|ORIGINAL RESEARCH PAPER
|Year : 2013 | Volume
| Issue : 1 | Page : 32-38
Factors promoting sustainability of education innovations: A comparison of faculty perceptions and existing frameworks
Lawrence C Loh1, Stacey R Friedman2, William P Burdick3
1 Adjunct Lecturer, Departments of Global Health and Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
2 Associate Director, Evaluation and Planning, Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia, United States
3 Associate Vice President, for Education at FAIMER and Co-Director, FAIMER Institute; Clinical Professor of Emergency Medicine, Drexel University College of Medicine, Philadelphia, United States
|Date of Web Publication||31-May-2013|
Lawrence C Loh
Department of Global Health and Epidemiology, Dalla Lana School of Public Health, University of Toronto, 155 College St, Sixth Floor, Toronto, Ontario, M5T 3M7
Source of Support: This research project was supported in part by the Foundation for dvancement of International Medical Education and Research. However, the fi ndings and conclusions do not necessarily refl ect the opinions of this organization., Conflict of Interest: None
Introduction: Health professions education uses innovative projects to promote faculty development and institution change. Faculty perceptions of the factors that promote project sustainability affect how faculty conceptualize and implement their innovations, which influences whether and how they plan for sustainability. This paper compares educators' perceptions of factors that influence sustainability in innovative projects with factors identified in project sustainability literature, to identify areas of convergence and divergence. Methods: Using questionnaires, faculty development fellowship participants from Brazil and India shared their perceptions on factors influencing their project's sustainability. An analysis framework was developed from existing project sustainability literature; faculty responses were then coded through an iterative process. Results: Key sustainability themes identified by faculty included project-level factors related to project design, stakeholder support, monitoring and evaluation, and project outcomes. Identified context level factors were related to institutional and governmental support as well as self-motivation and peer support. Availability of resources and funding were identified as relevant at both the project and context levels. Project-level factors were more often cited than context-level factors as key to ensuring sustainability. Conclusions: Faculty development efforts in health professions education should employ strategies to target these themes in promoting innovation sustainability. These include preengagement with institutional leaders, alignment with public sector goals, strategic diffusion of information, project expansion and transferability, capacity building in monitoring and evaluation, and creation of a community of educators for information exchange and support.
Keywords: Developing countries, medical education, medical faculty, organizational innovation, program sustainability
|How to cite this article:|
Loh LC, Friedman SR, Burdick WP. Factors promoting sustainability of education innovations: A comparison of faculty perceptions and existing frameworks. Educ Health 2013;26:32-8
| Introduction|| |
Education innovation projects allow health professions educators to introduce new teaching and assessment methods,  revise curricula,  and create faculty development opportunities.  Faculty perceptions of factors promoting project sustainability affect how faculty conceptualize and implement their innovations, which influences whether and how they plan for sustainability.
Definitions of innovation, while varied, generally refer to introducing new products, processes, or services for the purpose of improvement. This may involve introducing ideas that are wholly new or new to a given environment.  Project sustainability, in turn, is crucial for achieving longer-term changes, along with sustained attention to the target issue and project diffusion and replication.  Simply defined, sustainability is "the ability of a project to maintain its operations, services and benefits during its projected life time." 
However, there are additional nuances to sustainability. Sustainability may not be the continuation of a project in its full original form; it may refer to partial or modified continuation, or expansion to other settings.  Operational definitions of sustainability include continuation of a project's beneficial outcomes; continuation of a project, perhaps modified, in an identifiable form; or the development of capacity (e.g., among community members) to continue to carry out project activities.  Related to this is the potential for "institutionalization" of a project by incorporating aspects of the project into routine organizational policies, practices, or processes.
Within health professions education, projects have been widely used for faculty development, and have also been noted as potential vehicles for institution change.  While the project management literature has examined factors supporting the sustainability of new methods, ideas, and products, , specific examination of factors influencing the sustainability of innovative projects in health professions education remains limited. ,
This paper presents a qualitative analysis of data collected from faculty in Brazil and India who are engaged in education innovation projects and have been asked to consider sustainability in their project planning. Their responses offer information-rich sources for faculty reflections on what factors educators believe will sustain their own innovative projects. We compare these perceptions with factors identified in project sustainability literature, to identify areas of convergence and divergence.
Improved understanding of educator perceptions of factors that support project sustainability in health professions education (and of factors identified in literature on sustainability that may be overlooked by faculty and their institutions) can inform faculty development around projects and better equip faculty, institutions and other project stakeholders for project success. Sustainability of innovations can also ensure a maximum return on investments in limited-resource settings.
By examining perceptions of faculty from Brazil and India, we also aimed to explore the role that national context might have in perceptions of sustainability, recognizing the notable differences in each nation's health and education context.
| Context|| |
Faculty and their projects exist in varied national and local contexts. We examined perceptions of faculty from Brazil and India. Brazil has a universal health care system and a strong central planning authority that oversees the development of national health professions curricula and continuous quality improvement in conjunction with input from various stakeholders in civil society and the public.  India also has a central planning authority, which faces challenges with over 300 medical schools,  of which a growing number are private. This poses challenges in student selection, standard setting, and faculty development. 
The Foundation for Advancement of International Medical Education and Research (FAIMER) includes education innovation projects as a key learning experience during its two-year part-time fellowships for health professions educators.  The FAIMER fellowship programs include on-site contact sessions combined with distance learning. There are currently six FAIMER fellowship programs, one international program with on-site sessions held in the United States, and five regional institutes (three in India, one in Brazil, and one in South Africa).
Central to the FAIMER fellowship application process is a proposal for an education innovation project. All proposals are reviewed for clarity, feasibility, and potential institutional impact. The selection process favors projects that demonstrate a link to improved community health, and requires all projects to have written support from Fellows' institutional leadership. Modules on leadership and management skills in FAIMER curriculum include content on sustaining change, and fellows are encouraged to think through their long-term project vision and what factors might support sustainability.
Fellows vary in prior experience and knowledge in the field of health professions education, but all are involved in leading their innovation projects. Projects vary in their area of focus, with common focus areas including education methods and models, curriculum revision and integration, student assessment, program evaluation and alignment of education with health care context, health systems, and population health needs. 
| Methods|| |
Fellows (N=169) starting the FAIMER programs in Brazil and India in 2008, 2009, and 2010 were asked to complete an online questionnaire at the end of their first year of the fellowship. Several open-ended questions asked about their perceptions of various aspects of the fellowship. To determine perceptions of project sustainability, we analyzed responses to one free-text response question which asked: "Do you think that your project will be sustained or expanded during the next three to five years? If yes, based on what evidence? If not, why not?" Questionnaires and responses were in English for the India fellowships and in Portuguese for the Brazil fellowship; responses were similarly obtained in those languages, with responses for the Brazil program translated to English prior to analysis. Ethics review for this program evaluation was obtained from the University of Pennsylvania Institutional Research Board (IRB).
An initial literature search was conducted for frameworks that describe factors in the sustainability of projects. PubMed, ERIC, and Google Scholar were keyword searched with the term "project sustainability" alone and with other keywords "education" and "educational." Resulting abstracts were hand searched for relevance in providing comprehensive frameworks of factors related to project sustainability. Google was also keyword searched with the keyword "project sustainability" for gray literature.
These searches yielded three theoretical frameworks, deemed relevant given their basis of underlying case studies, literature reviews, and original research in resource-limited settings. These included a United States Agency for International Development (USAID) framework, entitled "The Sustainability of Donor-Assisted Rural Water Supply Projects",  a United Nations Development Program (UNDP) framework for sustainability of international development projects  and a framework from the European Commission Directorate on Education (EC) focused on the sustainability of international higher education and vocational training cooperation projects. 
Our analysis framework developed from integrating and synthesizing all three reference frameworks. The European Commission framework was selected as the basis for organizing factors, as this provided a means to clearly differentiate between aspects internal (i.e., project-level) and external (i.e., context-level) to the project that could facilitate or impede project sustainability. The former refers to factors that are inherent to the project design and implementation, while context-level factors exist in the external environment surrounding a project. 
With this division as a basis, all three framework documents were reviewed to ascertain themes and criteria, which were then categorized, tabulated and integrated into a common framework. Duplications were removed or consolidated. A preliminary coding scheme was then developed based on this theoretical framework. Two of the authors engaged in independent coding of the exit survey data followed by joint discussion to iteratively apply and refine the preliminary coding scheme. Application of this framework to the data found that the main categories adequately captured the data, with the addition of a category for "Self-motivation and peer support."
Initial data review also resulted in creation of additional subcategories to capture specificity within main categories (e.g., within networks and partnerships, partnerships were further sub-categorized as being with governmental entities or other institutions). Once a comprehensive coding scheme was reached, the two authors proceeded, through independent review, to analyze all data, with joint discussion between them to resolve coding discrepancies.
| Results|| |
A total of 138 Fellows (82%) responded to the questionnaire item (71 from the Indian and 67 from the Brazil programs). Of these, seven of the Indian fellowship respondents were faculty from countries other than India (Bangladesh, Malaysia, Nepal, Oman, Saudi Arabia, and the United Arab Emirates) - these respondents were not included in the analysis. All Brazilian fellowship respondents were faculty in Brazil.
[Table 1] shows the resulting framework with categories and subcategories endorsed by more than one respondent in bold text. The text offers elaboration on findings in these categories, including quotes from respondents. Quoted responses from Brazilian faculty have been translated [Table 1].
|Table 1: Framework of factors infl uencing sustainability of projects in health professions education*|
Click here to view
Identified project-level factors were related to project design, stakeholder support, monitoring and evaluation, and project outcomes. Identified context level factors were related to institutional and governmental support as well as self-motivation and peer support. Availability of resources and funding was identified as an important consideration at both the project and context levels.
Nature of project's design and selected strategy
Comments about project design highlighted the importance of planning for project growth and sustainability. Respondents expressed that replication or expansion in additional departments at the same institution supports sustainability through widening of scope and potential longevity of impact.
"Project is sustainable and expandable. Other departments in my institute can take such type of projects and can evaluate assessment system in their own subjects. This will lead to overall evaluation of assessment system of MBBS curriculum which ultimately aimed to produce competent doctors to serve society."
Similarly, the designation of further initiatives, through more in-depth study of topic area or adaptation of processes for broader application, was also identified by respondents as project sustaining.
"Based on the 'process' that I could develop, I look forward to replicate the same to other topics to teach social determinants of health elements (in community medicine) to the medical undergraduates."
Other respondents explained that they have a longer-term vision for the project, suggesting the importance to sustainability of framing longer-term project goals and objectives
"A long-term goal of my project is to create the Permanent Forum Discussion of Health Care of Women, with the participation of institutions and entities."
In response to being asked for evidence of sustainability, some respondents described the technology used in projects, including teleconferencing facilities, Moodle, and course-based websites. Respondents noted the demand for and positive responses to their chosen technologies, although the connection between technology and sustainability was not explicitly described.
"This project prove[d] that teleconference is [an] effective teaching learning method. The same type of live interactive teleconference will be implemented for other programs developed by our school. The same program is very much in demand and students as well as authority want that it should be continued."
"The Moodle platform was incorporated in the [first and second year] programs and will be implemented this year to the [third year]. The students are committed to the project and the program board and the IES [Institute of Higher Education] support it."
Respondents expressed that sustainability would be enhanced if their projects met a specific, recurring need, or provided unique benefits to trainees or faculty. While some noted that their project had already demonstrated benefits others anticipated that their project will meet identified needs.
"The feedback obtained is encouraging [and] it has been proposed to be included in the curriculum."
"Feedback of students is need of the hour. It is an essential aspect of teaching process."
Respondents noted community involvement and support as related to sustainability, referring to communities both within and outside the academic institution. One respondent, for example, noted that sustainability was supported by "demand for training […] expressed by faculty and preceptors." When referring to involvement of external communities (e.g., health professionals working in the local community), responses focused on expansion and permanence of projects. For example, one respondent stated that the project would be sustainable because it had expanded to become a permanent program including health care professionals working with arterial hypertension and diabetes in the primary care system of an entire city.
Monitoring and evaluation strategies
Ongoing evaluation was seen as a tool to improve and expand the project by using data gathered about project processes and outcomes, including the needs and perspectives of students and other stakeholders, to inform project planning and demonstrate the need for the project. Respondents noted that improvements made based on evaluation would support sustainability.
"Improvement is necessary in all fields of life. So I can try to refine cases with rubrics, review it from time to time. Evaluate cases as well as PBL sessions to see the impact."
Fellows also expressed the potential for evaluation results to promote longer-term project goals.
"I believe that the demonstration of the inefficiency of care through the diagnosis offered by the project, coupled with service statistics may support the need for wider discussion on the topic."
A sense of project ownership and motivation among project stakeholders was identified as another key to maintaining projects. Common responses identified institutional leadership and other faculty as advisors and champions; these responses often went beyond citing supportive attitudes to noting the importance of supportive action and ownership.
"Other faculty in my department are also motivated and are likely to participate in any future work."
"To make it sustainable, ownership has to be transferred to the institution. I am trying for it. I had done the groundwork and sensitized the authority. I believe that it will happen in future."
Sustainability was seen to be related to a clearly defined project time schedule, with changes in activities depending on the readiness levels of project participants. Respondents noted the importance of clear timeframes and a sense of urgency during roll-out.
"I believe the project has a good chance if it sustains the urgency of deployment in the course of a faculty development program."
Capacity for securing adequate resources
The ability for the project to be self-sustaining - either through using its outputs to build more resources or capacity development with tools readily available - was identified as important to sustainability.
"The program can be self-sustained because […] the tools to implement it are available."
There were several project-level factors in the theoretical framework that did not emerge as themes in responses. These included operational factors related to effective project management and leadership, as well as the presence of long-term project champions (i.e., continuity of project staff over time). The nature of the population targeted by the intervention also was not identified by any of the responses.
Context level factors
Self-motivation and peer support
Both support from the FAIMER community and self-motivation were endorsed by respondents as factors promoting project sustainability.
"The project is sustainable and can also be expanded as I myself am motivated to continue the work."
"The scope of the project can be increased - for that to happen, networking with FAIMER people will be essential."
Support from institutions, integration with institution strategy, and improvement of institutional curriculum and programming were all mentioned contextual factors in favor of sustainability. The use of project findings by institutional leadership was also noted as important to project longevity.
"The institution is aware and has consented for the project work, which makes it even more sustainable and expandable."
"Already our university has constituted a body to explore the possibilities of implementing our findings."
Respondents expressed that government support via policies and programs that are aligned with their projects, including national curriculum planning and nationally run programs, promoted project sustainability. In particular, Brazilian faculty cited established programs and agreements.
"I note the agreements signed between the municipal health secretary and the IES in 2009."
"[My project] develops an activity already established in the program and planned in the DCN (national curricular guidelines)."
Respondents noted the value of confirmed funding for specific investments such as construction or equipment, and funding announcements tied to the operation of the project for a certain period of time. One respondent noted that approved five-year funding would ensure their innovation would be sustained, while another highlighted funding for the construction of a laboratory and procuring of equipment that would support their project in the long-term.
Several broad context factors were not mentioned by respondents as linked to sustainability. These include demographic factors, such as general population characteristics and population health indicators (e.g., aging, or a rise in non-communicable disease) and socio-cultural factors, including the media and other societal aspects of the culture, including but not limited to ethnic and language differences, religious divisions, intergroup relations, and the status of women.
Other broader factors not mentioned include the national economy (e.g., economic growth rate and employment opportunities), and the status of technology infrastructure and resources in the country, political factors, and donor factors.
Looking at the main categories of the framework, organizational support (namely, government support via policies and programs) figured more prominently in responses of fellows from Brazil than India; responses made reference to national curriculum planning in Brazil and nationally run programs. A few other factors were mentioned by respondents from Brazil but not India, including: timing (i.e., having a defined time schedule) and adequate financing.
| Discussion|| |
When asked what factors favor project sustainability, health professions educators engaged in implementing education innovations noted the importance of a project's design, development, and evaluation, and also noted stakeholder support and adequate resources. Less mentioned were more distal contextual factors such as national demographic, political, cultural, and economic influences. There was also no mention of donor factors such as the commitment and flexibility of donors, which may be explained by the fact that most respondents' projects did not rely on any donor funding.
Responses paralleled recent work by Scheirer and Dearing, published after completion of our data analysis, which identified factors influencing public health project sustainability.  The authors identified three types of factors: (1.) Characteristics of the intervention (i.e., project-level factors), (2.) Factors in the organization setting (i.e., context), and (3.) Factors in the community environment (i.e., context). They also note the importance of organizational capacity, adequate resources, relationships, and evidence for effectiveness.
In our study, emphasis by the respondents on project-level factors, such as design, technology, outcomes, community involvement, monitoring and evaluation strategies, ownership, and timing, reflects the importance of mentoring and guidance of faculty during project design, so that these factors are adequately considered. For example, faculty may be encouraged to broaden the mandate and structure of their projects, and in doing so, develop a more transferable project design that could be used in other departments. Similarly, training in monitoring and evaluation would permit fellows and their institutions to consider the needs of their stakeholders, and to continually review and redevelop their projects over time, leading to continuous improvement that would ensure the project remains relevant and viable over the long run.
Community participation through involvement of other faculty educators and students, integration with community needs, as well as support from related professional groups was also cited as an important factor. Leadership, group dynamics, consensus building, and change management may contribute to greater sustainability by emphasizing and enabling community engagement, and these are key elements of the FAIMER faculty development curriculum.
Likewise, faculty identified project expansion to other departments and settings as evidence for, and supportive of, a sustained trajectory. Propagation of a project idea or concept can promote sustainability, even if the originator of the innovation fails to maintain their initial efforts. This notion of momentum through diffusion to other units and institutions has implications for strategies related to communication of outcomes. Building a community of educators in a region that regularly communicates through a dedicated journal, listserv, or periodic conferences may support sustainability of projects.
Staffing and operational support were not identified as key factors for sustainability. Given fixed resources, many projects were likely designed so that they were not dependent on increased staffing. In addition, faculty may regularly operate without administrative support. Specific development priorities could include guiding faculty in project operations, specifically planning and management, as opportunities arise for additional staffing and operational management authority.
Institutional and public sector support were identified as affecting sustainability. As part of the fellowship application, FAIMER requires a letter indicating leadership support for the applicant's project, and this may be an important precondition to future institutional support. Such strategies to encourage leadership support of projects in their early stages may help to foster sustainability.
Public sector support is another critical sustainability factor. The prominence of governmental support in Brazilian faculty responses as compared with Indian faculty responses likely reflects the nature of educational curriculum planning and development in both countries. Brazil's centralized health planning authority has several national health initiatives as well as national curriculum standards developed; ,,, many of the responses made reference to existing programs under which their projects were incorporated. Conversely, Indian faculty were more likely to identify project-level factors as supporting sustainability - beyond institutions, very little emphasis was given to the role of government support in sustaining their individual projects. This likely reflects the more fragmented nature of the health professions education system in India, ,[ 24] which may raise questions for the need of greater advocacy for innovation in Indian government planning authorities. This same difference may explain why Brazilian and not Indian faculty noted the value of having a defined project time schedule and adequate financing, both of which are integral features of large-scale longitudinal government initiatives.
These health sciences faculty members did not identify context factors such as demographic, socio-cultural, and economic factors as connected to project sustainability. Donor factors, which arose from the initial frameworks reviewed,  were perhaps not mentioned by respondents as fellows are asked upon application to the fellowship to ensure they have adequate project resources, and therefore many of the projects are either self-initiatives or related to existing university or private donation funding. Social, economic, and political factors are more diffuse, but may play a significant, if indirect, role in sustainability of education projects. Adequate funding for higher education, robust accreditation systems, transparent promotion systems based on scholarly work in education as well as health sciences are all goals needing advocacy from a strong field of health sciences education and having implications for project sustainability.
Our study also encountered some limitations. As is usual with qualitative approaches, this was a purposive sample of educators engaged in innovations and encouraged to reflect on sustainability. They are thus rich sources of information to explore a topic for which there has been relatively little investigation, however, findings may not be generalizable. In addition, respondents were faculty in Brazilian and Indian contexts, and findings may be specific to these settings, though it can be assumed that some of the broader factors identified by faculty would still apply elsewhere. Future investigations can extend and verify these findings to continue to build our understanding of sustainability of health professions educators' projects.
| Conclusions|| |
Sustained innovations will see long-term benefits to the institution that could include improved curriculum and teaching, stronger research efforts, and greater student involvement. Furthermore, in contexts with limited educational resources, maximizing investments in educational innovations will require special attention to designing projects that will stand the test of time.
Faculty development efforts in should target certain key themes to enhance the sustainability of innovation projects through informing and reinforcing educator perceptions of what promotes sustainability. These themes include attention to desired outcomes, pre-engagement with institutional leaders, alignment with public sector goals, strategic diffusion of information to promote project expansion and transferability, capacity building in monitoring and evaluation techniques, and creation of a community of educators for information exchange, professional support, and advocacy.
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