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

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

doi:10.1186/s43058-020-00053-1

Cited by 44Health Policy Implementation ScienceHealth Sciences Research and EducationHealthcare Quality and Management

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

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Nevedal, Andrea L., Reardon, Caitlin M., Jackson, George L., Cutrona, Sarah L., White, Brandolyn, Gifford, Allen L., Orvek, Elizabeth, DeLaughter, Kathryn +5 more·2020·Implementation Science Communications

DOI 10.1186/s43058-020-00053-1PMC PMC7427879

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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.

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Empirical research shows the presence of internal and external champions, supporters, and advocates influences program sustainment.
“Empirical research also shows that the presence of internal and external champions, supporters, and advocates influences program sustainment [26, 51–53]”
From Using qualitative comparative analysis to uncover multiple pathways to program sustainment: implications for community-based youth substance misuse prevention (2022) · cites this paper as [53]
The Discussion identifies engaging key stakeholders as important to sustainment, and the Results report that some teams did not sustain their practices after losing necessary staff. But the paper describes external change agents’ support during initial implementation, not as an influence on sustainment; it says implementation support providers were not involved during the sustainment phase. It therefore does not establish the claim for both internal and external champions, supporters, and advocates. (LLM, conf=0.86)
Experimental — accuracy not yet measured
Empirical research shows organizational capacity, such as having adequate resources and staff to deliver the program, is integral to a program's success and continued delivery.
“and that organizational capacity, such as having adequate resources and staff to deliver the program [19, 24, 31, 53] is integral to a program’s success and continued delivery.”
From Using qualitative comparative analysis to uncover multiple pathways to program sustainment: implications for community-based youth substance misuse prevention (2022) · cites this paper as [53]

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Additional file 3 of Understanding pathways from implementation to sustainment: a longitudinal, mixed methods analysis of promising practices implemented in the Veterans Health Administration
Nevedal, A., Widerquist, M. A. O., Reardon, C. M., Arasim, M. E., Jackson, G. L., White, B. S., Burns, M., Fix, G. M., DeLaughter, K. L., Cutrona, S. L., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26717059
Self-citation
Additional file 1 of Understanding pathways from implementation to sustainment: a longitudinal, mixed methods analysis of promising practices implemented in the Veterans Health Administration
Nevedal, A., Widerquist, M. A. O., Reardon, C. M., Arasim, M. E., Jackson, G. L., White, B. S., Burns, M., Fix, G. M., DeLaughter, K. L., Cutrona, S. L., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26717053
Self-citation
Additional file 1 of Sustainment of diverse evidence-informed practices disseminated in the Veterans Health Administration (VHA): initial development and piloting of a pragmatic survey tool
Reardon, C. M., Damschroder, L. J., Opra Widerquist, M. A., Arasim, M. E., Jackson, G. L., White, B. S., Cutrona, S. L., Fix, G. M., Gifford, A. L., DeLaughter, K. L., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26561785
Self-citation
Additional file 3 of Identifying and understanding the contextual factors that shaped mid-implementation outcomes during the COVID-19 pandemic in organizations implementing mental health recovery innovations into services
Piat, M., Wainwright, M., Cherkas, D., LeBlanc, S., Sofouli, E., Rivest, M.-P., Albert, H., Casey, R., O’Rourke, J. J., & Labonté, L. (2021) · Figshare · doi:10.6084/m9.figshare.16625623
Additional file 1 of Identifying and understanding the contextual factors that shaped mid-implementation outcomes during the COVID-19 pandemic in organizations implementing mental health recovery innovations into services
Piat, M., Wainwright, M., Cherkas, D., LeBlanc, S., Sofouli, E., Rivest, M.-P., Albert, H., Casey, R., O’Rourke, J. J., & Labonté, L. (2021) · Figshare · doi:10.6084/m9.figshare.16625617
Additional file 4 of Identifying and understanding the contextual factors that shaped mid-implementation outcomes during the COVID-19 pandemic in organizations implementing mental health recovery innovations into services
Piat, M., Wainwright, M., Cherkas, D., LeBlanc, S., Sofouli, E., Rivest, M.-P., Albert, H., Casey, R., O’Rourke, J. J., & Labonté, L. (2021) · Figshare · doi:10.6084/m9.figshare.16625626
Additional file 2 of Understanding pathways from implementation to sustainment: a longitudinal, mixed methods analysis of promising practices implemented in the Veterans Health Administration
Nevedal, A., Widerquist, M. A. O., Reardon, C. M., Arasim, M. E., Jackson, G. L., White, B. S., Burns, M., Fix, G. M., DeLaughter, K. L., Cutrona, S. L., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26717056
Self-citation
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Bravata, D. M., Miech, E. J., Myers, L. J., Perkins, A. J., Zhang, Y., Rattray, N. A., Baird, S. A., Penney, L., Austin, C., & Damush, T. M. (2022) · Figshare · doi:10.6084/m9.figshare.20226923
Additional file 5 of Identifying and understanding the contextual factors that shaped mid-implementation outcomes during the COVID-19 pandemic in organizations implementing mental health recovery innovations into services
Piat, M., Wainwright, M., Cherkas, D., LeBlanc, S., Sofouli, E., Rivest, M.-P., Albert, H., Casey, R., O’Rourke, J. J., & Labonté, L. (2021) · Figshare · doi:10.6084/m9.figshare.16625629
Additional file 2 of Sustainment of diverse evidence-informed practices disseminated in the Veterans Health Administration (VHA): initial development and piloting of a pragmatic survey tool
Reardon, C. M., Damschroder, L. J., Opra Widerquist, M. A., Arasim, M. E., Jackson, G. L., White, B. S., Cutrona, S. L., Fix, G. M., Gifford, A. L., DeLaughter, K. L., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26561788
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Innovative Use of Rapid Qualitative Methods to Inform Neurological Services at the Department of Veterans Affairs
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Merging Implementation Practice and Science to Scale Up Promising Practices: The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) Program
Jackson, G. L., Cutrona, S. L., White, B. S., Reardon, C. M., Orvek, E., Nevedal, A., Lindquist, J. H., Gifford, A. L., White, L., King, H. A., et al. (2020) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/j.jcjq.2020.11.014 · Cited by 25 · see citing works
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Identifying, Replicating, and Spreading Health care Innovations across a Nation‐Wide Health care System: VHA Diffusion of Excellence
Jackson, G., Cutrona, S. L., White, B. S., Reardon, C., Orvek, E., Nevedal, A., Lindquist, J. H., Gifford, A. L., King, H. A., DeLaughter, K. L., et al. (2020) · Health Services Research · doi:10.1111/1475-6773.13411 · Cited by 1 · see citing works
Self-citation
Understanding pathways from implementation to sustainment: a longitudinal, mixed methods analysis of promising practices implemented in the Veterans Health Administration
Nevedal, A., Widerquist, M. A. O., Reardon, C. M., Arasim, M. E., Jackson, G. L., White, B. S., Burns, M., Fix, G. M., DeLaughter, K. L., Cutrona, S. L., et al. (2024) · Implementation Science · doi:10.1186/s13012-024-01361-z · Cited by 25 · see citing works
Self-citation
Diffusion of excellence: evaluating a system to identify, replicate, and spread promising innovative practices across the Veterans health administration
Jackson, G. L., Fix, G. M., White, B. S., Cutrona, S. L., Reardon, C. M., Damschroder, L. J., Burns, M., DeLaughter, K. L., Widerquist, M. A. O., Arasim, M. E., et al. (2024) · Frontiers in Health Services · doi:10.3389/frhs.2023.1223277 · Cited by 9 · see citing works
Self-citation
Sustainment of diverse evidence-informed practices disseminated in the Veterans Health Administration (VHA): initial development and piloting of a pragmatic survey tool
Reardon, C. M., Damschroder, L. J., Widerquist, M. A. O., Arasim, M. E., Jackson, G. L., White, B. S., Cutrona, S. L., Fix, G. M., Gifford, A. L., DeLaughter, K. L., et al. (2023) · Implementation Science Communications · doi:10.1186/s43058-022-00386-z · Cited by 11 · see citing works
Self-citation

Authors: Nevedal, A. L., Reardon, C. M., Jackson, G. L., Cutrona, S. L., White, B., Gifford, A. L., Orvek, E., DeLaughter, K., White, L., King, H. A., Henderson, B., Vega, R., & Damschroder, L.
Affiliations: VA Palo Alto Health Care System (US)
VA Ann Arbor Healthcare System (US)
Duke University (US)
University of Massachusetts Chan Medical School (US)
Durham VA Health Care System (US)
Boston University (US)
Center for Health Optimization and Implementation Research (US)
Veterans Health Administration (US)
Corresponding author: Nevedal, Andrea L.
ORCID: Nevedal, Andrea L.
Reardon, Caitlin M.
Cutrona, Sarah L.
White, Brandolyn
Gifford, Allen L.
Orvek, Elizabeth
DeLaughter, Kathryn
King, Heather A.
Vega, Ryan
Damschroder, Laura
Venue: Implementation Science Communications
Publisher: Springer Science and Business Media LLC
Published: 2020-07-03
Volume: 1
Issue: 1
Pages: 61-61
ISSN: 2662-2211 (ISSN-L)
DOI: 10.1186/s43058-020-00053-1
PMC: PMC7427879
OpenAlex: W3038361036
Cited by: 44
References: 37
Citations by year: 2026: 3 · 2025: 5 · 2024: 10 · 2023: 4 · 2022: 10 · 2021: 11 · 2020: 1
FWCI: 6.79
Type: journal article
Language: en
Open access: gold
doi.org
Licence: cc-by
creativecommons.org/licenses/by/4.0 (tdm)
creativecommons.org/licenses/by/4.0 (vor)
Locations: Implementation Science Communications (publishedVersion, cc-by)
PubMed Central (publishedVersion, cc-by)
PubMed (publishedVersion)
eScholarship@UMassChan (submittedVersion, cc-by)
DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders: Quality Enhancement Research Initiative (PEC-17-002)
Topics: Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
Health Sciences › Health Professions › General Health Professions › Health Sciences Research and Education
Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
Keywords: evidence-based practice implementation, learning health systems, Veterans Health Administration, implementation barriers, implementation facilitators, Consolidated Framework for Implementation Research, implementation support, centralized decision-making, health system innovation, diffusion of innovations, integrated health system, implementation teams

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

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