Implementer and Researcher Perspectives on Sustaining, Spreading and Scaling up, Quality Improvement Interventions

Authors: Laur C, Corrado AM, Grimshaw JM, and Ivers N

Presenter: Dr. Celia Laur

Institution: Women’s College Hospital 


Quality Improvement (QI) programs rarely consider how their intervention can be sustained long term. Failing to adequately consider sustainability contributes to research waste and has the potential to make patient outcomes worse, if patients relied upon the QI program to improve quality of care. A survey of authors of randomized trials of diabetes QI interventions included in an ongoing systematic review found that 78% of trials reported improved quality of care, but 40% of these trials were not sustained following study completion. This study further explores why and how the effective interventions were sustained, spread or scaled. 


A qualitative approach was used, focusing on case examples. Diabetes QI program trial authors were purposefully sampled and recruited for telephone interviews. Authors were eligible if they had completed the author survey, agreed to follow-up, and had a completed a diabetes QI trial they deemed “effective”. Snowball sampling was used if the participant identified someone who could provide a different perspective on the same trial. Interviews were transcribed verbatim. Inductive thematic analysis was conducted to identify barriers and facilitators to sustainability, spread, and/or scale of the QI program, using case examples to show trajectories across projects and people. 


Eleven trial authors (n=9 male; 13 studies) were recruited from the United States (n=8), Canada (n=2) and Australia (n=1), including: physicians (n=5), pharmacists (n=2), non-clinicians (n=2), a dietitian (n=1), and a psychologist (n=1). 12/13 studies featured interventions that were deemed “effective” in the survey; 5/13 reported that the intervention was “sustained”. In the interviews, one participant clarified that only the ideas were sustained, not the intervention, while another said the intervention was sustained because it was being used elsewhere. Two participants indicated it was sustained for a few years after funding ended but has since stopped. One is still sustained. Three interacting themes, termed the “3C’s”, helped explain the variation in sustainability, spread, and scale: i) understanding the concepts of implementation, sustainability, sustainment, spread and scale; ii) having the appropriate competencies; and iii) the need for individual, organisational and system capacity. Participant stories highlighted the varied trajectories of how projects evolved and how some research careers adapted to increase impact. One participant had an effective intervention, however left academia in order to implement it at scale. Another had an effective pilot that quickly gained interest and was scaled nationally, with research conducted to understand how it should be sustained and spread. However, the timing did not align, and the scaled interventions failed before the results of the other study were complete. 


Challenges in defining sustainability, spread and scale make it difficult to fully understand impact. However, it is clear that from the beginning of intervention design, implementers and researchers need to understand the concepts and have the competency and capacity to plan for feasible and sustainable interventions that have potential to be sustained, spread and/or scaled if found to be effective. Principles of Integrated Knowledge Translation appear to play a key role in having a sustained intervention. 


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