Finally, Phase VII refers to processes related to maintaining or sustaining an intervention in a practice setting (Burke & Gitlin, 2012). The steps involved in and the challenges of sustainability are yet unknown. However, interventions may need to be supported in different ways to ensure continued fidelity to its implementation. Effective strategies for sustaining interventions may be dependent upon the type of intervention and setting. There may be no single approach that works for all behavioral interventions. Hand washing is an example of a proven intervention that has been integrated into hospital and other clinical settings, yet requires continued reinforcement of its use to sustain this basic proven practice. Various strategies have been tested and are in use, including signage or placement of hand-washing equipment such as liquid dispensers in patient rooms (Mayer et al., 2011).
As already discussed, moving an intervention from Phase I to Phase VII is referred to as a forward translation, in which each phase moves an intervention along for its ultimate implementation in a practice setting. However, new evidence may emerge from embedding an intervention into a practice setting or with implementation and sustainability experience. Dramatic modifications may call for new testing of the intervention in a Phase III or Phase IV context (backward translation).
Advantage of the Elongated Pipeline
The advantage of the elongated pipeline is that it recognizes the long haul and complex set of activities required to move an intervention from development to evaluation to implementation. These latter elongated phases, however, need more careful delineation and will benefit from the knowledge gleaned from implementation science (see Chapter 19).
As shown in Figure 2.2, these seven phases can be further classified into four overlapping and interactive larger domains of activities: development (discovery, Phases I and II); evaluation (Phases III and IV); implementation (Phases V and VI); and sustainability (Phase VII). This larger grouping of activities has the advantage of recognizing the interconnectedness of each of these phases.