title: Identification of promising strategies to sustain improvements in hospital practice: a qualitative case study.
abstract: BACKGROUND
  A quality improvement collaborative is an intensive project involving a combination of implementation strategies applied in a limited "breakthrough" time window. After an implementation project, it is generally difficult to sustain its success. In the current study, sustainability was described as maintaining an implemented innovation and its benefits over a longer period of time after the implementation project has ended. The aim of the study was to explore potentially promising strategies for sustaining the Enhanced Recovery After Surgery (ERAS) programme in colonic surgery as perceived by professionals, three to six years after the hospital had successfully finished a quality improvement collaborative.
  
  
  METHODS
  A qualitative case study was performed to identify promising strategies to sustain key outcome variables related to the ERAS programme in terms of adherence, time needed for functional recovery and hospital length of stay (LOS), as achieved immediately after implementation. Ten hospitals were selected which had successfully implemented the ERAS programme in colonic surgery (2006-2009), with success defined as a median LOS of 6 days or less and protocol adherence rates above 70%. Fourteen semi-structured interviews were held with eighteen key participants of the care process three to six years after implementation, starting with the project leader in every hospital. The interviews started by confronting them with the level of sustained implementation results. A direct content analysis with an inductive coding approach was used to identify promising strategies. The mean duration of the interviews was 37 minutes (min 26 minutes - max 51 minutes).
  
  
  RESULTS
  The current study revealed strategies targeting professionals and the organisation. They comprised internal audit and feedback on outcomes, small-scale educational booster meetings, reminders, changing the physical structure of the organisation, changing the care process, making work agreements and delegating responsibility, and involving a coordinator. A multifaceted self-driven promising strategy was applied in most hospitals, and in most hospitals promising strategies were suggested to sustain the ERAS programme.
  
  
  CONCLUSIONS
  Joining a quality improvement collaborative may not be enough to achieve long-term normalisation of transformed care, and additional investments may be needed. The findings suggest that certain post-implementation strategies are valuable in sustaining implementation successes achieved after joining a quality improvement collaborative.
authors.affiliation: Department of Family Medicine, CAPHRI, Maastricht University Medical Centre, P.O. box 616, 6200, MD, Maastricht, The Netherlands. stephanie.ament@mumc.nl.|GROW, School for Oncology & Developmental Biology, Maastricht University Medical Centre, P.O. box 5800, 6202, AZ, Maastricht, The Netherlands. stephanie.ament@mumc.nl.|Department of Clinical Epidemiology and Medical Technology Assessment, KEMTA, Maastricht University Medical Centre, P.O. box 5800, 6202, AZ, Maastricht, the Netherlands. stephanie.ament@mumc.nl.
authors.forename: Stephanie M C
authors.initials: SM
authors.lastname: Ament
authors.affiliation: Department of Family Medicine, CAPHRI, Maastricht University Medical Centre, P.O. box 616, 6200, MD, Maastricht, The Netherlands. f.gillissen@mca.nl.|GROW, School for Oncology & Developmental Biology, Maastricht University Medical Centre, P.O. box 5800, 6202, AZ, Maastricht, The Netherlands. f.gillissen@mca.nl.|Department of Surgery, Medical Centre Alkmaar, P.O. box 501, 1800, AM, Alkmaar, The Netherlands. f.gillissen@mca.nl.|Department of Clinical Epidemiology and Medical Technology Assessment, KEMTA, Maastricht University Medical Centre, P.O. box 5800, 6202, AZ, Maastricht, the Netherlands. f.gillissen@mca.nl.
authors.forename: Freek
authors.initials: F
authors.lastname: Gillissen
authors.affiliation: Department of Family Medicine, CAPHRI, Maastricht University Medical Centre, P.O. box 616, 6200, MD, Maastricht, The Netherlands. albine.moser@zuyd.nl.|Faculty of Care & Nursing, Zuyd University, P.O. box 550, 6400, AN, Heerlen, The Netherlands. albine.moser@zuyd.nl.
authors.forename: Albine
authors.initials: A
authors.lastname: Moser
authors.affiliation: Department of Family Medicine, CAPHRI, Maastricht University Medical Centre, P.O. box 616, 6200, MD, Maastricht, The Netherlands. jose.maessen@mumc.nl.|Department of Patient & Integrated Care, Maastricht University Medical Centre, P.O. box 5800, 6202, AZ, Maastricht, The Netherlands. jose.maessen@mumc.nl.|Faculty of Care & Nursing, Zuyd University, P.O. box 550, 6400, AN, Heerlen, The Netherlands. jose.maessen@mumc.nl.
authors.forename: José M C
authors.initials: JM
authors.lastname: Maessen
authors.affiliation: Department of Family Medicine, CAPHRI, Maastricht University Medical Centre, P.O. box 616, 6200, MD, Maastricht, The Netherlands. c.dirksen@mumc.nl.|Department of Clinical Epidemiology and Medical Technology Assessment, KEMTA, Maastricht University Medical Centre, P.O. box 5800, 6202, AZ, Maastricht, the Netherlands. c.dirksen@mumc.nl.
authors.forename: Carmen D
authors.initials: CD
authors.lastname: Dirksen
authors.affiliation: GROW, School for Oncology & Developmental Biology, Maastricht University Medical Centre, P.O. box 5800, 6202, AZ, Maastricht, The Netherlands. mf.vonmeyenfeldt@maastrichtuniversity.nl.|Department of Surgery, Maastricht University Medical Centre, P.O. box 5800, 6202, AZ, Maastricht, The Netherlands. mf.vonmeyenfeldt@maastrichtuniversity.nl.
authors.forename: Maarten F
authors.initials: MF
authors.lastname: von Meyenfeldt
authors.affiliation: Department of Family Medicine, CAPHRI, Maastricht University Medical Centre, P.O. box 616, 6200, MD, Maastricht, The Netherlands. trudy.vanderweijden@maastrichtuniversity.nl.
authors.forename: Trudy
authors.initials: T
authors.lastname: van der Weijden
mesh_terms: D003299:Cooperative Behavior; D006761:Hospitals / Q000592:standards*; D006801:Humans; D007407:Interviews as Topic; D007902:Length of Stay; D008505:Medical Staff, Hospital / Q000523:psychology; D011182:Postoperative Care / Q000592:standards*; D036301:Qualitative Research; D058996:Quality Improvement; D020127:Recovery of Function