The Sustainability of New Programs and Innovations: A Review of the Empirical Literature and Recommendations for Future Research

Background: The introduction of evidence-based programs and practices into healthcare settings has been the subject of an increasing amount of research in recent years. While a number of studies have examined initial implementation efforts, less research has been conducted to determine what happens beyond that point. There is increasing recognition that the extent to which new programs are sustained is influenced by many different factors and that more needs to be known about just what these factors are and how they interact. To understand the current state of the research literature on sustainability, our team took stock of what is currently known in this area and identified areas in which further research would be particularly helpful. This paper reviews the methods that have been used, the types of outcomes that have been measured and reported, findings from studies that reported long-term implementation outcomes, and factors that have been identified as potential influences on the sustained use of new practices, programs, or interventions. We conclude with recommendations and considerations for future research. Methods: Two coders identified 125 studies on sustainability that met eligibility criteria. An initial coding scheme was developed based on constructs identified in previous literature on implementation. Additional codes were generated deductively. Related constructs among factors were identified by consensus and collapsed under the general categories. Studies that described the extent to which programs or innovations were sustained were also categorized and summarized. Results: Although “sustainability” was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves. Conclusions: Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment

Middle managers’ role in implementing evidence-based practices in healthcare: a systematic review

Abstract Background Middle managers are in a unique position to promote the implementation of evidence-based practices (EBPs) in healthcare organizations, yet knowledge of middle managers’ role in implementation and determinants (e.g., individual-, organizational-, and system-level factors) which influence their role remains fractured, spanning decades and disciplines. To synthesize understanding, we undertook a systematic review of studies of middle managers’ role in healthcare EBP implementation and determinants of that role. Methods We searched MEDLINE/PubMed and Business Source Complete (Ebsco) for literature on middle managers’ role in healthcare EBP implementation and its determinants. We abstracted data from records that met inclusion criteria (i.e., written in English, peer-reviewed, and reporting either a protocol or results of an empirical study) into a matrix for analysis. We summarized categorical variables using descriptive statistics. To analyze qualitative data, we used a priori codes and then allowed additional themes to emerge. Results One hundred five records, spanning across several countries and healthcare settings and relating to a range of EBPs, met our inclusion criteria. Studies of middle managers’ role in healthcare EBP implementation and its determinants substantially increased from 1996 to 2015. Results from included studies suggest that middle managers shape implementation climate in addition to fulfilling the four roles hypothesized in extant theory of middle managers’ role in implementation. However, extant studies offered little understanding of determinants of middle managers’ role. Conclusions Our findings suggest that middle managers may play an important role in facilitating EBP implementation. Included studies offered little understanding regarding the relative importance of various roles, potential moderators of the relationship between middle managers’ roles and EBP implementation, or determinants of middle managers’ role in EBP implementation. Future studies should seek to understand determinants and moderators of middle managers’ role. Clearer understanding may facilitate the translation of evidence into practice

Improving quality of care through routine, successful implementation of evidence-based practice at the bedside: an organizational case study protocol using the Pettigrew and Whipp model of strategic change

BACKGROUND: Evidence-based practice (EBP) is an expected approach to improving the quality of patient care and service delivery in health care systems internationally that is yet to be realized. Given the current evidence-practice gap, numerous authors describe barriers to achieving EBP. One recurrently identified barrier is the setting or context of practice, which is likewise cited as a potential part of the solution to the gap. The purpose of this study is to identify key contextual elements and related strategic processes in organizations that find and use evidence at multiple levels, in an ongoing, integrated fashion, in contrast to those that do not. METHODS: The core theoretical framework for this multi-method explanatory case study is Pettigrew and Whipp's Content, Context, and Process model of strategic change. This framework focuses data collection on three entities: the Why of strategic change, the What of strategic change, and the How of strategic change, in this case related to implementation and normalization of EBP. The data collection plan, designed to capture relevant organizational context and related outcomes, focuses on eight interrelated factors said to characterize a receptive context. Selective, purposive sampling will provide contrasting results between two cases (departments of nursing) and three embedded units in each. Data collection methods will include quantitative tools (e.g., regarding culture) and qualitative approaches including focus groups, interviews, and documents review (e.g., regarding integration and “success”) relevant to the EBP initiative. DISCUSSION: This study should provide information regarding contextual elements and related strategic processes key to successful implementation and sustainability of EBP, specifically in terms of a pervasive pattern in an acute care hospital-based health care setting. Additionally, this study will identify key contextual elements that differentiate successful implementation and sustainability of EBP efforts, both within varying levels of a hospital-based clinical setting and across similar hospital settings interested in EBP

Factors affecting the use of patient survey data for quality improvement in the Veterans Health Administration

<p>Abstract</p> <p>Background</p> <p>Little is known about how to use patient feedback to improve experiences of health care. The Veterans Health Administration (VA) conducts regular patient surveys that have indicated improved care experiences over the past decade. The goal of this study was to assess factors that were barriers to, or promoters of, efforts to improve care experiences in VA facilities.</p> <p>Methods</p> <p>We conducted case studies at two VA facilities, one with stable high scores on inpatient reports of emotional support between 2002 and 2006, and one with stable low scores over the same period. A semi-structured interview was used to gather information from staff who worked with patient survey data at the study facilities. Data were analyzed using a previously developed qualitative framework describing organizational, professional and data-related barriers and promoters to data use.</p> <p>Results</p> <p>Respondents reported more promoters than barriers to using survey data, and particularly support for improvement efforts. Themes included developing patient-centered cultures, quality improvement structures such as regular data review, and training staff in patient-centered behaviors. The influence of incentives, the role of nursing leadership, and triangulating survey data with other data on patients' views also emerged as important. It was easier to collect data on current organization and practice than those in the past and this made it difficult to deduce which factors might influence differing facility performance.</p> <p>Conclusions</p> <p>Interviews with VA staff provided promising examples of how systematic processes for using survey data can be implemented as part of wider quality improvement efforts. However, prospective studies are needed to identify the most effective strategies for using patient feedback to improve specific aspects of patient-centered care.</p

Applying a Model of Teamwork Processes to Emergency Medical Services

Introduction: Effective teamwork has been shown to optimize patient safety. However, researchcentered on the critical inputs, processes, and outcomes of team effectiveness in emergency medicalservices (EMS) has only recently begun to emerge. We conducted a theory-driven qualitative studyof teamwork processes—the interdependent actions that convert inputs to outputs—by frontline EMSpersonnel in order to provide a model for use in EMS education and research.Methods: We purposively sampled participants from an EMS agency in Houston, TX. Full-timeemployees with a valid emergency medical technician license were eligible. Using semi-structuredformat, we queried respondents on task/team functions and enablers/obstacles of teamwork in EMS.Phone interviews were recorded and transcribed. Using a thematic analytic approach, we combinedcodes into candidate themes through an iterative process. Analytic memos during coding and analysisidentified potential themes, which were reviewed/refined and then compared against a model ofteamwork processes in emergency medicine.Results: We reached saturation once 32 respondents completed interviews. Among participants, 30(94%) were male; the median experience was 15 years. The data demonstrated general support forthe framework. Teamwork processes were clustered into four domains: planning; action; reflection;and interpersonal processes. Additionally, we identified six emergent concepts during open coding:leadership; crew familiarity; team cohesion; interpersonal trust; shared mental models; and proceduralknowledge.Conclusion: In this thematic analysis, we outlined a new framework of EMS teamwork processes todescribe the procedures that EMS operators employ to convert individual inputs into team performanceoutputs. The revised framework may be useful in both EMS education and research to empiricallyevaluate the key planning, action, reflection, and interpersonal processes that are critical to teamworkeffectiveness in EMS

Applying a Model of Teamwork Processes to Emergency Medical Services

Introduction: Effective teamwork has been shown to optimize patient safety. However, researchcentered on the critical inputs, processes, and outcomes of team effectiveness in emergency medicalservices (EMS) has only recently begun to emerge. We conducted a theory-driven qualitative studyof teamwork processes—the interdependent actions that convert inputs to outputs—by frontline EMSpersonnel in order to provide a model for use in EMS education and research.Methods: We purposively sampled participants from an EMS agency in Houston, TX. Full-timeemployees with a valid emergency medical technician license were eligible. Using semi-structuredformat, we queried respondents on task/team functions and enablers/obstacles of teamwork in EMS.Phone interviews were recorded and transcribed. Using a thematic analytic approach, we combinedcodes into candidate themes through an iterative process. Analytic memos during coding and analysisidentified potential themes, which were reviewed/refined and then compared against a model ofteamwork processes in emergency medicine.Results: We reached saturation once 32 respondents completed interviews. Among participants, 30(94%) were male; the median experience was 15 years. The data demonstrated general support forthe framework. Teamwork processes were clustered into four domains: planning; action; reflection;and interpersonal processes. Additionally, we identified six emergent concepts during open coding:leadership; crew familiarity; team cohesion; interpersonal trust; shared mental models; and proceduralknowledge.Conclusion: In this thematic analysis, we outlined a new framework of EMS teamwork processes todescribe the procedures that EMS operators employ to convert individual inputs into team performanceoutputs. The revised framework may be useful in both EMS education and research to empiricallyevaluate the key planning, action, reflection, and interpersonal processes that are critical to teamworkeffectiveness in EMS

Institutionalizing evidence-based practice: an organizational case study using a model of strategic change

Abstract Background There is a general expectation within healthcare that organizations should use evidence-based practice (EBP) as an approach to improving the quality of care. However, challenges exist regarding how to make EBP a reality, particularly at an organizational level and as a routine, sustained aspect of professional practice. Methods A mixed method explanatory case study was conducted to study context; i.e., in terms of the presence or absence of multiple, inter-related contextual elements and associated strategic approaches required for integrated, routine use of EBP ('institutionalization'). The Pettigrew et al. Content, Context, and Process model was used as the theoretical framework. Two sites in the US were purposively sampled to provide contrasting cases: i.e., a 'role model' site, widely recognized as demonstrating capacity to successfully implement and sustain EBP to a greater degree than others; and a 'beginner' site, self-perceived as early in the journey towards institutionalization. Results The two sites were clearly different in terms of their organizational context, level of EBP activity, and degree of institutionalization. For example, the role model site had a pervasive, integrated presence of EBP versus a sporadic, isolated presence in the beginner site. Within the inner context of the role model site, there was also a combination of the Pettigrew and colleagues' receptive elements that, together, appeared to enhance its ability to effectively implement EBP-related change at multiple levels. In contrast, the beginner site, which had been involved for a few years in EBP-related efforts, had primarily non-receptive conditions in several contextual elements and a fairly low overall level of EBP receptivity. The beginner site thus appeared, at the time of data collection, to lack an integrated context to either support or facilitate the institutionalization of EBP. Conclusion Our findings provide evidence of some of the key contextual elements that may require attention if institutionalization of EBP is to be realized. They also suggest the need for an integrated set of receptive contextual elements to achieve EBP institutionalization; and they further support the importance of specific interactions among these elements, including ways in which leadership affects other contextual elements positively or negatively.</p