Adherence to evidence-based clinical practice (EBP) is linked to better health care quality and improved patient outcomes.1 Variation in adherence to EBP persists nationwide.2 As care delivery systems seek solutions to improve quality and lower cost in a fee-for-value environment, implementation scientists are seeking to understand what implementation strategies work best under what conditions. Intermountain Healthcare (Intermountain) has been at the forefront of the discussion with innovative proposals seeking to deliver extraordinary care.3,4 Sustaining these improvements over time represents a formidable challenge.
Early EBP implementation gains can be deceptive. Projects can appear at first to be highly successful, yielding improvements in adherence to EBP and outcomes. However, once the focus has shifted away from the implementation, gains often decline over time. This phenomenon is so common that at Intermountain we believe that strong, systematic approaches to address sustainability are needed. Evidence suggests that process performance tends to deteriorate over time for a variety of reasons. Often, adherence to a new process is the result of an extraordinary level of organizational focus and vigilance. At some point, however, the organization's "attention span" shifts to a different problem. Without strong structures in place to sustain process performance, people revert to old habits. Some of this is a function of natural limitations on the human mind-limitations of memory and concentration. People have a natural tendency to seek ways to reduce the burden of their work, so they may gravitate toward shortcuts. External factors can also cause deterioration in process performance. These include turnover, new competing demands on performers' time, and attention, as well as changes to ancillary processes, work schedules, physical facilities, equipment, supplies, or organizational structure.
We think about a process change leader at Intermountain as analogous to a builder of a house. Every competent home builder approaches the work with the full understanding that, even when the home is completely built, the elements will act upon the house leading to deterioration over time. Armed with this understanding, each builder selects materials and construction methods that will increase the ability of the home to withstand the elements. Despite these precautions, every homeowner knows that it is still necessary to periodically inspect the roof and exterior walls, and that some measures must be periodically taken to repair damage and restore the home. Rather than hoping for the best, Intermountain process leaders are taught that the forces of deterioration as described earlier will begin to act upon the process. They should take proactive measures to shore up their processes against the forces of deterioration, and they should prepare the owners of the work process to monitor and react to signs of process deterioration when it does occur.
How does Intermountain sustain gains from implementation work and prevent deterioration?
First, we start thinking about sustainability in the way we design and execute the initial EBP implementation. Key elements in the initial implementation that promote sustainability include senior leadership commitment to change; a clear, evidence-based intervention; a robust implementation approach; frontline engagement; and the use of cross-functional implementation support.3 We have a formal process for chartering projects and initiatives, which entails identifying sponsors, articulating the roles and responsibilities of the various team members, writing a structured project plan, and providing progress reports to appropriate levels of leadership on a regular basis. These fundamentals help to ensure that the new process will be seen by clinicians as a permanent change and not simply a fleeting trend.
Second, we see the increased organization attention during the implementation as temporary. During this period, we strive to ensure that best practices become a habit. Attention must be paid to habit formation. The cues and rewards for good work habits should be built right into the work environment.5 For example, one of our emergency departments (EDs) has created a yellow sheet to serve as a clear visual cue to physicians that the triage nurse has identified the patient as a possible septic patient, thus triggering the use of the sepsis protocol.
Third, we reduce barriers to doing the right thing first. Modifications to physical layouts, equipment, and information systems can work to ensure that the EBP fits into the natural workflow. In the case of deimplementation, making it more difficult or burdensome to perform the process in an alternative (wrong) manner is desirable. For example, studies have shown that bronchodilators (once commonly used for treatment of bronchiolitis in infants) are simply not effective for that purpose. Education and information campaigns failed to produce a sustained change in practice. Many hospitals across the country discovered that they could affect a sustained improvement by simply removing bronchodilators as an option on the standard order set for bronchiolitis. They had increased the burden of doing the wrong thing enough to produce a sustained change in practice.
Fourth, we design the new process so that deviations from standards will be highly visible-both to the person deviating and to other members of the team. Such high visibility will allow for ongoing team collaboration. If one person's memory fails, a team member can speak up and nudge that person back on track. This effect is enhanced if the process is designed such that correct performance of the process by one team member is a prerequisite to another team member performing his or her task. Such task dependency creates an ongoing sense of peer accountability, which serves as a bulwark against process deterioration. Timely administration of alteplase in Intermountain EDs requires significant care team engagement across multiple roles within the ED with each team member positioned to encourage the best practice and instill a sense of peer accountability. We are seeing sustained gains in adherence to timely alteplase administration at Intermountain after 6 months, due in part to team collaboration.
Fifth, before the project team is dismantled, we create a process for ongoing monitoring and reporting on process sustainability. At Intermountain, we have adopted our own customized version of Lean Management, called the Intermountain Operating Model. Embedded in this model are many systems and processes that help us to sustain adherence to operational and clinical standards. Almost every unit has a color-coded visual huddle board or performance board, with leading and lagging indicators of organizational performance. Green indicates adequate performance; red denotes failures or gaps. Daily huddles centered on these visual boards help caregivers to maintain awareness of key processes and provide early warning on performance deterioration helping avert major process breakdowns. Nursing units, for example, use these huddles and boards to sustain performance on processes like central line bundles, falls assessments, and hand hygiene. If poor performance persists for a specified period, the operational leader is required to write a "return-to-green plan," diagnosing the problem and detailing an action plan to address the problem. Significant problems are escalated to higher levels of leadership through a system of tiered escalation huddles, so that issues can be addressed with appropriate resources and at appropriate levels.6
Finally, we strive for well-conceived ongoing education plans. Such plans address how new staff and physicians will learn the necessary details of the process and how the knowledge of all staff and physicians will be periodically refreshed. Traditional classroom training is one option for education, but other modes or education are used, including computer-based training, review modules during staff meetings or huddles, and on-the-job coaching.
ADVANCING SUSTAINABILITY RESEARCH
As health care delivery systems become increasingly cost-conscious, strategies to retain hard-fought gains in EBP adherence are preferable to more costly cyclic efforts to reintroduce improvements. As implementation science research studies mechanisms to improve implementation effectiveness, equal attention should be given to studying the mechanisms that sustain adherence to evidence-based care.
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