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

Nevedal et al. Implementation Science Communications https://doi.org/10.1186/s43058-020-00053-1 (2020) 1:61 RESEARCH Implementation Science Communications Open Access Implementation and sustainment of diverse practices in a large integrated health system: a mixed methods study Andrea L. Nevedal1* , Caitlin M. Reardon2, George L. Jackson3,4, Sarah L. Cutrona5,6, Brandolyn White3, Allen L. Gifford5,7, Elizabeth Orvek5,6, Kathryn DeLaughter5,6, Lindsay White5, Heather A. King3,4, Blake Henderson8, Ryan Vega9 and Laura Damschroder2 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. (Continued on next page) * Correspondence: 1 Center for Innovation to Implementation, VHA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Nevedal et al. Implementation Science Communications (2020) 1:61 Page 2 of 13 (Continued from previous page) 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 largescale model of diffusion. Team predictions about sustainability after the first 6 months of implementation provide a promising early assessment and point of intervention to increase sustainability. Keywords: Consolidated Framework for Implementation Research (CFIR), Qualitative methods, Model of diffusion, Sustainability, Learning health system, Veterans, Veterans Health Administration (VHA), VHA Innovation Ecosystem, VHA Diffusion of Excellence Contributions to the literature  Examples of system-level structures and processes to identify, diffuse, and sustain best practices are rare; the VHA DoE can serve as a model of diffusion for other large learning health systems.  Our findings indicate that implementation timelines may be arbitrarily set and that failure to meet pre-specified implementation milestones does not necessarily hinder sustainment.  Research on sustainability is nascent; our results indicate that teams’ anticipated sustainment after initial implementation may be a useful assessment and present a fruitful point of intervention when teams do not expect to sustain their practice. Background Implementation science is the systematic study of methods to encourage the integration of evidence-based practices (EBPs) into routine care to improve outcomes [1, 2]. EBPs include practices that are supported by sufficient evidence from research studies, clinical experience, and/or patient values and preferences [1, 3]. Implementation is the means by which an EBP is assimilated into an organization and usually a deliberately initiated process, where individuals aim to bring EBPs into routine use as designed [4, 5]. Despite established effectiveness and despite implementation efforts, most EBPs are not rapidly implemented or sustained in health systems, delaying or halting benefits to patients, employees, and systems [1, 6–12]. As a result, health systems are seeking to evolve into learning health systems, with one goal to support continuous learning and innovation. Though learning systems have successfully improved health care quality and efficiency [13], knowledge is only just emerging about how learning health systems may accelerate identification, diffusion, and sustainment of multiple EBPs across systems. The Veterans Health Administration (VHA), the largest integrated health system in the USA, seeks to evolve into a learning health system [8, 10, 14–16]. As part of this evolution [17, 18], the VHA developed the Innovation Ecosystem, which aims to embed innovation in the core fabric of the VHA, build a collaborative innovation community, and deliver a (...truncated)