Solutions for Sustainability Planning: The Long Term Success Tool
By Dr. Julia E. Moore, Executive Director
If I could wave a magic wand that made it possible to answer one implementation science question it would be:
“How can we successfully sustain the outcomes of our successful implementation efforts?”
I believe this is one of the most important implementation science questions we need to answer, because as we get better at designing our initiatives (by selecting implementation strategies using theory and evidence), and improve the way that we implement, spread and scale effective initiatives, we need to be able to sustain our successes – otherwise we are creating a pattern of implementing new effective initiatives over and over without reaping the benefits of all of our efforts.
There are brilliant researchers answering hard questions about sustainability right now. But as someone who works with and supports professionals designing, implementing, evaluating, spreading and scaling initiatives, sometimes it’s hard for me to figure out what implementers can “do” with the research that is coming out on sustainability. For example, we have these incredible lists of factors that affect sustainability. In the hands of implementers, these lists might seem like lists of barriers to sustaining what they’re currently implementing. These lists don’t provide guidance on how to address these issues, and how to prevent them in the first place.
Planning for sustainability: use a sustainability assessment
One concrete piece of guidance that all implementation efforts should include is developing a sustainability plan and using a sustainability assessment. There is research that shows that if you plan for sustainability, you increase the chances of sustaining what you implement. This might seem obvious, but you’d be surprised at how many projects do not explicitly plan for sustainability early on.
There are three commonly used sustainability assessment tools that can help you plan for sustainability:
I’ve been part of projects that have used all three of these, and each of them can be extremely helpful and valuable, given the right situation. But they don’t all work in all contexts. For example, the Program Sustainability Assessment Tool works best in community settings when using an evidence-based program. The NHS Sustainability Model works best in a healthcare setting where you have a guideline or best practice.
In this issue of the Implementation in Action bulletin, Dr. Laura Lennox describes how she and her colleagues developed the Long Term Success Tool, the newest of the sustainability tools, and one I have had great experiences with over the past year. Dr. Laura Lennox is Deputy Lead for Innovation and Evaluation at The Applied Research Collaboration (ARC) within Imperial College London. Her research focuses on understanding how healthcare systems can maximise investments and reduce waste to produce long term change for patient care. She is particularly interested in exploring the process of achieving sustainability in practice and investigating how sustainability can be influenced with the use of specific strategies and initiatives.
The Long Term Success Tool to plan for sustainability
By Laura Lennox, Deputy Lead for Innovation and Evaluation, Imperial College London
While sustainability issues are recognised as occurring across multiple stages of initiative implementation, the majority of studies still report only the continuation or discontinuation of initiatives without insight into how these results were achieved (1). In 2015, I began a study to explore how individuals and teams influence sustainability throughout implementation and how tools or frameworks can be used in this process to prompt action and support sustainability. Over a four year period, a longitudinal mixed methods study was conducted to provide insight into the process of sustaining within three Quality Improvement (QI) Programmes in the UK.
The Long Term Success Tool
To prospectively measure and support sustainability throughout the initiatives, a structured sustainability tool was used: The Long Term Success Tool (LTST) (2). The LTST supports those implementing improvements to reflect on 12 factors (Fig 1) to identify risks and prompt actions to enhance sustainability over time (2).
Using a questionnaire, team members rated each factor individually and anonymously, providing comments to suggest actions or share concerns about progress. Team scores were brought together to produce aggregated visual charts demonstrating how the initiative is performing against the given factor (Fig 2) and comment lists for each factor were used to prompt team discussions. To ensure the study captured system and staff changes, the tool was used every 3-6 months throughout the study to assess progress, identify emerging risks and record actions and strategies taken by teams to sustain over time.
Impact of using a sustainability tool
Sustainability research is often criticised for being too retrospective with decisions of when and how to study sustainability largely driven by practical and financial constraints (1,3,4). Lack of rigorous measurement within sustainability research is identified as a key limitation within implementation science with few studies employing rigorous prospective methods to study the phenonmena (1,5,6). The use of the LTST provided a single lens to focus and provide scope to our study, directing and standardising data capture of this complex topic. It also provided a structured way to capture perceptions of sustainability risks and plans across diverse improvement teams from multiple settings and programmes. The application of the LTST across programmes also supported several benefits for the improvement teams including: supporting teams to build relationships and enhance collaborative working, share diverse opinions, voice and identify actions in response to feedback (7).
Sustainability is a challenging concept to delve into but the use of the LTST may provide a useful approach to assess teams’ perceptions of sustainability to prompt planning and actions to increase chances of long-term success. For more information on the development and how to apply the LTST please visit: https: //bmjopen.bmj.com/content/7/9/e014417
Download a PDF version of the tool.
References:
Shelton R, Cooper BR, Stirman SW. The Sustainability of Evidence-Based Interventions and Practices in Public Health and Health Care. Ssrn. 2018;
Lennox L, Doyle C, Reed J, Bell D. What makes a sustainability tool valuable, practical, and useful in real world healthcare practice? A qualitative study on the development of the Long Term Success Tool in Northwest London. BMJ Open. 2017;7(e014417):1–13.
Bowman CC, Sobo EJ, Asch SM, Gifford AL. Measuring persistence of implementation: QUERI Series. Implement Sci [Internet]. 2008 Jan [cited 2014 Aug 27];3(21). Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2390585&tool=pmcentrez&rendertype=abstract
Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: Lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Qual Saf. 2012;21(10):876–84.
Stirman SW, Kimberly J, Cook N, Calloway A, Castro F, Charns M. The sustainability of new programs and innovations : a review of the empirical literature and recommendations for future research. Implement Sci [Internet]. 2012;7(1):17. Available from: http://www.implementationscience.com/content/7/1/17
Lennox L, Maher L, Reed J. Navigating the sustainability landscape: A systematic review of sustainability approaches in healthcare. Implement Sci. 2018;13(1):1–17.
Lennox L, French C, Reed J. A qualitative exploration of sustainability processes for improvement: the role of structured sustainability tools. In: Nugus P, editor. Transitions and Boundaries in the Coordination and Reform of Health Services. Palgrave Macmillan; 2020. p. In Press.
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