Tijn Kool, MD PhD, is Full Professor Appropriate Care at the Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands. Andrea M. Patey, PhD, is Senior Research Associate in the Centre for Implementation Research in the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada. Simone van Dulmen, PhD, is Senior Researcher in Appropriate and Sustainable Healthcare at the Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands. Jeremy M. Grimshaw, MBChB, PhD, Senior Scientist in the Centre for Implementation Research in the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada.

• Preface xChapter 1 Why Should We Reduce Medical Overuse? 1Karen Born and Wendy LevinsonIt Started with Quality Improvement 1Then Came a Focus on Overuse 3Overuse as a Global Healthcare Quality Concern 5What Can Be Done to Address Overuse? 6Choosing Wisely 7What Can you Expect in the Following Chapters? 9References 10Chapter 2 Why Does Overuse Exist? 13Tijn Kool, Simone van Dulmen, Andrea M. Patey, and Jeremy M. GrimshawA Multifactorial Challenge on Different Levels 13Healthcare Professional Factors 14Patient Factors 15Preference for Acquiring Something 16Clinical Care Context Factors 16Absence of an Open Culture 17Absence of Clear Leadership 17Healthcare Organisation Factors 18Insufficient Time 18Lack of Coordination Amongst Healthcare Providers 19Healthcare System Factors 19Payment System that Rewards Volume 19Influence of the Pharmaceutical and Medical Device Industry 20Healthcare Insurance Policy 20Key Points 20References 21Chapter 3 Why Is It So Hard to Change Behaviour and How Can We Influence It? 23Jill J. Francis, Sanne Peters, Andrea M. Patey, Nicola McCleary, Leti van Bodegom- Vos, and Harriet HiscockThe Challenge of Behaviour Change 24Is The Behaviour a Routine? 24Is The Behaviour Rewarding? 24Do Habits or Routines Play a Role in Sustaining the Behaviour? 26Four Crucial Questions to Address Before Working to Support Behaviour Change 28Why Is It So Difficult to Change the Behaviour of Healthcare Professionals? 30Designing Interventions to Change Behaviour 35Summary 36Sources of Information for Supporting Practice Change Among Healthcare Professionals 36References 36Chapter 4 How Can We Reduce Overuse: The Choosing Wisely De- Implementation Framework 41Jeremy M. Grimshaw and Andrea M. PateyIntroduction 41The Choosing Wisely De- Implementation Framework 44Phase 0: Identification of Potential Areas of Low- Value Healthcare 44Phase 1: Identification of Local Prioritiesfor the Implementation of Recommendations 45Phase 2: Identification of Barriers and Enablers to Implementing Recommendations and Potential Interventions to Overcome These 46Phase 3: Evaluation of the Implementation 48Phase 4: Spread of Effective Implementation Programs 49Key Points 50References 51Chapter 5 How Can You Engage Patients in De- Implementation Activities? 54Stuart G. Nicholls, Brian Johnston, Barbara Sklar, and Holly EtchegaryWhat Is Patient Engagement and Why is it Relevant to De- Implementation? 54Making a Patient Engagement Plan 56The Level of Engagement 57Area 1 – Patient Engagement in Agenda Setting and Prioritisation 61Area 2 – Patient Engagement in the Design and Conduct of De- Implementation Activities 64Area 3 – Patient Engagement in Spread 65Important Considerations when Engaging Patients 66Key Points 68Sources of Information 69General Resources 69Planning Tools 69Patient Engagement Methods 70Evaluation Tools 70References 70Chapter 6 Identifying Potential Areas of Low- Value Healthcare- Phase 0 73Moriah E. Ellen, Saritte M. Perlman, and Jeremy M. GrimshawHow to Identify Low- Value Care? 73Resources to Identify Low- Value Care 75Recommendation Lists 76Clinical Practice Guidelines 77Health Technology Assessments 77Evidence Syntheses and Systematic Reviews 78From Identification to Measurement 78Key Points 84Sources of Further Information 84References 84Chapter 7 Measuring Low- Value Care and Choosing Your Local Priority (Phase 1) 88Carole E. Aubert, Karen Born, Eve A. Kerr, Sacha Bhatia, and Eva W. VerkerkChoosing Your Local Priority 89Measuring Low- Value Care 89Baseline Measurements 90Estimating Improvement Potential 91Evaluating De- Implementation Effects 91Measuring Unintended Consequences 94Measurement Methods and Data Source 95Setting Specific, Measurable, Achievable, Relevant, and Time- Bound (SMART) Targets 98Providing Data and Feedback to Stakeholders 98Key Points 100References 100Chapter 8 Identifying Target Behaviours and Potential Barriers to Change (Phase 2a) 103Andrea M. Patey, Nicola McCleary, Justin Presseau, Tijn Kool, Simone van Dulmen, and Jeremy M. GrimshawThe Importance of Fully Understanding the Problem 104Getting Started 104Identifying Who Needs to do What Differently 105Using the Action, Actor, Context, Target, Time (Aactt) Framework 106Identifying Drivers of Current Behaviour and Barriers and Enablers to Changing Behaviour 109Collecting Data 112Interviews 112Focus Groups 114Surveys 116Analysing the Data 118Narrowing Down the Drivers or Barriers Identified 118Key Points 119Useful Resources 120References 120Appendix: Sample Interview Guide for Healthcare Providers Using the Tdf 122Introduction Script 122Background 123Chapter 9 Selecting De-Implementation Strategies and Designing Interventions: Phase 2b 131Justin Presseau, Nicola McCleary, Andrea M. Patey, Sheena McHugh, and Fabiana LorencattoWhat Do You Need To Do Before Selecting De- Implementation Strategies? 132Ten General Principles to Consideras you Develop a de- Implementation Intervention 1321. There Are No Magic Bullets: Design Your De- Implementation Intervention to Address Specific Barriers and Enablers 1322. De- Implementation Interventions Are Often Also Implementation Interventions when Substituting One Practice with Another 1333. Routinised, Habitually Performed Care May Be Operating Semi- Automatically 1344. Follow the Evidence Wherever Possible when Designing Your De- Implementation Intervention 1355. Avoid the Tower of Babel: Leverage Existing Listsof Change Strategies and Use Them to Help Match Specific Strategies to Identified Barriers/Enablers 1366. Avoid Conflating Intervention Content with Its Method of Delivery 1397. Decide on Tailoring and Adaptation 1408. Co- Development, User- Centred Design to Enhance Feasibility, Acceptability, and Implementability 1409. Prioritise Equity 14110. Describe How the Strategy Works by Developing a De- Implementation Logic Model of Change 142Key Points 143Sources 144References 144Chapter 10 Evaluating De- Implementation Interventions: Phase 3 149Beatriz Goulao, Eva W. Verkerk, Kednapa Thavorn, Justin Presseau, and Monica TaljaardWhy Should We Evaluate? 150Outcomes 150Types of Evaluations 151Randomised Evaluations 152Non- Randomised Evaluations 154Selecting the Most Appropriate Evaluation Method 156How and Why Does the Intervention Work? 158Does the Intervention Offer Good Value for Money? 160Key Points 161References 162Chapter 11 Preserving Results and Spreading Interventions: Phase 4 166Simone van Dulmen, Daniëlle Kroon, and Tijn KoolWhy Are Sustainability and Spread So Important? 166What Is Sustainability? 167Factors Influencing Sustained Change 168Factors Related to the Process 168Factors Related to Staff 170Factors Related to the Organisation 170How Can You Facilitate Sustainability? 171Assessing Sustainability 172Sustainability and Culture 173Spreading Successful De- Implementation Interventions 174Scaling Strategy 175De- Implementation Intervention 176Adopters or Adopting Organisation 177External Context 177Key Points 178References 178Chapter 12 Training the Next Generation of Healthcare Providers to Address Overuse and Avoid Low- Value Care 181Brian M. Wong, Christopher Moriates, Lorette Stammen, and Karen BornIntroduction 182High- Value Care Competencies 182Teaching Students and Trainees To Provide High- Value Care 183Educational Changes to the Formal Curriculum 183Faculty Role Modellingand Supportive Learning Environments 186Assessing High- Value Care Learning Outcomes 190Enablers of Educational Change 191Aligning Continuing Professional Development and Quality Improvement 192Key Points 193Sources 196References 196Chapter 13 Examples from Clinical Practice 199Simone van Dulmen, Daniëlle Kroon, Tijn Kool, Kyle Kirkham, and Johanna Caro MendivelsoIntroduction 199References 215Chapter 14 Starting Tomorrow 217Tijn Kool, Andrea M. Patey, Jeremy M. Grimshaw, and Simone van DulmenIndex 221

Tijn Kool, MD PhD, is Full Professor Appropriate Care at the Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands. Andrea M. Patey, PhD, is Senior Research Associate in the Centre for Implementation Research in the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada. Simone van Dulmen, PhD, is Senior Researcher in Appropriate and Sustainable Healthcare at the Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands. Jeremy M. Grimshaw, MBChB, PhD, Senior Scientist in the Centre for Implementation Research in the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada.

• Preface xChapter 1 Why Should We Reduce Medical Overuse? 1Karen Born and Wendy LevinsonIt Started with Quality Improvement 1Then Came a Focus on Overuse 3Overuse as a Global Healthcare Quality Concern 5What Can Be Done to Address Overuse? 6Choosing Wisely 7What Can you Expect in the Following Chapters? 9References 10Chapter 2 Why Does Overuse Exist? 13Tijn Kool, Simone van Dulmen, Andrea M. Patey, and Jeremy M. GrimshawA Multifactorial Challenge on Different Levels 13Healthcare Professional Factors 14Patient Factors 15Preference for Acquiring Something 16Clinical Care Context Factors 16Absence of an Open Culture 17Absence of Clear Leadership 17Healthcare Organisation Factors 18Insufficient Time 18Lack of Coordination Amongst Healthcare Providers 19Healthcare System Factors 19Payment System that Rewards Volume 19Influence of the Pharmaceutical and Medical Device Industry 20Healthcare Insurance Policy 20Key Points 20References 21Chapter 3 Why Is It So Hard to Change Behaviour and How Can We Influence It? 23Jill J. Francis, Sanne Peters, Andrea M. Patey, Nicola McCleary, Leti van Bodegom- Vos, and Harriet HiscockThe Challenge of Behaviour Change 24Is The Behaviour a Routine? 24Is The Behaviour Rewarding? 24Do Habits or Routines Play a Role in Sustaining the Behaviour? 26Four Crucial Questions to Address Before Working to Support Behaviour Change 28Why Is It So Difficult to Change the Behaviour of Healthcare Professionals? 30Designing Interventions to Change Behaviour 35Summary 36Sources of Information for Supporting Practice Change Among Healthcare Professionals 36References 36Chapter 4 How Can We Reduce Overuse: The Choosing Wisely De- Implementation Framework 41Jeremy M. Grimshaw and Andrea M. PateyIntroduction 41The Choosing Wisely De- Implementation Framework 44Phase 0: Identification of Potential Areas of Low- Value Healthcare 44Phase 1: Identification of Local Prioritiesfor the Implementation of Recommendations 45Phase 2: Identification of Barriers and Enablers to Implementing Recommendations and Potential Interventions to Overcome These 46Phase 3: Evaluation of the Implementation 48Phase 4: Spread of Effective Implementation Programs 49Key Points 50References 51Chapter 5 How Can You Engage Patients in De- Implementation Activities? 54Stuart G. Nicholls, Brian Johnston, Barbara Sklar, and Holly EtchegaryWhat Is Patient Engagement and Why is it Relevant to De- Implementation? 54Making a Patient Engagement Plan 56The Level of Engagement 57Area 1 – Patient Engagement in Agenda Setting and Prioritisation 61Area 2 – Patient Engagement in the Design and Conduct of De- Implementation Activities 64Area 3 – Patient Engagement in Spread 65Important Considerations when Engaging Patients 66Key Points 68Sources of Information 69General Resources 69Planning Tools 69Patient Engagement Methods 70Evaluation Tools 70References 70Chapter 6 Identifying Potential Areas of Low- Value Healthcare- Phase 0 73Moriah E. Ellen, Saritte M. Perlman, and Jeremy M. GrimshawHow to Identify Low- Value Care? 73Resources to Identify Low- Value Care 75Recommendation Lists 76Clinical Practice Guidelines 77Health Technology Assessments 77Evidence Syntheses and Systematic Reviews 78From Identification to Measurement 78Key Points 84Sources of Further Information 84References 84Chapter 7 Measuring Low- Value Care and Choosing Your Local Priority (Phase 1) 88Carole E. Aubert, Karen Born, Eve A. Kerr, Sacha Bhatia, and Eva W. VerkerkChoosing Your Local Priority 89Measuring Low- Value Care 89Baseline Measurements 90Estimating Improvement Potential 91Evaluating De- Implementation Effects 91Measuring Unintended Consequences 94Measurement Methods and Data Source 95Setting Specific, Measurable, Achievable, Relevant, and Time- Bound (SMART) Targets 98Providing Data and Feedback to Stakeholders 98Key Points 100References 100Chapter 8 Identifying Target Behaviours and Potential Barriers to Change (Phase 2a) 103Andrea M. Patey, Nicola McCleary, Justin Presseau, Tijn Kool, Simone van Dulmen, and Jeremy M. GrimshawThe Importance of Fully Understanding the Problem 104Getting Started 104Identifying Who Needs to do What Differently 105Using the Action, Actor, Context, Target, Time (Aactt) Framework 106Identifying Drivers of Current Behaviour and Barriers and Enablers to Changing Behaviour 109Collecting Data 112Interviews 112Focus Groups 114Surveys 116Analysing the Data 118Narrowing Down the Drivers or Barriers Identified 118Key Points 119Useful Resources 120References 120Appendix: Sample Interview Guide for Healthcare Providers Using the Tdf 122Introduction Script 122Background 123Chapter 9 Selecting De-Implementation Strategies and Designing Interventions: Phase 2b 131Justin Presseau, Nicola McCleary, Andrea M. Patey, Sheena McHugh, and Fabiana LorencattoWhat Do You Need To Do Before Selecting De- Implementation Strategies? 132Ten General Principles to Consideras you Develop a de- Implementation Intervention 1321. There Are No Magic Bullets: Design Your De- Implementation Intervention to Address Specific Barriers and Enablers 1322. De- Implementation Interventions Are Often Also Implementation Interventions when Substituting One Practice with Another 1333. Routinised, Habitually Performed Care May Be Operating Semi- Automatically 1344. Follow the Evidence Wherever Possible when Designing Your De- Implementation Intervention 1355. Avoid the Tower of Babel: Leverage Existing Listsof Change Strategies and Use Them to Help Match Specific Strategies to Identified Barriers/Enablers 1366. Avoid Conflating Intervention Content with Its Method of Delivery 1397. Decide on Tailoring and Adaptation 1408. Co- Development, User- Centred Design to Enhance Feasibility, Acceptability, and Implementability 1409. Prioritise Equity 14110. Describe How the Strategy Works by Developing a De- Implementation Logic Model of Change 142Key Points 143Sources 144References 144Chapter 10 Evaluating De- Implementation Interventions: Phase 3 149Beatriz Goulao, Eva W. Verkerk, Kednapa Thavorn, Justin Presseau, and Monica TaljaardWhy Should We Evaluate? 150Outcomes 150Types of Evaluations 151Randomised Evaluations 152Non- Randomised Evaluations 154Selecting the Most Appropriate Evaluation Method 156How and Why Does the Intervention Work? 158Does the Intervention Offer Good Value for Money? 160Key Points 161References 162Chapter 11 Preserving Results and Spreading Interventions: Phase 4 166Simone van Dulmen, Daniëlle Kroon, and Tijn KoolWhy Are Sustainability and Spread So Important? 166What Is Sustainability? 167Factors Influencing Sustained Change 168Factors Related to the Process 168Factors Related to Staff 170Factors Related to the Organisation 170How Can You Facilitate Sustainability? 171Assessing Sustainability 172Sustainability and Culture 173Spreading Successful De- Implementation Interventions 174Scaling Strategy 175De- Implementation Intervention 176Adopters or Adopting Organisation 177External Context 177Key Points 178References 178Chapter 12 Training the Next Generation of Healthcare Providers to Address Overuse and Avoid Low- Value Care 181Brian M. Wong, Christopher Moriates, Lorette Stammen, and Karen BornIntroduction 182High- Value Care Competencies 182Teaching Students and Trainees To Provide High- Value Care 183Educational Changes to the Formal Curriculum 183Faculty Role Modellingand Supportive Learning Environments 186Assessing High- Value Care Learning Outcomes 190Enablers of Educational Change 191Aligning Continuing Professional Development and Quality Improvement 192Key Points 193Sources 196References 196Chapter 13 Examples from Clinical Practice 199Simone van Dulmen, Daniëlle Kroon, Tijn Kool, Kyle Kirkham, and Johanna Caro MendivelsoIntroduction 199References 215Chapter 14 Starting Tomorrow 217Tijn Kool, Andrea M. Patey, Jeremy M. Grimshaw, and Simone van DulmenIndex 221

Tijn Kool, MD PhD, is Full Professor Appropriate Care at the Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands. Andrea M. Patey, PhD, is Senior Research Associate in the Centre for Implementation Research in the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada. Simone van Dulmen, PhD, is Senior Researcher in Appropriate and Sustainable Healthcare at the Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands. Jeremy M. Grimshaw, MBChB, PhD, Senior Scientist in the Centre for Implementation Research in the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada.

• Preface xChapter 1 Why Should We Reduce Medical Overuse? 1Karen Born and Wendy LevinsonIt Started with Quality Improvement 1Then Came a Focus on Overuse 3Overuse as a Global Healthcare Quality Concern 5What Can Be Done to Address Overuse? 6Choosing Wisely 7What Can you Expect in the Following Chapters? 9References 10Chapter 2 Why Does Overuse Exist? 13Tijn Kool, Simone van Dulmen, Andrea M. Patey, and Jeremy M. GrimshawA Multifactorial Challenge on Different Levels 13Healthcare Professional Factors 14Patient Factors 15Preference for Acquiring Something 16Clinical Care Context Factors 16Absence of an Open Culture 17Absence of Clear Leadership 17Healthcare Organisation Factors 18Insufficient Time 18Lack of Coordination Amongst Healthcare Providers 19Healthcare System Factors 19Payment System that Rewards Volume 19Influence of the Pharmaceutical and Medical Device Industry 20Healthcare Insurance Policy 20Key Points 20References 21Chapter 3 Why Is It So Hard to Change Behaviour and How Can We Influence It? 23Jill J. Francis, Sanne Peters, Andrea M. Patey, Nicola McCleary, Leti van Bodegom- Vos, and Harriet HiscockThe Challenge of Behaviour Change 24Is The Behaviour a Routine? 24Is The Behaviour Rewarding? 24Do Habits or Routines Play a Role in Sustaining the Behaviour? 26Four Crucial Questions to Address Before Working to Support Behaviour Change 28Why Is It So Difficult to Change the Behaviour of Healthcare Professionals? 30Designing Interventions to Change Behaviour 35Summary 36Sources of Information for Supporting Practice Change Among Healthcare Professionals 36References 36Chapter 4 How Can We Reduce Overuse: The Choosing Wisely De- Implementation Framework 41Jeremy M. Grimshaw and Andrea M. PateyIntroduction 41The Choosing Wisely De- Implementation Framework 44Phase 0: Identification of Potential Areas of Low- Value Healthcare 44Phase 1: Identification of Local Prioritiesfor the Implementation of Recommendations 45Phase 2: Identification of Barriers and Enablers to Implementing Recommendations and Potential Interventions to Overcome These 46Phase 3: Evaluation of the Implementation 48Phase 4: Spread of Effective Implementation Programs 49Key Points 50References 51Chapter 5 How Can You Engage Patients in De- Implementation Activities? 54Stuart G. Nicholls, Brian Johnston, Barbara Sklar, and Holly EtchegaryWhat Is Patient Engagement and Why is it Relevant to De- Implementation? 54Making a Patient Engagement Plan 56The Level of Engagement 57Area 1 – Patient Engagement in Agenda Setting and Prioritisation 61Area 2 – Patient Engagement in the Design and Conduct of De- Implementation Activities 64Area 3 – Patient Engagement in Spread 65Important Considerations when Engaging Patients 66Key Points 68Sources of Information 69General Resources 69Planning Tools 69Patient Engagement Methods 70Evaluation Tools 70References 70Chapter 6 Identifying Potential Areas of Low- Value Healthcare- Phase 0 73Moriah E. Ellen, Saritte M. Perlman, and Jeremy M. GrimshawHow to Identify Low- Value Care? 73Resources to Identify Low- Value Care 75Recommendation Lists 76Clinical Practice Guidelines 77Health Technology Assessments 77Evidence Syntheses and Systematic Reviews 78From Identification to Measurement 78Key Points 84Sources of Further Information 84References 84Chapter 7 Measuring Low- Value Care and Choosing Your Local Priority (Phase 1) 88Carole E. Aubert, Karen Born, Eve A. Kerr, Sacha Bhatia, and Eva W. VerkerkChoosing Your Local Priority 89Measuring Low- Value Care 89Baseline Measurements 90Estimating Improvement Potential 91Evaluating De- Implementation Effects 91Measuring Unintended Consequences 94Measurement Methods and Data Source 95Setting Specific, Measurable, Achievable, Relevant, and Time- Bound (SMART) Targets 98Providing Data and Feedback to Stakeholders 98Key Points 100References 100Chapter 8 Identifying Target Behaviours and Potential Barriers to Change (Phase 2a) 103Andrea M. Patey, Nicola McCleary, Justin Presseau, Tijn Kool, Simone van Dulmen, and Jeremy M. GrimshawThe Importance of Fully Understanding the Problem 104Getting Started 104Identifying Who Needs to do What Differently 105Using the Action, Actor, Context, Target, Time (Aactt) Framework 106Identifying Drivers of Current Behaviour and Barriers and Enablers to Changing Behaviour 109Collecting Data 112Interviews 112Focus Groups 114Surveys 116Analysing the Data 118Narrowing Down the Drivers or Barriers Identified 118Key Points 119Useful Resources 120References 120Appendix: Sample Interview Guide for Healthcare Providers Using the Tdf 122Introduction Script 122Background 123Chapter 9 Selecting De-Implementation Strategies and Designing Interventions: Phase 2b 131Justin Presseau, Nicola McCleary, Andrea M. Patey, Sheena McHugh, and Fabiana LorencattoWhat Do You Need To Do Before Selecting De- Implementation Strategies? 132Ten General Principles to Consideras you Develop a de- Implementation Intervention 1321. There Are No Magic Bullets: Design Your De- Implementation Intervention to Address Specific Barriers and Enablers 1322. De- Implementation Interventions Are Often Also Implementation Interventions when Substituting One Practice with Another 1333. Routinised, Habitually Performed Care May Be Operating Semi- Automatically 1344. Follow the Evidence Wherever Possible when Designing Your De- Implementation Intervention 1355. Avoid the Tower of Babel: Leverage Existing Listsof Change Strategies and Use Them to Help Match Specific Strategies to Identified Barriers/Enablers 1366. Avoid Conflating Intervention Content with Its Method of Delivery 1397. Decide on Tailoring and Adaptation 1408. Co- Development, User- Centred Design to Enhance Feasibility, Acceptability, and Implementability 1409. Prioritise Equity 14110. Describe How the Strategy Works by Developing a De- Implementation Logic Model of Change 142Key Points 143Sources 144References 144Chapter 10 Evaluating De- Implementation Interventions: Phase 3 149Beatriz Goulao, Eva W. Verkerk, Kednapa Thavorn, Justin Presseau, and Monica TaljaardWhy Should We Evaluate? 150Outcomes 150Types of Evaluations 151Randomised Evaluations 152Non- Randomised Evaluations 154Selecting the Most Appropriate Evaluation Method 156How and Why Does the Intervention Work? 158Does the Intervention Offer Good Value for Money? 160Key Points 161References 162Chapter 11 Preserving Results and Spreading Interventions: Phase 4 166Simone van Dulmen, Daniëlle Kroon, and Tijn KoolWhy Are Sustainability and Spread So Important? 166What Is Sustainability? 167Factors Influencing Sustained Change 168Factors Related to the Process 168Factors Related to Staff 170Factors Related to the Organisation 170How Can You Facilitate Sustainability? 171Assessing Sustainability 172Sustainability and Culture 173Spreading Successful De- Implementation Interventions 174Scaling Strategy 175De- Implementation Intervention 176Adopters or Adopting Organisation 177External Context 177Key Points 178References 178Chapter 12 Training the Next Generation of Healthcare Providers to Address Overuse and Avoid Low- Value Care 181Brian M. Wong, Christopher Moriates, Lorette Stammen, and Karen BornIntroduction 182High- Value Care Competencies 182Teaching Students and Trainees To Provide High- Value Care 183Educational Changes to the Formal Curriculum 183Faculty Role Modellingand Supportive Learning Environments 186Assessing High- Value Care Learning Outcomes 190Enablers of Educational Change 191Aligning Continuing Professional Development and Quality Improvement 192Key Points 193Sources 196References 196Chapter 13 Examples from Clinical Practice 199Simone van Dulmen, Daniëlle Kroon, Tijn Kool, Kyle Kirkham, and Johanna Caro MendivelsoIntroduction 199References 215Chapter 14 Starting Tomorrow 217Tijn Kool, Andrea M. Patey, Jeremy M. Grimshaw, and Simone van DulmenIndex 221