Implementation and sustainment of diverse practices in a large integrated health system: a mixed methods study

Andrea L Nevedal; Caitlin M Reardon; George L Jackson; Sarah L Cutrona; Brandolyn White; Allen L Gifford; Elizabeth Orvek; Kathryn DeLaughter; Lindsay White; Heather A King; Blake Henderson; Ryan Vega; Laura Damschroder

doi:10.1186/s43058-020-00053-1

Implementation and sustainment of diverse practices in a large integrated health system: a mixed methods study

Implement Sci Commun. 2020 Jul 3:1:61. doi: 10.1186/s43058-020-00053-1. eCollection 2020.

Authors

Andrea L Nevedal¹, Caitlin M Reardon², George L Jackson^{3

4}, Sarah L Cutrona^{5

6}, Brandolyn White³, Allen L Gifford^{5

7}, Elizabeth Orvek^{5

6}, Kathryn DeLaughter^{5

6}, Lindsay White⁵, Heather A King^{3

4}, Blake Henderson⁸, Ryan Vega⁹, Laura Damschroder²

Affiliations

¹ Center for Innovation to Implementation, VHA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025 USA.
² Center for Clinical Management Research, VHA Ann Arbor Healthcare System, 2215 Fuller Rd., 152, Ann Arbor, MI 48105 USA.
³ Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VHA Health Care System, HSR&D (152) Suite 600, 411 West Chapel Hill Street, Durham, NC 27701 USA.
⁴ Department of Population Health Sciences and Division of General Internal Medicine, Duke University School of Medicine, 215 Morris Street, Durham, NC 27701 USA.
⁵ Center for Healthcare Organization & Implementation Research, Bedford & Boston VHA Medical Centers, 200 Springs Road (152), Building 70, Bedford, MA 01730 USA.
⁶ Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, The Albert Sherman Center, Worcester, MA 01605 USA.
⁷ Section of General Internal Medicine & Department of Health Law, Policy & Management, Boston University, 715 Albany St., Talbot Building, T2W, Boston, MA 02118 USA.
⁸ Diffusion of Excellence, VHA Innovation Ecosystem, 810 Vermont Avenue NW, Washington, DC, 20420 USA.
⁹ VHA Office of Discovery, Education and Affiliate Networks, 810 Vermont Avenue NW, Washington, DC, 20420 USA.

Abstract

Background: One goal of health systems seeking to evolve into learning health systems is to accelerate the implementation and sustainment of evidence-based practices (EBPs). As part of this evolution, the Veterans Health Administration (VHA) developed the Innovation Ecosystem, which includes the Diffusion of Excellence (DoE), a program that identifies and diffuses Gold Status Practices (GSPs) across facilities. The DoE hosts an annual "Shark Tank" competition in which leaders bid on the opportunity to implement a GSP with 6 months of implementation support. Over 750 diverse practices were submitted in cohorts 2 and 3 of Shark Tank; 23 were designated GSPs and were implemented in 31 VA networks or facilities. As part of a national evaluation of the DoE, we identified factors contributing to GSP implementation and sustainment.

Methods: Our sequential mixed methods evaluation of cohorts 2 and 3 of Shark Tank included semi-structured interviews with at least one representative from 30/31 implementing teams (N = 78/105 people invited) and survey responses from 29/31 teams (N = 39/47 invited). Interviews focused on factors influencing implementation and future sustainment. Surveys focused on sustainment 1.5-2 years after implementation. The Consolidated Framework for Implementation Research (CFIR) informed data collection and directed content analysis. Ordinal scales were developed inductively to rank implementation and sustainment outcomes.

Results: Over 50% of teams (17/30) successfully implemented their GSP within the 6-month implementation period. Despite extensive implementation support, significant barriers related to centralized decision-making, staffing, and resources led to partial (n = 6) or no (n = 7) implementation for the remaining teams. While 12/17 initially successful implementation teams reported sustained use of their GSP, over half of the initially unsuccessful teams (n = 7/13) also reported sustained GSP use 1.5 years after the initial implementation period. When asked at 6 months, 18/27 teams with complete data accurately anticipated their future sustainability based on reported sustainment an average of 1.5 years later.

Conclusions: Most teams implemented within 6 months and/or sustained their GSP 1.5 years later. High levels of implementation and sustainment across diverse practices and teams suggest that VHA's DoE is a successful large-scale model of diffusion. Team predictions about sustainability after the first 6 months of implementation provide a promising early assessment and point of intervention to increase sustainability.

Keywords: Consolidated Framework for Implementation Research (CFIR); Learning health system; Model of diffusion; Qualitative methods; Sustainability; VHA Diffusion of Excellence; VHA Innovation Ecosystem; Veterans; Veterans Health Administration (VHA).