Some years ago, my (research chemist) mother worked in the pilot plant of a major rubber company where new products were developed and tested. In the pilot plant, researchers were forbidden to use Waring blenders. Why? Because no matter how easy it was to produce a new product with a high-speed blender, the energy cost was prohibitive when it was time to scale up to real-world production. And so it goes with many quality improvement (QI) projects. Great ideas and innovative interventions too often come with a cost in time, effort, money, and personnel that is not sustainable once the initial project ends. The lesson here is that improvers need to think from the beginning about how their interventions can be scaled up and sustained.
In this issue of Pediatrics, Gilkey et al1 describe an effort to apply interventions that had been shown in a variety of outpatient clinic settings to improve the rate of human papillomavirus (HPV) vaccinations across their health system. Most of the interventions cited were multifactorial and involved significant input of resources. For example, 1 intervention is described as a “provider-focused intervention that included repeated contacts, education, individualized feedback, and strong quality improvement incentives.”2 The authors had to decide which aspects of the previously tested interventions were likely to be most effective and simultaneously most amenable to spread to multiple sites within the context of their particular health system.
These authors addressed a common and difficult question in QI: how does one take small projects with positive results and scale them up across multiple sites? Sustaining successful projects and taking them to scale depends on a carefully considered choice of focus area, the detail and completeness of the project plan, and the ability to incorporate the improvement work into daily operations.
In choosing a focus area, awareness of the context is critical to a project’s long-term viability. Context includes the immediate practice environment, the organization or system within which the practice works, and how the quality issue fits within the larger community. For the current project, the cultural issues around parental resistance to the HPV vaccine are particularly relevant. The focus area should be aligned with the strategic goals and priorities of the organization both locally and at a system level, and available funding (both long-term and short-term), existing information technology resources, and the potential to integrate into existing workflow should be considered.
The depth and completeness of planning for a QI effort, once a focus area is chosen, may be the single most important factor in its long-term success. The aim(s), measures, and proposed interventions of the improvement effort itself must be hammered out in detail. Equally important, how the improvement will be sustained and scaled up must get significant attention in the initial plan for the project. Training and new skill development, supporting people in new behaviors that reinforce the new practices, problem solving, and assignment of responsibility all need to be considered.3
Interventions that can integrate with existing systems (data collection, workflow) are ideal for sustainability, serving to reinforce the changes as standard work. Gilkey et al1 were able to adapt an existing structure in the vaccine report card that was already in use in their system. Unless new ideas become part of how the organization does its business, momentum is lost and improvement cannot be sustained. When the new ways of working become the norm, they will no longer need special support to continue.
Over the last several years, >50 QI projects addressing HPV vaccination have been submitted to the American Board of Pediatrics and >2000 pediatricians have been awarded Maintenance of Certification credit for their improvement work; positive results were reported in most of these projects. Authors of a systematic review of interventions to increase HPV vaccination coverage found that interventions that were focused only on providers were less successful than those that engaged providers along with system changes. However, the reviewers point out that of the interventions that were followed over time, many revealed waning effects.4 It is critical that the gains of QI projects be sustained and the efforts scaled up, so that the hard work that went into each of these projects is not wasted. The real challenge of QI may not be the initial improvement but rather continuing the work after the initial enthusiasm has dissipated.5
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-2500.
POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.