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After the pilot and a decision to adopt the evidence-based practice (EBP), the next step of the Iowa Model is to integrate and sustain the change. However, planning for successful sustainment begins early in the EBP process (Aarons et al., 2016; Moullin et al., 2020). By systematically following earlier steps in the Iowa Model, you create a strong foundation to integrate and sustain the EBP change (Iowa Model Collaborative, 2017). Plan for sustainability in more detail now. Shift the focus to implementation strategies for sustained use of the localized EBP protocol (see Figure 11.1) and build learning based on patient and clinician feedback found in the post-pilot evaluative data (Cullen, Hanrahan, et al., 2019; Cullen, Hanrahan, Steffen, et al., 2022; Fleiszer et al., 2016a; Fleuren et al., 2015). Progress thoughtfully, from adoption to sustained use, to avoid change fatigue that can hinder sustainability for this and future EBP work (Arsenault Knudsen et al., 2021; Flynn et al., 2019) and to ensure improvements for patients, clinicians, and the health system.


Implementation to Sustainability Phases

Integration involves the infusion, dissemination, and reinfusion of an innovation until it becomes routine and the norm for practice. Sustainability occurs when the following four criteria are met (Ament et al., 2017; Brownson, Colditz, et al., 2018; Cowie et al., 2020; Moore et al., 2017):

  1. The EBP change, clinical intervention, or program continues to be delivered.

  2. The individual behavior change (i.e., clinician practices, patient health behavior) is maintained over a defined period, usually 12 months or longer.

  3. The program and individual behavior change evolve, adapt, or are reinvented, when needed.

  4. The program continues to benefit individuals or systems.

After the initial pilot, use a systematic process to integrate the EBP into the routine work of the pilot area. Consider scale-up to expand the reach of effective EBP from one pilot setting to similar areas or populations or scale-out for adapting to new populations, delivery systems, or both (Aarons et al., 2017; Greenhalgh et al., 2017). Plan for proactive reinfusion involving renewed efforts to promote EBP integration.


Growing evidence in the sustainability literature supports steps outlined in the Iowa Model (Iowa Model Collaborative, 2017) as being helpful for sustaining EBP. Set the team up for successful sustainment by using a scholarly and systematic approach throughout the entire EBP process. Review each step in the Iowa Model to build upon existing strengths or identify areas the team should address (see Tool 11.1). The first step of the Iowa Model recognizes that triggering issues or opportunities may come from several sources. Notice that one of the triggers is clinician identification of the topic. In fact, ...

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