Chapter 11: Integrate and Sustain the Practice Change

INTRODUCTION

After the pilot and decision to integrate the practice change in the pilot area, additional work is needed to move from adoption to sustained use of the evidence-based practice (EBP) protocol. When instituting the practice change, the focus on implementation strategies shifts to pursuing integration and sustained use of the EBP change (see Figure 11.1) and learning from evaluative data (Cullen & Adams, 2012; Fleiszer, Semenic, Ritchie, Richer, & Denis, 2016a; Fleuren, van Dommelen, & Dunnink, 2015).

A number of implementation strategies will need to continue from earlier phases of implementation. The project team should review the clinician feedback about implementation strategies used during the pilot for this planning. Some strategies may be abandoned, some continued, and others added. Evidence to guide how to sustain practice change is still developing. However, a number of strategies have some evidence supporting continued use for sustainability (see Figure 11.2). This phase of implementation continues to require local leadership to coordinate practice improvements (Fleiszer et al., 2016a; Fleuren et al., 2015; Lowson et al., 2015; Nordqvist, Timpka, & Lindqvist, 2009) and continued participation by champions and point-of-care clinicians (Doyle et al., 2013; Fleiszer et al., 2016a; Ford, Krahn, Wise, & Oliver, 2011; Lowson et al., 2015; Wiltsey, Stirman et al., 2012). This is a time to promote peer influence (Hoke & Guarracino, 2016; Smith & Korenstein, 2015) but also continue to celebrate and recognize completed work (see Strategy 4-1). Progress toward this goal will be neither rapid nor smooth. Senior leaders need to provide visible support that acknowledges the value of the improvement to patient care (Fleiszer et al., 2016a; Ford et al., 2011) and sets the standard for using the EBP process.

Strategies for implementing practice innovations may need to be paired with strategies for removing old habits, including building teams with competing biases, emphasizing evidence over opinion, resisting extending evidence-based changes to unproven areas or populations, and encouraging clinicians to examine biases in their interpretation of evidence (Hanrahan et al., 2015; Ubel & Asch, 2015).

Resistance to change or psychological biases make it difficult for clinicians to let go of outdated practices. Work on implementation continues, and now is an important time to consider de-implementation. Often new EBP practices being implemented will change practice procedures. Sometimes science updates indicate practices need to be abandoned altogether (Nevin et al., 2015; Prasad & Ioannidis, 2014). Implementation and sustainment for practice recommendation reversal or abandonment may create new challenges for de-implementation of old practices (Hanrahan et ...