"Concrete ways we can make a difference": A multi-centre, multi-professional evaluation of sustainability in quality improvement education.

Quality improvement (QI) projects are a mandatory part of postgraduate medical training in the UK and graduating medical students must be competent in QI theory. We evaluated an educational toolkit that links concepts of sustainable healthcare with established quality improvement methodologies (the SusQI approach, available at www.susqi.org). The SusQI approach was implemented across a range of undergraduate and postgraduate nursing and medical education contexts. Educational strategies included guided online learning, live interactive webinars, small group activities and scaffolded project work. The evaluation strategy was informed by theories of academic motivation, educational value within communities of practice and behaviour change. A simultaneous nested design was tested using a mixed methods survey with input from learners and teachers. 177 survey responses were analysed to quantify and compare self-rated impacts of teaching across different audiences. Qualitative data were inductively coded into themes that were categorised according to above theoretical frameworks. Participants felt that this was 'time well spent' and many described transformative impacts that guided their daily professional practice beyond learning about QI. We suggest that meaningful space is found within both undergraduate and postgraduate healthcare curricula for SusQI, as a way of engaging and motivating learners to contribute to the creation of a sustainable healthcare system.

Teaching skills for sustainable health care.

In the context of accelerating concern regarding the climate and ecological crisis and the recognition of this crisis as a health threat, there is growing motivation among the health-care community to reduce the negative environmental impact of health care. Globally, the health-care sector is estimated to be the 5th largest carbon emitter. A health system that is socially, environmentally, and financially sustainable requires clinical leadership, yet few health-care workers possess the conceptual framework or practical skills for creating new models of care. Clinicians can protect planetary health as a core part of professional practice by integrating triple bottom line measures into quality improvement or quality management practices. Initial efforts to integrate sustainability into quality improvement teaching and training have been shown to transform learners' interest in quality improvement and environmental sustainability. Embedding sustainability principles and techniques into established quality improvement education and practice can operationalise planetary health, building the skills necessary for health-care system transformation at the speed and scale required.

The follow-up of renal transplant recipients by telephone consultation: three years experience from a single UK renal unit.

Although telephone consulting is increasingly used by clinicians seeking to balance rising caseloads, heightened patient expectation and the desire to ensure continued improvements in the quality, convenience and accessibility of the care they provide, its use to provide care to renal transplant recipients has not previously been described. Climate change is a major global public health threat. However, the provision of healthcare itself has a significant environmental impact. A transformation to lower carbon clinical care must be achieved without detriment to the quality of the patient care. This article reports the use of telephone consultation clinics to provide follow-up to renal transplant recipients over a three-year period. The benefits of this service to patients, providers and the environment are outlined, the existing literature regarding the provision of virtual care to patients with kidney disease is reviewed, and the possibilities of more widespread adoption are discussed.

Exploring environmental sustainability in UK and US dental curricula and related barriers and enablers: a cross-sectional survey in two dental schools.

Introduction Very little is known about the knowledge and attitudes of dental students and educators regarding environmental sustainability in dentistry (ESD), the presence of ESD in dental curricula, and barriers and enablers to embracing ESD in dental education.Methods A cross-sectional survey using piloted online questionnaires for students and educators was carried out at the Institute of Dentistry, Queen Mary University of London and at Harvard School of Dental Medicine. Data analysis included descriptive statistics and thematic analysis.Results ESD does not exist formally in the dental curricula at either institution. Despite poor knowledge, students and educators had very positive attitudes to embracing ESD in the curricula. The most noted barriers were lack of knowledge about ESD, lack of time for preparing ESD content, lack of ESD educational materials and infection control regulations. Enablers included embedding ESD in UK and US dental education standards, having institutional backing and support in terms of providing training, educational materials, capacity and incentives, as well as adopting a critical evidence-informed approach in reforming current infection control regulations.Conclusions Dental education and infection control regulatory bodies, as well as dental institutions, can embed ESD in UK and US dental curricula by supporting the implementation of identified enablers.

Clinical transformation: the key to green nephrology.

Climate change represents a major global public health threat. The very provision of healthcare itself has a significant untoward effect on the environment, to which kidney care is likely to contribute disproportionately. In this article we describe the four principles we believe will underpin a successful transformation to lower carbon kidney care: disease prevention, patient empowerment, lean service delivery and the preferential use of low-carbon technologies. We illustrate their application and their co-benefits, such as improvements in patient care and reductions in cost, with examples.

Sustainability in quality improvement: redefining value.

Sustainability can be considered a domain of quality in -healthcare, extending the responsibility of health services to patients not just of today but of the future. The longer term -perspective highlights the impacts of our healthcare system on our environment and communities and in turn back onto population health. A sustainable approach will therefore expand the healthcare definition of value to measure health outcomes against environmental and social impacts alongside financial costs. We set out a practical framework for including these new dimensions in an already well-defined model of quality improvement. This has the potential to harness the growing quality improvement movement to shape a more sustainable health service, while improving patient outcomes. Early experience suggests that the new model may also provide immediate -benefits, including additional motivation for clinicians to engage in quality improvement, directing their efforts towards high value interventions and enabling capture and communication of a wider range of impacts on patients, staff and communities.

Sustainability in quality improvement: measuring impact.

'Sustainable value' considers patient and population outcomes against environmental, social and economic costs or impacts, providing a framework for driving sustainable improvements in healthcare for current and future generations. Measuring the impact of a quality improvement initiative on sustainable value is a new endeavour. For this to be both meaningful and useful, we must balance academic rigour (using a reproducible methodology to capture the most relevant and important impacts) against pragmatism (working within the constraints of available time and data). Using case studies, we discuss how the different variables of sustainable value may be measured in practice.

Exploring emerging learning needs: a UK-wide consultation on environmental sustainability learning objectives for medical education.

OBJECTIVE: This study aimed to engage wide-ranging stakeholders and develop consensus learning objectives for undergraduate and postgraduate medical education. METHODS: A UK-wide consultation garnered opinions of healthcare students, healthcare educators and other key stakeholders about environmental sustainability in medical education. The policy Delphi approach informed this study. Draft learning objectives were revised iteratively during three rounds of consultation: online questionnaire or telephone interview, face-to-face seminar and email consultation. RESULTS: Twelve draft learning objectives were developed based on review of relevant literature. In round one, 64 participants' median ratings of the learning objectives were 3.5 for relevance and 3.0 for feasibility on a Likert scale of one to four. Revisions were proposed, e.g. to highlight relevance to public health and professionalism. Thirty three participants attended round two. Conflicting opinions were explored. Added content areas included health benefits of sustainable behaviours. To enhance usability, restructuring provided three overarching learning objectives, each with subsidiary points. All participants from rounds one and two were contacted in round three, and no further edits were required. CONCLUSIONS: This is the first attempt to define consensus learning objectives for medical students about environmental sustainability. Allowing a wide range of stakeholders to comment on multiple iterations of the document stimulated their engagement with the issues raised and ownership of the resulting learning objectives.

The health effects of climate change: what does a nurse need to know?

The scientific evidence for anthropogenic climate change has been established with increasing precision and there are widespread concerns about its potential to undermine the public health gains of the past century. There is also a growing consensus across private and public sector organisations at national and international level that carbon reduction should be a policy aim. Various international nursing organisations have made strong position statements on the issue, arguing that nurses should be actively engaged as part of their roles in both health promotion and clinical practice. We point to education for sustainability initiatives in other health professions and share resources for curriculum development in nursing. The nurses of tomorrow will make a unique and significant contribution to protecting population health in an unstable climate, if today's nursing educators can help prepare them for this role.

The green nephrology survey of sustainability in renal units in England, Scotland and Wales.

The impact of unmitigated climate change upon global health is predicted to be disastrous. However, the very provision of healthcare itself has a significant environmental impact, and the contribution of kidney care to the carbon footprint of the NHS is likely to be disproportionately high. Furthermore, the current economic climate will ensure that healthcare systems face unprecedented reductions in resources (or, at the very least, diminished expansion in the face of ongoing increases in demand). Improvements in the way that renal services use resources will address both issues. This survey was designed to identify a baseline for sustainability in kidney care, to support a clinical transformation to lower carbon kidney care by identifying fruitful areas for attention, and to act as an educational tool. The survey identified measures for improvement across the different areas of the provision of kidney care, including building energy use, patient and staff transport, water use and the consumption and procurement of resources. The results of the survey, which was completed by 58 adult and paediatric renal units across England, Scotland, and Wales, are reported here and potential changes are discussed.

Toward greener dialysis: a case study to illustrate and encourage the salvage of reject water.

Climate change is now considered to be a major global public health concern. However, the very provision of health care itself has a significant impact upon the environment. Action must be taken to reduce this impact. Water is a precious and finite natural resource. Vast quantities of high-grade water are required to provide haemodialysis. The reverse osmosis systems used in the purification process reject approximately two-thirds of the water presented to them. Therefore, around 250 litres of 'reject water' result from the production of the dialysate required for one treatment. This good quality reject water is lost-to-drain in the vast majority of centres worldwide. Simple methodologies exist to recycle this water for alternative purposes. We describe here a case study of the only UK renal service we know to have implemented such water-saving methodologies. We outline the benefits in terms of financial and environmental savings.