BACKGROUND/RATIONALE:
Change that is not sustained is a direct waste of resources expended in the change process and also has important indirect costs related to missed opportunities and damage to an organization's ability to implement change in the future. In 2008, VA Mental Health Service Lines at the clinic, facility, and VISN levels embarked on an ambitious effort of system redesign (SR). With the help of special, centrally-directed funding for the support of IHI-based, state-of-the-art change implementation techniques, well over one hundred SR projects aimed at a variety of worthy MH goals have been implemented. However, it was less clear how the sustainability of these SR ventures was being measured or supported over time. The project directly addressed a number of related implementation and clinical goals of the MH QUERI Strategic Plan.

OBJECTIVE(S):
Our research project was designed to examine the issue of sustainability as it relates to the VA Mental Health Systems Redesign initiative. The project had three specific objectives:
1) Describe the array of SR projects and their outcome measures that had been started in the first phase of the MHSR Project.
2) Use the 10 item British National Health Service Sustainability Index (SI) of Maher, Gustafson, and Evans (Maher et al, 2004) to:
(a) describe the variability in sustainability factors across VISNs and facilities;
(b) describe the predictors of sustainability index scores for the various projects; and
(c) predict outcome measures and their sustainability for individual projects. The model posits that sustained change is related to ten metrics that can be group as Process, Organization, and Staff factors, which are included in the sustainability index (SI); and
3) Interview a random sample of SR team members, including VISN 2 and 12 leadership, facility-level leadership, and clinical and administrative staff to better understand the factors that facilitate and impede change and sustainability.

METHODS:
This mixed methods approach using: (1) project and systems data, (2) survey data of the Sustainability Index, and (3) qualitative data from interviews of VISN 2 and 12 staff, identified facilitators and barriers to sustaining change in VA. This work tested the use of the SI to indicate need for interventions to improve sustainability that can provide a foundation for studies in both MH and non-MH VA change projects.

FINDINGS/RESULTS:
1)The MH SR Project resulted in a wide variety of efforts. Many were aimed at access but others addressed additional topics including inpatient and residential flow, and implementing evidence based practices.
2)While the MHSR Project aimed at a homogeneous model for change, the participation of leadership and team members in learning collaboratives and coaching was variable. Also highly variable was the sustainability index outcomes signaling significant heterogeneity across VISNs and facilities in their approach to implementation and sustainability of change.
3)The differences across types of employees and their response to the SI reflects the possibility that different approaches are needed for supporting change in different employee groups.
4)Larger studies are needed to show that the sustainability index will predict outcomes in VA.
5)The variance across VISNs and facilities in the total score and sub-scores of the SI suggests an opportunity for intervention and improvement. The British National Health Service uses the index to select appropriate interventions tailored to the problems faced by a given facility or VISN. A study of this approach to helping facilities having problems with change is warranted.

IMPACT:
This mixed methods approach using: (1) project and systems data, (2) survey data of the Sustainability Index, and (3) qualitative data from interviews of VISN 2 and 12 staff, identified facilitators and barriers to sustaining change in VA. This work tested the use of the SI to indicate need for interventions to improve sustainability that can provide a foundation for studies in both MH and non-MH VA change projects.

The degree of heterogeneity found in projects mostly aimed at relatively "simple" (albeit important) measures like access makes the study of sustainability in a more complex project such as mental health integration or the PACT program necessary and inviting. It seems likely that the variables measured by the sustainability index will be even more critical in these situations and we are embarking on a pilot study of that at this time after consulting with Dr. Kirchner.

VA leadership should consider use of sustainability measures in all future VA projects involving performance improvement-including but not limited to the Sustainability Index tested in this study. Sustainability is the last "S" in the VATAMMCS change model but more efforts are necessary to define how the VA will measure and define sustainability. This study, as well as including measures in future studies could make progress in this direction. This work could also contribute to the design of a model of sustainability to be used in future teaching of the VATAMMCS model.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Ford JH, Krahn D, Oliver KA, Kirchner J. Sustainability in primary care and Mental Health Integration projects in Veterans Health Administration. Quality management in health care. 2012 Oct 1; 21(4):240-51. [view]

Conference Presentations

1. Ford J, Krahn DD, Wise M, Oliver K, Wheelock A. Measuring and Improving Sustainability in Mental Health (MH) System Redesign within the Veterans Administration. Paper presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: none
Keywords: Mental health care delivery, Organizational issues, Quality assurance, improvement
MeSH Terms: none