What sustainability looks like

Reconnecting with what matters

Today I went back to visit AIIMS after a gap of almost two years.

AIIMS is known as India’s premier hospital, medical college and research institution. Despite its stature, it faces the inherent challenges of being a government hospital in India. I had started supporting AIIMS in 2016, while working as a Senior Improvement Advisor with a USAID funded project. The objective was to build a sustained quality improvement movement in India and in neighbouring countries. I learnt how to coach and how to simplify QI to its essence – not just at AIIMS but at various health facilities of all kinds across India and South Asia.

The work was informal and agile. After initial workshops on QI, teams and individuals who would take up various issues to improve in their setting would then themselves reach out to me or to others on our team and seek our coaching support. Over time clinicians who found that QI was helping them improve issues which had frustrated them for years – started teaching and involving others on their own.

Even after the USAID project ended in 2017, I and others from our team used to still get called by various teams at AIIMS and other health facilities for support. I found this fulfilling. There were efforts by others to sustain funding for quality improvement with varied success. Some of the work can be seen on https://www.pocqi.org/ ; https://sites.google.com/view/aiimsqi/

The work also spread to other institutions across India and to neighbouring countries.

What has been incredible is how things have continued to evolve despite no external technical assistance.

Today I caught up with individuals and teams I had worked with on and off over the years – and it was so satisfying to notice how our conversation was no longer about the nitty-gritty of writing an aim statement, or on what indicator to measure. It was more on how to engage more people, how to make it a multi-cadre effort, how to work at a departmental level. How to shift cultural norms. How to build synergies across teams in different departments.

There are still more mountains to climb, new complexities to address. Not all departments are on board. Due to choppy funding – it couldn’t become as institutionalised an effort as we had envisioned. The work still relies on individual motivation and commitment. Some wrinkles in how various teams and individuals are approaching improvement need ironing out.

What has stayed the same was the heartfelt determination with which each person spoke of their efforts – how they could see the pain and problems of the patients and families and wished to solve them – whether it was infections, emergency care, discharge or waiting time.

This wasn’t a check-the-box top down exercise. One person said to me ‘My family member had something similar happen to them, so when I am able to improve this issue for other patients it is very meaningful for me”

Another shared “Patients get so stressed when we discharge them within 2 days of their surgery”. She felt it’s so challenging for patients and families to remember so much information and manage things alone after discharge. Another shared how incorrect culture report affects the whole line of treatment for the patient.

They no longer need the promise of a journal publication or a poster presentation as a motivation to be involved in quality improvement. They have tapped into a motivation far more meaningful – something no workshop and no coach can instil.

In listening to them, I was reminded of Avedis Donabedian – considered a founding figure of the study of quality in healthcare. He had said –“Systems awareness and systems design are important for health professionals, but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success.Ultimately, the secret of quality is love.”

I thank all the people I met today for all that I learnt in our discussions, for patiently explaining you projects, for your humility in asking questions, and for your persistence despite challenges.

We often talk of sustainability in global health – and I get irritated the way this term is thrown around, the expectations of perfect sustainability from funders and from even well-intentioned colleagues and critics. Most things in life are not ‘sustainable’, and neither would we want them to be.

We need a more organic view of sustainability. This work that began in 2015 and goes on even in 2025. It has taken its own shape and form. Some old faces, some new.

Sustainability is not just about the funding or the indicators. It is about the head, hearts and hands of the people doing the work. It cannot be forced, it cannot be predicted. With space and trust – a new, as-yet-unknowable future will emerge.

There is little documentation of the work and transformation that continues to happen at AIIMS and in many other places. Often the most meaningful work in the world goes on quietly without anyone noticing.

I am writing today because I want to in some small way document this quiet but consistent work – as people have taught each other how to improve systems – not in large workshops with budgets for flex-board posters and lunches; but one-one on in the wards & corridors.

Often those of us in a coaching role avoid speaking of our own selves while ensuring others get the platform. But today I don’t want to be self-effacing. Today I felt really good and grateful about the part I have also had the opportunity to play in this – so I wanted to give myself the gift of acknowledgement and celebration.

I have been to many places in India and around the world to support improvements in care, but seeing things evolve over time at AIIMS, a stones throw from where I live, has been special.

However, I am in no way central to this movement, I have been one of many. This work has been kept alive by a myriad of people in the institution itself – some help clear administrative hurdles, some coach, some work to get funding and others provide vision. I will not be able to capture the complexity and detail of all that has transpired. And even in writing this post I am doing a disservice to many whose contribution I have not covered.

Each of you is seen and each of you is celebrated.

And to many of you I will forever remain grateful for enabling me to nurture my niche and find fulfilment in my work.