Sustainability in Quality Improvement (SusQI) at Health System Level

Technical Case Study

From: Centre for Sustainable Healthcare

Why take action?  

In line with the global need to build climate resilient, low carbon sustainable health systems¹, the way in which healthcare is delivered must be transformed worldwide. Historically, sustainability in healthcare has been viewed as the responsibility of estates and facilities. However, carbon footprint studies reveal that supply chain emissions, including pharmaceuticals and medical equipment, contribute the largest share of healthcare’s greenhouse gas emissions, and the influence of clinical decisions and models of care on resource use is increasingly recognised^2,3. Frameworks and tools are therefore needed to enable health professionals to lead a transformation to sustainable, high-quality care.  

Quality improvement (QI) is a proven and accepted means of systematically improving service delivery and patient outcomes. Embedding sustainability into pre-existing QI methodology to focus on sustainable value is a practical, widely applicable, and effective tool for positive change towards low carbon sustainable health systems. 

 

What is Sustainability in Quality Improvement (SusQI)? 
The SusQI framework outlines the steps in which sustainability should be considered within existing QI methodology, embedding the principles of sustainable clinical practice within QI to holistically improve healthcare⁴. The unique consideration of environmental and social values in addition to economic cost, measured against health outcomes, determines sustainable value (Figure 1).  The ultimate goal is healthcare that is high quality and high value. 

 

 

What are the benefits of SusQI? 
Outcomes from implementation of the SusQI framework include, but are not limited to:  

• Better clinical outcomes of patients and populations 

• Reduction of greenhouse gas emissions resulting from healthcare delivery 

• Focus on improving social value from service delivery 

• Neutralizing or reducing financial cost of healthcare delivery 

• Empowerment of patients to address their climate concerns 

• Empowerment of staff to make positive change and improve job satisfaction (especially important given low morale and pre-existing pressures on workforces) 

The above outcomes are evidenced in Impact Reports⁵ from Green Team Competitions, an award-winning programme run by Centre for Sustainable Healthcare which empowers the National Health Service (NHS) and other healthcare delivery organisations to implement the SusQI framework to transform knowledge on the need for sustainable healthcare into action. The annual impact review from 2022 estimates saving 56 tonnes CO2e and £59,000 per organisation partaking.

 

How to get started 

There is substantial evidence supporting the value of QI in improving health systems around the world, including in the NHS^6,7. Therefore, it is logical to harness these opportunities to create more climate friendly and resilient services and translate knowledge on sustainable healthcare into action. This is further reflected in national policy, such as NHS Scotland’s sustainability strategy, outlining the need for “clinicians to make sustainability a core consideration in quality improvement work and the planning and delivery of clinical services⁸.” 

The SusQI framework (Figure 2), published in 2018,⁴ outlines four stages of the quality improvement process at which sustainability should be considered and actively implemented.  The CSH SusQI website has an easy to implement step-by-step guide for each stage of the process.  

1. Setting goals

The first part of the SusQI framework involves defining the problem and goal of the process. During this, consideration should be given to negative environmental impacts and a culture of resource stewardship. 

 

2. Studying the system 

Before thinking about improvements, it is vital to understand the current system. This can be done through value process maps where environmental, social, and financial resource allocation is identified. This can recognise wasteful or valueless steps and carbon hotspots within a pathway or process which can be addressed through improvement projects. 

 

3. Designing the improvement 

When considering an improvement to address a problem identified whilst studying the system, the principles of sustainable clinical practice (Figure 3); prevention, patient empowerment, lean pathways, and low carbon alternatives, should be considered for application. 

 

4. Measuring impact 

As with all QI, a clear set of measures are essential for assessing changes in improvement. SusQI is unique in the consideration of a set of measures within the sustainable value equation (Figure 1). Clinical outcomes for patients and population health can be compared before and after an intervention. Environmental impact can be measured through a reduction in activity/resources used or through a carbon emissions assessment.  Social impacts for patients, staff and carers should be measured in addition to estimating financial costs/savings.  

Practical ways to implement SusQI within a health system 

Start early 

• Incorporating SusQI into undergraduate as well as postgraduate education of professionals working in healthcare will enable a wider reach of practice.  Since education in QI is increasingly a requirement for health professionals, incorporating SusQI into this offers a way to deliver practice-focused sustainable healthcare education without expanding the curriculum or time needed for training. This is an ongoing process requiring collaboration and faculty development. However, there is an appetite for change in education facilities and CSH has been able to support local academic institutes through its Academy programme. 

Normalize practice 

• In recent times, there has been a shift in interest for SusQI from clinicians with an interest in sustainable healthcare, as well as QI and sustainability leads. This likely reflects recent policy changes including the The Health and Social Care Act 2022 and the requirement of all NHS organisations to create a Green Plan in alignment with the NHS’s net zero agenda. Similarly, health systems should consider opportunities to integrate SusQI into their policies and processes. 

• Normalizing and embedding sustainability knowledge within existing QI programmes and equipping local leads with the skills to enact and supervise SusQI projects allows the practice to embed and spread throughout organisations. 

Make it competitive 

• The Green Team Competition programme (GTC) is an award-winning initiative supporting health delivery organisations to design and deliver SusQI projects in a variety of teams.  

• The Green Surgery Challenge was a specialty- specific adaptation of the Green Team Competition, supported by the Royal Colleges of Surgeons of England and Edinburgh.  This facilitated exploration of a specialty’s sustainability at a national level and provided valuable case studies which have since informed the landmark Green Surgery Report.  

 

Tracking progress  

The growing appreciation of SusQI is evident as CSH collaborates with organisations in Australia and Canada to facilitate sustainable transformations in healthcare and education through the Academy and GTC.  

There are approximately 138 case studies within the CSH resource library of SusQI projects all resulting in their own range of environmental, social and financial savings. These are actively advertised throughout CSH networks and courses to encourage others to adopt similar improvements, enabling spread of sustainable transformation in workforces with limited capacity. Not all projects facilitated through the SusQI course are reported back as case studies so this is likely an underestimate of the true extent of progress, which remains difficult to quantify. 

Independent evaluation of the 2022 GTC in seven organisations summarised an average projected saving of 56 tonnes CO2e and £59,000 per organisation partaking. Co-benefits of positive effects on staff morale and barriers such as buy-in and resource constraints were highlighted. The evaluation identified a decline in momentum after the programme ended which may affect long-term impact demonstrating the importance of embedding sustainable QI⁹ in healthcare policies and practices.  

Multi-centre evaluation of SusQI integration into undergraduate and postgraduate education has demonstrated increased motivation for, and engagement with QI, with the adoption of a new sustainability lens¹⁰. Evaluation from SusQI educators has been equally positive, supporting feasibility for adoption of SusQI across diverse educational organisations¹¹. There are plans for independent evaluation of the Academy programme.  

  

In practice

A two-pronged approach has been used to embed SusQI into routine practice across healthcare provision: in healthcare education and in healthcare delivery.  

Healthcare education 

Structured courses on SusQI and Teaching SusQI with supporting resources such as educator packs including template teaching sessions have enabled the dissemination of knowledge on the topic. The SusQI Academy Programme is a formal package that enables tailored support to integrate Sustainability into QI teaching and practices. Following on from this, the SusQI Beacon Site accreditation provides recognition of integrated Sustainability in QI available to both education and healthcare delivery organisations (aspiring or established). 

Example in practice:  King’s College London, Faculty of Nursing, Midwifery & Palliative Care  

• An original pilot Beacon site and SusQI Academy member since March 2023 

• 12 SusQI leads across Adult/Child/Mental Health Nursing and Midwifery  

• SusQI embedded across all programmes at pre-registration, BSc and MSc level 

• Interest in SusQI has spread to the Nursing & Midwifery Council and disseminated to Kingston University Faculty of Nursing which has since joined the SusQI Academy. 

 

Healthcare delivery 

Example in practice: Midlands Partnership NHS Foundation Trust 

• SusQI Academy member since November 2022 

• Sustainability now embedded into all levels of QI training 

• QI Tools and Templates adapted to include sustainability 

• Sustainability leads work closely with the improvement team to measure environmental impact of all improvement work. 

Example in practice: Green Team Competition: Northampton General Hospital NHS Trust and Northamptonshire Healthcare Foundation Trust, 2022.  

Four teams from across Northamptonshire engaged in the SusQI mentoring programme to develop, run, and measure impact of projects that add sustainable value to their service. Combined, the projected annual savings were £71,529 and 53,221 kgCO2e (equivalent of driving 150,000 miles in an average car).   

Example case study from the winning team:  

Key resources 

Centre for Sustainable Healthcare  Home | Sustainable Quality Improvement (susqi.org) 
Since 2008, the Centre for Sustainable Healthcare has engaged healthcare professionals, patients, and wider community to understand the connections between health and environment, and to reduce healthcare's resource footprint.  The Centre offers strategic input and consultancy on sustainable healthcare research and practice.  

 

More information

For more information, please contact: info@sustainablehealthcare.org.uk 

 

References 

1. World Health Organization. Climate Change. World Health Organization. 2023. Available from: https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health 
2. Health Care Without Harm. Health care’s climate footprint. How the health sector contributes to the global climate crisis and opportunities for action. Health Care Without Harm. 2019 Sep. Available from: https://www.arup.com/perspectives/publications/research/section/healthcares-climate-footprint 
3. NHS England (2022) Delivering a ‘net zero’ national health service. Available at: www.england.nhs.uk/greenernhs/a-net-zero-nhs. 
4. Mortimer F, Isherwood J, Wilkinson A, Vaux E. Sustainability in quality improvement: redefining value. Future Healthc J. 2018 Jun;5(2):88-93. doi: 10.7861/futurehosp.5-2-88. PMID: 31098540; PMCID: PMC6502556. 
5. Centre for Sustainable Healthcare. Green Teams Competition Impact Reports. 2023. Available from: https://www.susqi.org/impact-reports 
6. Alderwick H et al. Making the case for quality improvement: lessons for NHS boards and leaders. The King’s Fund. 2017. Available from: https://www.kingsfund.org.uk/publications/making-case-quality-improvement 
7. Nana Mensah Abrampah, Shamsuzzoha Babar Syed, Lisa R Hirschhorn, Bejoy Nambiar, Usman Iqbal, Ezequiel Garcia-Elorrio, Vijay Kumar Chattu, Mahesh Devnani, Edward Kelley, Quality improvement and emerging global health priorities, International Journal for Quality in Health Care, Volume 30, Issue suppl_1, April 2018, Pages 5–9, doi.org/10.1093/intqhc/mzy007 
8. NHS Scotland. Climate Emergency & Sustainability Strategy. 2022. Available from: https://www.gov.scot/binaries/content/documents/govscot/publications/strategy-plan/2022/08/nhs-scotland-climate-emergency-sustainability-strategy-2022-2026/documents/nhs-scotland-climate-emergency-sustainability-strategy-2022-2026/nhs-scotland-climate-emergency-sustainability-strategy-2022-2026/govscot%3Adocument/nhs-scotland-climate-emergency-sustainability-strategy-2022-2026.pdf 
9. Roach I,  Shaw S and Ferrey A. Implementing sustainable healthcare projects in the NHS: A Qualitative Evaluation of the 2022 Green Teams Competition. 2023.  Unpublished manuscript. 
10. Rosanna Spooner, Victoria Stanford, Siobhan Parslow-Williams, Frances Mortimer & Kathleen Leedham-Green (2022) Concrete ways we can make a difference: A multi-centre, multi-professional evaluation of sustainability in quality improvement education. Medical Teacher, 44:10, 1116-1124, DOI: 10.1080/0142159X.2022.2064737 
11. Stanford V, Clack A, Mortimer F and Leedham-Green K. (2023) Strategies for implementing Sustainability in Quality Improvement (SusQI) education: educator perspectives. Unpublished manuscript