Table 2 TNP Sustainment Themes & Theme Definitions

Program outcomes that address leadership priorities are necessary for sustainment

Leadership is interested in outcomes that illustrate a cost benefit and outcomes that address shortcomings on VA metrics on which facilities are graded.

“You know, every, like every other hospital in the VA system, the VA, our VA here, our mission statement seems to wax and wane with what’s on the, whatever the issues are of the day with the SAIL report, so when we first started applying for this program, then there were issues with the readmission rate, specifically with certain different special diagnoses and then that transformed into issues with the mortality data, both the 30-day and the in-house mortality.” (site champion).

Local perceptions of the need for TNP or redundancy of TNP impacted perceived sustainability

Some facilities felt they already had services in place that overlapped with the TNP, making the TNP less impactful.

“It’s very duplicative here […] We are fortunate to have a number of RN coordinators. We have inpatient pharmacists that help with discharge meds, we have PACT nurses that call patients after discharge, we had ortho nurses calling patients after discharge, and so in this setting, this role was quite duplicative and so that was one of our challenges of trying to better understand how we could make it a meaningful intervention, still fulfilling the protocol and not stepping on other providers’ toes..”(Transitions Nurse).

Lack of leadership buy-in, changing leadership priorities, and leadership turnover were perceived barriers to sustainment

In the VA, leadership buy-in in necessary to push facility programs forward. With competing facility priorities, TNP sustainment was not seen as imment at some facilties. When new leardership came on they had to be made aware of TNP and new relationships needed to be develop to create buy-in.

“Well, I think you certainly have to engage your executive leadership, and I think the most bang for the buck is with your nurse executive because if you get that person that’s a champion for your program, you’re gonna have a lot more chance for success I think when the time comes for budgetary decisions to be made”(site champion).