Understanding pathways from implementation to sustainment: a longitudinal, mixed methods analysis of promising practices implemented in the Veterans Health Administration.

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 82 VHA facilities. This setting provides a unique opportunity to understand sustainment determinants and pathways. Our objective was to characterize the longitudinal pathways of practices as they transition from initial implementation to long-term sustainment at each facility. METHODS: A longitudinal, mixed-methods evaluation of 82 VHA facilities. Eighty-two facility representatives, chosen by leadership as points-of-contact for 57 DoE practices, were eligible for post-implementation interviews and annual sustainment surveys. 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 approximately five years post-implementation (e.g., 2021 sustainment outcomes), of the 82 facilities, about one-third fully sustained their practice compared to one-third that did not fully sustain their practice because it was in a "liminal" stage (neither sustained nor discontinued) or permanently discontinued. The remaining one-third of facilities had missing 2021 sustainment outcomes. A higher percentage of facilities (70%) had inconsistent primary outcomes (changing over time) compared to facilities (30%) with consistent primary outcomes (same over time). Thirty-four percent of facilities with sustained practices reported resilience since they overcame implementation and sustainment barriers. Facilities with sustained practices reported more positive secondary outcomes compared to those that did not sustain their practice. Key factors facilitating practice sustainment included: demonstrating practice effectiveness/benefit, sufficient organizational leadership, sufficient workforce, and adaptation/alignment with local context. Key factors hindering practice sustainment included: insufficient 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. CONCLUSIONS: We identified diverse pathways from implementation to sustainment, and our data underscore that initial implementation outcomes may not determine long-term sustainment outcomes. 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.

Supporting Veteran's Administration Medical Center Directors' Decisions When Adopting Innovative Practices: Development and Implementation of the "QuickView" and "WishList" Tools.

Background Since 2015, the Veterans Health Administration (VHA) Diffusion of Excellence Program has supported spread of practices developed by frontline employees. Shark Tank-style competitions encourage "Sharks" nationwide (VHA medical center/regional directors) to bid for the opportunity to implement practices at their institutions. Methods The authors evaluated bidding strategies (2016-2020), developing the "QuickView" practice comparator to promote informed bidding. Program leaders distributed QuickView and revised versions in subsequent competitions. Our team utilized in-person observation, online chats after the competition, bidder interviews, and bid analysis to evaluate QuickView use. Bids were ranked based on demonstrated understanding of resources required for practice implementation. Results Sharks stated that QuickView supported preparation before the competition and suggested improvements. Our revised tool reported necessary staff time and incorporated a "WishList" from practice finalists detailing minimum requirements for successful implementation. Bids from later years reflected increased review of facilities' current states before the competition and increased understanding of the resources needed for implementation. Percentage of bids describing local need for the practice rose from 2016 to 2020: 4.7% (6/127); 62.1% (54/87); 78.3% (36/46); 80.6% (29/36); 89.7% (26/29). Percentage of bids committing specific resources rose following QuickView introduction: 81.1% (103/127) in 2016, 69.0% (60/87) in 2017, then 73.9% (34/46) in 2018, 88.9% (32/36) in 2019, and 89.7% (26/29) in 2020. Discussion In the years following QuickView/WishList implementation, bids reflected increased assessment before the competition of both local needs and available resources. Conclusion Selection of a new practice for implementation requires an understanding of local need, necessary resources, and fit. QuickView and WishList appear to support these determinations.

Leveraging Organizational Conditions for Innovation: A Typology of Facility Engagement in the Veterans Health Administration Shark Tank-Style Competition.

Introduction The development and spread of innovation are known challenges in health care. The US Veterans Health Administration (VHA) created a "Shark Tank"-style competition directed at frontline employees. In this annual, systemwide competition, employees submit innovations to the competition, and winning innovations receive support for implementation in other facilities. Method A multiple case study design was used to understand facility engagement in the competition, and the relationship between engagement and organizational conditions. The authors created a typology to describe the relationship between facility engagement in the competition and organizational conditions for innovation. Results Overall, there was high participation in the VHA's competition across all 130 facilities. The authors identified 7 mutually exclusive types of facility engagement. Discussion As expected, facilities with the most established conditions for innovation were the most engaged in the competition. Additionally, other facilities had various ways to be involved. Consequently, there may be benefit to the VHA tailoring how they work with facilities, based on organizational conditions. Larger facilities with ongoing research and more resources may be more suited to develop innovations, whereas smaller facilities could benefit from a focus on adoption. Conclusion These insights are valuable to the VHA and can be used by other health care systems to tailor innovation programs and allocate resources based on diverse needs across a vast health care system.

Evaluation of an implementation package to deliver the COPD CARE service.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and is estimated to be the leading cause of death in the next 15 years. Patients with COPD suffer from persistent chronic cough, sputum production and exacerbations leading to deteriorating lung function, worsening quality of life and loss of independence. While evidence-based interventions exist to improve the well-being of patients with COPD, incorporation of these interventions into routine clinical care is challenging. Chronic Obstructive Pulmonary Disease Coordinated Access to Reduce Exacerbations (COPD CARE) is a team-based, coordinated care transitions service integrating evidence-based interventions for COPD management within the patient care delivery model to reduce readmissions. This evaluation considers the process of scaling the COPD CARE service across medical facilities using an implementation package designed for service expansion. The implementation package was developed at the United States Veterans Health Administration and implemented at two medical centres. Core dissemination and implementation science methods were applied to guide design and delivery of the implementation package.The aims of this evaluation were to (1) evaluate the impact of the implementation package on use of evidence-based interventions for COPD management and (2) explore clinician perceptions of the implementation package. This prospective mixed-methods quality improvement project included two Plan Do Check Act (PDCA) cycles conducted over a 24-month period. Electronic health record data demonstrated significant improvements in the count of evidence-based interventions incorporated into routine clinical care after training completion (p<0.001), offering preliminary effectiveness of the package to improve uptake of best practices for COPD management. Clinician perceptions of the implementation package, measured by questionnaire at multiple time points, demonstrated significant improvements for all scales at the end of the final PDCA cycle. Clinicians described the implementation package as positively impacting clinician confidence, interprofessional collaboration and patient care delivery.

Sustainment of diverse evidence-informed practices disseminated in the Veterans Health Administration (VHA): initial development and piloting of a pragmatic survey tool.

BACKGROUND: There are challenges associated with measuring sustainment of evidence-informed practices (EIPs). First, the terms sustainability and sustainment are often falsely conflated: sustainability assesses the likelihood of an EIP being in use in the future while sustainment assesses the extent to which an EIP is (or is not) in use. Second, grant funding often ends before sustainment can be assessed. The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program is one of few large-scale models of diffusion; it seeks to identify and disseminate practices across the VHA system. The DoE sponsors "Shark Tank" competitions, in which leaders bid on the opportunity to implement a practice with approximately 6 months of implementation support. As part of an ongoing evaluation of the DoE, we sought to develop and pilot a pragmatic survey tool to assess sustainment of DoE practices. METHODS: In June 2020, surveys were sent to 64 facilities that were part of the DoE evaluation. We began analysis by comparing alignment of quantitative and qualitative responses; some facility representatives reported in the open-text box of the survey that their practice was on a temporary hold due to COVID-19 but answered the primary outcome question differently. As a result, the team reclassified the primary outcome of these facilities to Sustained: Temporary COVID-Hold. Following this reclassification, the number and percent of facilities in each category was calculated. We used directed content analysis, guided by the Consolidated Framework for Implementation Research (CFIR), to analyze open-text box responses. RESULTS: A representative from forty-one facilities (64%) completed the survey. Among responding facilities, 29/41 sustained their practice, 1/41 partially sustained their practice, 8/41 had not sustained their practice, and 3/41 had never implemented their practice. Sustainment rates increased between Cohorts 1-4. CONCLUSIONS: The initial development and piloting of our pragmatic survey allowed us to assess sustainment of DoE practices. Planned updates to the survey will enable flexibility in assessing sustainment and its determinants at any phase after adoption. This assessment approach can flex with the longitudinal and dynamic nature of sustainment, including capturing nuances in outcomes when practices are on a temporary hold. If additional piloting illustrates the survey is useful, we plan to assess the reliability and validity of this measure for broader use in the field.

Diffusion of excellence: evaluating a system to identify, replicate, and spread promising innovative practices across the Veterans health administration.

Introduction: The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program provides a system to identify, replicate, and spread promising practices across the largest integrated healthcare system in the United States. DoE identifies innovations that have been successfully implemented in the VHA through a Shark Tank style competition. VHA facility and regional directors bid resources needed to replicate promising practices. Winning facilities/regions receive external facilitation to aid in replication/implementation over the course of a year. DoE staff then support diffusion of successful practices across the nationwide VHA. Methods: Organized around the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework, we summarize results of an ongoing long-term mixed-methods implementation evaluation of DoE. Data sources include: Shark Tank application and bid details, tracking practice adoptions through a Diffusion Marketplace, characteristics of VHA facilities, focus groups with Shark Tank bidders, structured observations of DoE events, surveys of DoE program participants, and semi-structured interviews of national VHA program office leaders, VHA healthcare system/facility executives, practice developers, implementation teams and facilitators. Results: In the first eight Shark Tanks (2016-2022), 3,280 Shark Tank applications were submitted; 88 were designated DoE Promising Practices (i.e., practices receive facilitated replication). DoE has effectively spread practices across the VHA, with 1,440 documented instances of adoption/replication of practices across the VHA. This includes 180 adoptions/replications in facilities located in rural areas. Leadership decisions to adopt innovations are often based on big picture considerations such as constituency support and linkage to organizational goals. DoE Promising Practices that have the greatest national spread have been successfully replicated at new sites during the facilitated replication process, have close partnerships with VHA national program offices, and tend to be less expensive to implement. Two indicators of sustainment indicate that 56 of the 88 Promising Practices are still being diffused across the VHA; 56% of facilities originally replicating the practices have sustained them, even up to 6 years after the first Shark Tank. Conclusion: DoE has developed a sustainable process for the identification, replication, and spread of promising practices as part of a learning health system committed to providing equitable access to high quality care.

Balancing reality in embedded research and evaluation: Low vs high embeddedness.

Embedding research and evaluation into organizations is one way to generate "practice-based" evidence needed to accelerate implementation of evidence-based innovations within learning health systems. Organizations and researchers/evaluators vary greatly in how they structure and operationalize these collaborations. One key aspect is the degree of embeddedness: from low embeddedness where researchers/evaluators are located outside organizations (eg, outside evaluation consultants) to high embeddedness where researchers/evaluators are employed by organizations and thus more deeply involved in program evolution and operations. Pros and cons related to the degree of embeddedness (low vs high) must be balanced when developing these relationships. We reflect on this process within the context of an embedded, mixed-methods evaluation of the Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program. Considerations that must be balanced include: (a) low vs high alignment of goals; (b) low vs high involvement in strategic planning; (c) observing what is happening vs being integrally involved with programmatic activities; (d) reporting findings at the project's end vs providing iterative findings and recommendations that contribute to program evolution; and (e) adhering to predetermined aims vs adapting aims in response to evolving partner needs.

Merging Implementation Practice and Science to Scale Up Promising Practices: The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) Program.

INTRODUCTION: The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program developed and manages a framework for identification, replication, and diffusion of promising practices throughout the nation's largest integrated health care system. DoE identifies promising practices through a "Shark Tank" competition with winning bidders receiving external implementation facilitation. DoE further supports diffusion of successful practices across the VHA. METHODS: This article presents results of a mixed methods implementation evaluation of DoE, focusing on program reach, program participation and decisions to adopt innovative practices, implementation processes, and practice sustainment. Data sources include practice adoption metrics, focus groups with bidders (two focus groups), observations of DoE events (seven events), surveys of stakeholders (five separate surveys), and semistructured interviews of facility directors, practice developers, implementation teams, and facilitators (133 participants). RESULTS: In the first four Shark Tank cohorts (2016-2018), 1,676 practices were submitted; 47 were designated Gold Status Practices (practices with facilitated implementation). Motivation for participation varied. Generally, staff led projects targeting problems they felt passionate about, facility directors focused on big-picture quality metrics and getting middle manager support, and frontline staff displayed variable motivation to implement new projects. Approximately half of facilitated implementation efforts were successful; barriers included insufficient infrastructure, staff, and resources. At the facility level, 73.3% of facilities originating or receiving facilitated implementation support have maintained the practice. VHA-wide, 834 decisions to adopt these practices were made. CONCLUSION: DoE has resulted in the identification of many candidate practices, promoted adoption of promising practices by facility directors, and supported practice implementation and diffusion across the VHA.

Dynamic Diffusion Network: Advancing moral injury care and suicide prevention using an innovative model.

Healthcare providers across a wide variety of settings face a common challenge: the need to provide real time care for complex problems that are not adequately addressed by existing protocols. In response to these intervention gaps, frontline providers may utilize existing evidence to develop new approaches that are tailored to specific problems. It is imperative that such approaches undergo some form of evaluation, ensuring quality control while permitting ongoing adaptation and refinement. "Dynamic diffusion" is an innovative approach to intervention improvement and dissemination whereby care practices are delivered and continuously evaluated under real-world conditions as part of a structured network experience. This "dynamic diffusion network" (DDN) promotes cross-pollination of ideas and shared learning to generate relatively rapid improvements in care. The pilot Mental Health and Chaplaincy DDN was developed to advance suicide prevention efforts and moral injury care practices being conducted by 13 chaplain-mental health professional teams across the Veterans Health Administration. Lessons learned from the pilot DDN include the importance of the following: geographic and cultural diversity among innovation collaborators to ensure the broadest possible relevance of solutions; leadership support to facilitate engagement of frontline providers in quality improvement efforts; and participation in a community of practice to motivate providers and offer opportunities for direct collaboration and cross-pollination of ideas.

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

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.

Diffusion of Excellence: Accelerating the Spread of Clinical Innovation and Best Practices across the Nation's Largest Health System.

The time it takes for clinical innovation and evidence-based practices to reach patients remains a major challenge for the health care sector. In 2015, the Veterans Health Administration (VHA) launched the Diffusion of Excellence Initiative aimed at aligning organizational resources with early-stage to midstage promising practices and innovations to replicate, scale, and eventually spread those with greatest potential for impact and positive outcomes. Using a 5-step systematic approach refined over time, frontline VHA staff have submitted more than 1676 practices since the initiative's inception, 47 of which have been selected as high-impact, Gold Status practices. These Gold Status practices have been replicated more than 412 times in Veterans Affairs hospitals across the country, improving care for more than 100,000 veterans and approximately $22.6 million in cost avoidance for the VHA. More importantly, practices such as Project HAPPEN (Hospital-Acquired Pneumonia Prevention by Engaging Nurses to complete oral care) and rapid availability of intranasal naloxone have saved veterans' lives. Several practices are now being implemented across the country, and the Diffusion of Excellence Initiative is playing a pivotal role as the VHA works to modernize its health care system. This initiative serves as a promising model for other health care systems seeking to accelerate the spread and adoption of clinical innovation and evidence-based practices.

Molecularly-imprinted nanoparticles that recognize Naja mossambica cytotoxins: binding studies and biological effects.

We report the development of molecularly imprinted polyacrylamide nanoparticles that bind to and neutralize the activity of cytotoxins present in the venom of the Mozambique Spitting Cobra (Naja mossambica mossambica). The binding activity of these nanoparticles is avid and specific. These findings hold promise for the development of a synthetic antivenom.