The Perils of a “My Work Here is Done” Perspective: A Mixed Methods Evaluation of Sustainment of an Intervention to Improve Quality of Transient Ischemic Attack Care

BACKGROUND Sustaining quality improvement has been recognized as a key implementation challenge. The objectives of this study were to evaluate sustainment during the implementation of a novel quality improvement intervention for Transient Ischemic Attack (TIA) across six geographically diverse medical centers and to identify specific factors contributing to sustainment. METHODS The PREVENT study was a five-year, stepped-wedge implementation trial at six US Department of Veterans Affairs sites; active implementation was initiated in three waves, with two facilities per wave. Six control sites were matched to each of the six PREVENT active implementation sites (total number of control sites was 36). Mixed methods were used to assess change in quality of care from baseline to active implementation to sustainment (measured by the “without-fail rate” and to identify factors which promoted or hindered sustainment. RESULTS The without-fail rate at PREVENT sites improved from 36.7% at baseline to 54.0% during active implementation and settled to 48.3% during sustainment. At control sites, the without-fail rate improved from 38.6% at baseline to 41.8% during active implementation and remained steady at 43.0% during sustainment. Changes in quality of care during sustainment varied across PREVENT sites: the without-fail rate improved at three sites, declined at two sites, and remained unchanged at one site. In adjusted analyses, although the without-fail rate improved at PREVENT sites compared with control sites during active implementation, no statistically significant difference in quality between intervention and control sites was identified during the sustainment phase. Factors that promoted sustainment were integration of key processes of care into routine practice and establishing systems for reflecting and evaluating on performance data to plan quality improvement activities or respond to changes in quality. Challenges during sustainment included competing demands from new facility quality priorities, low patient volume, and potential problems with coding impairing use of performance data. CONCLUSIONS Facilities seeking to sustain evidence-based practices while embodying the Learning Healthcare System’s core values can harness the combined power of staff and data systems by embedding quality improvement processes within routine care and establishing systems for reviewing and reflecting upon performance data.TRIAL REGISTRATION clinicaltrials.gov: NCT02769338