Background
Background and rationale for the implementation and sustainment facilitation experiment
Rationale for the ISF Experiment’s EBP, outcomes, and strategies
Rationale for the targeted EBP
Rationale for the primary outcomes
Rationale for the strategies tested
The ISF Experiment’s Objective and Scientific Hypotheses
Hypotheses | |
---|---|
H1 | The positive relationship between the implementation and sustainment facilitation and staff time-to-proficiency will be moderated by |
H1a Staff’s motivational interviewing experience | |
H1b Staff’s personal recovery status | |
H1c Organization’s readiness for implementing change | |
H1d Organization’s implementation climate | |
H1e Organization’s leadership engagement | |
H1f Organization’s tension for change | |
H2 | The positive relationship between the implementation and sustainment facilitation and staff implementation effectiveness will be moderated by |
H2a Staff’s motivational interviewing experience | |
H2b Staff’s personal recovery status | |
H2c Organization’s readiness for implementing change | |
H2d Organization’s implementation climate | |
H2e Organization’s leadership engagement | |
H2f Organization’s tension for change | |
H3 | The positive relationship between the implementation and sustainment facilitation and staff level of sustainment will be moderated by |
H3a Staff’s motivational interviewing experience | |
H3b Staff’s personal recovery status | |
H3c Organization’s readiness for implementing change | |
H3d Organization’s implementation climate | |
H3e Organization’s leadership engagement | |
H3f Organization’s tension for change | |
H4 | Staff implementation effectiveness will mediate the relationship between staff time-to-proficiency and staff level of sustainment |
Methods
Participants, interventions, and outcomes
Study setting
Eligibility criteria
Intervention: preparation, implementation, and sustainment strategies
Discrete implementation strategies Defining characteristic according to Proctor et al. [41] | Operational definition of key dimensions for each discrete implementation strategy | ||||||
---|---|---|---|---|---|---|---|
Actor(s) | Actions(s) | Target(s) of the action | Temporality | Dose | Targeted implementation outcome(s) | Justification | |
A. Centralized technical assistance: Develop and use a system to deliver technical assistance focused on implementation issues | Regional ATTC (e.g., Mid-America, Northwest, Northeast) | The overarching discrete implementation strategy that encompasses the other discrete implementation strategies listed below | 2 BI staff per ASO | The initial kickoff meeting should be within 1 month of completing the exploration phase | Fidelity (i.e., proficiency and implementation effectiveness | ||
B. Develop educational materials: Develop and format guidelines, manuals, toolkits, and other supporting materials in ways that make it easier for stakeholders to learn about the innovation and for clinicians to learn how to deliver the clinical innovation | Regional ATTC | The Motivational Interviewing-Based Brief Intervention (MIBI) protocol manual, which provides information and knowledge about how the MIBI is intended to be implemented | 2 BI staff per ASO | Finalization of educational materials (e.g., MIBI protocol manual) should be prior to the initial kickoff meeting | Fidelity (i.e., proficiency and implementation effectiveness | ||
C. Develop and organize quality monitoring system:
Develop and organize systems and procedures that monitor clinical processes and/or outcomes for quality assurance and improvement | Regional ATTC | A Web-based system (sat2hivproject.org), that enables secure and efficient sharing of data relevant to the evidence-based practice (EBP) preparation and implementation process | 2 BI staff per ASO | Finalization of quality monitoring systems (i.e., sat2hivproject.org) should be prior to the initial kickoff meeting | Fidelity (i.e., proficiency and implementation effectiveness) | ||
D. Develop tools for quality monitoring: Develop, test, and introduce quality-monitoring tools with inputs (e.g., measures) specific to the innovation being implemented | Regional ATTC | The Independent Tape Rater Scale (ITRS), which enables reliable and valid rating of the extent to which BI staff deliver the EBP with fidelity | 2 BI staff per ASO | Finalization of tools for quality monitoring (i.e., ITRS) should be prior to the initial kickoff meeting | Fidelity (i.e., proficiency and implementation effectiveness) | ||
E. Distribute educational materials: Distribute educational materials (e.g., manuals) in person, by mail, and/or electronically. | Regional ATTC | Distribute professionally printed copies of the MIBI protocol manual to each BI staff | 2 BI staff per ASO | Distribute at the workshop training | Fidelity (i.e., proficiency and implementation effectiveness) | ||
F. Conduct educational meetings: Hold meetings targeted toward providers, administrators, other organizational stakeholders, and community, patient or consumer, and family stakeholders to teach them about the clinical innovation | Regional ATTC | In-person and Web-based meetings that enable direct interaction between the actors (ATTC) and targeted users of the EBP (BI staff) | 2 BI staff per ASO | Educational meetings should begin at least 3 months before the implementation phase begins | Fidelity (i.e., proficiency and implementation effectiveness) | ||
G. Make training dynamic: Vary the information delivery methods to cater to different learning styles and work contexts and shape the training in the innovation to be interactive | Regional ATTC | Incorporate standardized role plays that enable EBP trainees (BI staff) to practice with each other and that facilitate understanding of the EBP from both staff and client perspectives | 2 BI staff per ASO | Should begin during the first contact | Fidelity (i.e., proficiency and implementation effectiveness) | ||
H. Audit and provide feedback: Collect and summarize clinical performance data over a specified period, and give data to clinicians and administrators in the hopes of changing provider behavior. | Regional ATTC | Generate and email standardized feedback reports to EBP trainees (BI staff) using the standardized quality monitoring tool (ITRS) | 2 BI staff per ASO | Should begin approximately 1–2 weeks following the end of the in-person educational training workshop | Fidelity (i.e., proficiency and implementation effectiveness) | ||
I. Provide ongoing consultation: Provide clinicians with continued consultation with an expert in the clinical innovation | Regional ATTC | Phone-based individualized meetings that enable direct contact between the actor (ATTC trainer) and one EBP trainee (BI staff) | 2 BI staff per ASO | Should begin approximately 1–2 weeks following the end of the in-person educational training workshop | Fidelity (i.e., proficiency and implementation effectiveness) | ||
J. Create a learning collaborative: Develop and use groups of providers or provider organizations that will implement the clinical innovation and develop ways to learn from one another to foster better implementation | Regional ATTC | Web-based group meetings that enable direct contact between the actor (ATTC trainer) and a group (10–14 targeted users of the EBP, BI staff), who can share lessons learned | 2 BI staff per ASO | Should begin approximately 3–4 weeks after the implementation phase begins | Fidelity (i.e., proficiency and implementation effectiveness) |
Discrete implementation strategies: Defining characteristic according to Proctor et al. [41] | Operational definition of key dimensions for each discrete implementation strategy | ||||||
---|---|---|---|---|---|---|---|
Actor(s) | Actions(s) | Target(s) of the action | Temporality | Dose | Targeted implementation outcome(s) | Justification | |
K. Use an improvement and implementation advisor: Seek guidance from experts in implementation, including consultation with outside experts (e.g., university-affiliated faculty members, quality improvement experts, implementation professionals) | An individual with training and experience in assisting organizations with practice improvement and implementation efforts | The overarching implementation strategy that encompasses the other discrete implementation strategies listed below | An ASO’s designated staff working on the project (SWOP) team (2 BI staff and 2–4 leadership staff) Implementation readiness, implementation climate, leadership engagement | The initial kickoff meeting should be held within 1 month of completing the exploration phase | Fidelity (i.e., proficiency and implementation effectiveness) and sustainment | ||
L. Develop tools for quality improvement: Develop, test, and introduce quality-improvement tools with inputs (e.g., measures) specific to the innovation being implemented | An individual with training and experience in assisting organizations with practice improvement and implementation efforts | Decisional Balance Exercise; Performance Review, Evaluation, and Planning Exercise; Climate Evaluation and Optimization Exercise | SWOP team. Implementation readiness, implementation climate, leadership engagement | Finalization of tools for quality improvement (e.g., decisional balance worksheet) should be prior to the initial kickoff meeting | Fidelity (i.e., proficiency and implementation effectiveness) and sustainment | ||
M. Organize implementation team meetings: Develop and support teams of clinicians who are implementing the innovation and give them protected time to reflect on the implementation effort, share lessons learned, and support one another’s learning | An individual with training and experience in assisting organizations with practice improvement and implementation efforts | Meetings that enable direct interaction between the actors—implementation and sustainment facilitation (ISF) staff— and SWOP team | SWOP team. Implementation readiness, implementation climate, leadership engagement | First implementation team meeting should be held within 1 month of completing the exploration phase | Fidelity (i.e., proficiency and implementation effectiveness) and sustainment | ||
N. Identify and prepare champions: Cultivate relationships with people who will champion the clinical innovation and spread the word of the need for it | An individual with training and experience in assisting organizations with practice improvement and implementation efforts | Learning about and engaging with the SWOP team | SWOP team. Implementation readiness, implementation climate, leadership engagement | Identification and preparation of champions should begin during the process of organizing the initial implementation team meeting | fidelity (i.e., proficiency and implementation effectiveness) and sustainment | ||
O. Assess for readiness and identify barriers: Assess various aspects of an organization to determine its degree of readiness to implement, barriers that may impede implementation, and strengths that can be used in the implementation effort | An individual with training and experience in assisting organizations with practice improvement and implementation efforts | Utilization of the ISF exercises described above (L. Develop tools for quality improvement) | SWOP team. Implementation readiness, implementation climate, leadership engagement | Assessments of readiness and identification of barriers should begin during the process of organizing the initial implementation team meeting | Fidelity (i.e., proficiency and implementation effectiveness) and sustainment | ||
P. Conduct local consensus discussions: Include providers and other stakeholders in discussions that address whether the chosen problem is important and whether the clinical innovation to address it is appropriate | An individual with training and experience in assisting organizations with practice improvement and implementation efforts | Completion of an in-person, stakeholder-engagement and sustainment-planning meeting | SWOP team. Implementation readiness, implementation climate, leadership engagement | Should be held as soon as possible after the first implementation month has been completed | Fidelity (i.e., proficiency and implementation effectiveness) and Sustainment | ||
Q. Conduct cyclical small tests of change: Implement changes in a cyclical fashion using small tests of change | An individual with training and experience in assisting organizations with practice improvement and implementation efforts | Completion of study-act-plan-do cycles | SWOP team. Implementation readiness, implementation climate, leadership engagement | Should begin as soon as necessary | Fidelity (i.e., proficiency and implementation effectiveness) and sustainment |
Blended Strategy and the discrete strategies that it encompasses | Month 1 | Month 2 | Month 3 | ||||||
---|---|---|---|---|---|---|---|---|---|
Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | |
Addiction Technology Transfer Center (ATTC)
| |||||||||
A. Centralized technical assistance | As needed | NA | NA | As needed | NA | NA | As needed | NA | 5 h |
B. Develop educational materials | + | + | |||||||
C. Develop and organize quality monitoring systems | + | + | |||||||
D. Develop tools for quality monitoring | + | + | |||||||
E. Distribute educational materials | + | + | |||||||
F. Conduct educational meetings | + | + | |||||||
G. Make training dynamic | + | + | |||||||
H. Audit and Provide feedback | |||||||||
I. Provide ongoing consultation | |||||||||
J. Create a learning collaborative | |||||||||
Implementation and sustainment facilitation (ISF)
| |||||||||
K. Use an improvement and implementation advisor | As needed | NA | NA | As needed | As needed | As needed | 1 h | 1 h | 1 h |
L. Develop tools for quality improvement | + | ||||||||
M. Organize implementation team meetings | + | + | + | + | + | + | |||
N. Identify and prepare champions | + | + | + | + | + | + | |||
O. Assess for readiness and identify barriers | + | + | + | ||||||
P. Conduct local consensus discussions | |||||||||
Q. Conduct cyclical small tests of change |
Blended Strategy and the discrete strategies that it encompasses | Month 4 | Month 5 | Month 6 | ||||||
---|---|---|---|---|---|---|---|---|---|
Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | |
Addiction Technology Transfer Center (ATTC)
| |||||||||
A. Centralized technical assistance | 16 h | NA | 16 h | As needed | NA | 2–4 h | As needed | NA | 2–4 h |
B. Develop educational materials | |||||||||
C. Develop and organize quality monitoring systems | |||||||||
D. Develop tools for quality monitoring | |||||||||
E. Distribute educational materials | + | + | |||||||
F. Conduct educational meetings | + | + | |||||||
G. Make training dynamic | + | + | |||||||
H. Audit and Provide feedback | + | + | + | + | |||||
I. Provide ongoing consultation | + | + | + | + | |||||
J. Create a learning collaborative | |||||||||
Implementation and sustainment facilitation (ISF)
| |||||||||
K. Use an improvement and implementation advisor | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h |
L. Develop tools for quality improvement | |||||||||
M. Organize implementation team meetings | + | + | + | + | + | + | + | + | + |
N. Identify and prepare champions | + | + | + | + | + | + | + | + | + |
O. Assess for readiness and identify barriers | + | + | + | + | + | + | + | + | + |
P. Conduct local consensus discussions | |||||||||
Q. Conduct cyclical small tests of change |
Blended Strategy and the discrete strategies that it encompasses | Month 1 | Month 2 | Month 3 | ||||||
---|---|---|---|---|---|---|---|---|---|
Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | |
Addiction Technology Transfer Center (ATTC)
| |||||||||
A. Centralized technical assistance | As needed | NA | NA | As needed | NA | NA | As needed | NA | 5 h |
B. Develop educational materials | |||||||||
C. Develop and organize quality monitoring systems | |||||||||
D. Develop tools for quality monitoring | |||||||||
E. Distribute educational materials | |||||||||
F. Conduct educational meetings | |||||||||
G. Make training dynamic | |||||||||
H. Audit and Provide feedback | + | + | + | + | + | + | |||
I. Provide ongoing consultation | |||||||||
J. Create a learning collaborative | + | + | + | + | + | + | |||
Implementation and sustainment facilitation (ISF)
| |||||||||
K. Use an improvement and implementation advisor | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h |
L. Develop tools for quality improvement | |||||||||
M. Organize implementation team meetings | + | + | + | + | + | + | + | + | + |
N. Identify and prepare champions | + | + | + | + | + | + | + | + | + |
O. Assess for readiness and identify barriers | + | + | + | + | + | + | + | + | + |
P. Conduct local consensus discussions | + | + | + | ||||||
Q. Conduct cyclical small tests of change | + | + | + | + | + | + |
Blended Strategy and the discrete strategies that it encompasses | Month 4 | Month 5 | Month 6 | ||||||
---|---|---|---|---|---|---|---|---|---|
Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI Staff | Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | Training, coaching, or Facilitation Staff | ASO’s leadership Staff | ASO’s BI staff | |
Addiction Technology Transfer Center (ATTC)
| |||||||||
A. Centralized technical assistance | 16 h | NA | 16 h | As needed | NA | 2-4 h | As needed | NA | 2-4 h |
B. Develop educational materials | |||||||||
C. Develop and organize quality monitoring systems | |||||||||
D. Develop tools for quality monitoring | |||||||||
E. Distribute educational materials | |||||||||
F. Conduct educational meetings | |||||||||
G. Make training dynamic | |||||||||
H. Audit and Provide feedback | + | + | + | + | + | + | |||
I. Provide ongoing consultation | |||||||||
J. Create a learning collaborative | + | + | + | + | + | + | |||
Implementation and sustainment facilitation (ISF)
| |||||||||
K. Use an improvement and implementation advisor | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h` | 1 h |
L. Develop tools for quality improvement | |||||||||
M. Organize implementation team meetings | + | + | + | + | + | + | + | + | + |
N. Identify and prepare champions | + | + | + | + | + | + | + | + | + |
O. Assess for readiness and identify barriers | + | + | + | + | + | + | + | + | + |
P. Conduct local consensus discussions | |||||||||
Q. Conduct cyclical small tests of change | + | + | + | + | + | + | + | + | + |
Blended Strategy and the discrete strategies that it encompasses | Month 1 | Month 2 | Month 3 | ||||||
---|---|---|---|---|---|---|---|---|---|
Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | |
Addiction Technology Transfer Center (ATTC)
| |||||||||
A. Centralized technical assistance | NA | NA | NA | NA | NA | NA | NA | NA | NA |
B. Develop educational materials | |||||||||
C. Develop and organize quality monitoring systems | |||||||||
D. Develop tools for quality monitoring | |||||||||
E. Distribute educational materials | |||||||||
F. Conduct educational meetings | |||||||||
G. Make training dynamic | |||||||||
H. Audit and Provide feedback | |||||||||
I. Provide ongoing consultation | |||||||||
J. Create a learning collaborative | |||||||||
Implementation and sustainment facilitation (ISF)
| |||||||||
K. Use an improvement and implementation advisor | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h |
L. Develop tools for quality improvement | + | + | + | + | + | + | + | + | + |
M. Organize implementation team meetings | + | + | + | + | + | + | + | + | + |
N. Identify and prepare champions | + | + | + | + | + | + | + | + | + |
O. Assess for readiness and identify barriers | + | + | + | + | + | + | + | + | + |
P. Conduct local consensus discussions | + | + | + | + | + | + | + | + | + |
Q. Conduct cyclical small tests of change | + | + | + | + | + | + | + | + | + |
Blended strategy and the discrete strategies that it encompasses | Month 4 | Month 5 | Month 6 | ||||||
---|---|---|---|---|---|---|---|---|---|
Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’s BI staff | Training, coaching, or facilitation staff | ASO’s leadership staff | ASO’S BI staff | |
Addiction Technology Transfer Center (ATTC)
| |||||||||
A. Centralized technical assistance | NA | NA | NA | NA | NA | NA | NA | NA | NA |
B. Develop educational materials | |||||||||
C. Develop and organize quality monitoring systems | |||||||||
D. Develop tools for quality monitoring | |||||||||
E. Distribute educational materials | |||||||||
F. Conduct educational meetings | |||||||||
G. Make training dynamic | |||||||||
H. Audit and Provide feedback | |||||||||
I. Provide ongoing consultation | |||||||||
J. Create a learning collaborative | |||||||||
Implementation and sustainment facilitation (ISF)
| |||||||||
K. Use an improvement and implementation advisor | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h | 1 h |
L. Develop tools for quality improvement | + | + | + | + | + | + | + | + | + |
M. Organize implementation team meetings | + | + | + | + | + | + | + | + | + |
N. Identify and prepare champions | + | + | + | + | + | + | + | + | + |
O. Assess for readiness and identify barriers | + | + | + | + | + | + | + | + | + |
P. Conduct local consensus discussions | + | + | + | + | + | + | + | + | + |
Q. Conduct cyclical small tests of change | + | + | + | + | + | + | + | + | + |
Addiction Technology Transfer Center strategy
Implementation and sustainment facilitation strategy
Outcomes
Measurement instrument | Measurement instrument time points and procedures | |||||
---|---|---|---|---|---|---|
Staff survey #1 (t = month 0) | Preparation phase assessment (t = months 1–6) | Implementation phase assessment (t = months 7–12) | Staff survey #2 (t = month 13) | Staff survey #3 (t = month 19) | Measure name (purpose) Description | |
Independent Tape Rater Scale [26] | Xa
| Time to proficiency (preparation outcome) | ||||
Independent Tape Rater Scale [26] | Xb
| Implementation effectiveness [31] (implementation outcome) A continuous staff measure representing the sum of the standardized cumulative number of MIBIs delivered by BI staff (i.e., consistency) and the cumulative integrity score of their delivery of the MIBI (i.e., quality) | ||||
Staff survey | Xc
| Xc
| Xc
| Level of sustainment (sustainment outcome) A continuous staff measure (no specified range) that represents the number of MIBIs a BI staff self-reports having delivered during the past 6 months | ||
Staff survey | Xc
| Xc
| Xc
| Motivational Interviewing Experience (moderator variable) A staff measure indicating a BI staff’s perception of their motivational interviewing experience (0 = none, 1 = beginner, 2 = intermediate, 3 = advanced, 4 = expert) | ||
Staff survey | Xc
| Xc
| Xc
| Readiness for implementing change (moderator variable) A continuous organization measure (ranges from 1 to 5) that represents the organizational average of 6 items, each rated on a 5-point scale (1 = disagree, 2 = somewhat disagree, 3 = neither agree nor disagree, 4 = somewhat agree, 5 = agree) and adapted from Shea et al.’ readiness measure [106] | ||
Staff survey | Xc
| Xc
| Xc
| Implementation climate (moderator variable) A continuous organization measure (ranges from 1 to 5) that represents the organizational average of 6 items, each rated on a 5-point scale (1 = disagree, 2 = somewhat disagree, 3 = neither agree nor disagree, 4 = somewhat agree, 5 = agree) and adapted from Jacobs et al.’ implementation measure [107] | ||
Staff survey | Xc
| Xc
| Xc
| Leadership engagement (moderator variable) A continuous organization measure (ranges from 0 to 6) that represents the organizational average of 4 items, each rated on a 7-point scale (0 = not at all to 6 = highest extent possible) and developed for this study based on the leadership engagement construct described by Damschroder et al.—commitment, involvement, and accountability of leaders with the implementation [108] | ||
Staff Survey | Xc
| Xc
| Xc
| Tension for change (moderator variable) A continuous organization measure (ranges from 0 to 6) that represents the organizational average of 3 items, each rated on a 7-point scale (0 = not at all to 6 = highest extent possible) and developed for this study based on the tension for change construct described by Damscroder et al.—stakeholders’ shared perception of the extent to which a change is important, needed, and desired [108] |
Participant timeline
Sample size
Recruitment
Assignment of interventions
Allocation
Blinding (masking)
Data collection, management, and analysis
Data collection and management
Statistical methods
Monitoring
Data monitoring
Harms
Auditing
Ethics and dissemination
Research ethics approval
Protocol amendments
Consent
Confidentiality
Declaration of interests
Access to data
Ancillary and post-trial care
Dissemination policy
Discussion
Trial-relevant events that have occurred to date
Calendar year | Calendar month | Project year | Project month | Key project-relevant events |
---|---|---|---|---|
2014 | July | Year 1 | Month 1 | The grant received a $565,695 (16%) reduction in its total budget, which resulted in reducing the targeted number of participating organizations and dropping a specific aim on the cost-effectiveness of the ISF intervention |
August | Month 2 | |||
September | Month 3 | |||
October | Month 4 | |||
November | Month 5 | The Principal Investigator (Dr. Garner) moved from Chestnut Health Systems to RTI International The grant was relinquished to the National Institute on Drug Abuse (NIDA) | ||
December | Month 6 | |||
2015 | January | Month 7 | Cohort 1: Preparation phase initiated | |
February | Month 8 | The grant, minus the costs incurred during the first 5 months of the grant, was awarded to RTI International with Dr. Garner as the Principal Investigator | ||
March | Month 9 | |||
April | Month 10 | |||
May | Month 11 | |||
June | Month 12 | Cohort 1: Preparation phase completed | ||
July | Year 2 | Month 13 | Cohort 1: Implementation phase initiated The updated United States National HIV/AIDS Strategy was released | |
August | Month 14 | |||
September | Month 15 | |||
October | Month 16 | |||
November | Month 17 | |||
December | Month 18 | Cohort 1: Implementation phase completed | ||
2016 | January | Month 19 | Cohort 1: Sustainment phase initiated Cohort 2: Preparation phase initiated | |
February | Month 20 | |||
March | Month 21 | |||
April | Month 22 | |||
May | Month 23 | |||
June | Month 24 | Cohort 1: Sustainment phase completed Cohort 2: Preparation phase completed | ||
July | Year 3 | Month 25 | Cohort 2: Implementation phase initiated | |
August | Month 26 | |||
September | Month 27 | |||
October | Month 28 | |||
November | Month 29 | |||
December | Month 30 | Cohort 2: Implementation phase completed |