NR 528 Week 8 Sustainability Plan Example

Sustainability Plan: Removing the Supports Around the Head-of-Bed Practice One at a Time, in a Set Order, With a Signal That Brings Each Back if the Practice Slips

Student Name

College of Nursing, Chamberlain University

NR 528: Leading and Managing Evidence-Based Change in Nursing

Instructor Name

Month Day, Year

Sustainability Plan: Removing the Supports Around the Head-of-Bed Practice One at a Time, in a Set Order, With a Signal That Brings Each Back if the Practice Slips

What Is Fragile

The practice itself, a raised backrest for every patient on a running feed, is simple. What is fragile is the help around it during the first months: the project lead on the unit most mornings answering questions, weekly audits posted every Monday, a line about head-of-bed angle in every shift huddle, unannounced audit checks, and the attention that comes with a new project. By week 16, the unit's day shift had reached the practice on 88% of observations and night shift on 82%, up from 52% and 28% before the project. The question this plan answers is what happens when the help is removed, and how the unit will know if the practice is slipping.

Principle 1: Remove Supports One at a Time

If all supports stop at once and the practice slips, nobody will know which one mattered. The plan removes them in a set order, with at least four weeks between each, and watches the monthly audit after each removal. If compliance holds, the next support comes off. If it falls, the last support removed comes back.

The Order

First, week 17: the project lead's daily presence. This support is the most personal and the least sustainable, since it depends on one person. It is removed first to test whether the practice now belongs to the unit. The project lead remains available by message and attends the monthly huddle.

Second, week 21: weekly audits become monthly. The two volunteer auditors will keep auditing, but for a single week in every month and at the usual four times, and the unannounced checks continue at two per month.

Third, week 25: the huddle line. The daily reminder in huddle stops, replaced by a monthly one-minute report of the latest audit.

Not removed: the structural supports. The angle indicators on every bed, the flowsheet field, the contraindication order, the pause-and-restart labels on pumps, the charge nurse's look at each fed patient's bed on rounds, the float and agency card, and the knee-first positioning technique all stay permanently. They cost little to keep and do not depend on anyone's enthusiasm.

The Signals That Bring Supports Back

The monthly audit is plotted on the same run chart used during implementation, one line for each shift, with the median of the implementation period marked. The plan uses simple rules to decide when a support should return, since run charts can distinguish a real shift in performance from ordinary variation (Perla et al., 2011). If either shift falls below 80% in two consecutive monthly audits, or shows a run of points below its implementation median, the unit restores weekly audits and the huddle line on that shift for one month and asks the shift's staff what has changed. If the balancing measure, new sacral or heel pressure injuries in tube-fed patients, rises above the baseline average for two months, the wound care nurse reviews each case.

Ownership After the Project

The project ends formally at week 25, and ownership moves to roles rather than people. The nurse manager owns the monthly audit and its reporting. The charge nurses own the safety round check. The unit educator owns the practice in orientation for new hires and in the annual competency checklist. The wound care nurse owns the mattress and skin review rule. Supply chain owns par levels of slide sheets and replacement indicators. Each owner has agreed in writing, and the list is posted beside the run chart.

What Could Undo the Practice

Four events are most likely to undo the practice, and each has a planned response. The first is turnover: new hires learn the practice in orientation, but travel and agency nurses may miss it, which is why the float and agency card stays. The second is new equipment. If the hospital replaces the unit's beds, the new models must have a visible angle display or an indicator fitted before they reach the floor, and the nurse manager has asked supply chain to include this in any bed purchase. The third is a change of feeding pumps, which would remove the pause-and-restart labels, so the unit educator will label any new pumps before use. The fourth is a winter surge with high census and heavy agency use; during a surge, the huddle line returns automatically rather than waiting for the audit to fall.

What the Monthly Report Contains

The monthly report is one page. It shows the run chart for each shift, the number of observations taken, the number of flat beds found and what was happening when each was found, such as a bath, a return from imaging or a bed change, and the count of new pressure injuries in tube-fed patients. Its last line states whether any support needs to return. The report goes to the nurse manager, the unit practice council and the night charge nurses, the group most affected by the original problem.

The Cost of What Stays

The permanent supports are cheap. Replacement angle indicators and pump labels cost little each year, the flowsheet field is already built, the charge nurse's round check adds about a minute per tube-fed patient, and one audit week a month takes each volunteer auditor perhaps two hours. The expensive support, the project lead's time, is the first to go. That order is deliberate: a practice that needs costly help to survive is not yet sustained, and the plan tests that early.

Why the Practice Should Last

Lewin described lasting change as moving a group to a new stable pattern and then securing it so it does not drift back (Lewin, 1947). The permanent supports are this unit's way of securing it: they make the right action easier than the wrong one, whatever the shift and whoever is working. The clinical basis has not changed: nutrition support guidance places high-risk tube-fed adults between 30 and 45 degrees (McClave et al., 2016), and in the Metheny et al. (2010) trial a protocol kept roughly 90% of patients at the target. Our unit's results are now close to that level. Keeping them there depends less on reminding people than on keeping the indicators, labels and checks in place when attention moves elsewhere.

References

Lewin, K. (1947). Frontiers in group dynamics: Concept, method and reality in social science; social equilibria and social change. Human Relations, 1(1), 5-41. https://doi.org/10.1177/001872674700100103

McClave, S. A., Taylor, B. E., Martindale, R. G., Warren, M. M., Johnson, D. R., Braunschweig, C., McCarthy, M. S., Davanos, E., Rice, T. W., Cresci, G. A., Gervasio, J. M., Sacks, G. S., Roberts, P. R., & Compher, C. (2016). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition, 40(2), 159-211. https://doi.org/10.1177/0148607115621863

Metheny, N. A., Davis-Jackson, J., & Stewart, B. J. (2010). Effectiveness of an aspiration risk-reduction protocol. Nursing Research, 59(1), 18-25. https://doi.org/10.1097/NNR.0b013e3181c3ba05

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895