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Measuring Sustainability Within the Veterans Administration Mental Health System Redesign Initiative

Ford, James H. II PhD; Krahn, Dean MD; Wise, Meg PhD; Oliver, Karen Anderson PhD

doi: 10.1097/QMH.0b013e3182314b20
Original Articles

Objective: To examine how attributes affecting sustainability differ across Veterans Health Administration organizational components and by staff characteristics.

Subjects: Surveys of 870 change team members and 50 staff interviews within the Veterans Affairs' Mental Health System Redesign initiative.

Methods: A 1-way ANOVA with a Tukey post hoc test examined differences in sustainability by Veteran Integrated Service Networks, job classification, and tenure from staff survey data of the Sustainability Index. Qualitative interviews used an iterative process to identify “a priori” and “in vivo” themes. A simple stepwise linear regression explored predictors of sustainability.

Results: Sustainability differed across Veteran Integrated Service Networks and staff tenure. Job classification differences existed for the following: (1) benefits and credibility of the change and (2) staff involvement and attitudes toward change. Sustainability barriers were staff and institutional resistance and nonsupportive leadership. Facilitators were commitment to veterans, strong leadership, and use of quality improvement tools. Sustainability predictors were outcomes tracking, regular reporting, and use of Plan, Do, Study, Adjust cycles.

Conclusions: Creating homogeneous implementation and sustainability processes across a national health system is difficult. Despite the Veterans Affairs' best evidence-based implementation efforts, there was significant variance. Locally tailored interventions might better support sustainability than “one-size-fits-all” approaches. Further research is needed to understand how participation in a quality improvement collaborative affects sustainability.

Center for Health Enhancement System Studies (Drs Ford and Wise) and Department of Psychiatry (Dr Krahn), University of Wisconsin, and William S. Middleton Memorial Veterans Hospital (Drs Krahn and Oliver), Madison, Wisconsin.

Correspondence: James H. Ford II, PhD, Center for Health Enhancement System Studies, University of Wisconsin-Madison, 1513 University Ave, Madison, WI 53706 (

The authors are indebted to Anna Wheelock for her hard work and dedication to this study. They are grateful to JoAnn Kirchner, PhD, Director of the Mental Health QUERI, Little Rock, VAMC, and Mary Schonn, PhD, for their general assistance support. The authors thank Andrea Gianopoulos for her editorial assistance. They thank Mary Schonn, PhD, Transformation Lead, Improving Veterans Mental Health, for her comments on an earlier version of the manuscript. We also appreciate the many employees of the Veterans Administration who took the time to participate in this study.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

This material is based on the work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development Mental Health QUERI (RRP 09–161). Dr Ford's work was also supported in part by grant 5 R01 DA020832 from the National Institute of Drug Abuse.

The authors declare no conflict of interest.

©2011Lippincott Williams & Wilkins, Inc.