The Sustainment and Sustainability of Quality Improvement Initiatives for the Health Care of Older Adults

Quality Improvement (QI) is increasingly viewed as the vehicle of choice by health care organizations seeking to respond to the changing health care needs of an aging population while making efficient use of limited resources. However, evidence suggests that 40% to 60% of QI initiatives fail to achieve lasting improvements. Despite the potential waste this statistic represents, we have a limited understanding of factors which promote a QI intervention’s continued use in practice (sustainment) and the maintenance of its benefits (sustainability). Moreover, existing research has largely focused on large academic institutions in urban centres. As such, recommendations derived from these studies may not be appropriate for less-resourced, rural, or remote settings, where adaptations—planned changes to the intervention—may be needed to ensure its survival. The impact of such adaptations on QI sustainment or sustainability has not been studied. This thesis draws from a scoping review and subsequent artificial neural network analysis of empirical studies of the sustainment and sustainability of QI interventions for the health care of older adults to identify contextual, intervention and implementation factors which predict sustainment and sustainability. This model significantly predicted sustainability, but not sustainment. Omission of organization type, intervention target, or reported adaptations resulted in a significant loss of predictive power. To further investigate this result, I conducted a comparative case study to examine how the dynamic interaction between adaptations and organizational context impacts sustainment and sustainability. By comparing 3-year trajectories for elder care QI interventions implemented through participation in a quality improvement collaborative in a 375-bed academic hospital and a 56-bed remote hospital 2500 km away from its nearest referral centre, I found evidence that ongoing adaptations which are responsive to changes in organizational or environmental context (e.g. patient needs, government and local health authority supports) promote sustainment. In addition, adaptations that promote sustainment and are consistent with the core functions of a QI intervention contribute to the sustainability of QI. To close, I offer a new framework informed by organizational learning theory which will help contextualize adaptations’ impact on the people, tasks and/or tools of an intervention and its long-term sustainment and sustainability.

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.