Examples and inspiration

Use the Plan – Do – Study – Act (PDSA) cycle

• View a PDSA worksheet from the IHI.
• Use the SusQI resources from the Centre for Sustainable Healthcare
• Use SMART goals (specific, measurable, achievable, relevant, time-bound)
• Consider environmental, financial, and social impact (the triple bottom line)
• Track change and celebrate success
• Get support from your Trust’s QI or Green Team

The pitch

Inhalers, specifically MDIs, contain propellants which are potent greenhouse gases. Inhalers contribute 3% of the NHS carbon footprint. There is significant variation in MDI vs DPI prescribing across the UK and internationally. In the UK we prescribe many more MDIs than Europe (70% vs 50%). In Sweden they only prescribe 15% MDIs. Our outcomes for COPD and asthma are not better, and in many cases poorer. This tells us we need to give more attention to using the right device for every patient, and provides an opportunity to reduce the environmental impact of inhaler prescribing.

Examples of success

• Green Inhaler Phase 2 QI Project (2023)

Practical tips 

• Engage your Trust QI team to help with measurable outcomes and run charts before starting.
• Be prepared for setbacks as local and national inhaler stocks fluctuate. 
• Always assess inhaler technique and incorporate patient preference.

The pitch

SABA overuse is both a clinical and sustainability problem. Reducing SABA overuse is the best example of how high quality patient care is also low carbon care.

Examples of success

• SENTINEL PLUS programme addressing SABA over-reliance, developed in Hull and East Yorkshire
• Reducing SABA overprescribing in East London

Practical tips

• Engage your Trust QI team to help with measurable outcomes and run charts before starting.
• Be prepared for setbacks as local and national inhaler stocks fluctuate. 

The pitch

Gloves are a huge source of single use plastic in healthcare, and reducing unnecessary glove use has health, environment, and financial benefits (improved hand hygiene practice, reduced single-use plastic, and reduced cost).

Examples of success

• Gloves Off SusQI project report from Hampshire Hospitals NHS Foundation Trust
• Examples and resources from the Intensive Care Society

Practical tips 

• Start with a short achievable time frame, with longer term goals.
• Ensure that guidance on glove use is clear and consistent from all sources eg posters on ward, infection control policies, medication preparation guidance.

The pitch

Antibiotics are often given as liquid in children when they could be tablets. Liquid is high cost, high carbon, high waste compared to tablets.

The project

The Kidzmed project was developed to help children and young people learn how to swallow tablets, using a simple six-step technique.

• Read about the KidzMed project in the BMJ
• Watch teaching demonstration on YouTube
• Access 15 minute training session on NHSE elfh Hub
• Download patient-facing resources

The pitch

Pressurised metered dose inhalers (pMDIs) carry a significant carbon footprint — a single ventolin inhaler is equivalent in emissions to driving 175 miles.* In departments where only a limited number of puffs are required per patient (such as reversibility testing in spirometry or burst therapy for viral-induced wheeze), inhalers have historically been disposed of after a single patient, wasting the majority of the medication. 

The project

Cleaning inhalers to allow multiple patient use at University Hospital Southampton NHS Trust.

• Southgate G, Crocker C and Harper S. 2024. 'Cleaning Inhalers to Allow Multi-Patient Use with the Use of Individual Patient Spacers’. University Hospital Southampton NHS Trust.

You recently came across the concept of lean pathway in healthcare by reading the BTS Position Statement on Sustainability and the Environment: Climate Change and Lung Health 2024. 

Today a patient came on hospital transport for assessment in the general Respiratory clinic. Their lung function appointment is not until next week which will require another visit to the hospital. The patient has hearing issues and has requested in-person rather than telephone appointments so they will need to return a third time to discuss results. 

You think a lean pathway approach could help this issue of multiple appointments leading to waste of both resources and patient time.

How can you identify key interested parties? 

• Brainstorming: Discuss your idea of lean pathway for clinic patients with colleagues/line manager/department lead and plan a QI approach. Identify a list of people that should be engaged for this project e.g respiratory clinic administrator, lung function booking team, clinic secretary, consultants, head of department etc. Discuss your idea with each of them to identify more people who could influence your pathway.
• Mapping of key players:. It can be useful to map your list of people using the Mendelow’s power-interest matrix (this process is also known as Stakeholder mapping). This helps to determine who is essential to meet as the core team, and who can be kept updated, making it easier to find times when key people can meet and maintain momentum. 

You have undertaken a QI project to reduce the plastic waste produced by respiratory procedures in your department. This involved engaging multiple interested parties, identifying potential areas of improvement and making some fundamental changes to the usage of equipment for each procedure. You need to keep everyone involved in the project updated on the status of your project and the impact of your greener approach to sustain the benefits of your intervention.

How to measure and report impact to the interested parties

Depending on the purpose and audience, different measures and ways of communicating will be effective. In all cases, think about how you can make it relatable to the audience. Using infographics and converting outcomes into more familiar measures can be very effective. Develop a clear and compelling message and focus on what your idea will improve (e.g. patient care, cost savings, efficiency, safety, or climate impact). Utilise multiple channels to communicate message- trust newsletters, internal intranet, posters, powerpoint slides, podcasts, videos

Give examples of things that can be done that lead to environmental impact such as:

• if you replace x miles in a car by an electric bus or bike you will save x
• If you reduce your red meat consumption by x, your risk of cardiovascular disease will reduce by x and also you are reducing the emission of greenhouse gases by X

Use Key Performance Indicators (KPIs): simple measures can be very powerful eg

• kg reduction in plastic waste or carbon footprint per procedure
• cost savings of your intervention over a year.

Reporting the status of your project

For more complex projects, you can use an Environment, Social and Governance framework (ESG) or NHS sustainability reporting frameworks.

You are leading a Gloves off QI project in your respiratory ward. You have identified interested parties for your project at ward and departmental level. You are looking for ways of engaging these people and what resources you might need. 

How to engage interested parties in your project? 

• Engaging local team: use daily ward huddle to spread awareness among colleagues about your project, create posters for display in ward clinical areas to highlight ways to avoid excessive glove use and put up prompts near the glove boxes on your ward. Create opportunities for staff to ask questions and share concerns about the change you propose. Involve infection control team at all stages to ensure clear messaging on when gloves are/are not recommended.
•  Engaging department/organisation: engage the staff through departmental teaching, staff emails or a newsletter. At an organisational level, you can present the findings of your QI project at a Grand Round or quality forum to raise awareness about your project and sustainability. You can join departmental meetings of other specialties to share your learning and support other teams to spread your success to create organisational change.
• Engaging patients: As part of King’s College Hospital NHS Trust’s Gloves Off project, a patient survey was conducted on attitudes to glove use. This provided an opportunity to inform patients about the benefits of hand washing over glove use, identified specific patient groups who needed adjustments or additional information, and also reassured staff that many patients preferred staff not to wear gloves for many tasks.

Research is needed into trends in UK practice with regard to single-use bronchoscopes and laryngoscopes. Further comprehensive assessment of the environmental impact of single use versus reusable bronchoscopes is needed, following one study published in 2018 on this.

Any research needs to take into account known broader health impacts of plastic production and disposal, estimated to result in global health care costs of $250 billion each year.

• Consider the impact of reusable vs disposable bronchoscopes – it is possible that disposable kits have comparable carbon footprint when cleaning and sterilisation is taken into account.
• Read a policy document from Brighton and Sussex Medical School: Reducing the environmental impact of medical devices adopted for use in the NHS