Influences of post-implementation factors on the sustainability, sustainment, and intra-organizational spread of complex interventions

Abstract

Background Complex interventions are increasingly applied to healthcare problems. Understanding of post-implementation sustainment, sustainability, and spread of interventions is limited. We examine these phenomena for a complex quality improvement initiative led by care aides in 7 care homes (long-term care homes) in Manitoba, Canada. We report on factors influencing these phenomena two years after implementation. Methods Data were collected in 2019 via small group interviews with unit- and care home-level managers (n = 11) from 6 of the 7 homes using the intervention. Interview participants discussed post-implementation factors that influenced continuing or abandoning core intervention elements (processes, behaviors) and key intervention benefits (outcomes, impact). Interviews were audio-recorded, transcribed verbatim, and analyzed with thematic analysis. Results Sustainment of core elements and sustainability of key benefits were observed in 5 of the 6 participating care homes. Intra-unit intervention spread occurred in 3 of 6 homes. Factors influencing sustainment, sustainability, and spread related to intervention teams, unit and care home, and the long-term care system. Conclusions Our findings contribute understanding on the importance of micro-, meso-, and macro-level factors to sustainability of key benefits and sustainment of some core processes. Inter-unit spread relates exclusively to meso-level factors of observability and practice change institutionalization. Interventions should be developed with post-implementation sustainability in mind and measures taken to protect against influences such as workforce instability and competing internal and external demands. Design should anticipate need to adapt interventions to strengthen post-implementation traction.

Developing a tool to measure enactment of complex quality improvement interventions in healthcare

“… 22 In the first phase of SSaSSy, researchers ascertained the extent to which SCOPE QI skills and knowledge were sustained since SCOPE concluded in 2017. 28 Participating QI teams were then assigned to one of two ‘Booster’ conditions: a Low-Booster or High-Booster (see table 1 ). 22 Both boosters included educational sessions and educational materials based on IHI’s Model for Improvement, 3 as well as varying levels of external support from an experienced QI Advisor.…”

“…SSaSSy is phasic and ongoing: we began working with QI teams in Manitoba in 2019, and are now implementing SSaSSy in long-term care homes in Alberta and British Columbia, Canada 22. In the first phase of SSaSSy, researchers ascertained the extent to which SCOPE QI skills and knowledge were sustained since SCOPE concluded in 2017 28. Participating QI teams were then assigned to one of two ‘Booster’ conditions: a Low-Booster or High-Booster (see table 1).…”

Child and adolescent mental health services in a devolved healthcare system: a qualitative exploration of sustainable practices

“…This is especially important given GM i-THRIVE’s short time frame. Post-implementation sustainability should be considered as early as possible in the implementation process for complex health interventions, so that protective strategies can be devised to overcome identified barriers [ 11 ]. This need, given that sustainable practice is such a crucial predictor of public health impact [ 12 ], was a fundamental driver of the present study.…”

“…Adopting a purely post hoc evaluation approach that takes place only once official implementation phases have ended [ 11 ] can limit the scope of sustainability analyses, whereas combining retrospective investigation methods with those that offer the potential for ongoing improvement may increase their utility [ 20 ]. GM i-THRIVE’s implementation and embedding stages are summarized below.…”

“…The data for the present study were collected from August to November of 2021, as Stage 4 (the reviewing of implementation projects and goals) was ending and Stage 5 (the continued embedding and monitoring of outcomes) was set to begin. This timing sits comfortably between a priori and post hoc research approaches, allowing investigation of sustainable factors occurring towards the end of, but still in the midst of, implementation [ 11 ].…”