Table 4 Summary of strategies to address threats to sustainability employed across the case studies

Engagement

1. Engaging with senior leaders to gain support and buy-in.

• Teams used governance or trust meetings as opportunities to communicate the rationale and impact of the work and to foster belief in the importance of the initiative.

“Every clinical governance meeting we bring an update on what has happened and we use it to continually drive the bundle…We just need to give them something to help keep them motivated” (I22, Service manager)

Y

Y

Y

Y

2. Involving patients to act as a catalyst for change

• Teams involved service users in coproducing initiative material and products to facilitate usability and effectiveness.

• Patients partnered to spread awareness and champion the initiative in other settings.

• Teams utilised patients and their experience to inspire action to continue the improvement work.

“There is something I can do and I will…bang my fist on the table to explain (MedRev)…in case there is someone at (another hospital) who hasn’t heard about it.” (I8_Patient representative)

Y

N

N

Y

3. Building collaboration and networks to foster multi-disciplinary approaches, cross-site learning, new relationships, and future collaborative working.

• Teams established networks and collaborations by attending forums, organising collaborative funding applications, setting up networks or multidisciplinary team meetings.

“Having this working relationship across all five sites in North West London that’s not going to go away and now there are other projects that we’ve...actually put in bids together and that seems like a really natural thing to do.” (I7_Project Manager)

N

Y

Y

Y

4. Building in and planning for accountability and ownership of the initiative to allow staff to better understand and balance workload and responsibilities.

• Teams built accountability for the work into workforce planning, clearly defined job roles and allocated tasks.

“We’ve built that into some of the job plans now…that’s part of the role so one of the benefits of people leaving and…getting other people in when they start you go that’s just what you do.” (I1_Clinical lead)

Y

N

N

Y

5. Ongoing promotion of the initiative to maintain momentum, to further promote interest and engagement, and to heighten staff morale and belief in the initiative.

• Teams promoted initiatives through forums, publications, meetings, newsletters, award nominations, conferences, and email updates.

“I did all the data collection weekly sending (it) out like hey, this is a really good example and encouraging people to get together and talk through examples of cases.” (I7_Project manager)

Y

Y

Y

Y

Integration

6. Consistent and continuous training and capacity building to enable a wider workforce to deliver the initiative and ensure staff have the capacity to consistently deliver the work despite turnover.

• Teams built capacity by adding information on initiatives to induction presentations and packages and having consistent education sessions.

“Training one person or having a consultant doing outreach long term is not the answer. We have to build the education model in to it.” (Allergy_6 month review transcripts)

N

Y

Y

Y

7. Embedding measurement and monitoring to enable feedback to staff and stakeholders to encourage continuation of the work.

• Teams displayed progress using graphs and charts on the ward to celebrate continuation of data collection over time.

• Teams fed-back process measures to show incremental changes to services to provide information to funders and leaders to support continuation of the work.

“It’s really good to keep looking at what we did…and keep measuring, because we’re still seeing improvements and all the time you’re still seeing improvements you want to keep on measuring, because it’s good.” (I14_Clinical lead)

Y

Y

Y

N

8. Integration of changes in systems, processes, and funding mechanisms to support initiative staffing, infrastructure and spread.

• Teams integrated documents onto online IT system and linked initiatives with existing funding mechanisms

“So we’ve got now a process by which…they’ve almost bought in forever, because we’re saying, well if you take this away, you’re not going to get your best practice tariff.” (I25_Project manager)

Y

Y

Y

Y

Adaptation

9. Identifying and applying for further funding to continue and spread the services

• Teams identified and applied for further funding such as CQUIN targets, and fellowship grants and prepared business cases for commissioners.

‘My colleague has applied for funding…the natural continuation is actually get the community to get engaged with the project itself.” (I11_Pharmacist)

Y

Y

Y

Y

10. Expanding the initiative to reach more patients, enhance equity of services and garner further impact and support from staff and organizational leaders

• Teams rolled out initiatives to further wards and expanded the programme to community settings.

“The idea is to roll out across the unit and into the community, and I think if this becomes the embedded way of working across the unit and the community, it’s got a far better chance of success.” (I6_QI manager)

Y

Y

Y

Y

11. Reducing the scope of the initiative to ensure feasible delivery and to build in mechanisms for continuation by 'starting small' and understanding how best to deliver the initiative in practice.

• Teams reduced their project target or postponed spread of the initiative to other sites.

“Taking our time and really looking into each aspect of the project has helped us sustain it…if we went into it, to a project the size it is now, I don’t think we would’ve ever been able to sustain that…if you start small and you get that right and you know what works, what doesn’t, you can then scale it up to a bigger project based on that.” (I19, Nurse)

Y

Y

N

N

12. Adaptation of the initiative processes and products to allow each improvement to be tailored to the setting and existing limitations, staff preferences, and emerging evidence.

• Teams adapted interventions by iteratively changing documents and responding to staff feedback on how forms or processes were working.

“Every three, five, ten years the guidelines change slightly, so we constantly have a group of specialised people that look at it…and make sure that we’re actually on the right page.” (I22_Service manager).

Y

Y

Y

Y