So now let's focus a little bit more on to more E's, specifically, Endure and Embed. If you remember our implementation framework, we are suggesting that within frontline staff, team leaders, and senior executives, you need to separately ask, "What can lead to endurance of the program among the frontline staff, among the team leaders, and among the senior executives? Those may turn out to be different things because of people's desires or because of what their expectations within their organization, what is expected of them? And so, has this become business as usual? That might be a different question for a senior executive than it is for frontline staff person. And how do I know that it's going to last after the end of the program? Well, the team leaders will have some different answers to that question than the people who are on the frontline. In general, you want to make sure that you have policies and procedures, you're training new people, you are walking the process reasonably often, in order to make sure that everything is still going as it did at its peak. And then, in the area of expand, again, for each one of those three audiences, you want to think about what else needs to be done here? Where else do we need to move this program? Who else needs to know about what we have done here? And who else needs to implement what we have done here? And then, is there something else that we should be working on? What is the next challenge? And how do we address it? That's your expand. So, looking closer at enduring and planning for sustainability, you might say, "There are staff and why would I worry about the distant future?" And I think that the answer to that is that, you can anticipate that there's going to be some turnover, that there will be some new staff coming in, there will be new projects, there'll be distractions from what you're trying to do, there will be complacency as well, "Oh, we've done such a good job with bloodstream infection reduction, that we really don't need to keep working on it. Or, it will just naturally roll out from here and will be preventing infections without even trying." And so, good results do lead to this complacency a little bit. And so you need to watch out for that. And then of course, there will be these emergencies or complex cases and somebody will say, "Well, we have to make an exception." Well, the more exceptions that are made, the less you actually have a reliable and sustained process. And so, you want to watch out for those as well. So planning for sustainability is really important. So it's important to consider whether your implementation and your sustainability of your intervention are the same thing. Many people will think of sustainability as unfolding naturally as part of an implementation. We kind of make an assumption that if we implement it well, then it will last over time. But in fact, it's more helpful to think of implementation as separate from sustainability. And that creates an opportunity from a focus on how to continue the intervention in the long run. So, if we start to think about implementation versus sustainability, then it becomes possible for us to think about the fact that you could be good at implementing and not good at sustaining. In fact, that's pretty common. Or you could be good at sustaining and not particularly good at implementation in the first place. And this is partly to do with the hierarchy or the culture of the organization. An organization that's very hierarchic tends to really be reliable and has great sustainment of the things that they've done or taken up, but they may not be that open to taking up new things. On the other hand, we often see organizations that are very open to new ideas and new implementations, having trouble sustaining over the long run because there's always a new idea coming down the pike. And so, even though you will expect yourself of course, to be in the high-implementer, high-sustainer category, what we see is in fact, that there are very few that, relative to the entire data pool, that will end up in that coveted category. And there will be those who will end up in these other quadrants of this graphic, including low-sustainers, who were low implementers in the first place. Some high-sustainers, who were low-implementers. And so they're holding onto a couple of pieces maybe of the overall intervention and they're holding onto those really well. But maybe they didn't do a great job implementing the whole package from the beginning. And then of course, we'll have those who did a good job with the initial implementation, but are having troubles continuing to sustain, in fact that maybe, the most common category that we'll see. So some previous work that we've done on Sustainability in Quality Improvement. This is an unpublished data source that I worked on back in early 2000s. And we did 65 interviews with 41 different sites that were participating in the Chronic Illness Care Collaboratives. And these were some inpatient sites and some primary care sites. What we found at a year was that 34 of those sites or 83 percent were sustaining the whole change process. And that includes both the process to bring about change, meaning the PTSA cycles, and also sustaining the improvements that they had been able to implement. 24 of those sites were even, in fact, continually expanding the implementation of the chronic care model. 10 of the sites though, were maintaining the gains or the main changes that they had made but they really weren't doing further change. And then finally, six of the sites had completely discontinued the change effort. And so, I think this is something that you can commonly see across quality improvement or other process changes, is that there are pressures that lead to the discontinuation, even of things that were successful and positive when they were in implementation phase. So that's something for you to watch out for and to think about with whatever improvement you're trying to undertake.
