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Clin J Am Soc Nephrol. 2016 May 6;11(5):916-24. doi: 10.2215/CJN.11501015. Epub 2016 Mar 25.

How to Sustain Change and Support Continuous Quality Improvement.

Author information

Division of Nephrology and
Division of Nephrology, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada;
Division of Nephrology and Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada;
Division of Gastroenterology and.
Division of Nephrology and.
Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Nephrology, Humber River Regional Hospital, Toronto, Ontario, Canada;
Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; and Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada;
Division of Nephrology, Stanford University School of Medicine, Palo Alto, California.


To achieve sustainable change, quality improvement initiatives must become the new way of working rather than something added on to routine clinical care. However, most organizational change is not maintained. In this next article in this Moving Points in Nephrology feature on quality improvement, we provide health care professionals with strategies to sustain and support quality improvement. Threats to sustainability may be identified both at the beginning of a project and when it is ready for implementation. The National Health Service Sustainability Model is reviewed as one example to help identify issues that affect long-term success of quality improvement projects. Tools to help sustain improvement include process control boards, performance boards, standard work, and improvement huddles. Process control and performance boards are methods to communicate improvement results to staff and leadership. Standard work is a written or visual outline of current best practices for a task and provides a framework to ensure that changes that have improved patient care are consistently and reliably applied to every patient encounter. Improvement huddles are short, regular meetings among staff to anticipate problems, review performance, and support a culture of improvement. Many of these tools rely on principles of visual management, which are systems transparent and simple so that every staff member can rapidly distinguish normal from abnormal working conditions. Even when quality improvement methods are properly applied, the success of a project still depends on contextual factors. Context refers to aspects of the local setting in which the project operates. Context affects resources, leadership support, data infrastructure, team motivation, and team performance. For these reasons, the same project may thrive in a supportive context and fail in a different context. To demonstrate the practical applications of these quality improvement principles, these principles are applied to a hypothetical quality improvement initiative that aims to promote home dialysis (home hemodialysis and peritoneal dialysis).


chronic kidney disease; clinical nephrology; end stage kidney disease; health resources; hemodialysis; home; humans; organizational innovation; peritoneal dialysis; quality improvement; renal dialysis

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