The concept of sustainability and the use of outcome indicators. A case study to continue a successful health counselling intervention.

BACKGROUND: To ensure the continuation of a successful pilot programme, the change process and the concept of sustainability need to be elaborated. So far, there are different theories on organizational change and sustainability but its practical application stay far behind. OBJECTIVES: To test the practical application of a theory-based concept of sustainability and to assess the role of the change agent. A health counselling programme for high-risk cardiovascular patients, called Heartbeat 2, was used as a case study. METHODS: Outcome indicators were assessed based on the questions: Why should health counselling be sustained? How should this be done and by whom? How much needs to occur and by when? Data were derived from registrations, reports and focus group interviews. RESULTS: The results indicate a need for a linkage system in the final stages of change so that the programme is maintained. Limitations of the external change agent are described. The outcome indicators appeared to be an adequate operationalization to monitor sustainability. The change process leading up to sustainability appeared to be highly complex due to unpredictable and unforeseen external factors. CONCLUSIONS: Our concept of sustainability appeared to be an adequate tool for the change agent to assess the extent of sustainability. An external change agent has limited influence on the management's decision-making processes during the sustainability stage. As long as the context is changing, definite choices to sustain the innovative service of health counselling in hospitals will not be made, which inherently means an ongoing change process to sustainabilit