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Cited by 423Healthcare Quality and ManagementHealth Policy Implementation ScienceHealthcare Facilities Design and Sustainability

Navigating the sustainability landscape: a systematic review of sustainability approaches in healthcare

Open access
Lennox, L., Maher, L., Reed, J.·2018·Implementation Science
DOI 10.1186/s13012-017-0707-4PMC PMC5810192
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Abstract

BACKGROUND: Improvement initiatives offer a valuable mechanism for delivering and testing innovations in healthcare settings. Many of these initiatives deliver meaningful and necessary changes to patient care and outcomes. However, many improvement initiatives fail to sustain to a point where their full benefits can be realised. This has led many researchers and healthcare practitioners to develop frameworks, models and tools to support and monitor sustainability. This work aimed to identify what approaches are available to assess and influence sustainability in healthcare and to describe the different perspectives, applications and constructs within these approaches to guide their future use. METHODS: A systematic review was carried out following PRISMA guidelines to identify publications that reported approaches to support or influence sustainability in healthcare. Eligibility criteria were defined through an iterative process in which two reviewers independently assessed 20% of articles to test the objectivity of the selection criteria. Data were extracted from the identified articles, and a template analysis was undertaken to identify and assess the sustainability constructs within each reported approach. RESULTS: The search strategy identified 1748 publications with 227 articles retrieved in full text for full documentary analysis. In total, 62 publications identifying a sustainability approach were included in this review (32 frameworks, 16 models, 8 tools, 4 strategies, 1 checklist and 1 process). Constructs across approaches were compared and 40 individual constructs for sustainability were found. Comparison across approaches demonstrated consistent constructs were seen regardless of proposed interventions, setting or level of application with 6 constructs included in 75% of the approaches. Although similarities were found, no approaches contained the same combination of the constructs nor did any single approach capture all identified constructs. From these results, a consolidated framework for sustainability constructs in healthcare was developed. CONCLUSIONS: Choosing a sustainability method can pose a challenge because of the diverse approaches reported in the literature. This review provides a valuable resource to researchers, healthcare professionals and improvement practitioners by providing a summary of available sustainability approaches and their characteristics. TRIAL REGISTRATION: This review was registered on the PROSPERO database: CRD42016040081 in June 2016.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review identified 62 published approaches for assessing or influencing sustainability in healthcare, finding 40 sustainability constructs and no two approaches with identical construct combinations. It developed a consolidated framework of six constructs present in more than 75% of approaches to help users compare and select sustainability approaches.

Key findings

  • The review included 62 publications identifying sustainability approaches: 32 frameworks, 16 models, 8 tools, 4 strategies, 1 checklist, and 1 process. It identified 40 individual sustainability constructs; approaches examined 8–31 constructs each, with an average of 17, and no two approaches contained the same combination of constructs or captured all 40.
  • Six constructs appeared in over 75% of approaches: General resources (90%), Demonstrating effectiveness (89%), Monitoring progress over time (84%), Stakeholder participation (79%), Integration with existing programs and policies (79%), and Training and capacity building (76%).
  • Sustainability was explicitly defined in 76% of approaches, with five definitions found: continued programme activities (86%), continued health benefits (44%), capacity built (19%), further development/adaptation (16%), and recovering costs (3%). 66% viewed sustainability prospectively throughout implementation, and 82% were designed for intervention or programme level.
  • 37% of approaches had no explicit theoretical link; 15 theories were identified, with four common theories covering 45% of papers: diffusion of innovations, complexity theory, ecological theory, and open systems theory. Development techniques included literature/systematic review (61%), professional expertise (26%), and interviews (24%).

Methods

  • PRISMA-guided systematic review registered on PROSPERO (CRD42016040081). Searches were run on Embase, HMIC, and Ovid MEDLINE in January 2017, with a follow-up search in September 2017, plus snowballing. Eligible papers were peer-reviewed publications introducing a tangible approach to influence and/or assess sustainability in healthcare; non-English papers, commentary, posters, protocols, conference proceedings, editorials, perspectives, and approaches embedded as a final stage of a larger process were excluded.
  • Two reviewers independently screened the first 20% of full-text articles; one author screened the remainder. Data extraction covered strategy name, purpose, healthcare setting, level of use, description, sustainability constructs, scoring mechanism, target user, definition of sustainability, theoretical underpinning, sustainability perspective, and method development details. One author extracted data, and a second author independently checked all extractions against full texts.
  • Template analysis was conducted in NVivo 10 using Shediac-Rizkallah and Bone’s conceptual sustainability framework as the baseline template. A second coder independently coded 25% of articles; inter-rater reliability was high with a kappa coefficient of 0.94. Results were summarised using ratios and narrative summaries.

Limitations

  • The paper states that one author conducted most screening, data extraction, and coding, which may have introduced bias in inclusion/exclusion or missing/erroneous information; this was mitigated by second-author screening of 20% of studies, second coding of 25%, and full-text checking of all extractions. It also states a disproportionate number of frameworks came from community and public health settings, that no existing quality assessment tool was used so the value or accuracy of constructs cannot be attributed, and that publication bias may have affected results because grey literature was identified but not included.
  • The paper states that frequency of constructs does not indicate they are the “right” constructs or that assessing them will achieve sustainability; the approaches must be applied and assessed in practice.
  • Evident from the text: the abstract reports 1748 publications identified and 227 full texts retrieved, while the Results report 2889 database publications, 121 further papers from snowballing/citation tracking, and 229 full texts retrieved, an inconsistency in reported search yields.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s13012-017-0707-4

Cites

98 of 98 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 106 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Acute settings were specified in 3% (2/62) of approaches.

    “A smaller number of approaches were designed for use in acute, 3% (2/62), and e-health settings, 3% (2/62).”
    Quote in the paperNot a substantial claim
  • Findingown data

    26% (16/62) of development processes used 'professional expertise' such as an advisory panel.

    “This was followed by 26% (16/62) using ‘professional expertise’ such as an advisory panel and 24% (15/62) using interviews.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Public health settings were specified in 31% (19/62) of approaches.

    “Public health settings were specified in 31% (19/62) of the approaches, followed by community healthcare in 26% of the approaches (16/62).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Six constructs were included in over 75% of the approaches: 'General resources' (90%), 'Demonstrating effectiveness' (89%), 'Monitoring progress over time' (84%), 'Stakeholder participation' (79%), 'Integration with existing programs and policies' (79%) and 'Training and capacity building' (76%).

    “Six constructs were included in over 75% of the approaches: ‘General resources’ (90%), ‘Demonstrating effectiveness’ (89%), ‘Monitoring progress over time’ (84%), ‘Stakeholder participation’ (79%), ‘Integration with existing programs and policies’ (79%) and ‘Training and capacity building’ (76%).”
    Quote in the paperSubstantial claim
  • Findingown data

    15 different theories were identified within the approaches that had an explicit link to theory.

    “Although 37% (23/62) did not have an explicit link to theory, 15 different theories were identified within the other approaches.”
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  • May combine two claims. 42
  • Classified as probably not a substantial claim. 47

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    Findingown data

    Comparison across approaches demonstrated that consistent constructs were seen regardless of proposed interventions, setting or level of application, with 6 constructs included in 75% of the approaches.

    “Comparison across approaches demonstrated consistent constructs were seen regardless of proposed interventions, setting or level of application with 6 constructs included in 75% of the approaches.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Sustainability approaches have been consistently developed and adapted since the late 1980s, with an average of two created every year.

    “Sustainability approaches have been consistently developed and adapted since the late 1980s with an average of two created every year Fig. 2.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Five distinct definitions for sustainability were identified across approaches.

    “Multiple definitions were found across approaches, but 5 distinct definitions for sustainability were identified:”
    Quote in the paperNot a substantial claim

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    Findingown data

    The majority of approaches explicitly stated the need to assess resources but not all indicated the type of resource.

    “The majority of the approaches explicitly stated the need to assess resources but not all indicated the type of resource.”
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    Findingown data

    The search strategy identified 1748 publications with 227 articles retrieved in full text for full documentary analysis.

    “The search strategy identified 1748 publications with 227 articles retrieved in full text for full documentary analysis.”
    Quote in the paperNot a substantial claim

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    Findingown data

    The remaining approaches aimed to provide guidance and strategies to influence sustainability or a combination of evaluation, planning and guidance.

    “The remaining approaches aimed to provide guidance and strategies to influence sustainability or a combination of evaluation, planning and guidance.”
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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The search strategy resulted in 2889 publications from the databases.

    “The search strategy resulted in 2889 publications from the databases.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Constructs across approaches were compared and 40 individual constructs for sustainability were found.

    “Constructs across approaches were compared and 40 individual constructs for sustainability were found.”
    Quote in the paperSubstantial claim

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    Findingown data

    No two approaches contained the same combination of the constructs, nor did any single approach capture all 40 constructs.

    “Comparison across approaches demonstrated that no two approaches contained the same combination of the constructs nor did any single approach capture all 40 constructs.”
    Quote in the paperSubstantial claim

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    Findingown data

    The resources construct included a complex combination of potential resources to consider, with four key resource types: funding, infrastructure, staff and Time.

    “This construct included a complex combination of potential resources to consider. Four key resource types were found: funding, infrastructure, staff and Time.”
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    Findingown data

    Titles and abstracts were examined, and 229 articles were retrieved in full text for full documentary analysis.

    “Titles and abstracts were examined, and 229 articles were retrieved in full text for full documentary analysis.”
    Quote in the paperNot a substantial claim

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    Findingown data

    Constructs across approaches were compared and contrasted, and 40 individual items for sustainability were found.

    “Constructs across approaches were compared and contrasted, and 40 individual items for sustainability were found.”
    Quote in the paperSubstantial claim

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    Findingown data

    The sustainability approaches come in a variety of forms: frameworks/conceptual frameworks (32), models (16), tools (8), guidance strategies (4), checklists (1) and processes (1).

    “The sustainability approaches come in a variety of forms: frameworks/conceptual frameworks (32), models (16), tools (8), guidance strategies (4), checklists (1) and processes (1).”
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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Snowballing and electronic citation tracking identified 121 further papers for potential inclusion.

    “Snowballing and electronic citation tracking identified 121 further papers for potential inclusion.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    No approaches contained the same combination of the constructs, nor did any single approach capture all identified constructs.

    “Although similarities were found, no approaches contained the same combination of the constructs nor did any single approach capture all identified constructs.”
    Quote in the paperSubstantial claim

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    Findingown data

    The number of constructs examined in each method ranged from 8 to 31 with an average of 17 constructs per method.

    “The number of constructs examined in each method ranged from 8 to 31 with an average of 17 constructs per method.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    e-health settings were specified in 3% (2/62) of approaches.

    “A smaller number of approaches were designed for use in acute, 3% (2/62), and e-health settings, 3% (2/62).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Four theoretical perspectives (diffusion of innovations theory, complexity theory, ecological theories and open systems theory) were most common and revealed two distinct positions guiding the use of sustainability approaches.

    “Four theoretical perspectives (diffusion of innovations theory, complexity theory, ecological theories and open systems theory) were most common and revealed two distinct positions guiding the use of sustainability approaches.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Findingcitation

    The first position views sustainability as a linear process following implementation, where sustainability is an end goal, a state to be reached or level of achievement.

    “The first views sustainability as a linear process following implementation. In this approach, sustainability is an end goal, a state to be reached or level of achievement [70].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [70] Rogers EM. Diffusion of innovations. Macmillian Publ. Co. 2003.

      Not checked in the free run.

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    Findingown data

    Retrospective approaches were more likely to specifically examine funding for the initiative and highlight the need to have a defined aim to show evidence for sustainability of an initiative once it has been 'completed'.

    “These approaches were more likely to specifically examine funding for the initiative and highlight the need to have a defined aim to show evidence for sustainability of an initiative once it has been ‘completed’.”
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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingreasoning

    Each approach provided a unique perspective on sustainability with no two being exactly alike.

    “Each provided a unique perspective on sustainability with no two being exactly alike.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingcitation

    The second position views sustainability as a concurrent process alongside implementation, where sustainability is a process to be influenced and adapted to impact initiative longevity.

    “The second views sustainability concurrent process alongside implementation, where sustainability is a process to be influenced and adapted to impact initiative longevity [71-73].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [71] Schneider M, Somers M. Organizations as complex adaptive systems: implications of complexity theory for leadership research. Leadersh Q. 2006;17:351–65. source

      Not checked in the free run.

    • cites [72] Bronfenbrenner U. The ecology of human development. Experiments by nature and design. London: Harvard Univerity Press; 1979. source

      Not checked in the free run.

    • cites [73] Katz D, Kahn RL. The social psychology of organizations. John Wiley & Sons Inc: Hoboken; 1978.

      Not checked in the free run.

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    Findingcitation

    Approaches to monitoring included diverse areas to assess including having appropriate data to document progress, having a management or monitoring system in place, and having regular reporting and feedback mechanisms.

    “Approaches to monitoring included diverse areas to assess including having appropriate data to document progress [64, 65], having a management or monitoring system in place [15, 53, 61, 66, 67], and having regular reporting and feedback mechanisms [46, 47, 52, 54, 68, 69].”
    Quote in the paperNot a substantial claim0 of 10 sources checked
    • cites [64] Saunders RP, Pate RR, Dowda M, Ward DS, Epping JN, Dishman RK. Assessing sustainability of Lifestyle Education for Activity Program ( LEAP ). Health Educ Res. 2012;27:319–30. source

      Not checked in the free run.

    • cites [65] Amaya AB, Caceres CF, Spicer N, Balabanova D, Amaya AB, Caceres CF, et al. After the Global Fund: who can sustain the HIV/AIDS response in Peru and how? Glob Public Health Taylor & Francis. 2014;9:176–97. source

      Not checked in the free run.

    • cites [15] Shigayeva A, Coker RJ. Communicable disease control programmes and health systems: an analytical approach to sustainability. Health Policy Plan. 2015;30:368–85. source

      Not checked in the free run.

    • cites [53] Atun R, de Jongh T, Secci F, Ohiri K, Adeyi O. Integration of targeted health interventions into health systems: a conceptual framework for analysis. Heal. Policy Plan. (C) Copyright Oxford University Press 2010.: (1)Professor of International Health Management, Imperial College, London, UK, (2)Researcher, Centre for Health Management, Imperial College London, UK, (3)Doctoral Researcher, Centre for Health Management, Imperial College London, UK, (4)Health Specialis; 2010. p. 104–11. source

      Not checked in the free run.

    • cites [61] Maher L, Gustafson D, Evans A. Sustainability model and guide. Coventry: NHS Institute for Innovation and Improvement; 2010.

      Not checked in the free run.

    • cites [66] Racine D. Reliable effectiveness: a theory on sustaining and replicating worthwhile innovations. Adm Policy Ment Heal. (C)2006 Kluwer Academic Publishers: (1)Independent Scholar, 1101 Parkside Avenue, Ewing, NJ 08618, USA; 2006. p. 356–87. source

      Not checked in the free run.

    • cites [67] Story WT, LeBan K, Altobelli LC, Gebrian B, Hossain J, Lewis J, et al. Institutionalizing community-focused maternal, newborn, and child health strategies to strengthen health systems: a new framework for the sustainable development goal era. Glob Health Globalization Health. 2017;13:37. source

      Not checked in the free run.

    • cites [46] Dorsey SG, Schiffman R, Redeker NS, Heitkemper M, McCloskey DJ, Weglicki LS, et al. National Institute of Nursing Research Centers of Excellence: a logic model for sustainability, leveraging resources, and collaboration to accelerate cross-disciplinary science. Nurs Outlook U S. 2014;62:384–93. source

      Not checked in the free run.

    • cites [47] Ford JH, Alagoz E, Dinauer S, Johnson KA, Pe-Romashko K, Gustafson DH. Successful organizational strategies to sustain use of A-CHESS: a mobile intervention for individuals with alcohol use disorders. J Med Internet Res. 2015;17:e201. source

      Not checked in the free run.

    • cites [52] Persaud D. Enhancing learning, innovation, adaptation, and sustainability in health care organizations: The ELIAS Performance Management Framework. Heal. Care Manag. (C) 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins: Author Affiliation: School of Health Administration, Dalhousie University, Halifax, Canada.; 2014. p. 183–204. source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Despite previous work finding that 'most frameworks proposed tend to be deterministic in nature where sustainability is viewed as an end goal', this review found that 66% of approaches reviewed saw sustainability as a process rather than an end state.

    “Despite previous work finding that ‘most frameworks proposed tend to be deterministic in nature where sustainability is viewed as an end goal’, we found that 66% of approaches we reviewed saw sustainability as a process rather than an end state [15].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [15] Shigayeva A, Coker RJ. Communicable disease control programmes and health systems: an analytical approach to sustainability. Health Policy Plan. 2015;30:368–85. source

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    Findingreasoning

    In studying an organisation or system's sustainability, there is a greater focus on assessing the readiness and capacity for the initiatives and involving stakeholders and community members.

    “In studying an organisation or system’s sustainability, there is a greater focus assessing the readiness and capacity for the initiatives and involving stakeholders and community members.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    This review found that a substantial number of approaches exist, with 62 approaches identified and included.

    “This review found that a substantial number of approaches exist with 62 approaches identified and included in this review.”
    Quote in the paperSubstantial claim

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    Findingown data

    No approaches contained the same combination of the constructs, nor did any single method capture all identified constructs.

    “Interestingly, no approaches contained the same combination of the constructs nor did any single method capture all identified constructs.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Findingnone given

    There is diversity in the literature on how sustainability is defined and how it can be influenced.

    “while there is diversity in the literature on how it is defined and how it can be influenced”
    Quote in the paperSubstantial claim

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    Findingown data

    Many sustainability approaches were developed within specific interventions and settings, yet similar constructs for sustainability were found across approaches.

    “although many approaches were developed within specific interventions and settings, similar constructs for sustainability were found”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Findingnone given

    This is the first review to consolidate available approaches for sustainability across diverse healthcare settings.

    “This is the first review to consolidate available approaches for sustainability across diverse healthcare settings.”
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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Many approaches presented in this review recommend that they be used and evaluated further within other healthcare initiatives and settings to explore applicability and further development needed.

    “Many approaches presented in this review recommend that they be used and evaluated further within other healthcare initiatives and settings to explore applicability and further development needed [11, 36, 56, 79].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [11] Chambers D a, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implementation Sci. 2013;8:117. source

      Not checked in the free run.

    • cites [36] Luke D a, Calhoun A, Robichaux CB, Elliott MB, Moreland-Russell S. The program sustainability assessment tool: a new instrument for public health programs. Prev Chronic Dis. 2014;11:130184. source

      Not checked in the free run.

    • cites [56] Lennox L, Doyle C, Reed J, Bell D. What makes a sustainability tool valuable, practical, and useful in real world healthcare practice? A qualitative study on the development of the long term success tool in Northwest London. BMJ Open. 2017;7:1–13. source

      Not checked in the free run.

    • cites [79] Fox A, Gardner G, Osborne S. A theoretical framework to support research of health service innovation. Aust Health Rev. 2014;39:70–5. source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The ability to adapt and continuously improve has been recognised as a potential definition of sustainability.

    “More recently, the ability to adapt and continuously improve has also been recognised as a potential definition of sustainability [14].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] Moore JE, Mascarenhas A, Bain J, Straus SE. Developing a comprehensive definition of sustainability. Implement Sci. 2017;12:110. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Sustainability as a process rather than an outcome incorporates adaptation, learning and continuous development.

    “This concept of sustainability as a ‘process’ rather than an ‘outcome’, incorporates concepts of adaptation, learning and continuous development [15].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [15] Shigayeva A, Coker RJ. Communicable disease control programmes and health systems: an analytical approach to sustainability. Health Policy Plan. 2015;30:368–85. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    Sustainability can be viewed as a change process that can be influenced by individuals throughout initiatives by continuing to develop and adapt in response to the needs of the system.

    “This lens allows sustainability to be viewed as a change process that can be influenced by individuals throughout initiatives by continuing to develop and adapt in response to the needs of the system [15–17].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [15] Shigayeva A, Coker RJ. Communicable disease control programmes and health systems: an analytical approach to sustainability. Health Policy Plan. 2015;30:368–85. source

      Not checked in the free run.

    • cites [16] Folke C, Carpenter S, Elmqvist T, Gunderson L, Holling C, Walker B. Resilience and sustainable development: building adaptive capacity in a world of transformations. Ambio. 2002;31:437–40. source

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    • cites [17] Fiksel J. Designing resilient, sustainable systems. Environ Sci Technol. 2003;37:5330–9. source

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    Premisecitation

    Sustainability is often viewed as an outcome where health benefits, activities or workforce capacity are maintained.

    “Sustainability is often viewed as an ‘outcome’ where health benefits, activities or workforce capacity are maintained [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health Educ Res. 1998;13:87–108. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Some work has reviewed frameworks for sustainability in specific settings and programmes, but little has been done to comprehensively review available approaches for sustainability across healthcare settings.

    “Some work has been undertaken to review frameworks for sustainability in specific settings and programmes, but little has been done to comprehensively review available approaches for sustainability across healthcare settings [15, 18, 19].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [15] Shigayeva A, Coker RJ. Communicable disease control programmes and health systems: an analytical approach to sustainability. Health Policy Plan. 2015;30:368–85. source

      Not checked in the free run.

    • cites [18] Scheirer MA, Dearing JW. An agenda for research on the sustainability of public health programs. Am J Public Health. 2011;101:2059–67. source

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    • cites [19] Johnson K, Hays C, Center H, Daley C. Building capacity and sustainable prevention innovations: a sustainability planning model. Eval Program Plann. 2004;27:135–49. source

      Not checked in the free run.

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    Premisecitation

    Many promising improvement initiatives fail to sustain and do not produce long-term benefits.

    “Despite the significant investment of staff time and other resources, many promising initiatives fail to sustain and do not produce long term benefits [1–6].”
    Quote in the paperSubstantial claim0 of 6 sources checked
    • cites [1] Stirman SW, Kimberly J, Cook N, Calloway A, Castro F, Charns M. The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research. Implement Sci BioMed Central Ltd. 2012;7:17. source

      Not checked in the free run.

    • cites [2] Williams L, Daggett V, Slaven JE, Yu Z, Sager D, Myers J, et al. A cluster-randomised quality improvement study to improve two inpatient stroke quality indicators. BMJ Qual Saf. 2015; bmjqs-2015-004188 source

      Not checked in the free run.

    • cites [3] Bowman CC, Sobo EJ, Asch SM, Gifford AL. Measuring persistence of implementation: QUERI series. Implement Sci. 2008;3 source

      Not checked in the free run.

    • cites [4] Virani T, Lemieux-charles L, Davis DA, Berta W. Sustaining change: once evidence-based practices are transferred, what then? Healthc Q. 2009;12:89–96. source

      Not checked in the free run.

    • cites [5] Scheirer MA. Is sustainability possible? A review and commentary on empirical studies of program sustainability. Am J Eval. 2005;26:320–47. source

      Not checked in the free run.

    • cites [6] Ham C. Evaluation of the projects within the National Booking Program. Birmingham; 2004.

      Not checked in the free run.

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    Premisecitation

    A systematic review of 125 studies of healthcare improvements found that projects do not maintain all aspects originally implemented, with fewer than half continuing interventions at high levels of fidelity.

    “A systematic review of 125 studies of improvements made in healthcare found that the projects do not maintain all aspects originally implemented with fewer than half continuing interventions at high levels of fidelity [1].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [1] Stirman SW, Kimberly J, Cook N, Calloway A, Castro F, Charns M. The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research. Implement Sci BioMed Central Ltd. 2012;7:17. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The systematic review was guided by PRISMA reporting standards.

    “A systematic review was undertaken guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting standards [21].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] PRISMA. PRISMA Statement [Internet]. Transparent Report. Syst. Rev. meta-analyses. 2015 [cited 2016 Jan 22]. Available from: http://www.prisma-statement.org/PRISMAStatement/Default.aspx .

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    To assess coding clarity and reliability, a second coder independently coded 25% of the articles and an inter-rater reliability score (kappa coefficient) was calculated.

    “To assess coding clarity and reliability, a second coder independently coded 25% of the articles and an inter-rater reliability score (kappa coefficient) was calculated.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    An inter-rater reliability score (kappa coefficient) was calculated between two coders using the NVivoPro coding comparison function to assess coding clarity and reliability.

    “To assess coding clarity and reliability, an inter-rater reliability score (kappa coefficient) was calculated between two coders using the NVivoPro coding comparison function [33].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [33] Nvivo. Run a coding comparison query [Internet]. Explor. your coding using queries. 2017. p. 1. Available from: http://help-nv11.qsrinternational.com/desktop/procedures/run_a_coding_comparison_query.htm .

      Not checked in the free run.

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    Study design and conductnone given

    To ensure that studies met the baseline quality expected, each article was assessed with the structured data extraction form.

    “To ensure the studies met the baseline quality expected, each article was assessed with the structured data extraction form.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    Approaches available in the grey literature were identified but not included in this review.

    “Approaches available in the grey literature were identified but not included in this review.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Missing data or discrepancies were discussed between authors and resolved by consensus.

    “Any missing data or discrepancies were discussed between authors and were resolved by consensus.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Agreement was reached for accuracy of all studies.

    “Agreement was reached for accuracy of all studies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The systematic review was registered on PROSPERO under registration number CRD 42016040081 in June 2016.

    “This systematic review was registered on the PROSPERO database under the registration number: CRD 42016040081 in June 2016 [26].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] Lennox L, Maher L, Bell D, Reed J. The sustainability landscape: a systematic review of sustainability strategies and their impact in healthcare settings. PROSPERO Int Prospect Regist Syst Rev. 2016;CRD4201604:1–4.

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Many existing tools do not capture the multiple meanings of "good quality" and "rightness".

    “Their use to determine the inclusion of qualitative studies is often not recommended as many existing tools do not capture the multiple meanings of “good quality” and “rightness”; therefore, studies should often not be excluded based on this quality assessment [22, 24].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [22] Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? BMJ Br Med J. 2001;322:1115–7. source

      Not checked in the free run.

    • cites [24] Walsh D, Downe S. Appraising the quality of qualitative research. Midwifery. 2006;22:108–19. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The selection of databases, search terms and search strategy was supported by a medical librarian to ensure overall quality and coverage of the systematic review.

    “The selection of databases, search terms and search strategy was supported by a medical librarian to ensure an overall quality and coverage of the systematic review.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Two authors independently screened the first 20% of full-text articles for inclusion.

    “Two authors independently screened the first 20% of the full-text articles for inclusion.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The lack of consensus on sustainability has led to contradictory recommendations for influencing sustainability and debate on what qualifies as a sustained improvement.

    “This has led to contradictory recommendations for influencing sustainability and debate on what qualifies as a sustained improvement [10, 13].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [10] Martin GP, Weaver S, Currie G, Finn R, Mcdonald R. Innovation sustainability in challenging health-care contexts: embedding clinically led change in routine practice. Heal Serv Manage Res. 2012;25:190–9. source

      Not checked in the free run.

    • cites [13] Pluye P, Potvin L, Denis J-L. Making public health programs last: conceptualizing sustainability. Eval Program Plann. 2004;27:121–33. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Theoretical perspectives guided how sustainability was defined within approaches and how it was viewed within healthcare systems.

    “Theoretical perspectives guided how sustainability was defined within approaches and how it was viewed within healthcare systems.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    One author extracted data from the articles and a second author independently checked the extracted information against the full-text articles.

    “One author (LL) extracted the data from the articles. This information was then independently checked against the full-text articles by the second author (LM).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Diverse healthcare settings use similar processes to achieve adoption, implementation, and sustainability, indicating that general learning and lessons can be gathered across settings to inform sustainability research.

    “It is recognised that diverse healthcare settings ‘use similar processes to achieve adoption, implementation, and sustainability’ which indicates general learning and lessons can be gathered from across settings to inform sustainability research [18].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] Scheirer MA, Dearing JW. An agenda for research on the sustainability of public health programs. Am J Public Health. 2011;101:2059–67. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The framework can help those considering creating a sustainability method in their own setting.

    “The framework can also help those considering creating a sustainability method in their own setting.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The choice to evaluate, monitor or plan for sustainability overtime rather than after implementation may indicate a shift in perspectives from sustainability as an outcome to sustainability as an ongoing process.

    “The choice to evaluate, monitor or plan for sustainability overtime rather than after implementation may indicate a shift in perspectives from sustainability as an outcome to sustainability as an ongoing process.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Given homogeneity of the individual constructs found, there is value in having an overarching resource and summary indicating the breadth of possible sustainability constructs to consider for sustainability in healthcare settings.

    “Given homogeneity of the individual constructs found, we believe there is value in having an overarching resource and summary, indicating the breadth of possible sustainability constructs to consider for sustainability in healthcare settings.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Interpretationcitation

    Continuous production of new sustainability approaches may lead to further division and confusion in the literature and ultimately result in fewer robust studies on the use of available sustainability approaches being published.

    “Those considering creating a sustainability approach should consider the information presented here and the available approaches for use before ‘recreating the wheel’ as continuous production may lead to further division and confusion in the literature and ultimately result in fewer robust studies on the use of available sustainability approaches being published [18].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18] Scheirer MA, Dearing JW. An agenda for research on the sustainability of public health programs. Am J Public Health. 2011;101:2059–67. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    If the definition of sustainability is broadened, adaptation could also signify sustained improvement, especially if the adaptations contributed further to health benefits or cost recovery.

    “If the definition is broadened, adaptation could also signify sustained improvement, especially if the adaptations contributed further to health benefits or cost recovery.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing). May combine two claims.

    Premisecitation

    Some have cautioned that while it may be valuable to assess sustainability throughout initiatives, data collection past the implementation stage is still required to assess the continuation of initiative activities or outcomes and determine whether sustainability is actually achieved.

    “As this perspective gains popularity, some have cautioned that while it may be valuable to assess sustainability throughout initiatives, data collection past the implementation stage is still required to assess the continuation of initiative activities or outcomes and determine whether sustainability is actually achieved [18].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18] Scheirer MA, Dearing JW. An agenda for research on the sustainability of public health programs. Am J Public Health. 2011;101:2059–67. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The consolidated framework for sustainability constructs in healthcare (Table 3) provides a knowledge base for those who may wish to review proposed sustainability constructs and draw on the substantial work and research already conducted in this area.

    “The consolidated framework for sustainability constructs in healthcare (Table 3) provides a knowledge base for those who may wish to review proposed sustainability constructs and draw on the substantial work and research already conducted in this area.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Value is seen in both views, but depending on what theoretical perspective is taken, planning, measurement and monitoring is significantly different.

    “Value is seen in both views, but depending on what theoretical perspective is taken, planning, measurement and monitoring is significantly different [8, 13, 61, 74, 75].”
    Quote in the paperSubstantial claim0 of 5 sources checked
    • cites [8] Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health Educ Res. 1998;13:87–108. source

      Not checked in the free run.

    • cites [13] Pluye P, Potvin L, Denis J-L. Making public health programs last: conceptualizing sustainability. Eval Program Plann. 2004;27:121–33. source

      Not checked in the free run.

    • cites [61] Maher L, Gustafson D, Evans A. Sustainability model and guide. Coventry: NHS Institute for Innovation and Improvement; 2010.

      Not checked in the free run.

    • cites [74] Rycroft-Malone J. The PARIHS framework—a framework for guiding the implementation of evidence-based practice. J Nurs Care Qual. 2004;19:297–304. source

      Not checked in the free run.

    • cites [75] Aarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health Serv Res. 2011;38:4–23. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Differences between prospective and retrospective approaches highlight how retrospective approaches tend to focus on delivery and evidence for continuation of initiatives while prospective approaches focus on building an initiative into an organisation, getting people on board and garnering networks that may help along the way.

    “These differences highlight how retrospective approaches tend to focus on delivery and evidence for continuation of initiatives while prospective approaches focus on building an initiative into an organisation, getting people on board and garnering networks that may help along the way.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationcitation

    While there are benefits of approaches created for specific settings, there is also a risk in continually creating 'new' approaches with similar constructs divided by semantics and personal interpretations of the literature.

    “While there are benefits of approaches created for specific settings, there is also a risk in continually creating ‘new’ approaches with similar constructs divided by semantics and personal interpretations of the literature [18, 20].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [18] Scheirer MA, Dearing JW. An agenda for research on the sustainability of public health programs. Am J Public Health. 2011;101:2059–67. source

      Not checked in the free run.

    • cites [20] Brinkerhoff DW, Goldsmith AA. Promoting the sustainability of development institutions: a framework for strategy. World Dev. 1992;20:369–83. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationcitation

    All definitions identified in the review represent interrelated facets of what sustainability means in practice.

    “All definitions identified in the review represent interrelated facets of what sustainability means in practice; therefore, those working in this field should explore the breadth of available sustainability domains in order to accurately represent the sustainability process and account for its full complexity and possible outcomes [7].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] Gruen RL, Elliott JH, Nolan ML, Lawton PD, Parkhill A, McLaren CJ, et al. Sustainability science: an integrated approach for health-programme planning. Lancet. 2008;372:1579–89. Elsevier Ltd source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Double data extraction is often not possible in many cases due to time and resources constraints.

    “it is also recognised that this is often not possible in many cases due to time and resources constraints [78].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [78] Buscemi N, Hartling L, Vandermeer B, Tjosvold L, Klassen TP. Single data extraction generated more errors than double data extraction in systematic reviews. J Clin Epidemiol. 2006;59:697–703. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationreasoning

    If we do not address sustainability appropriately, we continue to risk wasting valuable resources and losing significant progress and patient outcome improvements.

    “If we do not address it appropriately, we continue to risk wasting valuable resources and losing significant progress and patient outcome improvements.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationnone given

    The number of sustainability approaches may grow with necessary alterations to design and further development.

    “The number of sustainability approaches may grow with necessary alterations to design and further development, but there is a need for future authors to describe how new approaches fit within the findings presented here.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    Reporting which constructs were deemed important to assess does not indicate that these are the 'right' constructs or that they will lead to sustainability.

    “We reported which constructs were deemed to be important to assess, but this does not indicate that these are the ‘right’ constructs or that they will lead to sustainability.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Double data extraction is recommended in most systematic reviews.

    “Although double data extraction is recommended in most systematic reviews”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [78] Buscemi N, Hartling L, Vandermeer B, Tjosvold L, Klassen TP. Single data extraction generated more errors than double data extraction in systematic reviews. J Clin Epidemiol. 2006;59:697–703. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationown data

    Professional expertise may be difficult to assess for quality but appears to be very significant in the creation of sustainability approaches.

    “a technique that may be difficult to assess for quality but appears to be very significant in the creation of sustainability approaches.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Choosing a sustainability approach to support this process can pose a challenge to those looking to influence sustainability because of the diverse approaches reported in the literature.

    “Choosing a sustainability approach to support this process can pose a challenge to those looking to influence sustainability because of the diverse approaches reported in the literature.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The quality criteria in the data extraction form ensured each paper had a minimum level of data to adequately describe the approach, but did not assess quality of the approaches themselves.

    “While the quality criteria set out in our data extraction form allowed us to ensure each paper had a minimum level of data to adequately describe the approach, it did not assess quality of the approaches themselves.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Multiple authors were involved where possible in selection of studies (20% screened by a second author) and coding of constructs (25% of studies).

    “we involved multiple authors where possible in selection of the studies (20% screened by a second author) and coding of constructs (25% of studies).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    The review did not use an existing quality assessment tool and cannot attribute value or accuracy of constructs from each approach.

    “Another key limitation of this work is that we did not use an existing quality assessment tool and cannot attribute value or accuracy of constructs from each approach.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Data extraction was checked against full-text articles for all included papers.

    “Data extraction was also checked against full-text articles for all included papers.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The frequency of constructs does not indicate that assessing these constructs will achieve sustainability in practice or that they are correct or comprehensive.

    “this does not tell us that assessing these constructs will achieve sustainability in practice or that they are correct or comprehensive.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Sustainability of initiatives requires thoughtful planning and attention.

    “sustainability of initiatives requires thoughtful planning and attention.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Sustainability of improvements has been recognised as a challenge for some time.
77 of 77

  • The paper relies on this without support.

    Sustainability of improvements has been recognised as a challenge for some time.

    “Sustainability of improvements has been recognised as a challenge for some time”
1 of 1

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Full-text retrieval totals differ

    Minor

    The abstract reports 227 articles retrieved in full text, while the Results section reports 229 for the same full documentary analysis.

  • Fox approach has conflicting publication years

    Minor

    Table 1 dates the Fox et al. approach to 2015, while its cited reference [79] gives 2014.

  • Search-strategy publication totals differ

    Minor

    The abstract says the search strategy identified 1748 publications, whereas the Results section says it produced 2889 publications from the databases. The text does not explain whether these are counts from different stages.

  • Professional-expertise percentage changes

    Minor

    The development results report professional expertise in 26% (16/62) of approaches, but the limitations section gives 24% for approaches informed by professional expertise.

4 of 4

Cites

Flagged first, then by citations

2 of the 100 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. Lennox L, Maher L, Bell D, Reed J. The sustainability landscape: a systematic review of sustainability strategies and their impact in healthcare settings. PROSPERO Int Prospect Regist Syst Rev. 2016;CRD4201604:1–4.
  2. Viera AJ, Garrett JM. Understanding interobserver agreement: Fam. Med. 2005;37:360–3.
  3. Maher L, Gustafson D, Evans A. Sustainability model and guide. Coventry: NHS Institute for Innovation and Improvement; 2010.

Cited by

Sorted by citations

Related

Authors
Lennox, L., Maher, L., & Reed, J.
Affiliations
  • Imperial College London (GB)
  • Middlemore Hospital (NZ)
Corresponding author
Lennox, L.
ORCID
Venue
Implementation Science
Publisher
Springer Science and Business Media LLC
Published
2018-02-09
Volume
13
Issue
1
Pages
27-27
ISSN
1748-5908 (ISSN-L)
DOI
10.1186/s13012-017-0707-4
PMC
PMC5810192
OpenAlex
W2794446197
Semantic Scholar
ca7f175f679d8439f79b60e2b889eb0e65b07232
Cited by
421
References
100
Citations by year
2026: 33 · 2025: 50 · 2024: 51 · 2023: 73 · 2022: 73 · 2021: 60 · 2020: 49 · 2019: 22 · 2018: 9 · 2017: 1
FWCI
6.47
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • Implementation Science (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Spiral (Imperial College London) (submittedVersion, other-oa)
Funders
National Institute for Health Research (N/A)
Topics
  • Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
  • Social Sciences › Urban Studies › Healthcare Facilities Design and Sustainability
Keywords
sustainability in healthcare, improvement initiatives, sustainability framework, sustainability model, sustainability assessment tools, sustainability strategy, quality improvement, innovation implementation
MeSH terms
Delivery of Health Care, Health Personnel, Humans, Quality Assurance, Health Care, Checklist, Quality Improvement

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-06.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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