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Scale-Up is Not Enough

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Along with a recent upsurge in interest across implementation research generally, there has been a particular emphasis on scale-up or large-scale dissemination.  This focus on ‘going to scale’ has become a theme across knowledge translation, dissemination and implementation discussions, and in issues involving international development.  In many ways, this renewed focus takes us back to the pioneering work of Everett Rogers on diffusion of innovations.

There is one problem with this emphasis, however, as illustrated by the now classic studies of providing pets for nursing home residents: if the development, innovation, program or policy (e.g., presence of pets) cannot be maintained or sustained, the long-term impact may actually make the situation worse than it was prior to intervention.  We also know that sustainability does not just happen; it needs to be planned for from the beginning.

This issue of sustainability, how it is conceptualized and approached, and how sustainability interventions are implemented is the topic of this month’s editorial and the related Advanced Topics in IS Webinar to be held on July 23, 2:00-3:00pm ET The issues involved include, but are not limited to:

  1. Planning for sustainability from the outset:  Long-term sustainability – of either outcomes or resources/programs - needs to be planned for from the outset. One approach to facilitate such planning might be similar to the evaluability analyses used by the Robert Wood Johnson Foundation and championed by Laura Leviton and colleagues.  This approach might involve asking a series of questions related to the likelihood of sustainability prior to funding or initiation of programs intended to produce long-term benefits.
  2. Cost and resource issues: Often programs and policies, whether evidence-based or not, require levels of money, expertise, training and supervision, time commitments and other resources that are not possible to maintain once the initial funding for initiation/research/evaluation is withdrawn.  Potential adopting settings would be able to make more informed choices if a greater proportion of outcome studies and evaluations included standard, transparent reporting on the costs and resources required to deliver a program successfully.
  3. Conceptualization of sustainability.  Possibly the greatest challenge has to do with conceptualizations of sustainability.  Often sustainability is assumed to mean continued delivery of the same intervention components in the same perpetual way.  The numerous problems with this conceptualization and alternative, and more dynamic conceptualizations of sustainability as a process that has to evolve over time to fit changing context (both internal and external) is the subject of the July Advanced Topics in Implementation Science, which will be led by Dr. David Chambers, NIMH.

For those who cannot participate in the webinar, an archive will be made available right here on this discussion forum after the session.

As always, I appreciate your reactions and feedback on these thoughts. Please share your point of view on this and other D&I issues.




If you missed the webinar

If you missed the webinar with Dr. David Chambers on July 23, 2013 that Russ mentioned aboved, don't worry.  The recording of the session is available here.  Watch the video and share your thoughts on what Russ and David discuss. How do you design research interventions that can be sustained over time as funding and resources (and context) change?  What are your measures of sustainment?

Don't forget to join us for future webinars on Advanced Topics for Implmentation Science Research.  More information available at the NCI Implementation Science Team website.

Health Affairs recently

Health Affairs recently launched a new blog around “diffusion” – implementation and dissemination science, translational science, scale, spread, adoption, and other labels. In this Blog series, they "seek to encompass all aspects of the journey between development of a health care innovation and widespread adoption of change in the health care delivery system. As innovators and disseminators know, this path can be windy and even tortuous, with backtracks and sidetracks taken as learnings are accumulated. In the midst of all the variability, implementers are researching and developing a knowledge base for the process."

This series of blogs will continue over the next year and culminate in a theme issue of Health Affairs journal in February of 2018 on how innovations are diffused across the health care delivery system.

The series kicks off today with articles from two author groups — one led by Will Shrank, chief medical officer of UPMC Health Plan and former Director of Research and Rapid-Cycle Evaluation for the Center for Medicare & Medicaid Innovation, and one by Jeff Selberg, head of the Peterson Center on Healthcare and former COO of the Institute for Healthcare Improvement. In different ways, the posts address the need for speed in diffusion.