Module 7
Sustainability means improvement gains continue over time, even as staff turns over, leadership changes, and new or competing priorities emerge.
Key Strategies
- Intuitive design and human factors: Make the right thing the easy thing. A screening tool embedded in the triage workflow is more reliable than one requiring navigation to a separate module.
- System-embedded practices: Move from memory-based to structurally supported behaviors (see Reliability Levels, Module 6).
- Audit + engagement: Data audits tell you whether the behavior is occurring. Engagement (observation, conversations, feedback) tells you why. Both are needed.
PMHCA Examples
These examples use the ED telepsychiatry consult line scenario. They describe things PMHCA helps partners put in place, since the hospital owns its own workflows.
- Order set: The consult line request is built into the ED's pediatric behavioral health order set as a quick-pick. Staff doesn't have to hunt for a phone number on a laminated card taped to the wall.
- Short intake form: The consult request form asks only for the fields the consultant actually needs, and it auto-fills patient details from the EHR. That way, a busy nurse can finish it in under a minute.
- Easy to find: The consult line number and hours appear where staff already look, such as the tracking board, the unit phone directory, or a speed-dial button. They don't live in a binder or on a shared drive.
- Primary care: Depression screening is set to trigger automatically at well-child visits for eligible ages, so it doesn't depend on a clinician remembering to order it.
- Written into policy: Consult line steps are written into the ED's pediatric behavioral health protocol and new-hire orientation. They no longer live only in one champion's head.
- Tied to roles, not names: Responsibilities are assigned to roles, such as "charge nurse initiates the consult request," rather than to a person like "Dr. Smith handles consults." When someone leaves, the task stays with the role.
- Handoff packet: When a PECC or ED champion changes, a one-page handoff packet goes to their replacement. It covers the workflow, key contacts, current measures, and open issues. PMHCA updates its partner contact list every quarter so new people get connected quickly.
- Existing dashboards: Consult line measures are added to the hospital's existing quality dashboard instead of a separate spreadsheet that someone has to remember to update.
- Standing agenda item: The consult line is a standing item on an existing ED or quality meeting. It doesn't need its own meeting, which is easy to cancel when priorities compete.
- Monthly data audit: Track the percentage of eligible pediatric behavioral health ED visits that had a consult line request. Also track the time from request to completed consult. A drop in either is an early warning sign.
- Conversations when use drops: When the data shows fewer consults, talk to the ED team to learn why. Maybe new nursing staff weren't oriented, the order set changed after an EHR upgrade, or staff lost trust after a slow response.
- Observation: A PMHCA team member or PECC watches the process during a shift. The goal is to see where the workflow breaks down in real life, not just on paper.
- Quick feedback: Send a two- or three-question pulse survey to clinicians who used the consult line, asking what worked and what got in the way.
- Closing the loop: Share results back with the ED team, including wins. That keeps the work visible when leadership or priorities shift.
Examples By Threat
- What it looks like: A trained ED nurse leaves. The replacement doesn't know the consult line exists, and requests a drop.
- How to protect against it: Include the consult line in new-hire orientation and the ED's pediatric behavioral health protocol. Assign steps to roles, not people. Watch the monthly data for dips after staffing changes, and offer a short refresher when you see one.
- What it looks like: A new ED medical director or nurse manager comes in with their own priorities and doesn't know why the consult line matters.
- How to protect against it: Keep a one-page summary of the problem the consult line solves, results to date, and what the partnership asks of the hospital. Schedule an introductory meeting with the new leader early. Consult line measures that already sit on the hospital's quality dashboard are easier for a new leader to keep than a separate report they didn't ask for.
- What it looks like: A new regulatory requirement, EHR upgrade, or staffing crisis pulls attention away. The standing meeting gets cancelled, and no one notices when consults decline.
- How to protect against it: Build the consult line into existing structures, such as the order set, protocol, dashboard, and an agenda item on a meeting that already happens. That way, it keeps running without extra effort. When an EHR upgrade is planned, ask to have the order set reviewed so it isn't lost in the change. Link the consult line to priorities the hospital already cares about, such as ED boarding time or length of stay, so it isn't seen as competing with them.