The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change

Abstract

Background: Despite growth in implementation research, limited scientific attention has focused on understanding and improving sustainability of health interventions. Models of sustainability have been evolving to reflect challenges in the fit between intervention and context.

Discussion: We examine the development of concepts of sustainability, and respond to two frequent assumptions -'voltage drop,' whereby interventions are expected to yield lower benefits as they move from efficacy to effectiveness to implementation and sustainability, and 'program drift,' whereby deviation from manualized protocols is assumed to decrease benefit. We posit that these assumptions limit opportunities to improve care, and instead argue for understanding the changing context of healthcare to continuously refine and improve interventions as they are sustained. Sustainability has evolved from being considered as the endgame of a translational research process to a suggested 'adaptation phase' that integrates and institutionalizes interventions within local organizational and cultural contexts. These recent approaches locate sustainability in the implementation phase of knowledge transfer, but still do not address intervention improvement as a central theme. We propose a Dynamic Sustainability Framework that involves: continued learning and problem solving, ongoing adaptation of interventions with a primary focus on fit between interventions and multi-level contexts, and expectations for ongoing improvement as opposed to diminishing outcomes over time.

Summary: A Dynamic Sustainability Framework provides a foundation for research, policy and practice that supports development and testing of falsifiable hypotheses and continued learning to advance the implementation, transportability and impact of health services research.

Figure 1

Program drift and voltage drop. Illustrating the concepts of 'program drift,’ in which the expected effect of an intervention is presumed to decrease over time as practitioners adapt the delivery of the intervention (A), and 'voltage drop,’ in which the effect of an intervention is presumed to decrease as testing moves from Efficacy to Effectiveness to Dissemination and Implementation (D&I) research stages (B).

Figure 2

The dynamic sustainability framework. Illustrating the goal of maximizing the fit between interventions, practice settings, and the broader ecological system over time (represented by T_0, T_1,…,T_n), each of which has constituent components that may vary.

Figure 3

Using the dynamic sustainability framework as an engine for quality improvement. The DSF depicts a dynamic view of sustainability, which allows for the evolution of an intervention within a changing delivery system. The changes in the shape of the puzzle pieces and of the contexts reflects the ongoing change to interventions, practice settings, and care systems, and shows the use of quality improvement methods to optimize the 'fit’ and improve the public health benefit of sustained use of interventions.