Understanding pathways from implementation to sustainment: a longitudinal mixed methods analysis of promising practices implemented in the Veterans Health Administration
Authors: Nevedal Andrea , Widerquist Marilla Opra , Reardon Caitlin , Arasim Maria , Jackson George , White Brandolyn , Burns Madison , Fix Gemmae , DeLaughter Kathryn , Cutrona Sarah , Gifford Allen , Jasuja Guneet , Hogan Timothy , King Heather , Henderson Blake , Damschroder Laura 
Published: August 2023

Background
The Veterans Health Administration (VHA) is the United States’ largest learning health system. The Diffusion of Excellence (DoE) program is a large-scale model of diffusion that identifies and diffuses evidence-informed practices across VHA. During the period of 2016–2021, 57 evidence-informed practices were implemented across VHA facilities. This setting provides a unique opportunity to understand determinants and pathways of sustainment. Our objective was to characterize longitudinal pathways of practices as they transition from initial implementation to long-term sustainment.
Methods
A longitudinal mixed-methods evaluation with semi-structured post-implementation interviews and annual sustainment surveys of 82 implementation leads of 57 DoE practices was completed. Primary outcomes (implementation, sustainment), and secondary outcomes (institutionalization, effectiveness, anticipated sustainment) at four time-points were collected. We performed descriptive statistics and directed content analysis using Hailemariam et al.’s factors influencing sustainment.
Results
After 5 years of implementation, of the 82 implementation leads, about one-third reported their practice was fully sustained compared to one-third who reported their practice was not fully sustained because it was in a “liminal stage” (neither sustained nor discontinued) or permanently discontinued. The remaining one-third of leads were missing 2021 sustainment outcomes. Over time, a higher percentage of leads (43%) reported inconsistent findings across primary outcomes compared to those who (29%) reported consistent findings across primary outcomes. Thirty-four percent of leads with sustained practices reported resilience since they overcame implementation and sustainment barriers. Leads of sustained practices were more likely to report positive secondary outcomes compared to those that did not sustain their practice. Key barriers to practice sustainment included: inadequate workforce, not able to maintain practice fidelity/integrity, critical incidents related to the COVID-19 pandemic, organizational leadership did not support sustainment of practice, and no ongoing support. Key facilitators to practice sustainment included: demonstrating practice effectiveness/benefit, sufficient organizational leadership, adequate workforce, and adaptation/alignment with local context.
Conclusions
We identified diverse pathways from implementation to sustainment, and our data underscore that initial implementation outcomes may not determine long-term sustainment. This longitudinal evaluation contributes to understanding impacts of the DoE program, including return on investment, achieving learning health system goals, and insights into achieving high-quality healthcare in VHA.