Built to last? Barriers and facilitators of healthcare program sustainability : a systematic integrative review

Objective: To identify barriers and facilitators associated with the sustainability of implemented and evaluated improvement programs in healthcare delivery systems. Data sources and study setting: Six academic databases were searched to identify relevant peer-reviewed journal articles published in English between July 2011 and June 2022. Studies were included if they reported on healthcare program sustainability and explicitly identified barriers to, and facilitators of, sustainability. Study design: A systematic integrative review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Study quality was appraised using Hawker’s Quality Assessment Tool. Data collection/extraction methods: A team of reviewers screened eligible studies against the inclusion criteria and extracted the data independently using a purpose-designed Excel spreadsheet. Barriers and facilitators were extracted and mapped to the Integrated Sustainability Framework (ISF). Frequency counts of reported barriers/facilitators were performed across the included studies. Results: Of the 124 studies included in this review, almost half utilised qualitative designs (n = 52; 41.9%) and roughly one third were conducted in the USA (n = 43; 34.7%). Few studies (n = 29; 23.4%) reported on program sustainability beyond 5 years of program implementation and only 16 of them (55.2%) defined sustainability. Factors related to the ISF categories of inner setting (n = 99; 79.8%), process (n = 99; 79.8%) and intervention characteristics (n = 72; 58.1%) were most frequently reported. Leadership/support (n = 61; 49.2%), training/support/supervision (n = 54; 43.5%) and staffing/turnover (n = 50; 40.3%) were commonly identified barriers or facilitators of sustainability across included studies. Forty-six (37.1%) studies reported on the outer setting category: funding (n = 26; 56.5%), external leadership by stakeholders (n = 16; 34.8%), and socio-political context (n = 14; 30.4%). Eight studies (6.5%) reported on discontinued programs, with factors including funding and resourcing, poor fit, limited planning, and intervention complexity contributing to discontinuation. Conclusions: This review highlights the importance of taking into consideration the inner setting, processes, intervention characteristics and outer setting factors when sustaining healthcare programs, and the need for long-term program evaluations. There is a need to apply consistent definitions and implementation frameworks across studies to strengthen evidence in this area

Culture in context: the association between fit at work and staff outcomes

Empirical thesis.Bibliography: pages 89-107.Chapter 1. Introduction : fitting the thesis into fit literature -- Chapter 2. Literature review : mapping the fit supermarket -- Chapter 3. Methods : "the best thing since sliced bread : a new product in the fit supermarket -- Chapter 4. Quantitative findings : hypothesis testing and the goodness-of-fit of fit models -- Chapter 5. Qualitative findings : "maybe stories are just data with a soul" : Dr Brené Brown -- Chapter 6. Discussion and conclusion : how the thesis fits within the research landscape -- References -- Appendices.Organisational and workplace cultures are important factors in health systems through their capacity to influence outcomes, both for patients and employees. One potentially promising method of studying organisational and workplace cultures in health care is through the lens of person-environment fit, which examines the individuals' perceptions of if, and in what way, they are compatible with aspects of their work context. This thesis focuses on fit in relation to two contextual aspects: the person's work group and their organisation (termed person-group (P-G) fit and person-organisation (P-O) fit,respectively). A two-part method was used to study the associations between fit and staff outcomes, including job satisfaction, burnout and work stress in primary mental health facilities across Australia. In Part 1, an online survey was developed and validated using confirmatory factor analysis, prior to hypothesis testing. Part 2 consisted of follow-up interviews analysed using thematic analysis. Part 1 yielded two valid and reliable sub-scales. The subsequent multiple regression analyses indicated that P-O fit accounted for asignificant proportion of variability in all staff outcomes, but the P-G fit results were less conclusive. Results of Part 2 provided a more holistic description of the associations between different components of fit and their relation to staff outcomes. Ultimately, this thesis contributes a deeper understanding of fit in the context of a workplace and organisation.Mode of access: World wide web1 online resource (xxiv, 169 pages) diagrams, table

When complexity science meets implementation science: a theoretical and empirical analysis of systems change

Abstract Background Implementation science has a core aim – to get evidence into practice. Early in the evidence-based medicine movement, this task was construed in linear terms, wherein the knowledge pipeline moved from evidence created in the laboratory through to clinical trials and, finally, via new tests, drugs, equipment, or procedures, into clinical practice. We now know that this straight-line thinking was naïve at best, and little more than an idealization, with multiple fractures appearing in the pipeline. Discussion The knowledge pipeline derives from a mechanistic and linear approach to science, which, while delivering huge advances in medicine over the last two centuries, is limited in its application to complex social systems such as healthcare. Instead, complexity science, a theoretical approach to understanding interconnections among agents and how they give rise to emergent, dynamic, systems-level behaviors, represents an increasingly useful conceptual framework for change. Herein, we discuss what implementation science can learn from complexity science, and tease out some of the properties of healthcare systems that enable or constrain the goals we have for better, more effective, more evidence-based care. Two Australian examples, one largely top-down, predicated on applying new standards across the country, and the other largely bottom-up, adopting medical emergency teams in over 200 hospitals, provide empirical support for a complexity-informed approach to implementation. The key lessons are that change can be stimulated in many ways, but a triggering mechanism is needed, such as legislation or widespread stakeholder agreement; that feedback loops are crucial to continue change momentum; that extended sweeps of time are involved, typically much longer than believed at the outset; and that taking a systems-informed, complexity approach, having regard for existing networks and socio-technical characteristics, is beneficial. Conclusion Construing healthcare as a complex adaptive system implies that getting evidence into routine practice through a step-by-step model is not feasible. Complexity science forces us to consider the dynamic properties of systems and the varying characteristics that are deeply enmeshed in social practices, whilst indicating that multiple forces, variables, and influences must be factored into any change process, and that unpredictability and uncertainty are normal properties of multi-part, intricate systems

Accomplishing reform : successful case studies drawn from the health systems of 60 countries

Healthcare reform typically involves orchestrating a policy change, mediated through some form of operational, systems, financial, process or practice intervention. The aim is to improve the ways in which care is delivered to patients. In our book ‘Health Systems Improvement Across the Globe: Success Stories from 60 Countries’, we gathered case-study accomplishments from 60 countries. A unique feature of the collection is the diversity of included countries, from the wealthiest and most politically stable such as Japan, Qatar and Canada, to some of the poorest, most densely populated or politically challenged, including Afghanistan, Guinea and Nigeria. Despite constraints faced by health reformers everywhere, every country was able to share a story of accomplishment—defining how their case example was managed, what services were affected and ultimately how patients, staff, or the system overall, benefited. The reform themes ranged from those relating to policy, care coverage and governance; to quality, standards, accreditation and regulation; to the organization of care; to safety, workforce and resources; to technology and IT; through to practical ways in which stakeholders forged collaborations and partnerships to achieve mutual aims. Common factors linked to success included the ‘acorn-to-oak tree’ principle (a small scale initiative can lead to system-wide reforms); the ‘data-to-information-to-intelligence’ principle (the role of IT and data are becoming more critical for delivering efficient and appropriate care, but must be converted into useful intelligence); the ‘many-hands’ principle (concerted action between stakeholders is key); and the ‘patient-as-the-pre-eminent-player’ principle (placing patients at the centre of reform designs is critical for success).This work was supported by National Health and Medical Research Council [grant number 1054146 to J.B.].https://academic.oup.com/intqhcam2018School of Health Systems and Public Health (SHSPH

Accomplishing reform: successful case studies drawn from the health systems of 60 countries

Healthcare reform typically involves orchestrating a policy change, mediated through some form of operational, systems, financial, process or practice intervention. The aim is to improve the ways in which care is delivered to patients. In our book ‘Health Systems Improvement Across the Globe: Success Stories from 60 Countries’, we gathered case-study accomplishments from 60 countries. A unique feature of the collection is the diversity of included countries, from the wealthiest and most politically stable such as Japan, Qatar and Canada, to some of the poorest, most densely populated or politically challenged, including Afghanistan, Guinea and Nigeria. Despite constraints faced by health reformers everywhere, every country was able to share a story of accomplishment—defining how their case example was managed, what services were affected and ultimately how patients, staff, or the system overall, benefited. The reform themes ranged from those relating to policy, care coverage and governance; to quality, standards, accreditation and regulation; to the organization of care; to safety, workforce and resources; to technology and IT; through to practical ways in which stakeholders forged collaborations and partnerships to achieve mutual aims. Common factors linked to success included the ‘acorn-to-oak tree’ principle (a small scale initiative can lead to system-wide reforms); the ‘data-to-information-to-intelligence’ principle (the role of IT and data are becoming more critical for delivering efficient and appropriate care, but must be converted into useful intelligence); the ‘many-hands’ principle (concerted action between stakeholders is key); and the ‘patient-as-the-pre-eminent-player’ principle (placing patients at the centre of reform designs is critical for success).This work was supported by National Health and Medical Research Council [grant number 1054146 to J.B.].https://academic.oup.com/intqhcam2018School of Health Systems and Public Health (SHSPH