We will use a stakeholder-driven process called evidence-based quality improvement (EBQI) [3739, 6366] to ensure that our sustainability strategy reflects cultural needs and preferences. EBQI has been used frequently to develop strategies and adapt interventions in primary care, outpatient care, and pharmacy practice [38, 64, 67, 68]. Consistent with the DSF [40], we expect that engaging stakeholders will contribute to the most effective strategies. EBQI panels will operate according to principles of community-based participatory research [69] and best-practices for engaging stakeholders in implementation [70]. Childcare directors and educators will contribute the local knowledge needed to select and tailor strategies; the research team will provide expertise on implementation approaches.

The EBQI process will (1) leverage strategies that worked for high sustainability sites from aim 1, (2) prioritize barriers and facilitators to sustainability reported from sites and external stakeholders from aim 1, (3) identify theoretically informed sustainability strategies that match priorities/needs, and (4) tailor sustainability strategies to the early childhood context. The EBQI panel will include 8 to 12 stakeholders combining FF and WISE users, and the diversity of the panel will reflect the diversity of the target populations.

EBQI is a flexible process conducted across a series of meetings with topic-driven agendas; each session will last 2 h. In EBQI session 1, the research team will present a summary of aim 1 findings, conduct a “member checking” exercise to assess validity of the findings, reach consensus on prioritized barriers and facilitators to inform the sustainment strategies, and vet sustainment strategies identified in aim 1. In session 2, we will present potential sustainment strategies mapped by the research team to the ERIC [42] taxonomy of implementation strategies, incorporating knowledge on strategies that worked in high sustainability sites and predictors of sustainability (from aim 1). To reach a consensus on sustainment strategies, we will use techniques outlined by Powell et al. [71], including concept mapping with virtual polling. This method provides quantifiable information and promotes the efficient collection of input in real time. Our existing relationships with Extension offices and regional medical facilities will facilitate virtual meetings in all counties. In session 3, we will present the draft strategies/tools, collect feedback for revisions, and receive final approval. In sessions 4 and 5, we will present our plan for a future pilot test of the sustainability strategy to assess acceptability and adoption. Stakeholders will receive $50 per session. By applying the EBQI process to the study of sustainability rather than implementation, our findings may be broadly applicable to the field of implementation science.

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