17 The NHS estimated that 70% of QI projects fail.¹⁸ The overall low moderate sustainability score score for hospitals combined indicated that MOVE was not well sustained 1 year after it was introduced. Neither hospital was near the ideal score, and the qualitative comments revealed sustainability concerns. We believe that QI should be implemented responsibly with sustainability in mind. Lack of long-term evaluation of healthcare QI may be due in part to the fear of failure; ignoring the outcomes reduces the chances of criticism for a failed project.¹⁹

Possible reasons for the lower score from hospital B include the change in unit management during the implementation phase of the QI and/or their lack of a full-time on-site educator. Of interest, hospital A’s highest scores related to their unit manager and/or team leader discussing the importance of mobilization. Similarly, hospital B scored low with regard to a lack of discussion of the results of MOVE, a lack of monitoring, and a lack of informing new staff about the importance of MOVE. It has been suggested that healthcare leaders (frontline managers, clinicians, and educators) may benefit from mentorship opportunities with experts in spreading healthcare innovations.²⁰

A non-hierarchical multidisciplinary change team

The MOVE team sought to engage many key healthcare staff to champion the change initiative¹³; however, the results demonstrated that some groups of participants did not feel involved. Several of the qualitative comments suggested that a multidisciplinary team of champions would have been more effective. A collaborative approach where a diverse selection of employees, including those not typically responsible for mobilization, who come together for training and education may have helped spread the vision for change to more staff. Champions of MOVE QI at both hospitals were PTs; mobilization of seniors in acute care should not necessitate the attention of PT or OT in every instance of ambulation; their expertise should be reserved for complex assessments and rehabilitation. Further, mobilizing elderly patients is a skill within the practice scope of many members of the healthcare team and should be a shared duty to ensure patients mobilize regularly.

Longer implementation and follow-up

The number of comments gathered under the theme Ignorance is Bliss (n = 22) may be indicative of a lack of awareness about the initiative. Some staff members, it seemed, were faulting those responsible for dissemination of the QI initiative, suggesting MOVE was ineffectively implemented and consequently poorly sustained. Staff turnover and/or absence during the initial implementation could have contributed to this finding. The teams’ general lack of knowledge about MOVE suggests the process used to implement the intervention was unsuccessful. Maternity leaves and recent hires were provided as reasons for lack of involvement or having little to no knowledge about the MOVE initiative; these must be considered when implementing a QI initiative to ensure knowledge translation occurs when orienting employees to the workplace. A plan for long-term sustainability should be included in the development of the initiative, including resources planning for continued sustainment. Refresher education sessions can promote long-term sustainability of interventions.²¹ Longer term education, monitoring, and feedback might have helped sustain the MOVE QI.²²

With successful QI endeavors, participants identified the intervention went from a high level of visibility with frequent discussion, visual and auditory reminders, and cues from champions, to a low level of visibility where the change became the new way of working and the QI disappeared.²² Preliminary MOVE audit results were relayed to staff during the 20-week implementation period, yet the final audits were not circulated to units; it appears that implementation and monitoring stopped too early.

Need to address the barriers and strengths

An examination of the staffing levels and response rates might explain negative feedback pertaining to the theme Barriers to Change. The three employee groups with the lowest scores (HCAs, RNs, and LPNs) may have resisted the implementation of an initiative like MOVE believing it would increase workload. Since these employees spend the most time providing direct patient care, it may have been worthwhile for the MOVE team to spend some time addressing their fears.

Although this project identified many shortcomings of MOVE, some of the results point to staff understanding the necessity for change when it comes to the mobilization of patients on their units. Ideally, several employees with this attitude would be assigned to lead and champion the change initiative. The participant comments highlighted the staff members’ knowledge about the importance of mobilizing patients; whether this was already important to them or this resulted from the MOVE initiative is not clear.

Limitations of this study include a validated tool to assess sustainability for such a QI initiative could not be located and thus required the development of the moderate sustainability score tool. The small sample size, particularly for professions other than nursing, prohibits conclusive generalizations about the data for other professions.

Conclusion

If implemented successfully, QI initiatives like MOVE could not only promote health and well-being but could contribute to a more efficient, affordable, and sustainable healthcare system. Resources within provincial and Canadian healthcare systems are strained and a growing elderly population will continue to place a financial burden on these limited resources. Change initiatives focused on mobilization should be implemented with a focus on sustainability to ensure people and processes are in place so they can thrive long after the funding and initial protocols are withdrawn. The results of this project suggest that if MOVE were to be implemented elsewhere, increased efforts should be made to ensure long-term sustainability is considered. Leaders in healthcare must decide how best to allocate their funding and resources for a sustainable healthcare system with an ageing population. Leaders of QI should put as much focus on the long-term outcomes and sustainability of each initiative as they do with the implementation.

Supplemental material

Supplemental Material, MOVE_Sustainability_Survey - The sustainability of a quality improvement initiative

Supplemental Material, MOVE_Sustainability_Survey for The sustainability of a quality improvement initiative by Veronica Belostotsky, Catherine Laing and Deborah E. White in Healthcare Management Forum

Footnotes

Authors’ note

The data sets analyzed in this study are available from the corresponding author on reasonable request. Mollie Cole, manager with the Seniors Health Strategic Clinical Network (Alberta Health Services) was a mentor and liaison for this project. Arfan Raheen Afzal, adjunct assistant professor in the faculty of nursing at the University of Calgary provided statistical consultation for this project. Ethics approval was obtained from the University of Calgary Conjoint Health Research Ethics Board, and from Alberta Health Services seniors research administrators and hospital managers. Informed consent was obtained from participants by completing questionnaires. V.B. designed and conducted the study, analyzed and interpreted the data, and wrote the manuscript. C.L. was a major contributor to editing and drafting of the final manuscript. D.E.W. was also a contributor in editing and drafting the manuscript. All authors have read and approved the final manuscript.

ORCID iD

Veronica Belostotsky, BScN, MN

Supplemental material

Supplemental material for this article is available online.

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