Thank you for joining me today. My name is Dr. Laura Lennox and I'm the Deputy Lead for Innovation Evaluation for the Applied Research Collaboration in Northwest London and here at Imperial College. By background, I am a registered nurse, but mostly I work in research now with a specific interest in implementation and sustainability and spread of improvements in healthcare, which is what I'm going to speak about today. There are two perspectives when considering sustainability in healthcare. The first is a linear perspective where you think of sustainability as an endpoint or goal following implementation. More recently, there is acceptance that implementation often doesn't end completely and you will always have to address risks then have to overcome barriers in order to maintain incremental improvements over time. Sustainability is viewed more as a process and less of an endpoint in most recent sustainability research. We know that there are issues with sustainability and healthcare today. The main problem being that we dedicate significant resources to quality improvement initiatives. But many of these initiatives don't have a lasting impact on care. There are a number of publications that have outlined how only about one-third of improvement projects achieve long-term success. Very few of these actually maintained at high levels of fidelity, meaning that once you've implemented something, it will be significantly different when you go back to assess its sustainability in a few years time. Equally, there are a number of publications that have shown that quality improvement initiatives are not sustaining but there are also publications that are showing that they can be sustained. Leaving researchers and practitioners alike questioning, what makes something sustained versus not sustained and how can we use that learning to support overall sustainability? Very recently, we have seen a lot of rapid implementation of QI initiatives in response to COVID-19. This is of particular interest because we want to understand how can something be rapidly implemented but also maintained into the future so we can optimize the benefits of these small-scale QI initiatives that have been used? That will be the topic of the associated interview with this session. Why is sustainability the important to healthcare? It's important for a number of reasons. The first is that if you have failure of sustainability for certain activities, this leads to a number of variations in between services that are provided in similar organizations. It also leads to a lot of human and financial waste of resources as any of the benefits are lost over time. It is has also been shown in the literature that failure to sustain impacts the overall enthusiasm and willingness of staff, patients and the public to be involved in quality improvement initiatives as they see that the efforts that they've put into these initiatives aren't maintained. They are less likely to want to be involved in the future. Finally, we've been left with a lot of questions about the ethical considerations of whether or not researchers can go into healthcare organizations and test and implement innovations and improvements and if this isn't maintained over time, is it the job of those who initially work in the organization to maintain this, or should that be part of the social responsibility of the researcher to ensure that anything they are doing could be embedded in practice. To define sustainability, there are a lot of possible definitions. I just want to highlight this one here because it encompasses a more comprehensive definition that includes the maintenance of a program or behavior, but also demonstrates that these behaviors and programs can be changed over time as long as you are continuing to produce benefits for systems or individuals. This is mainly because you wouldn't want to maintain a project if it wasn't able to produce the benefits. You don't want to be continuing activities that aren't effective. The literature tells us that there are many who recognized reasons initiatives fail to sustain. The first is that there is often too many priorities or projects ongoing within organizations, you can't maintain enough attention to these individual projects that are going on. The second is that there's often not enough time dedicated to these improvement initiatives. The result is incomplete initial implementation, meaning that you can't maintain something that hasn't initially been implemented appropriately. There's also literature that within implementation, people are addressing easy things first. Meaning that they're addressing the immediate problems, which gives them much less time to plan for future sustainability. Finally, there's also a broad failure to recognize implementation and sustainability is parallel processes and if you were only thinking about sustainability at the end of implantation, you often miss the opportunity to create the support structures that you will need to embed the intervention in the system in the long-term. How can sustainability be supported and managed? Within literature, there isn't very much consensus about how it can be designed or planned for. But there is consensus that there are specific sustainability factors that can support you to maintain your gains over time. These are often encompassed within various models and frameworks and tools which can be used by improvement teams to monitor and assess sustainability throughout their project. We know that there are a number of available sustainability approaches such as models, tools, and processes, and these have been reported on in various systematic reviews including one most recently published that identified 62 available frameworks and tools. This just shows the appetite of creating and using sustainability tools has been growing over the last few years, as people try to find ways to assess and plan for sustainability within their projects. One of the main findings from this type of study is that you need to now test and validate some of these tools and practice in order to understand how they actually are supporting sustainability. In order to begin to assess and test some of these sustainability approaches, I'm going to walk you through an experience that I had at my previous QI program. Within my previous QI program, we tested the NHS Institute for Innovation and Improvement sustainability model. This was used for five years by project teams and we had a number of completions of this tool. But overall, teams found it difficult to use and engage with on an ongoing basis, as some of the design features and languages within the tool didn't exactly resonate with what was going on within their own projects. The findings from this piece of work concluded that we needed to develop a more user-friendly and practical tool that could be implemented by improvement teams on an ongoing basis. To develop this adapted method for sustainability, we engaged in a number of steps. Of course this included the previous literature reviews and experience that we had. Most importantly, we wanted to engage with stakeholders to understand how a tool could be designed to be practical and user-friendly and this involved a number of interviews and piloting. The feedback from this work was that a tool for sustainability needed to be concise, it needed to be easy to use. It needed to be visual, and it needed to be practical for people to use in an ongoing basis within their projects. All of this feedback was used to design a long-term success framework and tool. The long-term success tool used this feedback to be designed into a quick and easy questionnaire that could be done by project teams on an ongoing basis. It features 12 factors that are supported by the literature that can be assessed over time by group or a team of people where they can share their views about the potential risks they see for sustainability. The factors within the long term success tool are supported by the literature, but most importantly, they resonated and were tailored with stakeholders who were actually engaged in quality improvement initiatives. The factors fit into three domains, people, practice and setting. Domain of people encompasses five factors, and this asks questions about whether or not you have the appropriate involvement from staff and those who will be influenced or impacted by the changes that you're trying to make. It also specifically questions how skills and capabilities and training can be built in, so accountability for continual delivery for this initiative can be promoted in the future. The second domain is practice, and this encompasses four factors which ask about the structures in the systems that support a project to be implemented and sustained over time. Specifically asking about how you're monitoring feedback, what data you can collect to provide evidence of the benefits the project is producing. This is incredibly important in terms of providing the communication material you need to show that this piece of work should continue into the future. Finally, the third domain is setting. This encompasses three factors that ask about the organizational and environmental issues that might impact the continuation of a project. Specifically, if the improvement is supported by the large organization and how the project may be incorporated into specific strategies or priorities. You can gain buy-in from managers and organizational leaders to continue to deliver this project into the future. Now all of these factors show the complexity of this topic and it would be very difficult for any one person to be able to assess these over time without the structure of a tool or framework, which is why the use of the long term success tool and questionnaire is advocated. In terms of principles to remember when you're thinking about sustainability in healthcare settings. First, you really need to make time to consider the bigger picture to step back from implementation, plan for the long-term integration and embedding of the changes that you are trying to make. Second, long-term success needs to be considered early and throughout implementation. Only through doing this will you be able to identify the appropriate risks and actions to address any of the issues that might hinder you from sustaining in the long term. Finally, you really should consider the impact of specific factors that are promoted and spoken about within literature and within the long term success tool. This will give you a way to comprehensively think about this complex topic. Also by using a tool or framework, you can have a structured and systematic way to assess these factors over time to ultimately support the long-term success of any improvement initiative.
