Sustainability Series: what is sustainable quality improvement?

This month’s sustainability series blog focuses on SusQI- or Sustainable quality improvement.  Dr. Frances Mortimer, CSH’s Clinical Director provides and overview of SusQI as well as some updates on recently published papers. We are interested to hear of anyone using SusQI in their work, so do get in touch below or directly with Frances at:


Health systems are in constant need of improvement - and in some cases total redesign. Populations are ageing and changing, technologies continue to evolve and expand and meanwhile, services are creaking as they hang on to structures and processes inherited from an earlier time. 

Today’s health professionals are rightly expected not just to provide exemplary individual care, but to contribute to systematically improving the services within which that care is delivered. 

But what a waste if people work hard to improve a system and yet fail to notice that it relies on environmental and social resources that cannot be counted with a £ sign! They may optimise individual steps in a pathway but miss opportunities to promote wellbeing, reduce healthcare demand, empower patients or prevent ecological damage. 

What is sustainable quality improvement?

Sustainable Quality Improvement is an approach to improving healthcare in more holistic way. It takes a longer term view into account, approaching quality and value through the lens of a “triple bottom line”; the outcomes of a service are measured against its environmental, social and economic costs and impacts to determine its “sustainable value”. Adopting this broader perspective takes into account the longer-term sustainability of the social and ecological resources used by the system and pushes us to think more broadly about what the healthcare system is trying to achieve. Sustainable Quality Improvement looks to shape a system which can “provide high-quality care to patients not just of today but of the future.” (Mortimer et. al. 2018)

What progress has been made?

The Royal College of Physicians has recognised sustainability as a domain of quality in healthcare and has said that ‘healthcare should be considered not only in terms of what can be delivered to an individual today, but also to the population in general and the patients of the future.’ And if sustainability is part of quality, then it should also be an integral part of quality improvement, or QI.

In 2 papers, here and here published in the Future Healthcare Journal, my co-authors and I put forward a simple approach for incorporating sustainability into mainstream QI methodologies, which we have called the ‘SusQI’ framework. 

We believe that including sustainability and resource stewardship in QI provides a practical way for health professionals to respond to ethical challenges such as climate change and social inequalities. But we have also found that it can bring immediate benefits to the QI process itself, including new motivation and energy for change, highlighting wastes and opportunities otherwise overlooked, and directing projects systematically towards the highest value improvements.

How is SusQI used?

The SusQI framework has already been used in practice through the projects of some of the CSH scholars. For example, GP Charlie Kenward used the SusQI framework in his project as referenced here

North Bristol NHS Trust commissioned CSH to develop SusQI learning materials which are used as part of QI training for their foundation doctors and are accessible here:

Other Trusts are currently exploring the possibility of integrating SusQI across their quality programmes.

Get involved:

If you are involved in teaching, leading or contributing to quality improvement, please have a look at the SusQI framework and think whether you could apply it within your work. You can get in touch with me at:


Sustainability in quality improvement: redefining value.  Mortimer F, Isherwood J, Wilkinson A, Vaux E. Future Healthcare Journal, 2018 Vol.5(2):88-93
Sustainability in quality improvement: measuring impact.(link is external)  Mortimer F, Isherwood J, Pearce M, Kenward C, Vaux E. Future Healthcare Journal, 2018 Vol.5(2):94-97