How to go green with a sustainable quality improvement project

Introduction

Nurses represent the largest group of professionals in the healthcare workforce (World Health Organization (WHO), 2020). They are a powerful potential force in the fight to slow down the health crisis that is being fuelled by climate change (WHO, 2023). Mobilising this workforce to practise sustainable healthcare and adopt carbon-reducing actions will support the NHS in reaching its net-zero targets (NHS England, 2022).

Sustainable healthcare refers to the concept of providing high-quality, high-value care to the patients and populations of today, without compromising the ability of future generations to meet their healthcare needs (World Commission on Environment and Development, 1987). By recognising that resource use is finite, and acknowledging that costs are not just financial, but also human and environmental, a more holistic approach to healthcare can be adopted.

To achieve this, the focus must shift to the sustainable value of healthcare services and provision. This requires maximising patient and population outcomes, and conserving environmental, financial and human resources, while adding social value at every opportunity (Mortimer et al, 2018).

Introducing the framework

The Centre for Sustainable Healthcare’s Sustainability in Quality Improvement (SusQI) framework is a tool that outlines the steps in which sustainability should be considered within existing quality improvement (QI) methodology, embedding the principles of sustainable clinical practice within QI to holistically improve healthcare. The consideration of environmental and social values in addition to economic cost, measured against health outcomes, determines sustainable value (Fig 1). The primary goal is to deliver nursing care that is of high quality and high value.

What are the benefits of SusQI?

The benefits of using the SusQI framework include:

• Better clinical outcomes of patients and populations;
• Reduced greenhouse-gas emissions resulting from nursing care;
• Focus on improving social value from service delivery;
• Neutralised or reduced financial cost of healthcare delivery;
• Empowerment of patients to address their climate concerns;
• Empowerment of staff to make positive change and improve job satisfaction (this is especially important, given the low morale and pre-existing pressures on workforces).

What are the principles of sustainable healthcare?

When designing improvement ideas in QI, it is useful to consider the principles of sustainable healthcare. Fig 2 illustrates that the ultimate outcome from the improvement we make is to reduce carbon without reducing health. There are two ways we can do this, which are the primary drivers:

• Reducing activity;
• Reducing carbon intensity.

To reduce activity, we look to the secondary drivers. These are displayed in order of importance, with the first and most important being prevention of ill health (for example, through vaccination or breast cancer screening programmes).

The second is self-care (for example, patient education programmes and patient empowerment, such as managing exacerbations of chronic obstructive pulmonary disease or asthma). If we cannot prevent ill health or promote self-care, we look at leaner care pathways – that is, avoiding interventions that do not add any value to health outcomes. And lastly, if we cannot prevent ill health, promote self-care or make a system leaner, we can look at low-carbon alternatives, such as switching from a pressurised metered-dose inhaler (which contains potent greenhouse gases) to prescribing a dry-powder inhaler instead.

Nurses can also work with estates staff. Operational resource use examples of this would be switching diesel fleets to electric or switching to solar electric power, but this often sits outside of the area of clinical practice and is more applicable to estates departments.

The four steps of SusQI

The SusQI framework (Fig 3) outlines four steps of the QI process at which sustainability should be considered and actively implemented. SusQI has been designed to be embedded into existing QI methodology, such as the Institute for Healthcare Improvement’s Model for Improvement. The Centre for Sustainable Healthcare’s SusQI website has an easy to implement step-by-step guide (susqi.org/step-by-step-guide) to the process.

We will now look at how the four steps of the SusQI framework have been applied in nursing practice to address reducing unnecessary cannulation.

Step 1: set goals

The first step of the SusQI framework involves identifying and defining the problem (Fig 4). It is important at this step to just focus on what the problem is, rather than jumping to solutions, causes, blame or symptoms.

The following is an example of a problem: emergency department staff thought many patients were cannulated ‘just in case’ and many cannulas were either not used or used inappropriately, for example by giving intravenous (IV) fluids or IV paracetamol when the patient was able to take fluids and paracetamol orally. In response to this, the team set up a ‘Reducing unnecessary cannulation’ SusQI project.

“It is vital to understand the current system and how it works before thinking about solutions”

Step 2: studying the system

Before thinking about improvements, solutions or beginning any changes, it is vital to understand the current system and how it works. This can be achieved through value process maps, in which environmental, social and financial resource use is identified. This can help you to identify wasteful or valueless steps and carbon hotspots in a pathway or process, which can be addressed through your improvement project.

On a process map, it is possible to see clearly the:

• Environmental, social and financial costs;
• At what point in the pathway they occur.

Process maps are useful as they can point out where problems are in the current system. In our case study, a process map can highlight how people who were cannulated inappropriately were subjected to unnecessary discomfort and put at risk of harm due to infection from an invasive procedure. Another social impact is wasted staff time, when the cannula is not used.

Step 3: designing the improvement

When considering designing an improvement to address the identified problem, the principles of sustainable clinical practice should be considered (Fig 5). These are numbered in order of priority.

The first principle is prevention, because preventing the need for healthcare is considered to be the best healthcare of all, as well as the most sustainable. However, if a problem cannot be prevented, we must then look at the other principles. Many QI projects will address a combination of the principles.

An example of an improvement idea is designing an education campaign in the emergency department to engage staff: THINK before you cannulate! This improvement idea includes preventing unnecessary cannulation and a lean pathway by avoiding a potentially unnecessary clinical intervention during the emergency department admission pathway.

Step 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 family of measures within the sustainable value equation. 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 or through carbon footprinting methodology. Social impacts for patients, staff and carers should be measured in addition to estimating financial costs/savings.

Ways in which the social and environmental impacts in the example problem could be measured include:

• Number of cannulas inserted per week before and after the project;
• Number of cannulas used/not used in the emergency department before and after the project;
• Patient and staff surveys done before and after the intervention.

The cannulation project results (Fig 6) demonstrated better sustainable value by improving patient outcomes while reducing environmental and financial impact and improving social value. What is good for the environment usually results in cost savings, as demonstrated here. By making this small change, £27,831 was saved in monetary terms.

The project reduced the rate of unnecessary cannulation by 66% in the first 10 weeks of implementation; this improved patient outcomes by reducing infection risk and the use of inappropriate IV fluids. The intervention had a large environmental impact and saved 8,403kg of carbon dioxide equivalent, which is the equivalent of driving 24,817 miles in a petrol car. The project added social value by reducing pain by avoiding cannulation, increasing mobility and independence, improving workflow and saving staff time.

“If every nurse made small sustainable changes to their own areas of practice, they would make a huge difference collectively to the environment”

Conclusion

Climate change threatens our ability to provide quality healthcare but, by making nursing practice greener, we can improve patient outcomes, save staff time, increase morale, improve the environment and add social value. One challenge for nurses is finding the time and headspace to implement SusQI improvements, especially amid the nursing shortage crisis, but, as demonstrated by these projects, making small sustainable changes can actually save staff time, improve workflow and save money for more resources.

As nurses comprise the biggest workforce in healthcare, if every nurse made small sustainable changes to their own areas of practice, they could make a huge difference collectively to the environment and, ultimately, improve public health.

• If you are interested in doing you own SusQI project, you can access free resources and more case studies at susqi.org to help guide you through the process