How to implement and sustain changes in a healthcare QI project

To implement and sustain a QI change, turn a tested way of working into a supported routine: define the process, assign an operational owner, prepare staff and resources, and agree how performance will be monitored and problems addressed. Implementation is more than announcing a successful test.

This article covers the transition from testing to routine practice in our guide to running a successful QI project. It also explains how local implementation differs from spreading a change to another team.

What is the difference between testing, implementation and spread?

• Testing: trying a change to answer questions about how it works and what effect it has.
• Implementation: making the agreed change part of normal work in the setting where it will be used.
• Sustainment: maintaining the process and its benefits through ongoing ownership, review and response.
• Spread: helping other settings test, adapt and adopt the approach where it is relevant.

The IHI’s guidance on implementing changes emphasises testing under varying conditions and embedding the change into the way work is done. A checklist that works when the project lead personally reminds everyone still needs a plan for ordinary working conditions.

How do you know a change is ready for implementation?

Review the evidence with frontline staff, patient partners, the process owner and sponsor. Ask:

• Does the evidence support the intended improvement, with a credible explanation of the change’s contribution?
• Has the approach been tested with the people, workload and conditions relevant to routine use?
• Do process measures show that the new method is workable and used as intended?
• Have patient experience, staff workload and other balancing measures been considered?
• Are important uncertainties, risks and practical dependencies understood?
• Can the service support the change without relying on temporary project effort?

There is no universal number of successful PDSA cycles that proves readiness. If a critical question remains unanswered, design the next test before expanding the commitment. Record the decision and any conditions attached to it.

1. Define the new routine and its owner

Describe exactly who does what, when and where. Include how work starts, how it passes between people and what happens when the usual route is unavailable. Make the essential parts clear while recognising where staff need judgement.

Name the operational owner who will be accountable after the project team steps back. Confirm that they accept the responsibility and have the authority and support to act. A project lead and a long-term process owner may be different people.

2. Update documents and remove conflicting instructions

Put the current process where people will use it: a concise guide at the point of work, an updated procedure or the relevant digital workflow. Give documents an owner, version date and review date.

Check for old forms, duplicate instructions and unofficial copies that could pull staff back to the previous method. Retire or clearly mark superseded material through the organisation’s normal document-control process.

Ask a colleague who was not involved in the project to use the instructions. If they need the project team to explain essential steps, the documentation is not yet doing its job.

3. Prepare staff, resources and support

Agree what people need to know and demonstrate before using the new process. Tailor preparation to the task: a short walkthrough may be enough for a simple administrative step, while a more complex change may require supervised practice and formal training.

Include cover staff, new starters and people working different sessions. Explain why the change is being introduced, what evidence supports it and how to raise a concern.

Confirm ongoing time, equipment, supplies and system access with the people responsible for them. Record the cost and workload implications. A process that depends on unfunded extra effort is unlikely to become reliable routine practice.

4. Agree an implementation date and a review period

Specify the initial scope, start date, responsible people and support available. Consider a staged introduction where it allows the service to identify and resolve problems before extending use.

Set early review points and a route for reporting issues. Continue using small tests to refine the implementation arrangements where needed. If the new process creates an immediate concern, staff should know whom to contact and what alternative arrangements apply.

5. Build a sustainment and response plan

Decide which outcome, process and balancing measures will continue, who will maintain them and where they will be reviewed. Keep definitions consistent with the measurement plan, or document any change.

A useful response plan answers four questions:

1. What will prompt review? Define the relevant chart signal, process failure, feedback or other concern with appropriate improvement support.
2. Who will respond? Name the operational owner and cover.
3. What will they do? Check data, examine the workflow with staff and address the cause through the agreed route.
4. When will they check again? Record the follow-up and whether further testing is needed.

Aim targets and statistical control limits serve different purposes; do not use them interchangeably. Avoid reacting to every routine fluctuation as if it proves the process has changed.

Healthcare example: making clinic preparation routine

This is an illustrative implementation plan, not a claim of achieved results.

Imagine that an outpatient team has tested a room-readiness checklist across relevant sessions and staffing arrangements, and its review supports routine use.

The clinic manager accepts ownership. The final checklist specifies the essential preparation items, a named role completes it before the first booked appointment and an escalation route covers missing equipment. The current version is kept in the agreed location and included in cover-staff induction.

Before the start date, the manager checks that the preparation time and supplies are available. Staff practise the process and can identify whom to contact when an item cannot be completed.

During the initial review period, the team continues plotting waiting times by session, checking preparation completion and reviewing staff overtime and patient feedback. If preparation repeatedly fails, the manager investigates access, workload and supplies rather than assuming staff need another reminder.

The project record includes the owner’s acceptance, the documents handed over and the next review date. The team only claims benefits supported by the actual data collected.

When should you spread the change to another team?

First make the original approach and its evidence understandable. Explain the problem it addresses, the essential components, resources, limitations and conditions tested.

A receiving team should assess whether the same problem and conditions apply locally. Involve that team in adapting and testing the approach; sending a finished checklist does not establish that it will work in a different clinic.

Keep local implementation and wider spread as separate decisions. The original project can hand over a stable local process while a new piece of work explores use elsewhere.

Implementation and sustainment plan template

Record: change and scope; evidence supporting implementation; operational owner; start date; process documentation; training; resources; communication; measures; review schedule; response triggers; escalation route; outstanding actions; handover acceptance.

Download the QI implementation and sustainment plan for an editable Word template covering readiness, implementation and sustainment, with a completed healthcare example.

Frequently asked questions

Can we stop measuring after implementation?

Agree proportionate ongoing monitoring with the process owner. You may simplify collection as the process becomes established, but removing all review makes it harder to identify deterioration or unintended effects.

Who is responsible for sustaining the change?

The operational owner should accept responsibility for routine performance, supported by staff, managers and relevant specialists. The project team should make that handover explicit before closing.

What if performance deteriorates after rollout?

Follow the agreed response plan. Check the data and whether the process is being used, then examine changes in conditions, resources or workload. Adapt through further testing where needed and record what was learned.

Prepare for a clear handover

Use Simana’s project management tools to organise implementation actions and charting tools to support ongoing review. Continue with how to close out a QI project once responsibilities and follow-up are agreed.