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

In the paper

“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.”

In the paper

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

In the paper

“Multiple definitions were found across approaches, but 5 distinct definitions for sustainability were identified:”

In the paper

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

In the paper

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

In the paper

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

In the paper

“The search strategy resulted in 2889 publications from the databases.”

In the paper

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

In the paper

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

In the paper

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

In the paper

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

In the paper

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

In the paper

“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).”

In the paper

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

In the paper

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

In the paper

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

In the paper

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

In the paper

“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.”

In the paper

“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].”

What the sources say

• Not checked yetcites [70] Rogers EM. Diffusion of innovations. Macmillian Publ. Co. 2003.

In the paper

“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’.”

In the paper

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

In the paper

“The second views sustainability concurrent process alongside implementation, where sustainability is a process to be influenced and adapted to impact initiative longevity [71-73].”

What the sources say

• Not checked yetcites [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 yetcites [72] Bronfenbrenner U. The ecology of human development. Experiments by nature and design. London: Harvard Univerity Press; 1979. source
• Not checked yetcites [73] Katz D, Kahn RL. The social psychology of organizations. John Wiley & Sons Inc: Hoboken; 1978.

In the paper

“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].”

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [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 yetcites [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 yetcites [61] Maher L, Gustafson D, Evans A. Sustainability model and guide. Coventry: NHS Institute for Innovation and Improvement; 2010.
• Not checked yetcites [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 yetcites [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 yetcites [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 yetcites [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 yetcites [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

In the paper

“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].”

What the sources say

• Not checked yetcites [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

In the paper

“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.”

In the paper

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

In the paper

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

In the paper

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

In the paper

“although many approaches were developed within specific interventions and settings, similar constructs for sustainability were found”

In the paper

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

In the paper

“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].”

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [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 yetcites [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

In the paper

“More recently, the ability to adapt and continuously improve has also been recognised as a potential definition of sustainability [14].”

What the sources say

• Not checked yetcites [14] Moore JE, Mascarenhas A, Bain J, Straus SE. Developing a comprehensive definition of sustainability. Implement Sci. 2017;12:110. source

In the paper

“This concept of sustainability as a ‘process’ rather than an ‘outcome’, incorporates concepts of adaptation, learning and continuous development [15].”

What the sources say

• Not checked yetcites [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

In the paper

“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].”

What the sources say

• Not checked yetcites [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 yetcites [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
• Not checked yetcites [17] Fiksel J. Designing resilient, sustainable systems. Environ Sci Technol. 2003;37:5330–9. source

In the paper

“Sustainability is often viewed as an ‘outcome’ where health benefits, activities or workforce capacity are maintained [8].”

What the sources say

• Not checked yetcites [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

In the paper

“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].”

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [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

In the paper

“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].”

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [3] Bowman CC, Sobo EJ, Asch SM, Gifford AL. Measuring persistence of implementation: QUERI series. Implement Sci. 2008;3 source
• Not checked yetcites [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 yetcites [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 yetcites [6] Ham C. Evaluation of the projects within the National Booking Program. Birmingham; 2004.

In the paper

“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].”

What the sources say

• Not checked yetcites [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

In the paper

“A systematic review was undertaken guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting standards [21].”

What the sources say

• Not checked yetcites [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 .

In the paper

“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.”

In the paper

“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].”

What the sources say

• Not checked yetcites [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 .

In the paper

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

In the paper

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

In the paper

“Any missing data or discrepancies were discussed between authors and were resolved by consensus.”

In the paper

“Agreement was reached for accuracy of all studies.”

In the paper

“This systematic review was registered on the PROSPERO database under the registration number: CRD 42016040081 in June 2016 [26].”

What the sources say

• Not checked yetcites [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.

In the paper

“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].”

What the sources say

• Not checked yetcites [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 yetcites [24] Walsh D, Downe S. Appraising the quality of qualitative research. Midwifery. 2006;22:108–19. source

In the paper

“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.”

In the paper

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

In the paper

“This has led to contradictory recommendations for influencing sustainability and debate on what qualifies as a sustained improvement [10, 13].”

What the sources say

• Not checked yetcites [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 yetcites [13] Pluye P, Potvin L, Denis J-L. Making public health programs last: conceptualizing sustainability. Eval Program Plann. 2004;27:121–33. source

In the paper

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

In the paper

“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).”

In the paper

“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].”

What the sources say

• Not checked yetcites [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

In the paper

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

In the paper

“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.”

In the paper

“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.”

In the paper

“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].”

What the sources say

• Not checked yetcites [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

In the paper

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

In the paper

“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].”

What the sources say

• Not checked yetcites [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

In the paper

“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.”

In the paper

“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].”

What the sources say

• Not checked yetcites [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 yetcites [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 yetcites [61] Maher L, Gustafson D, Evans A. Sustainability model and guide. Coventry: NHS Institute for Innovation and Improvement; 2010.
• Not checked yetcites [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 yetcites [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

In the paper

“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.”

In the paper

“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].”

What the sources say

• Not checked yetcites [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 yetcites [20] Brinkerhoff DW, Goldsmith AA. Promoting the sustainability of development institutions: a framework for strategy. World Dev. 1992;20:369–83. source

In the paper

“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].”

What the sources say

• Not checked yetcites [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

In the paper

“it is also recognised that this is often not possible in many cases due to time and resources constraints [78].”

What the sources say

• Not checked yetcites [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

In the paper

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

In the paper

“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.”

In the paper

“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.”

In the paper

“Although double data extraction is recommended in most systematic reviews”

What the sources say

• Not checked yetcites [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

In the paper

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

In the paper

“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.”

In the paper

“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.”

In the paper

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

In the paper

“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.”

In the paper

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

In the paper

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

In the paper

“sustainability of initiatives requires thoughtful planning and attention.”