The Science of Quality Improvement Implementation: Developing Capacity to Make a Difference

Process evaluation of a co-design and implementation study to improve professional health literacy in a regional care hospital (PIKoG): a mixed-methods study

BACKGROUND

In connection with a hospital stay, patients have to make important health-related decisions. Adequately responding to the needs of patients requires good communication skills of healthcare professionals within healthcare organizations. The PIKoG project (As made for us - Improving professional health literacy in hospitals) aimed at improving professional health literacy by implementing participatory health literacy training and supporting measures in a hospital setting. This study aimed to analyze processes supporting and hindering the implementation of the complex intervention.

METHODS

A mixed-methods study was conducted, including focus group interviews and a paper-pencil survey with healthcare professionals. Data was combined and analyzed using categories derived from the Medical Research Council's guidance on process evaluation: (1) Implementation, (2) Mechanisms of impact, and (3) Context. Interview data were analyzed using structured qualitative content analysis according to Kuckartz. Survey data were analyzed descriptively.

RESULTS

One of three on-site, full-day health literacy training sessions was offered weekly. Supporting measures were implemented step by step over the course of a year. Both the training and the supporting measures were rated positively overall, but they could not be effectively integrated into daily routines. The COVID-19 pandemic as well as resource constraints adversely affected implementation by altering workflows, increasing stress levels and shifting priorities. The participatory approach and individual change agents fostered the implementation of the complex intervention. Nurses were reached the most, while physicians engaged least in the interventions. Adaptations during the implementation increased the use of the implemented measures and gave rise to ideas for future improvements.

CONCLUSION

The study highlights the challenges involved in implementing a complex intervention supporting professional health literacy in an organization and stresses the importance of considering available resources, recruiting opinion leaders, and being responsive to the needs of different groups. While the participatory co-design development approach was found to be valuable, it does not guarantee successful organizational change in times when hospitals face multiple challenges. Subsequent studies should therefore focus on investigating the capacities of healthcare organizations for organization-wide improvement processes and identify how healthcare organizations can be innovative and patient-centered even in the presence of extremely difficult contextual conditions.

TRIAL REGISTRATION

DRKS00019830, since 16th of April 2020.

Implementation of the virtual transitional care stroke intervention for older adults with stroke and multimorbidity: A qualitative descriptive study

Background

Older adults with stroke and multimorbidity experience frequent care transitions, which are often poorly coordinated and fragmented. We conducted a pragmatic randomized controlled trial (RCT) to test the implementation and effectiveness of the Transitional Care Stroke Intervention (TCSI), a 6-month, multi-component, evidence-informed intervention to support older adults with stroke and multimorbidity using outpatient stroke rehabilitation services. The TCSI was designed to support self-management, improve health outcomes, and enhance the quality and experience of care transitions.

Objective

To explore the facilitators and challenges to implementing the TCSI, from the perspective of healthcare providers (HCPs) (n = 12) and Managers (n = 3).

Methods

Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Data were collected from study documents, individual and group interviews conducted with HCPs and a Care Coordinator, and surveys from managers. Data were analyzed using thematic analysis.

Results

Intervention implementation was facilitated by: a) strong collaborative and interdependent HCP team relationships, b) dedicated resources (funding, staffing) to support intervention delivery, c) training and ongoing support, customized to individual HCP needs, d) organizational readiness, strong leadership, and effective champions, e) structures to facilitate virtual information-sharing, and f) regular monitoring of intervention implementation. Implementation challenges included: a) COVID-19 related challenges (staff turnover, community service disruptions), b) poor communication with community service providers, c) documentation burden (intervention-related), and d) virtual care delivery.

Conclusions

This research enhances understanding of the diversity of factors influencing implementation of the TCSI, and the conditions under which implementation is more likely to succeed.

Exploring Determinants of Effective Implementation of an Innovation Within Health Care: Qualitative Insights from Program Champions on Implementing One-at-a-Time Therapy Within Addictions and Mental Health Services in New Brunswick

Government of New Brunswick implemented One-at-a-Time (OAAT) therapy, a single-session approach to care, within Addiction and Mental Health (A&MH) services. We conducted interviews to understand determinants of implementation from program champions. Champions of the OAAT therapy implementation (N = 19; Child/Youth n = 8, Adult n = 11) working within A&MH services and school districts were recruited through the provincial implementation team. Transcripts were synthesized using thematic analysis. Determinants were organized as facilitators and barriers in accordance with the Consolidated Framework for Implementation Research (CFIR). Thematic analysis resulted in 18 themes and 5 recommendations. Facilitators within the inner setting included: (1) need for change and perceived benefits of OAAT therapy; (2) compatibility of OAAT therapy with previous practice and service processes; and (3) support received from champions and colleagues. Insufficient resources (e.g., staff and physical infrastructure), and a culture that favored long-term therapy were barriers. Navigating age of consent, and implementation around COVID-19 were barriers within the outer setting. Facilitators within the implementation process domain included: (1) interconnected teams across sites, regions and the province; (2) collaborative implementation planning; (3) flexibility to tailor implementation at sites; and (4) mentorship provided by champions. Insufficient standardization of the implementation and limited representation among affected parties (e.g., community partners) were barriers within the implementation process. This study elucidated determinants that influenced implementation of a new service delivery within an Eastern Canadian provincial health care system. Findings can serve as a heuristic for organizations looking to enact similar implementation initiatives.

Building capacity and capability for quality improvement: insights from a nascent regional health system

OBJECTIVES

Quality improvement (QI) is critical in facilitating advancements in patient outcomes, system efficiency and professional growth. This paper aimed to elucidate the underlying rationale and framework guiding JurongHealth Campus (JHC), a nascent Regional Health System, in developing its QI capacity and capability at all levels of the organisation.

METHODS

An exhaustive analysis of high-performance management systems and effective improvement frameworks was conducted, and the principles were customised to suit the local context.A three-phased approach was applied: (1) developing the JHC QI framework; (2) building capacity through a dosing approach and (3) building capability through QI projects and initiatives using the model for improvement (MFI). Three components of the RE-AIM implementation strategy were assessed: (1) Reach-overall percentage of staff trained; (2) Effectiveness-outcomes from organisation-wide improvement projects and (3) Adoption-number of QI projects collated and presented.

RESULTS

The percentage of staff trained in QI increased from 11.3% to 22.0% between January 2020 and March 2024, with over 350 projects documented in the central repository. The effectiveness of the MFI was demonstrated by improving inpatient discharges before 12pm performance from 21.52% to 25.84% and reducing the 30-day inpatient readmission rate from 13.92% to 12.96%.

CONCLUSION

Four critical factors for an effective QI framework were identified: (1) establishing a common language for improvement; (2) defining distinct roles and skills for improvement at different levels of the organisation; (3) adopting a dosing approach to QI training according to the defined roles and skills and (4) building a critical mass of committed staff trained in QI practice. The pragmatic approach to developing QI capability is both scalable and applicable to emerging healthcare institutions.

Implementation of a Clinical Vessel Wall MR Imaging Program at an Academic Medical Center

BACKGROUND AND PURPOSE

The slow adoption of new advanced imaging techniques into clinical practice has been a long-standing challenge. Principles of implementation science and the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework were used to build a clinical vessel wall imaging program at an academic medical center.

MATERIALS AND METHODS

Six phases for implementing a clinical vessel wall MR imaging program were contextualized to the RE-AIM framework. Surveys were designed and distributed to MR imaging technologists and clinicians. Effectiveness was measured by surveying the perceived diagnostic value of vessel wall imaging among MR imaging technologists and clinicians, trends in case volumes in the clinical vessel wall imaging examination, and the number of coauthored vessel wall imaging-focused publications and abstracts. Adoption and implementation were measured by surveying stakeholders about workflow. Maintenance was measured by surveying MR imaging technologists on the value of teaching materials and online tip sheets. The Integration dimension was measured by the number of submitted research grants incorporating vessel wall imaging protocols. Feedback during the implementation phases and solicited through the survey is qualitatively summarized. Quantitative results are reported using descriptive statistics.

RESULTS

Six phases of the RE-AIM framework focused on the following: 1) determining patient and disease representation, 2) matching resource availability and patient access, 3) establishing vessel MR wall imaging (VWI) expertise, 4) forming interdisciplinary teams, 5) iteratively refining workflow, and 6) integrating for maintenance and scale. Survey response rates were 48.3% (MR imaging technologists) and 71.4% (clinicians). Survey results showed that 90% of the MR imaging technologists agreed that they understood how vessel wall MR imaging adds diagnostic value to patient care. Most clinicians (91.3%) reported that vessel wall MR imaging results changed their diagnostic confidence or patient management. Case volumes of clinical vessel wall MR imaging performed from 2019 to 2022 rose from 22 to 205 examinations. Workflow challenges reported by MR imaging technologists included protocoling examinations and scan length. Feedback from ordering clinicians included the need for education about VWI indications, limitations, and availability. During the 3-year implementation period of the program, the interdisciplinary teams coauthored 27 publications and abstracts and submitted 13 research grants.

CONCLUSIONS

Implementation of a clinical imaging program can be successful using the principles of the RE-AIM framework. Through iterative processes and the support of interdisciplinary teams, a vessel wall MR imaging program can be integrated through a dedicated clinical pipeline, add diagnostic value, support educational and research missions at an academic medical center, and become a center for excellence.

Project ECHO®: a global cross-sectional examination of implementation success

BACKGROUND

Organizations implement innovations to disrupt the status quo and create value. Within sectors such as healthcare, innovations need to navigate large scale system and organizational factors to succeed. This research explores the implementation of a global innovation- Project ECHO®. Project ECHO® is a validated virtual communities of practice model organizational teams implement to build workforce capacity and capability. Project ECHO® has experienced broad global adoption, particularly within the healthcare sector, and is experiencing growth across other sectors. This study sought to examine the state of implementation success for Project ECHO® globally, to understand how these implementations compare across geographic and sectoral contexts, and understand what enablers/barriers exist for organizational teams implementing the innovation.

METHODS

An empirical study was conducted to collect data on 54 Project ECHO® implementation success indicators across an international sample. An online survey questionnaire was developed and distributed to all Project ECHO® hub organizations globally to collect data. Data was analyzed using descriptive statistics.

RESULTS

The 54 implementation success indicators measured in this survey revealed that the adoption of Project ECHO® across 13 organizations varied on a case-by-case basis, with a strong rate of adoption within the healthcare sector. Implementation teams from these organizations successfully implemented Project ECHO® within 12-18 months after completing Immersion partner launch training and operated 51 ECHO® Networks at the time of data collection. Implementation teams which liaised more regularly with ECHO® Superhub mentors often went on to launch a higher number of ECHO® Networks that were sustained over the longer term. This suggests that these implementation teams better aligned and consolidated their Project ECHO® pilots as new innovations within the local context and strategic organizational priorities. Access to research and evaluation capability, and a more automated digital client relationship management system were key limitations to showcasing implementation success outcomes experienced by the majority of implementation teams.

CONCLUSIONS

These findings make a valuable contribution to address a knowledge gap regarding how a global sample of organizations adopting Project ECHO® measured and reported their implementation successes. Key successes included pre-launch experimentation and expansion, Superhub mentorship, stakeholder engagement, and alignment to strategic priorities.

Barriers to the Implementation of Infant- and Family-Centered Developmental Care From Focus Groups With Neonatal Care Providers

AIM

Although infant- and family-centered developmental care (IFCDC) is scientifically grounded and offered in many hospitals to some extent, it has not yet been universally implemented as the standard of care. In this article, we aim to identify barriers to the implementation of IFCDC in Belgian neonatal care from the perspective of neonatal care providers.

METHODS

We conducted 8 online focus groups with 40 healthcare providers working in neonatal care services. An inductive thematic analysis was carried out by means of Nvivo.

RESULTS

The focus groups revealed barriers related to contextual, hospital, and neonatal unit characteristics. Barriers found in the hospital and neonatal unit were related to financing, staffing, infrastructure, access to knowledge/information and learning climate, leadership engagement, and relative priority of IFCDC. Contextual barriers were related to peer pressure and partnerships, newborn/parent needs and resources, external policy, and budgetary incentives.

CONCLUSION

Three main barriers to IFCDC implementation have been identified. Resources (staffing, financing, and infrastructure) must be available and aligned with IFCDC standards, knowledge and information have to be accessible and continuously updated, and hospital management should support IFCDC implementation to create an enabling climate, including compatibility with the existing workflow, learning opportunities, and priority setting.

Safe Ground Transport of Pediatric Patients: A Qualitative Assessment of Best Practice Guidelines Implementation

OBJECTIVE

The National Highway Traffic Safety Administration issued guidelines on the safe transport of pediatric patients to lessen the chance of injury during ambulance transport. However, adherence to these standards have been slow to take hold. The objective of this quality improvement study is to evaluate barriers and facilitators of safe transport at the individual, organizational, and societal levels and identify improvement opportunities in the safe transport of pediatric patients.

METHODS

This study was designed using an implementation science framework. Six focus groups were held with EMS clinicians to assess knowledge, behaviors, barriers, and facilitators of safe pediatric transport. Four interviews were conducted with EMS leadership to characterize organizational safe transport practices and policies. Detailed notes were taken during focus groups; interviews were recorded and transcribed. Qualitative data were analyzed using a thematic content analysis approach where team members reviewed transcripts using an established framework and identified major and minor themes related to safe pediatric transport.

RESULTS

Three focus groups were conducted in a hospital setting and three were conducted at EMS base stations. Interview participants included two paramedic leaders, an ambulance service chief executive officer, and an ambulance service clinical coordinator. Recurring themes included the belief that children were inherently difficult to transport, the sentiment that training in pediatric transport is lacking, and the acknowledgement that familiarity with pediatric transport guidelines is low. Additionally, a major theme was that situational practicality can take precedence over adherence to best practice recommendations. Participants reported the presence of organizational and external barriers that made it more difficult for EMS personnel to follow safety guidelines. This included equipment unavailability, lack of clear policies, low pediatric patient volume, manufacturer design preferences, and prevailing EMS culture/norms.

CONCLUSION

EMS clinicians need hands-on training and knowledge reinforcement in safe pediatric ground ambulance transport. EMS agencies should ensure that their crews have proper equipment, training, and protocols in place. Regulators and manufacturers can be catalysts for the implementation of these recommendations. Substantial change at the individual, organizational, and societal levels are needed to improve the safety of pediatric patients being transported via ground ambulance.

Organizational attributes that contribute to the learning & improvement capabilities of healthcare organizations: a scoping review

BACKGROUND

This study aims to explore and identify the organizational attributes that contribute to learning and improvement capabilities (L&IC) in healthcare organizations. The authors define learning as a structured update of system properties based on new information, and improvement as a closer correspondence between actual and desired standards. They highlight the importance of learning and improvement capabilities in maintaining high-quality care, and emphasize the need for empirical research on organizational attributes that contribute to these capabilities. The study has implications for healthcare organizations, professionals, and regulators in understanding how to assess and enhance learning and improvement capabilities.

METHODS

A systematic search of peer-reviewed articles published between January 2010 and April 2020 was carried out in the PubMed, Embase, CINAHL, and APA PsycINFO databases. Two reviewers independently screened the titles and abstracts and conducted a full-text review of potentially relevant articles, eventually adding five more studies identified through reference scanning. Finally, a total of 32 articles were included in this review. We extracted the data about organizational attributes that contribute to learning and improvement, categorized them and grouped the findings step-by-step into higher, more general-level categories using an interpretive approach until categories emerged that were sufficiently different from each other while also being internally consistent. This synthesis has been discussed by the authors.

RESULTS

We identified five attributes that contribute to the L&IC of healthcare organizations: perceived leadership commitment, open culture, room for team development, initiating and monitoring change, and strategic client focus, each consisting of multiple facilitating aspects. We also found some hindering aspects.

CONCLUSIONS

We have identified five attributes that contribute to L&IC, mainly related to organizational software elements. Only a few are identified as organizational hardware elements. The use of qualitative methods seems most appropriate to understand or assess these organizational attributes. We feel it is also important for healthcare organisations to look more closely at how clients can be involved in L&IC.

TRIAL REGISTRATION

Not applicable.

Facilitators and barriers impacting in-hospital Trauma Quality Improvement Program (TQIP) implementation across country income levels: a scoping review

OBJECTIVE

Trauma is a leading cause of mortality and morbidity globally, disproportionately affecting low/middle-income countries (LMICs). Understanding the factors determining implementation success for in-hospital Trauma Quality Improvement Programs (TQIPs) is critical to reducing the global trauma burden. We synthesised topical literature to identify key facilitators and barriers to in-hospital TQIP implementation across country income levels.

DESIGN

Scoping review.

DATA SOURCES

PubMed, Web of Science and Global Index Medicus databases were searched from June 2009 to January 2022.

ELIGIBILITY CRITERIA

Published literature involving any study design, written in English and evaluating any implemented in-hospital quality improvement programme in trauma populations worldwide. Literature that was non-English, unpublished and involved non-hospital TQIPs was excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers completed a three-stage screening process using Covidence, with any discrepancies resolved through a third reviewer. Content analysis using the Consolidated Framework for Implementation Research identified facilitator and barrier themes for in-hospital TQIP implementation.

RESULTS

Twenty-eight studies met the eligibility criteria from 3923 studies identified. The most discussed in-hospital TQIPs in included literature were trauma registries. Facilitators and barriers were similar across all country income levels. The main facilitator themes identified were the prioritisation of staff education and training, strengthening stakeholder dialogue and providing standardised best-practice guidelines. The key barrier theme identified in LMICs was poor data quality, while high-income countries (HICs) had reduced communication across professional hierarchies.

CONCLUSIONS

Stakeholder prioritisation of in-hospital TQIPs, along with increased knowledge and consensus of trauma care best practices, are essential efforts to reduce the global trauma burden. The primary focus of future studies on in-hospital TQIPs in LMICs should target improving registry data quality, while interventions in HICs should target strengthening communication channels between healthcare professionals.

Transformational Performance Improvement: Why Is Progress so Slow?

In this chapter, we identify three distinct transformational performance improvement (TPI) approaches commonly used to redesign work processes in health care organizations. We describe the unique components or tools that each approach uses to improve the delivery of health services. We also summarize what is empirically known about the effectiveness of each TPI approach according to systematic reviews and recent studies published in the peer-reviewed literature. Based on examination of this research, we discuss what knowledge is still needed to strengthen the evidence for whole system transformation. This involves the use of conceptual frameworks to assess and guide implementation efforts, and facilitators and barriers to change as revealed in a recent evaluation of one major initiative, the Lean Enterprise Transformation (LET) at the Veterans Health Administration. The analysis suggests ways in which TPI facilitators can be developed and barriers reduced to improve the effectiveness and sustainability of quality initiatives. Finally, we discuss appropriate study designs to evaluate TPI interventions that may strengthen the evidence for their effectiveness in real world practice settings.

Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review

BACKGROUND

Long-term sustained improvement following implementation of hospital-wide quality and safety initiatives is not easily achieved. Comprehensive theoretical and practical understanding of how gained improvements can be sustained to benefit safe and high-quality care is needed. This review aimed to identify enabling and hindering factors and their contributions to improvement sustainability from hospital-wide change to enhance patient safety and quality.

METHODS

A systematic scoping review method was used. Searched were peer-reviewed published records on PubMed, Scopus, World of Science, CINAHL, Health Business Elite, Health Policy Reference Centre and Cochrane Library and grey literature. Review inclusion criteria included contemporary (2010 and onwards), empirical factors to improvement sustainability evaluated after the active implementation, hospital(s) based in the western Organisation for Economic Co-operation and Development countries. Numerical and thematic analyses were undertaken.

RESULTS

17 peer-reviewed papers were reviewed. Improvement and implementation approaches were predominantly adopted to guide change. Less than 6 in 10 (53%) of reviewed papers included a guiding framework/model, none with a demonstrated focus on improvement sustainability. With an evaluation time point of 4.3 years on average, 62 factors to improvement sustainability were identified and emerged into three overarching themes: People, Process and Organisational Environment. These entailed, as subthemes, actors and their roles; planning, execution and maintenance of change; and internal contexts that enabled sustainability. Well-coordinated change delivery, customised local integration and continued change effort were three most critical elements. Mechanisms between identified factors emerged in the forms of Influence and Action towards sustained improvement.

CONCLUSIONS

The findings map contemporary empirical factors and their mechanisms towards change sustainability from a hospital-wide initiative to improve patient safety and quality. The identified factors and mechanisms extend current theoretical and empirical knowledgebases of sustaining improvement particularly with those beyond the active implementation. The provided conceptual framework offers an empirically evidenced and actionable guide to assist sustainable organisational change in hospital settings.

Implementation of the VA Intensive Dysphagia Treatment Program: A Mixed-Methods Evaluation

The Department of Veterans Affairs (VA) Intensive Dysphagia Treatment program serves a critical role in facilitating improvements to quality of care, standardization of outcomes, and increased access to structured therapy for Veterans with dysphagia. It has been implemented at 26 sites nationally and continues expanding. An explanatory sequential mixed-methods design was utilized for program evaluation to identify barriers and facilitators to implementation as reported by speech-language pathologists (SLPs) participating in the program. All 23 IDT program SLPs were invited to participate in an online survey. SLPs were asked to describe etiologies referred for SLP evaluation, most and least clinically useful program aspects, and characteristics of patients recommended for therapy. Qualitative interviews/focus groups were then conducted with 9 SLPs at 3 facilities with varying levels of program experience. Transcripts underwent systems engineering framework informed deductive thematic analysis. Interview/focus groups revealed overall positive feedback. Barriers included data entry challenges and provider understanding of long-term program goals, while facilitators included program structure enabling increased patient follow-up, outcomes tracking, and training in new treatment modalities. Through this evaluation process, program leadership garnered actionable feedback to improve further implementation of the IDT program. Ongoing efforts will further improve data entry, site onboarding procedures, and program communication.

Implementation Facilitators and Challenges of a Place-Based Intervention to Reduce Health Disparities in Harlem Through Community Activation and Mobilization

Background

To address significant health inequities experienced by residents of public housing in East and Central Harlem compared to other New Yorkers, NYC Department of Health and Mental Health (DOHMH) collaborated with community and academic organizations and the New York City Housing Authority to develop a place-based initiative to address chronic diseases in five housing developments, including a community activation and mobilization component led by community health organizers (CHOs).

Purpose

Guided by the Consolidated Framework for Implementation Research (CFIR), we evaluated the initial implementation of the community activation and mobilization component to systematically investigate factors that could influence the successful implementation of the intervention.

Methods

Nineteen in-depth qualitative interviews were conducted with a purposive sample of CHOs, community members and leaders, collaborating agencies and DOHMH staff. Interviews were transcribed verbatim, and themes and codes were developed to identify theoretically important concepts of the CFIR and emergent analytic patterns.

Results

Findings identified important facilitators to implementation: positive community perception of the program, CHO engagement and responsiveness to community needs, CHO norms and values and adaptability of DOHMH and CHOs to community needs. Challenges included the instability of the program in the first year, limited ability to address housing related issues, concerns about long term funding, competing community priorities, low expectations by the community for the program, time and labor intensity to build trust within the community, and the dual roles of CHOs as community advocates and DOHMH employees.

Conclusions

Findings will guide future community activation and mobilization activities. The study demonstrates the value of integrating implementation science and health equity frameworks.

The effectiveness of person-centred quality improvement strategies on the management and control of hypertension in primary care: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of person-centred quality improvement strategies on the management and control of adults with hypertension in primary care.

METHODS

A systematic review and meta-analysis was conducted using the Medline, Cochrane Central Register for Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature, and APA PsycINFO databases (January 1980 to March 2020). Randomized controlled trials that evaluated person-centred quality improvement strategies for the management and control of essential hypertension among adults ( ≥ 18 years) in primary care were included. Random effects models were used to estimate weighted mean differences (WMD) for the change in systolic and diastolic blood pressures (SBP, DBP) from baseline; risk ratios (RR) were calculated for the proportion of participants achieving target blood pressures, for each quality improvement strategy assessed. A qualitative review of the implementation details of the interventions was conducted to identify common components of interventions that were effective in improving blood pressure outcomes.

RESULTS

Eight studies were included (total of 5654 patients). Findings favour use of person-centred quality improvement interventions over usual care (RR = 1.23 [95% CI: 1.01; 1.48]) for improving blood pressure outcomes. Self-management (RR = 1.43 [95% CI: 1.23; 1.65]) had the greatest effects on blood pressure targets. Clinician education resulted in the greatest SBP reduction (WMD:6.09 mmHg [95% CI: 2.32; 9.85]), while patient education and patient reminder systems (both WMD:4.86 mmHg [95% CI: 0.88; 8.83]) saw the most improvements in DBP. While interventions varied in their strategy implementation, common features of effective interventions included tailored communication with patients, use of health information technology, and multidisciplinary collaboration.

CONCLUSION

Person-centred quality improvement strategies were effective in improving blood pressure outcomes. Further research is needed regarding the context of implementing interventions to provide greater insight into the components of a person-centred quality improvement intervention most effective in improving hypertension outcomes.

Bridging the Silos: A Comparative Analysis of Implementation Science and Improvement Science

Background

Implementation science and improvement science have similar goals of improving health care services for better patient and population outcomes, yet historically there has been limited exchange between the two fields. Implementation science was born out of the recognition that research findings and effective practices should be more systematically disseminated and applied in various settings to achieve improved health and welfare of populations. Improvement science has grown out of the wider quality improvement movement, but a fundamental difference between quality improvement and improvement science is that the former generates knowledge for local improvement, whereas the latter is aimed at producing generalizable scientific knowledge.

Objectives

The first objective of this paper is to characterise and contrast implementation science and improvement science. The second objective, building on the first, is to highlight aspects of improvement science that potentially could inform implementation science and vice versa.

Methods

We used a critical literature review approach. Search methods included systematic literature searches in PubMed, CINAHL, and PsycINFO until October 2021; reviewing references in identified articles and books; and the authors' own cross-disciplinary knowledge of key literature.

Findings

The comparative analysis of the fields of implementation science and improvement science centred on six categories: (1) influences; (2) ontology, epistemology and methodology; (3) identified problem; (4) potential solutions; (5) analytical tools; and (6) knowledge production and use. The two fields have different origins and draw mostly on different sources of knowledge, but they have a shared goal of using scientific methods to understand and explain how health care services can be improved for their users. Both describe problems in terms of a gap or chasm between current and optimal care delivery and consider similar strategies to address the problems. Both apply a range of analytical tools to analyse problems and facilitate appropriate solutions.

Conclusions

Implementation science and improvement science have similar endpoints but different starting points and academic perspectives. To bridge the silos between the fields, increased collaboration between implementation and improvement scholars will help to clarify the differences and connections between the science and practice of improvement, to expand scientific application of quality improvement tools, to further address contextual influences on implementation and improvement efforts, and to share and use theory to support strategy development, delivery and evaluation.

Boundary Objects as Dialogical Learning Accelerators for Social Change in Design for Health: Systematic Review

Background

Boundary objects can add value for innovative design and implementation research in health care through their organizational focus and the dynamic structure between ill-structured and tailored use. However, when innovation is approached as a boundary object, more attention will need to be paid to the preimplementation phase. Research and design thinking pay attention to the preimplementation stage but do not have a social or organizational focus per se. The integration of boundary objects in design methodologies can provide a more social and organizational focus in innovative design projects by mapping out the mechanisms that occur at boundaries during design. Four dialogical learning mechanisms that can be triggered at boundaries have been described in the literature: identification, coordination, reflection, and transformation. These mechanisms seem suitable for integration in innovative design research on health.

Objective

Focusing on innovation in health, this study aims to find out whether the different learning mechanisms can be linked to studies on health innovation that mention boundary objects as a concept and assess whether the related mechanisms provide insight into the stage of the design and implementation or change process.

Methods

The following 6 databases were searched for relevant abstracts: PubMed, Scopus, Education Resources Information Center, PsycINFO, Information Science and Technology Abstracts, and Embase. These databases cover a wide range of published studies in the field of health.

Results

Our initial search yielded 3102 records; after removing the duplicates, 2186 (70.47%) records were screened on the title and abstract, and 25 (0.81%) papers were included; of the 13 papers where we identified 1 mechanism, 5 (38%) described an innovation or innovative project, and of the 12 papers where we identified more mechanisms, 9 (75%) described the development or implementation of an innovation. The reflective mechanism was not identified solely but was present in papers describing a more successful development or implementation project of innovation. In these papers, the predetermined goals were achieved, and the process of integration was relatively smoother.

Conclusions

The concept of boundary objects has found its way into health care. Although the idea of a boundary object was introduced to describe how specific artifacts can fulfill a bridging function between different sociocultural sites and thus have a social focus, the focus in the included papers was often on the boundary object itself rather than the social effect. The reflection and transformation mechanisms were underrepresented in the included studies but based on the findings in this review, pursuing to trigger the reflective mechanism in design, development, and implementation projects can lead to a more fluid and smooth integration of innovation into practice.

Facilitators and barriers to implementation of Alberta family integrated care (FICare) in level II neonatal intensive care units: a qualitative process evaluation substudy of a multicentre cluster-randomised controlled trial using the consolidated framework for implementation research

OBJECTIVE

To evaluate the barriers and facilitators to implementing Alberta Family Integrated Care (AB-FICare [2019 Benzies]), a model of care for integrating parents into level II neonatal intensive care units (NICUs) care teams, from the perspective of healthcare providers (HCP) and hospital administrators.

DESIGN

Qualitative process evaluation substudy.

SETTING

Ten level II NICUs in six cities across Alberta, Canada.

PARTICIPANTS

HCP and hospital administrators (n=32) who were involved in the cluster-randomised controlled trial of AB-FICare in level II NICUs.

METHODS

Post-implementation semi-structured interviews were conducted via phone or in-person. The Consolidated Framework for Implementation Research was used to develop interview guides, code transcripts and analyse data.

RESULTS

Key facilitators to implementation of AB-FICare included (1) a receptive implementation climate, (2) compatibility of the intervention with individual and organisational practices, (3) available resources and access to knowledge and information for HCP and hospital administrators, (4) engagement of key stakeholders across the organisation, (5) engagement of and outcomes for intervention participants, and (6) reflecting and evaluating on implementation progress and patient and family outcomes. Barriers were (1) design quality and packaging of the intervention, (2) relative priority of AB-FICare in relation to other initiatives, and (3) learning climate within the organisation. Mixed influences on implementation depending on contextual factors were coded to eight constructs: intervention source, cost, peer pressure, external policy and incentives, staff needs and resources, structural characteristics, organisational incentives and rewards, and knowledge, beliefs and attitudes.

CONCLUSIONS

The characteristics of an organisation and the implementation process had largely positive influences, which can be leveraged for implementation of AB-FICare in the NICU. We recommend site-specific consultations to mitigate barriers and assess how swing factors might impact implementation given the local context, with the goal that strategies can be put in place to manage their influence on implementation.

TRIAL REGISTRATION NUMBER

NCT02879799.

Are quality improvement plans perceived to improve the quality of primary care in Ontario? Qualitative study

OBJECTIVE

To explore primary care administrators' perceptions of provincially mandated quality improvement plans, and barriers to and facilitators of using quality improvement plans as tools for improving the quality of primary care.

DESIGN

Qualitative descriptive study using semistructured interviews.

SETTING

Ontario.

PARTICIPANTS

Eleven primary care administrators (ie, executive directors, director of clinical services, office administrators) at 7 family health teams and 4 community health centres.

METHODS

All interviews were audiotaped and transcribed verbatim. Data were analyzed deductively to generate a framework based on a conceptual model of structural, organizational, individual, and innovation-related factors that influence the success of improvement initiatives and, inductively, to generate additional themes.

MAIN FINDINGS

Provincially mandated quality improvement plans seem to have raised awareness of and provided an overall focus on quality improvement, and have contributed to primary care organizations implementing initiatives to address quality gaps. Four factors that have contributed to the success of quality improvement plans relate to attributes of the quality improvement plans (adaptability and compatibility) and contextual factors (leadership and organizational culture). However, participants expressed that the use of quality improvement plans have not yet led to substantial improvements in the quality of primary care in Ontario, which may be owing to several challenges: poor data quality, lack of staff and physician engagement and buy-in, and lack of resources to support measurement and quality improvement.

CONCLUSION

Awareness of and focused attention on the need for high-quality patient care may have increased, but participants expressed that substantial improvements in quality care have yet to be achieved in Ontario. The lack of perceived improvements is likely the result of multifaceted and complex challenges primary care organizations face when trying to improve patient care. To effect positive change, organization- and health system-level efforts are needed to improve measurement capabilities, improve staff and physician engagement, and increase capacity for quality improvement among organizations.

Clinicians Report Barriers and Facilitators to High-Quality Ambulatory Oncology Care

BACKGROUND

Ambulatory oncology practices treat thousands of Americans on a daily basis with high-risk and high-cost antineoplastic agents. However, we know relatively little about these diverse practices and the organizational structures influencing care delivery.

OBJECTIVE

The aim of this study was to examine clinician-reported factors within ambulatory oncology practices that affect care delivery processes and outcomes for patients and clinicians.

METHODS

Survey data were collected in 2017 from 298 clinicians (nurses, physicians, nurse practitioners, and physician assistants) across 29 ambulatory practices in Michigan. Clinicians provided written comments about favorable and unfavorable aspects of their work environments that affected their ability to deliver high-quality care. We conducted inductive content analysis and used the Systems Engineering Initiative for Patient Safety work system model to organize and explain our findings.

RESULTS

Clinicians reported factors within all 5 work-system components of the Systems Engineering Initiative for Patient Safety model that affected care delivery and outcomes. Common themes surfaced, such as unfavorable aspects including staffing inadequacy and high patient volume, limited physical space, electronic health record usability issues, and order entry. Frequent favorable aspects focused on the skills of colleagues, collaboration, and teamwork. Some clinicians explicitly reported how work system factors were relational and influenced patient, clinician, and organizational outcomes.

CONCLUSIONS

These findings show how work-system components are interactive and relational reflecting the complex nature of care delivery.

IMPLICATIONS FOR NURSING PRACTICE

Data obtained from frontline clinicians can support leaders in making organizational changes that are congruent with clinician observations of practices' strengths and opportunities for improvement.

Improving professional health literacy in hospitals: study protocol of a participatory codesign and implementation study

INTRODUCTION

In connection with a hospital stay, patients have to make important health-related decisions. They need to find, understand, assess and apply health-related information, and therefore, require health literacy. Adequately responding to the needs of patients requires promoting the communication skills of healthcare professionals within healthcare organisations. Health-literate healthcare organisations can provide an environment strengthening professionals' and patients' health literacy. When developing health-literate healthcare organisations, it has to be considered that implementing organisational change is typically challenging. In this study, a communication concept based on previously evaluated communication training is codesigned, implemented and evaluated in four clinical departments of a university hospital.

METHOD AND ANALYSIS

In a codesign phase, focus group interviews among employees and patients as well as a workshop series with employees and hospital management are used to tailor the communication concept to the clinical departments and to patients' needs. Also, representatives responsible for the topic of health literacy are established among employees. The communication concept is implemented over a 12-month period; outcomes studied are health literacy on the organisational and patient levels. Longitudinal survey data acquired from a control cohort prior to the implementation phase are compared with data of an intervention cohort after the implementation phase. Moreover, survey data from healthcare professionals before and after the implementation are compared. For formative evaluation, healthcare professionals are interviewed in focus groups.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the Medical Faculty of the University of Oldenburg and is in accordance with the Declaration of Helsinki. Study participants are asked to provide written informed consent. The results are disseminated via direct communication within the hospital, publications and conference presentations. If the intervention turns out to be successful, the intervention and implementation strategies will be made available to other hospitals.

TRIAL REGISTRATION NUMBER

DRKS00019830.

Navigating change - managers' experience of implementation processes in disability health care: a qualitative study

Background

Effective implementation processes play a central role in health care organizations and affect the care of patients. Managers are pivotal in facilitating the use of new practices, but their experience and how it affects the implementation outcome are still largely unknown. In the field of disability health care in particular, managers experiences have scarcely been investigated. Therefore, the aim of this study is to explore managers’ experiences of the implementation process when transferring new practices into disability health care settings.

Methods

Semi-structured individual telephone interviews were conducted with managers at disability health care organizations in four administrative regions in central Sweden. A total of 23 managers with formal managerial responsibility from both public and private health care were strategically selected to be interviewed. The interviews were analysed using reflexive thematic analysis with an inductive approach.

Results

The analysis resulted in two themes about factors influencing the implementation process: firstly, Contextual factors set the agenda for what can be achieved, which highlighted aspects that hinder or enable the implementation process, such as internal and external conditions, the workplace culture, the employees and managers’ attitudes and openness to change: secondly, Leadership in the winds of change, which described the challenges of balancing managerial tasks with leading the change, and the importance of a leadership that involves the participation of the employees.

Conclusions

This study explored how and to what extent managers address and manage the implementation process and the many associated challenges. The findings highlight the importance of leadership support and organizational structure in order to transfer new practices into the work setting, and to encourage an organizational culture for leading change that promotes positive outcomes. We suggest that identifying strategies by focusing on contextual factors and on aspects of leadership will facilitate implementation processes.

Trial registration

The SWAN (Structured Water Dance Intervention) study was retrospectively registered on April 9, 2019 and is available online at ClinicalTrials.gov (ID: NCT03908801).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06570-6.

Leveraging digital transformation to empower clinical governance: enhancement in intermediate clinical endpoints and patients' survival after implementation of a continuous quality improvement program in a large dialysis network

BACKGROUND

Treatment of end-stage kidney disease patients is extremely challenging given the inter-connected functional derangements and comorbidities characterizing the disease. Continuous Quality Improvement (CQI) in healthcare is a structured clinical governance process helping physicians adhere to best clinical practices. The digitization of patient medical records and data warehousing technologies has standardized and enhanced the efficiency of the CQÍs evidence generation process. There is limited evidence that ameliorating intermediate outcomes would translate into better patient-centered outcomes. We sought to evaluate the relationship between Fresenius Medical Care (FME) medical patient review CQI (MPR-CQI) implementation and patients' survival in a large historical cohort study.

METHODS

We included all incident adult patients with 6 months survival on chronic dialysis registered in the EMEA region between 2011-2018. We compared medical Key Performance Indicator (KPI) target achievements and 2-year mortality for patients enrolled prior and after to MPR-CQI policy onset (Cohort A and Cohort B). We adopted a structural equation model where MPR-CQI policy was the exogenous explanatory variable, KPI target achievements the mediator variable, and survival was the outcome of interest.

RESULTS

4.270 patients (Cohort A: 2.397; Cohort B: 1.873) met the inclusion criteria. We observed an increase in KPI target achievements after MPR-CQI policy implementation. Mediation analysis demonstrated a significant reduction in mortality due to indirect effect of MPR-CQI implementation through improvement in KPI target achievement occurring in the post-implementation era (OR: 0.70; 95%CI: 0.65-0.76; p < 0.0001).

CONCLUSIONS

Our study suggests that MPR-CQI achieved by standardized clinical practice and periodical, structured, medical patient review may improve patients' survival through improvement in medical KPIs.

Assessing effectiveness and implementation of a perioperative enhanced recovery protocol for children undergoing surgery: study protocol for a prospective, stepped-wedge, cluster, randomized, controlled clinical trial

BACKGROUND

Perioperative enhanced recovery protocols (ERPs) have been found to decrease hospital length of stay, in-hospital costs, and complications among adult surgical populations but evidence for pediatric populations is lacking. The study is designed to evaluate the adoption, effectiveness, and generalizability of a 21-element ERP, adapted for pediatric surgery.

METHODS

The multicenter study is a stepped-wedge, cluster-randomized, pragmatic clinical trial that will evaluate the effectiveness of the ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) intervention while also assessing site-specific adaptations, implementation fidelity, and sustainability. The target patient population is pediatric patients, between 10 and 18 years old, who undergo elective gastrointestinal surgery. Eighteen (N = 18) participating sites will be randomly assigned to one of three clusters with each cluster, in turn, being randomly assigned to an intervention start period (stepped-wedge). Each cluster will participate in a Learning Collaborative, using the National Implementation Research Network's five Active Implementation Frameworks (AIFs) (competency, organization, and leadership), as drivers of facilitation of rapid-cycle adaptations and implementation. The primary study outcome is hospital length of stay, with implementation metrics being used to evaluate adoption, fidelity, and sustainability. Additional clinical outcomes include opioid use, post-surgical complications, and post-discharge healthcare utilization (clinic/emergency room visits, telephone calls to clinic, and re-hospitalizations), as well as, assess patient- and parent-reported health-related quality of life outcomes. The protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist.

DISCUSSION

The study provides a unique opportunity to accelerate the adoption of ERPs across 18 US pediatric surgical centers and to evaluate, for the first time, the effect of a pediatric-specific ENRICH-US intervention on clinical and implementation outcomes. The study design and methods can serve as a model for future pediatric surgical quality improvement implementation efforts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04060303 . Registered on 07 August 2019.

The care and keeping of clinicians in quality improvement

OBJECTIVE

Although frontline clinicians are crucial in implementing and spreading innovations, their engagement in quality improvement remains suboptimal. Our goal was to identify facilitators and barriers to the development and engagement of clinicians in quality improvement.

DESIGN

A 25-item questionnaire informed by theoretical frameworks was developed, tested and disseminated by email.

SETTINGS

Members and fellows of the International Society for Quality in Healthcare.

PARTICIPANTS

1010 eligible participants (380 fellows and 647 members).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Self-efficacy and effectiveness in conducting and leading quality improvement activities.

RESULTS

We received 212 responses from 50 countries, a response rate of 21%. Dedicated time for quality improvement, mentorship and coaching and a professional quality improvement network were significantly related to higher self-efficacy. Factors enhancing effectiveness were dedicated time for quality improvement, multidisciplinary improvement teams, professional development in quality improvement, ability to select areas for improvement and organizational values and culture. Inadequate time, mentorship, organizational support and access to professional development resources were key barriers. Personal strengths contributing to effectiveness were the ability to identify problems that need to be fixed, reflecting on and learning from experiences and facilitating sharing of ideas. Key quality improvement implementation challenges were adopting new payment models, demonstrating the business case for quality and safety and building a culture of accountability and transparency.

CONCLUSIONS

Our findings highlight areas that organizations and professional development programs should focus on to promote clinician development and engagement in quality improvement. Barriers related to training, time, mentorship, organizational support and implementation must be concurrently addressed to augment the effectiveness of other approaches.

Using implementation science to inform the integration of electronic patient-reported experience measures (ePREMs) into healthcare quality improvement: description of a theory-based application in primary care

BACKGROUND

Collecting and monitoring the information from patients through patient-reported experience measures (PREMs) about the quality of care they receive is important for tracking changes in healthcare quality, stimulate innovation, and enhance person-centred care. The objective of this theoretical paper is to discuss the use of implementation science theories, models, and frameworks to inform and evaluate the integration of the electronic collection of PREMs (ePREMs) in healthcare quality improvement for primary care in Canada.

METHODS

To assess potential knowledge-to-practice gaps in implementing ePREMs in primary care in Alberta, the overarching implementation model that will be used is the Knowledge to Action Cycle. An integrated knowledge translation approach will ensure ongoing engagement of key stakeholders (e.g. primary care providers, patients) throughout the study. ePREM implementation will be informed by the identification of barriers and facilitators to implementation using the Consolidated Framework for Implementation Research (CFIR). The CFIR brings an organizational perspective providing an opportunity to explore the intervention characteristics, the context of implementation, individual factors, and the processes that influence implementation of ePREMs in healthcare. Identified barriers and facilitators to ePREM implementation will be mapped to evidence-based implementation strategies and prioritized by stakeholders. The RE-AIM framework will be used to guide the evaluation of ePREM implementation outcomes after six months of implementation by assessing Reach, Effectiveness, Adoption, Implementation, and Maintenance (sustainability).

DISCUSSION

Consultations with stakeholders affirm the importance of using integrated knowledge translation approaches and the need to better understand how to integrate ePREMs in primary care. Using an implementations science approach, this study can provide guidance for mitigating important ePREM implementation challenges and promote the successful uptake and use of ePREMs for quality improvement in healthcare.

The role of accountable care organization affiliation and ownership in promoting physician practice participation in quality improvement collaboratives

BACKGROUND

Quality improvement collaboratives (QICs) have emerged as an important strategy to improve processes and outcomes of clinical care through interorganizational learning. Little is known about the organizational factors that support or deter physician practice participation in QICs.

PURPOSE

The aim of this study was to examine organizational influences on physician practices' propensity to participate in QICs. We hypothesized that practice affiliation with an accountable care organization (ACO) and practice ownership by a system or community health center (CHC) would increase the propensity of physician practices to participate in a QIC.

METHODOLOGY

Data from the third wave of the National Study of Physician Organizations, a nationally representative sample of medical practices (n = 1,359), were analyzed. Weighted multivariate regression analyses were estimated to examine the association of ACO affiliation, ownership, and QIC participation, controlling for practice size, health information technology capacity, public reporting participation, and practice revenue from Medicaid and uninsured patients. The Sobel-Goodman Test was used to explore the extent to which practice use of quality improvement (QI) methods such as Lean, Six Sigma, and use of plan-do-study-act cycles mediates the relationship between ACO affiliation and QIC participation.

FINDINGS

Only 13.6% of practices surveyed in 2012-2013 participated in a QIC. In adjusted analyses, ACO affiliation (odds ratio [OR] = 1.51, p < .01), CHC ownership (OR = 6.57, p < .001), larger practice size (OR = 14.72, p < .001), and health information technology functionality (OR = 1.15, p < .001) were positively associated with QIC participation. Practice use of QI methods partially mediated (13.1%-46.7%) the association of ACO affiliation with QIC participation.

PRACTICE IMPLICATIONS

ACO-affiliated practices are more likely than non-ACO practices to participate in QICs. Practice size rather than system ownership appears to influence QIC participation. QI methods often promoted and used by health care systems such as CHCs and ACOs may promote QIC participation.

Using clinical simulation to study how to improve quality and safety in healthcare

Simulation can offer researchers access to events that can otherwise not be directly observed, and in a safe and controlled environment. How to use simulation for the study of how to improve the quality and safety of healthcare remains underexplored, however. We offer an overview of simulation-based research (SBR) in this context. Building on theory and examples, we show how SBR can be deployed and which study designs it may support. We discuss the challenges of simulation for healthcare improvement research and how they can be tackled. We conclude that using simulation in the study of healthcare improvement is a promising approach that could usefully complement established research methods.

A quasi-experiment assessing the six-months effects of a nurse care coordination program on patient care experiences and clinician teamwork in community health centers

Background

Recognition that coordination among healthcare providers is associated with better quality of care and lower costs has increased interest in interventions designed to improve care coordination. One intervention is to add care coordination to nurses’ role in a formal way. Little is known about effects of this approach, which tends to be pursued by small organizations and those in lower-resource settings. We assessed effects of this approach on care experiences of high-risk patients (those most in need of care coordination) and clinician teamwork during the first 6 months of use.

Methods

We conducted a quasi-experimental study using a clustered, controlled pre-post design. Changes in staff and patient experiences at six community health center practice locations that introduced the added-role approach for high-risk patients were compared to changes in six locations without the program in the same health system. In the pre-period (6 months before intervention training) and post-period (about 6 months after intervention launch, following 3 months of training), we surveyed clinical staff (N = 171) and program-qualifying patients (3007 pre-period; 2101 post-period, including 113 who were enrolled during the program’s first 6 months). Difference-in-differences models examined study outcomes: patient reports about care experiences and clinician-reported teamwork. We assessed frequency of patient office visits to validate access and implementation, and contextual factors (training, resources, and compatibility with other work) that might explain results.

Results

Patient care experiences across all high-risk patients did not improve significantly (p > 0.05). They improved somewhat for program enrollees, 5% above baseline reports (p = 0.07). Staff-perceived teamwork did not change significantly (p = 0.12). Office visits increased significantly for enrolled patients (p < 0.001), affirming program implementation (greater accessing of care). Contextual factors were not reported as problematic, except that 41% of nurses reported incompatibility between care coordination and other job demands. Over 75% of nurses reported adequate training and resources.

Conclusions

There were some positive effects of adding care coordination to nurses’ role within 6 months of implementation, suggesting value in this improvement strategy. Addressing compatibility between coordination and other job demands is important when implementing this approach to coordination.

Mapping the Status of Healthcare Improvement Science through a Narrative Review in Six European Countries

With the aim to explore how improvement science is understood, taught, practiced, and its impact on quality healthcare across Europe, the Improvement Science Training for European Healthcare Workers (ISTEW) project "Improvement Science Training for European Healthcare Workers" was funded by the European Commission and integrated by 7 teams from different European countries. As part of the project, a narrative literature review was conducted between 2008 and 2019, including documents in all partners' languages from 26 databases. Data collection and analysis involved a common database. Validation took place through partners' discussions. Referring to healthcare improvement science (HIS), a variety of terms, tools, and techniques were reported with no baseline definition or specific framework. All partner teams were informed about the non-existence of a specific term equivalent to HIS in their mother languages, except for the English-speaking countries. A lack of consensus, regarding the understanding and implementation of HIS into the healthcare and educational contexts was found. Our findings have brought to light the gap existing in HIS within Europe, far from other nations, such as the US, where there is a clearer HIS picture. As a consequence, the authors suggest further developing the standardization of HIS understanding and education in Europe.

Partnering with patients in quality improvement: towards renewed practices for healthcare organization managers?

BACKGROUND

Around the world, many healthcare organizations engage patients as a quality improvement strategy. In Canada, the University of Montreal has developed a model which consists in partnering with patient advisors, providers, and managers in quality improvement. This model was introduced through its Partners in Care Programs tested with several quality improvement teams in Quebec, Canada. Partnering with patients in quality improvement brings about new challenges for healthcare managers. This model is recent, and little is known about how managers contribute to implementing and sustaining it using key practices.

METHODS

In-depth multi-level case studies were conducted within two healthcare organizations which have implemented a Partners in Care Program in quality improvement. The longitudinal design of this research enabled us to monitor the implementation of patient partnership initiatives from 2015 to 2017. In total, 38 interviews were carried out with managers at different levels (top-level, mid-level, and front-line) involved in the implementation of Partners in Care Programs. Additionally, seven focus groups were conducted with patients and providers.

RESULTS

Our findings show that managers are engaged in four main types of practices: 1-designing the patient partnership approach so that it makes sense to the entire organization; 2-structuring patient partnership to support its deployment and sustainability; 3-managing patient advisor integration in quality improvement to avoid tokenistic involvement; 4-evaluating patient advisor integration to support continuous improvement. Designing and structuring patient partnership are based on typical management practices used to implement change initiatives in healthcare organizations, whereas managing and evaluating patient advisor integration require new daily practices from managers. Our results reveal that managers at all levels, from top to front-line, are concerned with the implementation of patient partnership in quality improvement.

CONCLUSION

This research adds empirical support to the evidence regarding daily managerial practices used for implementing patient partnership initiatives in quality improvement and contributes to guiding healthcare organizations and managers when integrating such approaches.

Influence of external contextual factors on the implementation of health and social care interventions into practice within or across countries-a protocol for a 'best fit' framework synthesis

BACKGROUND

The widespread implementation of interventions is often hindered by a decline and variability in effectiveness across implementation sites. It is anticipated that variations in the characteristics of the external context in different sites, such as the political and funding environment, socio-cultural context, physical environment or population demographics can influence implementation outcome. However, there is only a limited understanding about which and how external contextual factors influence implementation. We aim to develop a comprehensive framework conceptualising the influence of external contextual factors on implementation, particularly when spreading health and social care interventions within or across countries.

METHODS

The review will use the 'best fit' framework synthesis approach. In the first stage of the review, we will examine existing frameworks, models, concepts and theories on external contextual factors and their influence on implementation from a variety of sectors and disciplines including health and social care, education, environmental studies and international development fields. The resulting a priori meta-framework will be tested and refined in the second review stage by analysing evidence from empirical studies focusing on the implementation of health and social care interventions within or across countries. Searches will be conducted in bibliographic databases such as MEDLINE, ERIC, HMIC and IBSS, grey literature sources and on relevant websites. We will also search reference lists, relevant journals, perform citation searches and ask experts in the field. There is no restriction to study type, setting, intervention type or implementation strategy to enable obtaining a broad and in-depth knowledge from various sources of evidence.

DISCUSSION

The review will lead to a comprehensive framework for understanding the influence of external contextual factors on implementation, particularly when spreading health and social care interventions within or across countries. The framework is anticipated to help identify factors explaining the decline and variability in effectiveness of interventions and assessing the prospects of implementation effectiveness, when spreading interventions. We do not intend to only develop another stand-alone implementation framework but one that can be used in conjunction with existing frameworks. The framework can be honed and validated in future empirical research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018084485.

A national quality improvement programme to improve survival after emergency abdominal surgery: the EPOCH stepped-wedge cluster RCT

Background

Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients.

Objectives

The objectives were to assess whether or not the QI programme improves 90-day survival after emergency abdominal surgery; to assess effects on 180-day survival, hospital stay and hospital readmission; and to better understand these findings through an integrated process evaluation, ethnographic study and cost-effectiveness analysis.

Design

This was a stepped-wedge cluster randomised trial. Hospitals were organised into 15 geographical clusters, and commenced the QI programme in random order over 85 weeks. Analyses were performed on an intention-to-treat basis. The primary outcome was analysed using a mixed-effects parametric survival model, adjusting for time-related effects. Ethnographic and economics data were collected in six hospitals. The process evaluation included all hospitals.

Setting

The trial was set in acute surgical services of 93 NHS hospitals.

Participants

Patients aged ≥ 40 years who were undergoing emergency abdominal surgery were eligible.

Intervention

The intervention was a QI programme to implement an evidence-based care pathway.

Main outcome measures

The primary outcome measure was mortality within 90 days of surgery. Secondary outcomes were mortality within 180 days, length of hospital stay and hospital readmission within 180 days. The main economic measure was the quality-adjusted life-years.

Data sources

Data were obtained from the National Emergency Laparotomy Audit database; qualitative interviews and ethnographic observations; quality-of-life and NHS resource use data were collected via questionnaires.

Results

Of 15,873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 participants in the usual care group and 7374 in the QI group. The primary outcome occurred in 1393 participants in the usual care group (16%), compared with 1210 patients in the QI group (16%) [QI vs. usual care hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.96 to 1.28]. No differences were found in mortality at 180 days or hospital readmission; there was a small increase in hospital stay in the QI group (HR for discharge 0.90, 95% CI 0.83 to 0.97). There were only modest improvements in care processes following QI implementation. The ethnographic study revealed good QI engagement, but limited time and resources to implement change, affecting which processes teams addressed, the rate of change and eventual success. In some sites, there were challenges around prioritising the intervention in busy environments and in obtaining senior engagement. The intervention is unlikely to be cost-effective at standard cost-effectiveness thresholds, but may be cost-effective over the lifetime horizon.

Limitations

Substantial delays were encountered in securing data access to national registries. Fewer patients than expected underwent surgery and the mortality rate was lower than anticipated.

Conclusions

There was no survival benefit from a QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. The modest impact of the intervention on process measures, despite good clinician engagement, may have been limited by the time and resources needed to improve patient care.

Future work

Future QI programmes must balance intervention complexity with the practical realities of NHS services to ensure that such programmes can be delivered with the resources available.

Trial registration

Current Controlled Trials ISRCTN80682973 and The Lancet protocol 13PRT/7655.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 32. See the NIHR Journals Library website for further project information.

Framework for Research on Implementation of Process Redesigns

BACKGROUND

Complex system interventions benefit from close attention to factors affecting implementation and resultant outcomes. This article describes a framework for examining these factors in process redesign (PR) and for assessing PR outcomes.

METHODS

Using literature scans and expert comment on draft frameworks based on the Consolidated Framework for Implementation Research, a team of researchers developed the PR framework for the Agency for Healthcare Research and Quality. As a case study, an independent team of researchers in a large care system subsequently applied the PR framework to implementation of Lean-based primary care redesigns.

RESULTS

The PR framework adds 2 domains to the Consolidated Framework for Implementation Research, focused on relevant measures of implementation and outcomes, as well as some new constructs to the Consolidated Framework for Implementation Research. Using the PR framework to guide a study of primary care PR, researchers found that the health care reform environment encouraged staff recognition of need for redesign, but physicians worried about key redesign issues, including colocation with care team partners and the competencies of the individuals assigned to manage new workflows. Team member acceptance of the redesign was also influenced by other features of the implementation process and contextual features, including the decision style of the local clinic.

CONCLUSIONS

The PR framework helped guide the qualitative study and aided researchers in informing their leadership about critical issues affecting PR implementation.

How do emergency departments and emergency leaders catalyze positive change through quality improvement collaborations?

Objectives

Quality Improvement and Patient Safety (QIPS) plays an important role in addressing shortcomings in optimal healthcare delivery. However, there is little published guidance available for emergency department (ED) teams with respect to developing their own QIPS programs. We sought to create recommendations for established and aspiring ED leaders to use as a pathway to better patient care through programmatic QIPS activities, starting internally and working towards interdepartmental collaboration.

Methods

An expert panel comprised of ten ED clinicians with QIPS and leadership expertise was established. A scoping review was conducted to identify published literature on establishing QIPS programs and frameworks in healthcare. Stakeholder consultations were conducted among Canadian healthcare leaders, and recommendations were drafted by the expert panel based on all the accumulated information. These were reviewed and refined at the 2018 CAEP Academic Symposium in Calgary using in-person and technologically-supported feedback.

Results

Recommendations include: creating a sense of urgency for improvement; engaging relevant stakeholders and leaders; creating a formal local QIPS Committee; securing funding and resources; obtaining local data to guide the work; supporting QIPS training for team members; encouraging interprofessional, cross-departmental, and patient collaborations; using an established QIPS framework to guide the work; developing reward mechanisms and incentive structures; and considering to start small by focusing on a project rather than a program.

Conclusion

A list of 10 recommendations is presented as guiding principles for the establishment and sustainable deployment of QIPS activities in EDs throughout Canada and abroad. ED leaders are encouraged to implement our recommendations in an effort to improve patient care.

Implementation of the HEART Pathway: Using the Consolidated Framework for Implementation Research

OBJECTIVE

The HEART Pathway is an evidence-based decision tool for identifying emergency department (ED) patients with acute chest pain who are candidates for early discharge, to reduce unhelpful and potentially harmful hospitalizations. Guided by the Consolidated Framework for Implementation Research, we sought to identify important barriers and facilitators to implementation of the HEART Pathway.

STUDY SETTING

Data were collected at 4 academic medical centers.

STUDY DESIGN

We conducted semi-structured interviews with 25 key stakeholders (e.g., health system leaders, ED physicians). We conducted interviews before implementation of the HEART Pathway tool to identify potential barriers and facilitators to successful adoption at other regional academic medical centers. We also conducted postimplementation interviews at 1 medical center, to understand factors that contributed to successful adoption.

DATA COLLECTION

Interviews were recorded and transcribed verbatim. We used a Consolidated Framework for Implementation Research framework-driven deductive approach for coding and analysis.

PRINCIPAL FINDINGS

Potential barriers to implementation include time and resource burden, challenges specific to the electronic health record, sustained communication with and engagement of stakeholders, and patient concerns. Facilitators to implementation include strength of evidence for reduced length of stay and unnecessary testing and iatrogenic complications, ease of use, and supportive provider climate for evidence-based decision tools.

CONCLUSIONS

Successful dissemination of the HEART Pathway will require addressing institution-specific barriers, which includes engaging clinical and financial stakeholders. New SMART-FHIR technologies, compatible with many electronic health record systems, can overcome barriers to health systems with limited information technology resources.

What Influences Sustainment and Nonsustainment of Facilitation Activities in Implementation? Analysis of Organizational Factors in Hospitals Implementing TeamSTEPPS

Implementation processes are often long and complex, requiring sustained facilitation efforts. Drawing on organizational and implementation literature, we examined the influence of senior management support (SMS), middle management support (MMS), facilitator team time availability (TIME) and team continuity (CONTINUITY) on sustainment of internal facilitation activities. For 2 years, we followed 10 small rural hospitals implementing TeamSTEPPS, a patient safety program, and conducted quarterly interviews with key informants. We coded, calibrated, and analyzed the data using the fuzzy-set qualitative comparative analysis. We found that five hospitals sustained facilitation activities and the combination of SMS, MMS, and CONTINUITY (i.e., presence of all three factors) was a sufficient condition for sustainment. Five other hospitals did not sustain facilitation activities and they either lacked MMS or lacked both TIME and CONTINUITY. In follow-up analyses, we found that team leadership continuity also influenced sustainment patterns. We discussed the implications for research and practice.

Impact of Intervention to Improve Nursing Home Resident-Staff Interactions and Engagement

Background and Objectives

For nursing home residents, positive interactions with staff and engagement in daily life contribute meaningfully to quality of life. We sought to improve these aspects of person-centered care in an opportunistic snowball sample of six Veterans Health Administration nursing homes (e.g., Community Living Centers-CLCs) using an intervention that targeted staff behavior change, focusing on improving interactions between residents and staff and thereby ultimately aiming to improve resident engagement.

Research Design and Methods

We grounded this mixed-methods study in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change. We implemented the intervention by (a) using a set of evidence-based practices for implementing quality improvement and (b) combining primarily CLC-based staff facilitation with some researcher-led facilitation. Validated resident and staff surveys and structured observations collected pre and post intervention, as well as semi-structured staff interviews conducted post intervention, helped assess intervention success.

Results

Sixty-two CLC residents and 308 staff members responded to the surveys. Researchers conducted 1,490 discrete observations. Intervention implementation was associated with increased staff communication with residents during the provision of direct care and decreased negative staff interactions with residents. In the 66 interviews, staff consistently credited the intervention with helping them (a) develop awareness of the importance of identifying opportunities for engagement and (b) act to improve the quality of interactions between residents and staff.

Discussion and Implications

The intervention proved feasible and influenced staff to make simple enhancements to their behaviors that improved resident-staff interactions and staff-assessed resident engagement.

Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial)

BACKGROUND

Improving the quality and safety of perioperative care is a global priority. The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was a stepped-wedge cluster randomised trial of a quality improvement (QI) programme to improve 90-day survival for patients undergoing emergency abdominal surgery in 93 hospitals in the UK National Health Service.

METHODS

The aim of this process evaluation is to describe how the EPOCH intervention was planned, delivered and received, at both cluster and local hospital levels. The QI programme comprised of two interventions: a care pathway and a QI intervention to aid pathway implementation, focussed on stakeholder engagement, QI teamwork, data analysis and feedback and applying the model for improvement. Face-to-face training and online resources were provided to support senior clinicians in each hospital (QI leads) to lead improvement. For this evaluation, we collated programme activity data, administered an exit questionnaire to QI leads and collected ethnographic data in six hospitals. Qualitative data were analysed with thematic or comparative analysis; quantitative data were analysed using descriptive statistics.

RESULTS

The EPOCH trial did not demonstrate any improvement in survival or length of hospital stay. Whilst the QI programme was delivered as planned at the cluster level, self-assessed intervention fidelity at the hospital level was variable. Seventy-seven of 93 hospitals responded to the exit questionnaire (60 from a single QI lead response on behalf of the team); 33 respondents described following the QI intervention closely (35%) and there were only 11 of 37 care pathway processes that > 50% of respondents reported attempting to improve. Analysis of qualitative data suggests QI leads were often attempting to deliver the intervention in challenging contexts: the social aspects of change such as engaging colleagues were identified as important but often difficult and clinicians frequently attempted to lead change with limited time or organisational resources.

CONCLUSIONS

Significant organisational challenges faced by QI leads shaped their choice of pathway components to focus on and implementation approaches taken. Adaptation causing loss of intervention fidelity was therefore due to rational choices made by those implementing change within constrained contexts. Future large-scale QI programmes will need to focus on dedicating local time and resources to improvement as well as on training to develop QI capabilities.

EPOCH TRIAL REGISTRATION

ISRCTN80682973 https://doi.org/10.1186/ISRCTN80682973 Registered 27 February 2014 and Lancet protocol 13PRT/7655.

Measuring Constructs of the Consolidated Framework for Implementation Research in the Context of Increasing Colorectal Cancer Screening in Federally Qualified Health Center

OBJECTIVE

To operationalize constructs from each of the Consolidated Framework for Implementation Research domains and to present psychometric properties within the context of evidence-based approaches for promoting colorectal cancer screening in federally qualified health centers (FQHCs).

METHODS

Data were collected from FQHC clinics across seven states. A web-based Staff Survey and a Clinic Characteristics Survey were completed by staff and leaders (n = 277) from 59 FQHCs.

RESULTS

Internal reliability of scales was adequate ranging from 0.62 for compatibility to 0.88 for other personal attributes (openness). Intraclass correlations for the scales indicated that 2.4 percent to 20.9 percent of the variance in scale scores occurs within clinics. Discriminant validity was adequate at the clinic level, with all correlations less than 0.75. Convergent validity was more difficult to assess given lack of hypothesized associations between factors expected to predict implementation.

CONCLUSIONS

Our results move the field forward by describing initial psychometric properties of constructs across CFIR domains.

HRM practices and organizational change: Evidence from Italian clinical directorates

PURPOSE

The healthcare sector has been facing major reforms, among which the introduction of the Clinical Directorate (CD) model for hospitals. The purpose of this work is to explore the degree of implementation of innovative Human Resource Management (HRM) practices within CDs, in order to understand whether, after more than 15 years from their introduction, they have been able to transform their managerial approach concretely, in line with the CD model's objectives. The tools have been attributed to three main HR initiatives: training, control, and evaluation ones.

DESIGN AND METHODS

During on-site visits in 33 Italian hospitals, data were collected by conducting semi-structured interviews with their CEOs and Clinical Directors. Data concerned both the mere adoption of HRM tools within CDs, as well as their effective degree of implementation. The answers to the questions were translated into a system of percentage scores, so as to detect mean percentages of implementation in each CD. Findings: The general degree of implementation of HRM practices is still somewhat distant from a theoretically excellent and full implementation, especially if we consider the important lag of time since the reforms affected the sector. Nevertheless, results open the way to important considerations about the effectiveness of the CD model. Original value: The original methodology and scoring system suggested in this work produce a concise evaluation of the development of an effective HRM system within CDs. Our framework of analysis allows interesting benchmarking activities among different CDs of an organization and, ultimately, among different organizations. Moreover, the methodology presented may constitute a valid source of information in order to carry out future research on the items able to affect the implementation of such tools.

Organizational culture and climate as moderators of enhanced outreach for persons with serious mental illness: results from a cluster-randomized trial of adaptive implementation strategies

Background

Organizational culture and climate are considered key factors in implementation efforts but have not been examined as moderators of implementation strategy comparative effectiveness. We investigated organizational culture and climate as moderators of comparative effectiveness of two sequences of implementation strategies (Immediate vs. Delayed Enhanced Replicating Effective Programs [REP]) combining Standard REP and REP enhanced with facilitation on implementation of an outreach program for Veterans with serious mental illness lost to care at Veterans Health Administration (VA) facilities nationwide.

Methods

This study is a secondary analysis of the cluster-randomized Re-Engage implementation trial that assigned 3075 patients at 89 VA facilities to either the Immediate or Delayed Enhanced REP sequences. We hypothesized that sites with stronger entrepreneurial culture, task, or relational climate would benefit more from Enhanced REP than Standard REP. Veteran- and site-level data from the Re-Engage trial were combined with site-aggregated measures of entrepreneurial culture and task and relational climate from the 2012 VA All Employee Survey. Longitudinal mixed-effects logistic models examined whether the comparative effectiveness of the Immediate vs. Delayed Enhanced REP sequences were moderated by culture or climate measures at 6 and 12 months post-randomization. Three Veteran-level outcomes related to the engagement with the VA system were assessed: updated documentation, attempted contact by coordinator, and completed contact.

Results

For updated documentation and attempted contact, Veterans at sites with higher entrepreneurial culture and task climate scores benefitted more from Enhanced REP compared to Standard REP than Veterans at sites with lower scores. Few culture or climate moderation effects were detected for the comparative effectiveness of the full sequences of implementation strategies.

Conclusions

Implementation strategy effectiveness is highly intertwined with contextual factors, and implementation practitioners may use knowledge of contextual moderation to tailor strategy deployment. We found that facilitation strategies provided with Enhanced REP were more effective at improving uptake of a mental health outreach program at sites with stronger entrepreneurial culture and task climate; Veterans at sites with lower levels of these measures saw more similar improvement under Standard and Enhanced REP. Within resource-constrained systems, practitioners may choose to target more intensive implementation strategies to sites that will most benefit from them.

Trial registration

ISRCTN: ISRCTN21059161. Date registered: April 11, 2013.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0787-9) contains supplementary material, which is available to authorized users.

Implementing Frontline Worker-Led Quality Improvement in Nursing Homes: Getting to "How"

BACKGROUND

Despite emerging frameworks for quality improvement (QI) implementation, little is known about how the implementation process works, particularly in nursing home settings. A study was conducted to describe "how"' a complex frontline worker-led QI program was implemented in nursing homes.

METHODS

Six focus groups were conducted in February 2017 with participants of a year-long, multicomponent, unit-level QI intervention in seven nursing homes in the Canadian province of Manitoba. Constant comparative analysis was used to examine perspectives of different groups of QI program participants-35 health care aides, health professionals, and managers.

RESULTS

Five themes important to the implementation process were identified: (1) "supportive elements of the QI program structure," (2) "navigating the workplace," (3) "negotiating relationships," (4) "developing individual skills," and (5) "observable program impact." Data on theme integration suggest that "supportive elements of the QI program structure" (Theme 1), "developing individual skills" (Theme 4), and "observable program impact" (on residents, health care aides, and leaders; Theme 5) operated as part of a reinforcing feedback loop that boosted team members' ability to navigate the workplace, negotiate relationships, and implement the QI program.

CONCLUSION

Health care aide-led QI teams are feasible. However, a leadership paradox exists whereby worker-led QI programs also must incorporate concrete mechanisms to promote strong leadership and sponsor support to teams. The findings also point to the underexplored impact of interpersonal relationships between health care aides and professional staff on QI implementation.

Team dynamics within quality improvement teams: a scoping review

PURPOSE

This scoping review examines what is known about the processes of quality improvement (QI) teams, particularly related to how teams impact outcomes. The aim is to provide research-informed guidance for QI leaders and to inform future research questions.

DATA SOURCES

Databases searched included: MedLINE, EMBASE, CINAHL, Web of Science and SCOPUS.

STUDY SELECTION

Eligible publications were written in English, published between 1999 and 2016. Articles were included in the review if they examined processes of the QI team, were related to healthcare QI and were primary research studies. Studies were excluded if they had insufficient detail regarding QI team processes.

DATA EXTRACTION

Descriptive detail extracted included: authors, geographical region and health sector. The Integrated (Health Care) Team Effectiveness Model was used to synthesize findings of studies along domains of team effectiveness: task design, team process, psychosocial traits and organizational context.

RESULTS OF DATA SYNTHESIS

Over two stages of searching, 4813 citations were reviewed. Of those, 48 full-text articles are included in the synthesis. This review demonstrates that QI teams are not immune from dysfunction. Further, a dysfunctional QI team is not likely to influence practice. However, a functional QI team alone is unlikely to create change. A positive QI team dynamic may be a necessary but insufficient condition for implementing QI strategies.

CONCLUSIONS

Areas for further research include: interactions between QI teams and clinical microsystems, understanding the role of interprofessional representation on QI teams and exploring interactions between QI team task, composition and process.

Integrating: A managerial practice that enables implementation in fragmented health care environments

BACKGROUND

How some organizations improve while others remain stagnant is a key question in health care research. Studies identifying how organizations can implement improvement despite barriers are needed, particularly in primary care.

PURPOSES

This inductive qualitative study examines primary care clinics implementing improvement efforts in order to identify mechanisms that enable implementation despite common barriers, such as lack of time and fragmentation across stakeholder groups.

METHODOLOGY

Using an embedded multiple case study design, we leverage a longitudinal data set of field notes, meeting minutes, and interviews from 16 primary care clinics implementing improvement over 15 months. We segment clinics into those that implemented more versus those that implemented less, comparing similarities and differences. We identify interpersonal mechanisms promoting implementation, develop a conceptual model of our key findings, and test the relationship with performance using patient surveys conducted pre-/post-implementation.

FINDINGS

Nine clinics implemented more successfully over the study period, whereas seven implemented less. Successfully implementing clinics exhibited the managerial practice of integrating, which we define as achieving unity of effort among stakeholder groups in the pursuit of a shared and mutually developed goal. We theorize that integrating is critical in improvement implementation because of the fragmentation observed in health care settings, and we extend theory about clinic managers' role in implementation. We identify four integrating mechanisms that clinic managers enacted: engaging groups, bridging communication, sensemaking, and negotiating. The mean patient survey results for integrating clinics improved by 0.07 units over time, whereas the other clinics' survey scores declined by 0.08 units on a scale of 5 (p = .02).

PRACTICE IMPLICATIONS

Our research explores an understudied element of how clinics can implement improvement despite barriers: integrating stakeholders within and outside the clinic into the process. It provides clinic managers with an actionable path for implementing improvement.

Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study

BACKGROUND

Hospital organisational culture affects patient outcomes including mortality rates for patients with acute myocardial infarction; however, little is known about whether and how culture can be positively influenced.

METHODS

This is a 2-year, mixed-methods interventional study in 10 US hospitals to foster improvements in five domains of organisational culture: (1) learning environment, (2) senior management support, (3) psychological safety, (4) commitment to the organisation and (5) time for improvement. Outcomes were change in culture, uptake of five strategies associated with lower risk-standardised mortality rates (RSMR) and RSMR. Measures included a validated survey at baseline and at 12 and 24 months (n=223; average response rate 88%); in-depth interviews (n=393 interviews with 197 staff); and RSMR data from the Centers for Medicare and Medicaid Services.

RESULTS

We observed significant changes (p<0.05) in culture between baseline and 24 months in the full sample, particularly in learning environment (p<0.001) and senior management support (p<0.001). Qualitative data indicated substantial shifts in these domains as well as psychological safety. Six of the 10 hospitals achieved substantial improvements in culture, and four made less progress. The use of evidence-based strategies also increased significantly (per hospital average of 2.4 strategies at baseline to 3.9 strategies at 24 months; p<0.05). The six hospitals that demonstrated substantial shifts in culture also experienced significantly greater reductions in RSMR than the four hospitals that did not shift culture (reduced RSMR by 1.07 percentage points vs 0.23 percentage points; p=0.03) between 2011-2014 and 2012-2015.

CONCLUSIONS

Investing in strategies to foster an organisational culture that supports high performance may help hospitals in their efforts to improve clinical outcomes.