Sustainability in Quality Improvement

Today's healthcare professionals are expected to do more than just deliver excellent patient care; they are also expected to contribute to improving healthcare services, using a process called Quality Improvement (QI).  

The climate and ecological crisis represents the most important threat to human health and wellbeing of the century. The healthcare sector has a significant carbon footprint, and healthcare professionals are increasingly motivated to reduce the harmful environmental and social impact of our health systems. Despite this, there is still a gap in knowledge and skills among healthcare professionals in how to deliver more sustainable healthcare. 

By embedding sustainability into quality improvement, social and environmental challenges in healthcare can be addressed as a core part of professional practice, using a recognised method for change. 


The SusQI framework 

Sustainable QI (or SusQI) recognises that there are finite environmental, social and financial resources available to deliver a high standard of patient care. The overall goal of sustainable quality improvement is to maximise sustainable value. This means to deliver the best possible health outcomes with minimum financial and environmental costs, while adding positive social value at every opportunity. As in standard cost-benefit analysis, the concept can be expressed as an equation, where value = outcomes / costs:

The Sustainability in Quality Improvement framework (SusQI) is an approach to improving healthcare in a holistic way, by assessing quality and value through the lens of a “triple bottom line”. In SusQI, the health outcomes of a service are measured against its environmental, social and economic costs and impacts to determine its “sustainable value”.  The framework was developed by CSH with partners, including the Royal College of Physicians.


Benefits of integrating the SusQI framework 

SusQI embeds the CSH principles of sustainable clinical practice: prevention, patient empowerment and self-care, lean clinical pathways, and low carbon alternatives. 

Including sustainability and resource stewardship in QI allows health professionals to respond to ethical challenges such as climate change and social inequalities. It also benefits the QI process itself: inspiring new energy for change, highlighting wastes and opportunities otherwise overlooked, and directing projects systematically towards the highest value improvements. 



SusQI Learning Resources 

 The Centre for Sustainable Healthcare have designed a range of resources to equip health professionals and educators with the skills to integrate sustainability into quality improvement projects and education. 

Sustainable Quality Improvement Course

This intensive course introduces health professionals and educators to the concept of ‘sustainable value’ and the ‘SusQI’ framework for integrating sustainability into quality improvement. Learning from real examples, participants explore in depth how the framework can be applied in practice to develop preventative, holistic, lean, low carbon care. The course includes 4-6-hours of multi-media self-study, a 4-hour interactive workshop and a follow-up interactive masterclass 1-2 months after the workshop to discuss projects-in-progress. Learn more Project Resources

Our website ( has a step-by-step guide to take you through the four steps of a SusQI project. Each step of this guide contains open-access resources for carrying out your project, including worked examples of driver diagrams and process maps as well as a carbon calculation guide and project development template. Learn more


Teaching Sustainable Quality Improvement Course

This course uses the ‘SusQI’ framework, developed by CSH, to help health professions educators and students to integrate sustainability concepts into mainstream quality improvement teaching. It meets curriculum requirements while also responding to growing concern about the need for the health sector to respond to the climate and ecological emergency, and lead by example.  The course is equally applicable to all health professions and to the undergraduate and postgraduate level. Learn more


Teaching Sustainable Quality Improvement Educators Pack

This open access Educator Pack is available on It is designed for educators who are teaching quality improvement and want to embed sustainability into their educational content, as well as QI project supervisors who want to support students in undertaking a SusQI project. This pack contains everything you will need to teach SusQI to a range of learners and includes pre-reading and introductory material, a full slide set, interactive activities with student and facilitator worksheets and a guide on assessment. Learn more


SusQI training within healthcare organisations, Trusts, and Integrated Care Systems 

Course Block Booking

Achieving sustainable transformation requires widespread staff engagement and training. CSH offers block booking discounts on our Sustainable Quality Improvement courses and can provide a commissioned course date to train your staff together, facilitating network building across your organisation. This enables your organisation to equip staff with the motivation, skills, and resources necessary to develop and implement innovative low-carbon healthcare projects that align with your Green/Sustainability Plan. Learn more


Green Ward Competition

The Green Ward Competition is an award-winning, tried & tested leadership and engagement programme to transform healthcare by cutting carbon, improving patient care & staff experience and saving money. The Sustainable Quality Improvement approach is used as a method of change and CSH facilitators work directly with participating teams to develop, run and measure SusQI projects. Learn more


Embedding SusQI within university courses and training programmes  

We offer training, resources, and support to selected Beacon Sites inside universities, to help them become leaders in SusQI teaching and practice. Current beacon sites include: 

  • Kings College London Medical and Nursing Schools 
  • East Anglia Foundation School 
  • Severn Foundation School 
  • Northumbria Nursing Schools 
  • Bristol Medical School 
  • Queen’s University Belfast Medical School 
  • HEE North East Faculty of Sustainable Healthcare  

Learn more

Sustainable Quality Improvement e-LFH programme  

CSH has partnered with the HEE Northeast Faculty of Sustainable Healthcare and e-Learning for Health (e-lfh) to produce a free e-learning module on Sustainability in Quality Improvement for all healthcare groups. 

Due for release in early 2022, 'Environmental Sustainability in Quality Improvement' provides learners with insight into the value of embedding sustainable healthcare principles into each step of quality improvement. It includes interactive activities and case studies of successful projects. 

Its launch will complement the existing module ‘Building a Net Zero NHS' with animated film and case study examples. 


Sustainable Quality Improvement Projects in Action 

These case studies were compiled from health professionals across the United Kingdom who have integrated sustainability into their quality improvement projects. Several of these originated from the CSH's Green Ward Competition. For a more comprehensive list of sustainable quality improvement projects, please visit our CSH Case Studies page or join one of our CSH Networks. 

SusQI case study

Read the report, here


SusQI case studyRead the report, here

Where is SusQI being used? 

Our work has spread to sites within six of the eight HEE regions, as well as Wales and Northern Ireland.  We are also currently forming new partnerships with sites in Scotland and the Republic of Ireland.  

SusQI spread

On a national level, SusQI has also been included in the new Generalism curriculum developed by HEE, a professional learning and development program which will be undertaken by all trainee doctors across England. The Academy of Medical Royal Colleges has already included sustainability as part of their Quality Improvement curriculum(link).  

Internationally, the sustainable value equation has been integrated into the new Assessment Framework for Quality Standards and Measures of the Netherlands National Care Institute. The SusQI team are also engaging with the International Society for Quality in Healthcare (ISQua) and the Institute for Healthcare Improvement (IHI) to understand how sustainability could be embedded into international quality improvement standards. It has also been included by the Planetary Health Report Card which is used globally to assess the inclusion of planetary health in healthcare education (link). 

SusQI Publications 

  • 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. Mortimer F, Isherwood J, Pearce M, Kenward C, Vaux E. Future Healthcare Journal, 2018 Vol.5(2):94-97 
  • Clery P, d'Arch Smith S, Marsden O, Leedham-Green K. Sustainability in quality improvement (SusQI): a case-study in undergraduate medical education. BMC Med Educ. 2021 Aug 12;21(1):425 
  • Marsden, O., Clery, P., D’Arch Smith, S. et al. Sustainability in Quality Improvement (SusQI): challenges and strategies for translating undergraduate learning into clinical practice. BMC Med Educ 21, 555 (2021). 
  • Spooner, R., Stanford, V., Parslow-Williams, S., Mortimer, F., Leedham-Green, K. “Concrete ways we can make a difference”: a multi-centre, multi-professional evaluation of sustainability within quality improvement education. In submission.