Relational factors that impact EBI sustainability
Support from clinic champions increases a clinic’s ability to implement needed EBIs[[260, 262, 314]] and boosts leadership support for CRC screening.[[258]] There is a small reinforcing loop (R1), as strong leadership support gives credibility to screening champions by backing their efforts.[[369]] Maintaining leadership support also strengthens partnerships, increasing the long-term sustainability of EBIs.[[178]]
Reinforcing loop 2 (R2) occurs because sustainable EBIs require ongoing partnerships. Team-based care structures further impact EBI sustainability by minimizing momentum loss from staff turnover[[111, 411]] and increasing a clinic’s ability to implement EBIs.[[259, 364]] Partnerships and leadership support are crucial for successful EBI implementation.[[118, 2]]
Increasing funding stability enhances leadership support for CRC screening, as available funding simplifies prioritizing EBI implementation. Stable funding also directly boosts EBI sustainability,[[153, 155]] improving the clinic’s ability to address CRC screening barriers.[[139, 153, 245]]
Cited references for this diagram
Third, support from clinic leadership is essential for continuing CRC screening promotion efforts and exploring innovative solutions to emergent challenges, especially when faced with limited clinic resources and staff capacity.[[42, 59]]
Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health. 2023 Feb;48(1):113-126. doi: 10.1007/s10900-022-01154-9. Epub 2022 Oct 29. PMID: 36308666; PMCID: PMC9617236.
The other most commonly given reasons for stopping specific EBIs included limited staff time or staff turnover and the desire to implement other EBIs (and not being able to implement all EBIs at one time).
Hannon PA, Maxwell AE, Escoffery C, Vu T, Kohn MJ, Gressard L, Dillon-Sumner L, Mason C, DeGroff A. Adoption and Implementation of Evidence-Based Colorectal Cancer Screening Interventions Among Cancer Control Program Grantees, 2009-2015. Prev Chronic Dis. 2019 Oct 10;16:E139. doi: 10.5888/pcd16.180682. PMID: 31603404; PMCID: PMC6795067.
Across EBIs, many grantees mentioned successful partnerships as key facilitators to implementation. In many cases, grantees’ partners led implementation activities; in others, they provided connections, materials, or staff time.
Hannon PA, Maxwell AE, Escoffery C, Vu T, Kohn MJ, Gressard L, Dillon-Sumner L, Mason C, DeGroff A. Adoption and Implementation of Evidence-Based Colorectal Cancer Screening Interventions Among Cancer Control Program Grantees, 2009-2015. Prev Chronic Dis. 2019 Oct 10;16:E139. doi: 10.5888/pcd16.180682. PMID: 31603404; PMCID: PMC6795067.
Implementation readiness — an organization’s combined capacity, commitment, and willingness to implement a new program, policy, or practice — facilitates implementation success.[[16–18]] Because public health resources are limited, identifying a clinic’s readiness to successfully implement and sustain interventions, as well as gaps in clinic resources or practices that need to be addressed before implementation, is critical. Such assessment practices can guide clinics to select interventions with the greatest potential for long-term sustainability, and in turn help maximize the impact of public health spending, optimize clinic success, reduce cancer disparities, and improve population health.
Hohl SD, Melillo S, Vu TT, Escoffery C, DeGroff A, Schlueter D, Ross LW, Maxwell AE, Sharma KP, Boehm J, Joseph D, Hannon PA. Development of a Field Guide for Assessing Readiness to Implement Evidence-Based Cancer Screening Interventions in Primary Care Clinics. Prev Chronic Dis. 2022 May 12;19:E25. doi: 10.5888/pcd19.210395. PMID: 35550244; PMCID: PMC9109642.
Only 58% of clinics reported having good leadership support to maintain implementation of CRC screening EBIs, including mailed fecal testing. Fewer clinics reported having funding stability, organizational capacity, or the ability to adapt practices to ensure sustainability of EBI implementation. Although the CRCCP and other programs are designed with sustainability as a long-term goal, sustainability is an on-going challenge in clinics with limited resources and changing priorities that are reflected in budget changes.
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
Over half of clinics (58%) reported having leadership support to a great/very great extent to sustain the implementation of EBIs after the CRCCP screening initiative ends, but only 29% reported having a great/very great extent of funding stability in place to do so (Table 7).
Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci. 2024 Apr;25(Suppl 1):124-135. doi: 10.1007/s11121-023-01496-3. Epub 2023 Mar 23. PMID: 36952143; PMCID: PMC10034905.
Unexpectedly, implementation of EBIs did not become easier over time, possibly because of the need to build and sustain partnerships over time with health care providers and organizations.
Joseph DA, DeGroff A. The CDC Colorectal Cancer Control Program, 2009-2015. Prev Chronic Dis. 2019 Dec 5;16:E159. doi: 10.5888/pcd16.190336. PMID: 31808418; PMCID: PMC6896829.
Given the limited nature of public health funding cycles, it is critical that health systems change efforts not only work to achieve population health outcomes but also dedicate time and resources to integrating effective strategies for increased likelihood of long-term sustainability. Integrating EBIs and SAs into existing FQHC processes proved essential to CRCCP sustainability.
Schlueter D, DeGroff A, Soloe C, Arena L, Melillo S, Tangka F, Hoover S, Subramanian S. Factors That Support Sustainability of Health Systems Change to Increase Colorectal Cancer Screening in Primary Care Clinics: A Longitudinal Qualitative Study. Health Promot Pract. 2023 Jul;24(4):755-763. doi: 10.1177/15248399221091999. Epub 2022 May 18. PMID: 35582930; PMCID: PMC9672135.
Respondents stated that adopting a team-based approach to care facilitated sustainability by safeguarding FQHCs from losing momentum when staff turnover and fostering shared commitment to CRC screening.
Schlueter D, DeGroff A, Soloe C, Arena L, Melillo S, Tangka F, Hoover S, Subramanian S. Factors That Support Sustainability of Health Systems Change to Increase Colorectal Cancer Screening in Primary Care Clinics: A Longitudinal Qualitative Study. Health Promot Pract. 2023 Jul;24(4):755-763. doi: 10.1177/15248399221091999. Epub 2022 May 18. PMID: 35582930; PMCID: PMC9672135.
Clear, visible leadership support helped facilitate sustainability by enabling institutionalization of EBIs and SAs within FQHCs. Champions leveraged external policies/reporting requirements (e.g., Health Resources and Services Administration Uniform Data System CRC screening performance measure) to make the case for sustained implementation of EBIs/SAs to upper levels of clinic administration.
Schlueter D, DeGroff A, Soloe C, Arena L, Melillo S, Tangka F, Hoover S, Subramanian S. Factors That Support Sustainability of Health Systems Change to Increase Colorectal Cancer Screening in Primary Care Clinics: A Longitudinal Qualitative Study. Health Promot Pract. 2023 Jul;24(4):755-763. doi: 10.1177/15248399221091999. Epub 2022 May 18. PMID: 35582930; PMCID: PMC9672135.
Respondents in this study largely discussed the utility of integration within existing team-based care structures. Clinics without team-based structures in place prior to implementing a CRC health systems change effort may require additional support as they adjust to providing integrated services.
Schlueter D, DeGroff A, Soloe C, Arena L, Melillo S, Tangka F, Hoover S, Subramanian S. Factors That Support Sustainability of Health Systems Change to Increase Colorectal Cancer Screening in Primary Care Clinics: A Longitudinal Qualitative Study. Health Promot Pract. 2023 Jul;24(4):755-763. doi: 10.1177/15248399221091999. Epub 2022 May 18. PMID: 35582930; PMCID: PMC9672135.
Respondents described aspects of FQHC communication and culture that bolstered early implementation, including the importance of identifying champions from varied roles (e.g., QI expert, physician) during FQHC recruitment or early implementation who could help prioritize CRC screening within FQHCs.
Schlueter D, DeGroff A, Soloe C, Arena L, Melillo S, Tangka F, Hoover S, Subramanian S. Factors That Support Sustainability of Health Systems Change to Increase Colorectal Cancer Screening in Primary Care Clinics: A Longitudinal Qualitative Study. Health Promot Pract. 2023 Jul;24(4):755-763. doi: 10.1177/15248399221091999. Epub 2022 May 18. PMID: 35582930; PMCID: PMC9672135.
Whether champions served in leadership or other FQHC staff roles, their ongoing promotion of EBIs and SAs, and clear and consistent leadership support, was paramount to prioritize these efforts. CRC screening champions have been associated with increased CRC screening rates and higher overall clinic performance.
Schlueter D, DeGroff A, Soloe C, Arena L, Melillo S, Tangka F, Hoover S, Subramanian S. Factors That Support Sustainability of Health Systems Change to Increase Colorectal Cancer Screening in Primary Care Clinics: A Longitudinal Qualitative Study. Health Promot Pract. 2023 Jul;24(4):755-763. doi: 10.1177/15248399221091999. Epub 2022 May 18. PMID: 35582930; PMCID: PMC9672135.
Clinic champions, also found to be more common in Q4 clinics, can play an important role in facilitating EBI implementation.
Sharma KP, Leadbetter S, DeGroff A. Characterizing clinics with differential changes in the screening rate in the Colorectal Cancer Control Program of the Centers for Disease Control and Prevention. Cancer. 2021 Apr 1;127(7):1049-1056. doi: 10.1002/cncr.33325. Epub 2020 Dec 10. PMID: 33301173; PMCID: PMC9242539.
At the clinic level, a team-based approach was found to support staff ability to integrate implementation of EBIs and supporting activities to promote CRC screening with other patient care activities.
Soloe C, Arena L, Schlueter D, Melillo S, DeGroff A, Tangka F, Hoover S, Subramanian S. Factors that support readiness to implement integrated evidence-based practice to increase cancer screening. Implement Sci Commun. 2022 Oct 6;3(1):106. doi: 10.1186/s43058-022-00347-6. PMID: 36199117; PMCID: PMC9535984.
Finally, leaders’ expectations for integrated implementation can set the tone for clinic staff, creating a culture of readiness for the uptake of integration. For example, leadership support of CRC screening champions, individuals serving as internal advocates for screening, can help add credibility to champion activities.
Soloe C, Arena L, Schlueter D, Melillo S, DeGroff A, Tangka F, Hoover S, Subramanian S. Factors that support readiness to implement integrated evidence-based practice to increase cancer screening. Implement Sci Commun. 2022 Oct 6;3(1):106. doi: 10.1186/s43058-022-00347-6. PMID: 36199117; PMCID: PMC9535984.
Third, staff turnover was seen as a major barrier to both implementation success and sustainability. The burden consists of the need to train new staff, the loss of institutional knowledge, and the need to rebuild informal communication channels that are often required for coordination of multilevel interventions and supporting activities.
Subramanian S, Tangka FKL, Hoover S, DeGroff A. Integrated interventions and supporting activities to increase uptake of multiple cancer screenings: conceptual framework, determinants of implementation success, measurement challenges, and research priorities. Implement Sci Commun. 2022 Oct 5;3(1):105. doi: 10.1186/s43058-022-00353-8. PMID: 36199098; PMCID: PMC9532830.
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