The unpredictable journeys of spreading, sustaining and scaling healthcare innovations: a scoping review

The hierarchy of needs for laboratory medicine requires a foundational care delivery model

Under the collective weight of growing test volume, staffing constraints, and Medicare reimbursements cuts, an enhancement-based, alternative payment structure focused on rewarding the laboratory's care delivery efforts via benchmarking is appealing. However, achieving a value-based payment model requires the development of an inclusive laboratory care delivery model (LCDM) framework. Today, a holistic, practical LCDM framework for laboratory medicine does not exist. However, such creation is essential for establishing unifying tenants of practice for value-tracing by which standardized key performance and population health indicators can be derived. LAB-CARES is the first step in formulating an LCDM with the primary objective of defining and streamlining the processes and strategies necessary to deliver and articulate the value of diagnostic excellence across the healthcare system. The goal of LAB-CARES is to maximize efficiencies, enhance quality, disseminate clinical expertise, increase patient safety, and promote integrative practice. LAB-CARES is designed to improve an individual patient's quality of life (longitudinal laboratory results - beyond one test) and their surrounding communities (e.g., through surveillance and prevention - beyond one patient). Further professional conversation and efforts are paramount to integrate LAB-CARES as a formalized structure within the healthcare landscape.

Experiences of central child health services teams regarding a special governmental investment in child health services

BACKGROUND

Historically marked by a high infant mortality rate, Sweden's healthcare reforms have successively led to a robust, decentralized universal child health system covering over 97% of the population 0-5 years. However, inequities in health have become an increasing problem and the public health law explicitly states that health inequities should be reduced, resulting in various government initiatives. This study examines the experiences of Central Child Health Services (CCHS) teams during the implementation of the Child Health Services Accessibility Agreement between the State and the regions starting in 2017. The agreement aimed to enhance child health service accessibility, especially in socio-economically disadvantaged areas, but broadly stated guidelines and the short-term nature of funding have raised questions about its effectiveness. The aim of this study was to understand the experiences of CCHC teams in implementing the Child Health Services Accessibility Agreement, focusing on investment decisions, implementation efforts, as well as facilitators and barriers to using the funds effectively.

METHODS

CCHC teams were purposefully sampled and invited via email for interviews, with follow-ups for non-respondents. Conducted from January to October 2023, the interviews were held digitally and recorded with individuals familiar with the agreement's implementation within these teams. Both authors analyzed the transcripts thematically, applying Braun and Clarke's framework. Participants represented a cross-section of Sweden's varied healthcare regions.

RESULTS

Three main themes emerged from the thematic analysis: "Easy come, easy go," highlighting funding uncertainties; "What are we supposed to do?" expressing dilemmas over project prioritization and partner collaboration; and "Building castles on sand," focusing on the challenges of staff retention and foundational program stability. Respective subthemes addressed issues like fund allocation timing, strategic decision-making, and the practical difficulties of implementing extended home visiting programs, particularly in collaboration with social services.

CONCLUSIONS

This study uncovered the challenges faced in implementing the Child Health Services Accessibility Agreement across different regions in Sweden. These obstacles underline the need for precise guidelines regarding the use of funds, stable financing for long-term project sustainability, and strong foundational support to ensure effective interprofessional collaboration and infrastructure development for equitable service delivery in child health services.

Hospital process performance and the adoption of medical devices: An organization-based view

Over the past two decades, there has been a growing scholarly interest in the adoption of technology in healthcare. While numerous studies have delved into the effects of specific technologies on the performance of different organizational units and medical specialties, the findings have often been divergent. Unlike the established literature, our approach focuses on the organization's perspective to analyze how technology impacts process performance in hospital settings. More precisely, we compiled a tailored dataset from 56 healthcare organizations in Italy and conducted a comprehensive analysis of panel data from 2016 to 2019, utilizing Ordinary Least Squares (OLS) regression as our main analytical tool. The data shows a clear relationship between an organization's use of medical devices and its overall process performance. Our research highlights the importance of achieving substantial improvements in process performance by strategically integrating new technologies and devices. Policymakers are encouraged to consider introducing incentives to drive hospitals to invest in innovative technologies. Furthermore, monitoring expenditures on new devices could serve as a valuable metric for assessing the extent of technology adoption within clinical practices.

Fidelity, pragmatism and the "grey line" in between-exploring the delivery of a pragmatic physical activity randomised controlled trial-a secondary analysis

BACKGROUND

Intervention fidelity in health services research has been poor with a reported lack of understanding about what constitutes pragmatic adaptation of interventions and what constitutes failure to maintain intervention fidelity. However, the challenges facing those delivering such interventions have not been thoroughly explored. The aims of this study were to critically explore the challenges in maintaining fidelity experienced by physiotherapy staff and support workers when delivering a complex intervention for older people living with frailty.

METHODS

This study is a secondary analysis of data from a process evaluation of a large randomised controlled trial (RCT). The process evaluation employed qualitative methodologies with mixed methods including a variety of data collection methods, including participant observation, semi-structured interviews and documentary analysis. Thematic analysis was used to make sense of the data.

RESULTS

Many therapy staff felt ongoing confusion about what was acceptable to adapt and what needed to follow the protocol exactly. We found that some therapy staff were able to embrace the challenges of pragmatically adapting interventions while maintaining intervention fidelity, others stuck rigidly to the protocol and failed to adapt interventions where it was necessary.

CONCLUSION

It was clear that the understanding of fidelity and pragmatism was poor. While pragmatic trials are vital to replicate real world clinical practice, further guidance may need to be developed in order to guide the level of adaptation that is acceptable before fidelity is undermined.

Innovation in the Delivery of Behavioral Health Services

Several factors motivate the need for innovation to improve the delivery of behavioral health services, including increased rates of mental health and substance use disorders, limited access to services, inconsistent use of evidence-based practices, and persistent racial and ethnic disparities. This narrative review identifies promising innovations that address these challenges, assesses empirical evidence for the effectiveness of these innovations and the extent to which they have been adopted and implemented, and suggests next steps for research. We review five categories of innovations: organizational models, including a range of novel locations for providing services and new ways of organizing services within and across sites; information and communication technologies; workforce; treatment technologies; and policy and regulatory changes. We conclude by discussing the need to strengthen and accelerate the contributions of implementation science to close the gap between the launch of innovative behavioral health services and their widespread use.

Practitioners support and intention to adopt universal access to self-collection in Australia's National Cervical Screening Program

OBJECTIVE

Primary care practitioners are crucial to engaging people in Australia's national cervical screening program. From July 2022, practitioners have been able to offer all screen-eligible people the choice to collect their own self-collected sample; an option introduced to increase equity. This study explored how practitioners are intending to incorporate universal access to self-collection into their clinical care.

METHODS

Semi-structed interviews with 27 general practitioners, nurses, and practice managers from 10 practices in Victoria, Australia conducted between May and August 2022. Interviews were deductively coded, informed by the Consolidated Framework for Implementation Research. The Diffusion of Innovations theory was used to categorise intention to provide self-collection.

RESULTS

Participants were supportive of universal access to self-collection, citing benefits for screen-eligible people and that it overcame the limited adaptability of the previous policy. Most participants' practices (n = 7, 70%) had implemented or had plans to offer the option for self-collection to all. Participants deliberating whether to provide universal access to self-collection held concerns about the correct performance of the self-test and the perceived loss of opportunity to perform a pelvic examination. Limited time to change practice-level processes and competing demands within consultations were anticipated as implementation barriers.

CONCLUSIONS

The extent to which self-collection can promote equity within the program will be limited without wide-spread adoption by practitioners. Communication and education that addresses concerns of practitioners, along with targeted implementation support, will be critical to ensuring that self-collection can increase participation and Australia's progression towards elimination of cervical cancer.

Clinician perspectives of the implementation of an early intervention service for eating disorders in England: a mixed method study

BACKGROUND

The First Episode Rapid Early Intervention for Eating Disorders (FREED) service has been shown to reduce the wait for care and improve clinical outcomes in initial evaluations. These findings led to the national scaling of FREED in England. To support this scaling, we conducted a mixed method evaluation of the perceptions and experiences of clinicians in the early phases of scaling. The Normalisation Process Theory (NPT) was used as a conceptual lens to understand if and how FREED becomes embedded in routine practice.

METHODS

The convergent mixed method evaluation included 21 semi-structured interviews with clinicians from early adopter sites and 211 surveys administered to clinicians before, immediately after and 3 months after the FREED training. The interview guide and survey included questions evaluating attitudes towards early intervention for eating disorders (EDs) and NPT mechanisms. Interview data were analysed using an inductive thematic analysis. The NPT was applied to the inductively derived themes to evaluate if and how NPT domains impacted the implementation. Survey data were analysed using multilevel growth models.

RESULTS

Six themes and 15 subthemes captured barriers and facilitators to implementation at the patient, clinician, service, intervention, implementation and wider system levels. These interacted with the NPT mechanisms to facilitate or hinder the embedding of FREED. Overall, clinicians were enthusiastic and positive towards early intervention for EDs and FREED, largely because of the expectation of improved patient outcomes. This was a considerable driver in the uptake and implementation of FREED. Clinicians also had reservations about capacity and the potential impact on other patients, which, at times, was a barrier for its use. The FREED training led to significant improvements in positive attitudes and NPT mechanisms that were largely maintained at the 3-month follow-up. However, negative attitudes did not significantly improve following training.

CONCLUSIONS

Positive attitudes towards early intervention for EDs increased enthusiasm and engagement with the model. Features of the model and its implementation were effective at developing adopter commitment and capabilities. However, there were aspects of the model and its implementation which require attention in the future (e.g., capacity and the potential impact on the wider service).

Implementing a mental health app library in primary care: A feasibility study

Confronted with a wide range of digital health tools (DHT), professionals and patients need guidance to use these tools correctly and optimize health management. In the fall of 2020, a DHT library developed by Quebec-based company TherAppX was implemented in 22 institutions. The library was designed to enable healthcare professionals to use DHT in clinical care. The purpose of the current study was to assess the feasibility of implementing the library, including user experience, changes in DHT recommendation habits, and factors that helped or hindered the implementation process. A multi-methods design focusing on secondary use of quantitative data collected by TherAppX and semi-structured interviews with users was employed. While the quantitative analyses indicated infrequent use of the library, qualitative analyses highlighted several factors that hindered its implementation, including certain library and user characteristics and the unprecedented context of the COVID-19 pandemic. Nevertheless, the quantitative analyses confirmed interest in DHT and their usefulness during follow-ups. The results revealed a marginally significant pre-post changes in the frequency with which DHT were recommended. This study helped identify areas for improvements and indicates that further evaluation is needed. Future implementations would benefit from ensuring optimal conditions for a successful implementation.

Clinical Informatics Team Members' Perspectives on Health Information Technology Safety After Experiential Learning and Safety Process Development: Qualitative Descriptive Study

BACKGROUND

Although intended to support improvement, the rapid adoption and evolution of technologies in health care can also bring about unintended consequences related to safety. In this project, an embedded researcher with expertise in patient safety and clinical education worked with a clinical informatics team to examine safety and harm related to health information technologies (HITs) in primary and community care settings. The clinical informatics team participated in learning activities around relevant topics (eg, human factors, high reliability organizations, and sociotechnical systems) and cocreated a process to address safety events related to technology (ie, safety huddles and sociotechnical analysis of safety events).

OBJECTIVE

This study aimed to explore clinical informaticians' experiences of incorporating safety practices into their work.

METHODS

We used a qualitative descriptive design and conducted web-based focus groups with clinical informaticians. Thematic analysis was used to analyze the data.

RESULTS

A total of 10 informants participated. Barriers to addressing safety and harm in their context included limited prior knowledge of HIT safety, previous assumptions and perspectives, competing priorities and organizational barriers, difficulty with the reporting system and processes, and a limited number of reports for learning. Enablers to promoting safety and mitigating harm included participating in learning sessions, gaining experience analyzing reported events, participating in safety huddles, and role modeling and leadership from the embedded researcher. Individual outcomes included increased ownership and interest in HIT safety, the development of a sociotechnical systems perspective, thinking differently about safety, and increased consideration for user perspectives. Team outcomes included enhanced communication within the team, using safety events to inform future work and strategic planning, and an overall promotion of a culture of safety.

CONCLUSIONS

As HITs are integrated into care delivery, it is important for clinical informaticians to recognize the risks related to safety. Experiential learning activities, including reviewing safety event reports and participating in safety huddles, were identified as particularly impactful. An HIT safety learning initiative is a feasible approach for clinical informaticians to become more knowledgeable and engaged in HIT safety issues in their work.

"Early intervention isn't an option, it's a necessity": learning from implementation facilitators and challenges from the rapid scaling of an early intervention eating disorders programme in England

Introduction

The First Episode Rapid Early Intervention for Eating Disorders (FREED) service has shown promising outcomes for young people with an eating disorder, leading to national scaling and implementation across England. Between 2020 and 2023, the national implementation of FREED was supported by the Academic Health Science Networks (AHSNs), which are publicly funded organisations with the mission to spread innovations at scale and pace. This study aimed to investigate the views and experiences of AHSN programme leads on the national roll-out of FREED and the perceived sustainability of the model.

Methods and results

Semi-structured interviews were conducted with 13 programme leads across the AHSNs with direct experience supporting the national implementation of FREED. Thematic analysis was adopted using a critical realist approach. Initial sub-themes were inductively generated and then organised under seven larger themes representing the domains of the Non-adoption, Abandonment, and Challenges to Scale-Up, Spread and Sustainability (NASSS) framework. Each sub-theme was classified as a facilitator and/or barrier and then each larger theme/domain was assessed for its complexity (simple, complicated, complex). Data analysis revealed 28 sub-themes, 10 identified as facilitators, 13 as barriers, and five as both. Two domains were classed as simple, three as complicated, and two as complex. Sub-themes ranged from illness-related complexities to organisational pressures. Key facilitators included a high-value proposition for FREED and a supportive network. Key barriers included staffing issues and illness-related factors that challenge early intervention.

Discussion

Participants described broad support for FREED but desired sustained investment for continued provision and improving implementation fidelity. Future development areas raised by participants included enlarging the evidence base for early intervention, increasing associated training opportunities, and widening the reach of FREED. Results offer learning for early intervention in eating disorders and the scaling of new health initiatives.

Mobilizing pilot-based evidence for the spread and sustainability of innovations in healthcare: The role of innovation intermediaries

An endemic challenge facing healthcare systems around the world is how to spread innovation more widely and sustainably. A common response to this challenge involves conducting pilot implementation studies to generate evidence of the innovation's benefits. However, despite the key role that such studies play in the local adoption of innovation, their contribution to the wider spread and sustainability of innovation is relatively under-researched and under-theorized. In this paper we examine this contribution through an empirical examination of the experiences of an innovation intermediary organization in the English NHS (National Health Service). We find that their work in mobilizing pilot-based evidence involves three main strands; configuring to context; transitioning evidence; and managing the transition. Through this analysis we contribute to theory by showing how the agency afforded by intermediary roles can support the effective transitioning of pilot-based evidence across different phases in the innovation journey, and across different occupational groups, and can thus help to create a positive feedback loop from localized early implementers of an innovation to later more widespread adoption and sustainability. Based on these findings, we develop insights on the reasons for the unnecessary repetition of pilots - so-called 'pilotitis'- and offer policy recommendations on how to enhance the role of pilots in the wider spread and sustainability of innovation.

Test, evidence, transition projects in Scotland: developing the evidence needed for transition of effective interventions in cancer care from innovation into mainstream practice

BACKGROUND

A robust evidence base is required to assist healthcare commissioners and providers in selecting effective and sustainable approaches to improve cancer diagnosis and treatment. Such evidence can be difficult to build, given the fast-paced and highly pressured nature of healthcare delivery, the absence of incentives, and the presence of barriers in conducting pragmatic yet robust research evaluations. Cancer Research UK (CRUK) has played an active part in building the evidence base through its funding of programmes to identify, evaluate and scale-up innovative approaches across the UK. The aim of this paper is to describe and explain the research design and intended approach and activities for two cancer services improvement projects in Scotland funded by CRUK.

METHODS

A hybrid effectiveness-implementation study design will assess both the efficiency of the new pathways and their implementation strategies, with the aim of generating knowledge for scale-up. A range of implementation, service and clinical outcomes will be assessed as determined by the projects' Theories of Change (ToCs). A naturalistic case study approach will enable in-depth exploration of context and process, and the collection and synthesis of data from multiple sources including routine datasets, patient and staff surveys, in-depth interviews and observational and other data. The evaluations are informed throughout by a patient/public representatives' group, and by small group discussions with volunteer cancer patients.

DISCUSSION

Our approach has been designed to provide a holistic understanding of how (well) the improvement projects work (in relation to their anticipated outcomes), and how they interact with their wider contexts. The evaluations will help identify barriers, facilitators, and unanticipated consequences that can impact scalability, sustainability and spread. By opting for a pragmatic, participatory evaluation research design, we hope to inform strategies for scaling up successful innovations while addressing challenges in a targeted manner.

Same, Same but Different: Comparing Program Fidelity at Early Versus Late Adopters of a Successful Long-Term School-Based Physical Activity Intervention

Schools have been identified as a promising setting for promoting physical activity (PA). Yet, to realize changes at the population level, successful school-based PA programs need to go to scale. The Svendborgproject is an effective school-based program promoting additional physical education (PE) lessons. The aim of this study is to determine program fidelity across different school groups, representing early and late adopters of the Svendborgproject, and how these are adapting the intervention. Three different school groups were identified, covering the original intervention schools and two groups of late adopters consisting of four former control schools, and five normal schools without any previous connection to the program. A PE teacher questionnaire (n = 122) was used to determine school fidelity. The results show that, while the original intervention schools have implemented the program with the highest fidelity, all schools have implemented the program with medium to high fidelity. It is suggested that having front-runner schools achieving early success with the program both strengthens political project support and provides strategies to back late adopters' implementation of the program. Furthermore, results from the current study suggest that continual promotion of the program by school heads is less important if support is established at the structural and organizational macro level. Finally, we highlight the importance of scaling up organizational capacity when scaling up program reach to assure a workable balance between fidelity and improving the fit to specific contexts.

Exploring the impact of evaluation on learning and health innovation sustainability: protocol for a realist synthesis

BACKGROUND

Within the Learning Health System (LHS) model, learning routines, including evaluation, allow for continuous incremental change to take place. Within these learning routines, evaluation assists in problem identification, data collection, and data transformation into contextualized information, which is then re-applied to the LHS environment. Evaluation that catalyzes learning and improvement may also contribute to health innovation sustainability. However, there is little consensus as to why certain evaluations seem to support learning and sustainability, while others impede it. This realist synthesis seeks to understand the contextual factors and underlying mechanisms or drivers that best support health systems learning and sustainable innovation.

METHODS

This synthesis will be guided by Pawson and colleagues' 2005 and Emmel and colleagues' 2018 guidelines for conducting realist syntheses. The review process will encompass five steps: (1) scoping the review, (2) building theories, (3) identifying the evidence, (4) evidence selection and appraisal, and (5) data extraction and synthesis. An Expert Committee comprised of leaders in evaluation, innovation, sustainability, and realist methodology will guide this synthesis. Review findings will be reported using the RAMESES guidelines.

DISCUSSION

The use of a realist review will allow for exploration and theorizing about the contextual factors and underlying mechanisms that make evaluations 'work' (or 'not work') to support learning and sustainability. Depending on results, we will attempt to synthesize findings into a series of recommendations for evaluations with the intention to support health systems learning and sustainability. Finalized results will be presented at national and international conferences, as well as disseminated via a peer-reviewed publication.

SYSTEMATIC REVIEW REGISTRATION

This realist synthesis protocol has been registered with PROSPERO ( https://www.crd.york.ac.uk/prospero/  ID 382690).

Strategies used throughout the scaling-up process of eConsult - Multiple case study of four Canadian Provinces

BACKGROUND

eConsult is a model of asynchronous communication connecting primary care providers to specialists to discuss patient care. This study aims to analyze the scaling-up process and identify strategies used to support scaling-up efforts in four provinces in Canada.

METHODS

We conducted a multiple case study with four cases (ON, QC, MB, NL). Data collection methods included document review (n = 93), meeting observations (n = 65) and semi-structured interviews (n = 40). Each case was analyzed based on Milat's framework.

RESULTS

The first scaling-up phase was marked by the rigorous evaluation of eConsult pilot projects and the publication of over 90 scientific papers. In the second phase, provinces implemented provincial multi-stakeholder committees, institutionalized the evaluation, and produced documents detailing the scaling-up plan. During the third phase, efforts were made to lead proofs of concept, obtain the endorsement of national and provincial organizations, and mobilize alternate sources of funding. The last phase was mainly observed in Ontario, where the creation of a provincial governance structure and strategies were put in place to monitor the service and manage changes.

CONCLUSIONS

Various strategies need to be used throughout the scaling-up process. The process remains challenging and lengthy because health systems lack clear processes to support innovation scaling-up.

User-operated audiometry - an evaluation of expert vs. non-expert headphone placement

OBJECTIVE

User-operated audiometry faces multiple barriers. One of these is the concern of audiologists that patients (non-experts) placing headphones by themselves results in invalid hearing thresholds due to greater placement variability.

DESIGN

Comparative study. Participants took the AMTAS pure-tone air-conduction audiometry under two different conditions, expert and non-expert circumaural headphone placement for five frequencies within the range 250-8000 Hz. Questionnaires were also used to gain insight into the usability of the user-operated audiometry system - as well as the participants' perceived handling of the audiometry headphones.

STUDY SAMPLE

Thirty participants (mean age 67.5 years).

RESULTS

No statistically significant mean differences in hearing thresholds between the expert and non-expert conditions were found. The mean system usability scale score was 84.5. Handling the headphones was also rated as being easy (30%) or very easy (60%) by most non-experts.

CONCLUSION

The conclusion of the study is that non-experts can be trusted to properly equip a pair of circumaural audiometry headphones for the correct conduction of pure-tone audiometry with only a few digital instructions.

Scaling-Up eConsult: Promising Strategies to Address Enabling Factors in Four Jurisdictions in Canada

BACKGROUND

Effective healthcare innovations are often not scaled up beyond their initial local context. Lack of practical knowledge on how to move from local innovations to large-system improvement hinders innovation and learning capacity in health systems. Studying scale-up processes can lead to a better understanding of how to facilitate the scale-up of interventions. eConsult is a digital health innovation that aims to connect primary care professionals with specialists through an asynchronous electronic consultation. The recent implementation of eConsult in the public health systems of four Canadian jurisdictions provides a unique opportunity to identify different enabling strategies and related factors that promote the scaling up of eConsult across jurisdictions.

METHODS

We conducted a narrative case study in four Canadian provinces, Quebec, Ontario, Manitoba, and Newfoundland & Labrador, over a 3-year period (2018-2021). We observed provincial eConsult committee meetings (n=65) and national eConsult forums (n=3), and we reviewed internal documents (n=93). We conducted semi-structured interviews with key actors in each jurisdiction (eg, researchers, primary care professionals, specialists, policy-makers, and patient partners) (n=40). We conducted thematic analysis guided by the literature on factors and strategies used to scale up innovations.

RESULTS

We identified a total of 31 strategies related to six key enabling factors to scaling up eConsult, including: (1) multi-actor engagement; (2) relative advantage; (3) knowledge transfer; (4) strong evidence base; (5) physician leadership; and (6) resource acquisition (eg, human, material, and financial resources). More commonly used strategies, such as leveraging research infrastructure and bringing together various actors, were used to address multiple enabling factors.

CONCLUSION

Actors used various strategies to scale up eConsult within their respective contexts, and these helped address six key factors that seemed to be essential to the scale-up of eConsult.

Employee-Driven Innovation in Health Organizations: Insights From a Scoping Review

BACKGROUND

Employee-driven innovation (EDI) occurs when frontline actors in health organizations use their firsthand experience to spur new ideas to transform care. Despite its increasing prevalence in health organizations, the organizational conditions under which EDI is operationalized have received little scholarly attention.

METHODS

This scoping review identifies gaps and assembles existing knowledge on four questions: What is EDI in health organizations and which frontline actors are involved? What are the characteristics of the EDI process? What contextual factors enable or impede EDI? And what benefits does EDI bring to health organizations? We searched seven databases with keywords related to EDI in health organizations. After screening 1580 studies by title and abstract, we undertook full-text review of 453 articles, retaining 60 for analysis. We performed a descriptive and an inductive thematic analysis guided by the four questions.

RESULTS

Findings reveal an heterogeneous literature. Most articles are descriptive (n = 41). Few studies are conceptual and empirical (n = 15) and four are conference papers. EDI was often described as a participatory, learning innovation process involving frontline clinical and non-clinical staff and managers. Majority EDI were top-down, often driven by the organization's focus on participatory improvement and innovation and research-based initiatives. Five categories of methods is used in top-down EDI, two thirds of which includes a learning, a team and/or a digital component. Hybrid EDI often involves a team-based component. Bottom-up EDI emerged spontaneously from the work of frontline actors. Enablers, barriers, and benefits of EDI are seen at macro, organizational, team and individual levels; some benefits spread to other health organizations and health systems.

CONCLUSION

This scoping review provides a comprehensive understanding of the organizational conditions under which EDI is operationalized. It offers insights for researchers, health organizations, and policy-makers about how and why frontline actors' involvement is crucial for the transformation of care.

[Déterminants du succès d'une démarche provinciale d'usage optimal des antipsychotiques chez les résidents en soins de longue durée selon les acteurs clés impliqués dans l'implantation]

Le Québec présente le taux de prescriptions d'antipsychotiques le plus élevé chez les personnes âgées de 65 ans et plus au Canada. La démarche « Optimiser les pratiques, les usages, les soins et les services - antipsychotiques » (OPUS-AP) vise à pallier cet enjeu. Étant donné ses premiers résultats prometteurs, notre étude visait à identifier les déterminants de son succès. Elle repose sur un devis d'étude de cas regroupant une analyse documentaire et 21 entrevues auprès d'acteurs clés impliqués dans l'implantation. Les résultats mettent en lumière cinq déterminants centraux : 1) une démarche intégrée, collaborative et probante; 2) des communications et des réseaux au service de la démarche; 3) un climat d'implantation favorable aux changements; 4) un engagement et une implication des parties prenantes; et 5) une stratégie d'application des connaissances intégrée et appuyée. Des défis et recommandations pour assurer la pérennisation et la mise à l'échelle d'OPUS-AP et inspirer des démarches similaires sont identifiés.

Iterative Development, Validation, and Certification of a Smartphone System to Assess Neonatal Jaundice: Development and Usability Study

BACKGROUND

Medical device development is an area facing multiple challenges, resulting in a high number of products not reaching the clinical setting. Neonatal hyperbilirubinemia, manifesting as neonatal jaundice (NNJ), is an important cause of newborn morbidity and mortality. It is important to identify infants with neonatal hyperbilirubinemia at an early stage, but currently there is a lack of tools that are both accurate and affordable.

OBJECTIVE

This study aimed to develop a novel system to assess the presence of NNJ. The device should provide accurate results, be approved as a medical device, be easy to use, and be produced at a price that is affordable even in low-resource settings.

METHODS

We used an iterative approach to develop a smartphone-based system to detect the presence of NNJ. We performed technical development, followed by clinical and usability testing in parallel, after which we initiated the regulatory processes for certification. We updated the system in each iteration, and the final version underwent a clinical validation study on healthy term newborns aged 1 to 15 days before all documentation was submitted for conformity assessment to obtain Conformité Européenne (CE) certification. We developed a system that incorporates a smartphone app, a color calibration card, and a server.

RESULTS

Three iterations of the smartphone-based system were developed; the final version was approved as a medical device after complying with Medical Device Regulation guidelines. A total of 201 infants were included in the validation study. Bilirubin values using the system highly correlated with total serum or plasma bilirubin levels (r=0.84). The system had a high sensitivity (94%) to detect severe jaundice, defined as total serum or plasma bilirubin >250 µmol/L, and maintained a high specificity (71%).

CONCLUSIONS

Our smartphone-based system has a high potential as a tool for identifying NNJ. An iterative approach to product development, conducted by working on different tasks in parallel, resulted in a functional and successful product. By adhering to the requirements for regulatory approval from the beginning of the project, we were able to develop a market-ready mobile health solution.

Scale-up of a chronic care model-based programme for type 2 diabetes in Belgium: a mixed-methods study

BACKGROUND

Type 2 diabetes (T2D) is an increasingly dominant disease. Interventions are more effective when carried out by a prepared and proactive team within an organised system - the integrated care (IC) model. The Chronic Care Model (CCM) provides guidance for its implementation, but scale-up of IC is challenging, and this hampers outcomes for T2D care. In this paper, we used the CCM to investigate the current implementation of IC in primary care in Flanders (Belgium) and its variability in different practice types.

METHODS

Belgium contains three different primary-care practice types: monodisciplinary fee-for-service practices, multidisciplinary fee-for-service practices and multidisciplinary capitation-based practices. Disproportional sampling was used to select a maximum of 10 practices for each type in three Flemish regions, leading to a total of 66 practices. The study employed a mixed methods design whereby the Assessment of Chronic Illness Care (ACIC) was complemented with interviews with general practitioners, nurses and dieticians linked to the 66 practices.

RESULTS

The ACIC scores of the fee-for-service practices - containing 97% of Belgian patients - only corresponded to basic support for chronic illness care for T2D. Multidisciplinary and capitation-based practices scored considerably higher than traditional monodisciplinary fee-for-service practices. The region had no significant impact on the ACIC scores. Having a nurse, being a capitation practice and having a secretary had a significant effect in the regression analysis, which explained 75% of the variance in ACIC scores. Better-performing practices were successful due to clear role-defining, task delegation to the nurse, coordination, structured use of the electronic medical record, planning of consultations and integration of self-management support, and behaviour-change intervention (internally or using community initiatives). The longer nurses work in primary care practices, the higher the chance that they perform more advanced tasks.

CONCLUSIONS

Besides the presence of a nurse or secretary, also working multidisciplinary under one roof and a capitation-based financing system are important features of a system wherein IC for T2D can be scaled-up successfully. Belgian policymakers should rethink the role of paramedics in primary care and make the financing system more integrated. As the scale-up of the IC varied highly in different contexts, uniform roll-out across a health system containing multiple types of practices may not be successful.

Scale and spread of innovation in health and social care: Insights from the evaluation of the New Care Model/Vanguard programme in England

OBJECTIVE

Little is known about how to achieve scale and spread beyond the early local adoption of an innovative health care programme. We use the New Care Model - or 'Vanguard' - programme in the English National Health Service to illuminate the process, assessing why only one of five Vanguard programmes was successfully scaled up.

METHODS

We interviewed a wide range of stakeholders involved in the Vanguard programme, including programme leads, provider organisations, and policymakers. We also consulted relevant documentation.

RESULTS

A lack of direction near the end of the Vanguard programme, a lack of ongoing resources, and limited success in providing real-time monitoring and evaluation may all have contributed to the failure to scale and spread most of the Vanguard models.

CONCLUSIONS

This programme is an example of the 'scale and spread paradox', in which localism was a key factor influencing the successful implementation of the Vanguards but ultimately limited their scale and spread.

Factors associated with the adoption of evidence-based innovations by substance use disorder treatment organizations: A study of HIV testing

INTRODUCTION

Though prior research shows that a range of important regulatory, market, community, and organizational factors influence the adoption of evidence-based practices (EBPs) among health care organizations, we have little understanding of how these factors relate to each other. To address this gap, we test a conceptual model that emphasizes indirect, mediated effects among key factors related to HIV testing in substance use disorder treatment organizations (SUTs), a critical EBP during the US opioid epidemic.

METHODS

We draw on nationally representative data from the 2014 (n = 697) and 2017 (n = 657) National Drug Abuse Treatment System Survey (NDATSS) to measure the adoption of HIV testing among the nation's SUTs and their key organizational characteristics; we also draw on data from the US Census Bureau; Centers for Disease Control; and legislative sources to measure regulatory and community environments. We estimate cross-sectional and longitudinal structural equation models (SEM) to test the proposed model.

RESULTS

Our longitudinal model of the adoption of HIV testing by SUTs in the United States identifies a pathway by which community and market characteristics (rurality and the number of other SUTs in the area) are related to key sociotechnical characteristics of these organizations (alignment of clients, staff, and harm-reduction culture) that, in turn, are related to the adoption of this EBP.

CONCLUSIONS

Results also show the importance of developing conceptual models that include indirect effects to account for organizational adoption of EBPs.

Sustaining and scaling a clinic-based approach to address health-related social needs

Objective

Scaling evidence-based interventions (EBIs) from pilot phase remains a pressing challenge in efforts to address health-related social needs (HRSN) and improve population health. This study describes an innovative approach to sustaining and further spreading DULCE (Developmental Understanding and Legal Collaboration for Everyone), a universal EBI that supports pediatric clinics to implement the American Academy of Pediatrics' Bright Futures™ guidelines for infants' well-child visits (WCVs) and introduces a new quality measure of families' HRSN resource use.

Methods

Between August 2018 and December 2019, seven teams in four communities in three states implemented DULCE: four teams that had been implementing DULCE since 2016 and three new teams. Teams received monthly data reports and individualized continuous quality improvement (CQI) coaching for six months, followed by lighter-touch support via quarterly group calls (peer-to-peer learning and coaching). Run charts were used to study outcome (percent of infants that received all WCVs on time) and process measures (percent of families screened for HRSN and connected to resources).

Results

Integrating three new sites was associated with an initial regression of outcome: 41% of infants received all WCVs on time, followed by improvement to 48%. Process performance was sustained or improved: among 989 participating families, 84% (831) received 1-month WCVs on time; 96% (946) were screened for seven HRSN, 54% (508) had HRSN, and 87% (444) used HRSN resources.

Conclusion

An innovative, lighter-touch CQI approach to a second phase of scale-up resulted in sustainment or improvements in most processes and outcomes. Outcomes-oriented CQI measures (family receipt of resources) are an important addition to more traditional process-oriented indicators.

Strategies for supporting the implementation of a task-shared psychological intervention in South Africa's chronic disease services: qualitative insights from health managers' experiences of project MIND

BACKGROUND

Although evidence indicates that task-shared psychological interventions can reduce mental health treatment gaps in resource-constrained settings, systemic barriers have limited their widespread implementation. Evidence on how to sustain and scale such approaches is scant. This study responds to this gap by examining the experiences of South African health managers involved in the implementation of a task-shared counselling service for Project MIND.

OBJECTIVES

To qualitatively describe managers' experiences of implementing the MIND programme and their insights into potential strategies for supporting sustained implementation.

METHODS

Two focus group discussions (FGDs) and eight in-depth interviews (IDIs) were conducted with managers of urban and rural primary care facilities in the Western Cape province. All managers were female and 30-50 years old. FGDs and IDIs used an identical semi-structured topic guide to explore the experiences of the MIND programme and perceived barriers to sustained implementation. Normalisation process theory (NPT) guided the thematic analysis.

RESULTS

Four themes emerged that mapped onto the NPT constructs. First, managers noted that their relational work with staff to promote support for the intervention and reduce resistance was key to facilitating implementation. Second, managers emphasised the need for staff reorientation and upskilling to foster openness to mental health practice and for adequate time for quality counselling. Third, managers underscored the importance of strengthening linkages between the health and social service sectors to facilitate delivery of comprehensive mental health services. Finally, managers recommended ongoing monitoring of the service and communication about its impacts as strategies for supporting integration into routine practice.

CONCLUSIONS

Findings contribute to the emerging literature on strategies to support implementation of task-shared interventions in low- and middle-income countries. The findings highlight the leadership role of managers in identifying and actioning these strategies. Investing in managers' capacity to support implementation of psychological interventions is critical for scale-up of these mental health innovations.

Measurement and Monitoring of Safety Framework: a qualitative study of implementation through a Canadian learning collaborative

BACKGROUND

The Measurement and Monitoring of Safety Framework (MMSF) aims to move beyond a narrow focus on measurement and past harmful events as the major focus for safety in healthcare organisations. There is limited evidence of MMSF implementation and impact.

OBJECTIVE

We aimed to examine participants' perspectives and experiences to increase understanding of the adaptive work of implementing the MMSF through a learning collaborative programme in diverse healthcare contexts across Canada.

METHODS

The Collaborative consisted of 11 teams from seven provinces. We conducted a qualitative study involving interviews with 36 participants, observations of 5 sites and learning sessions, and collection of documents.

RESULTS

Collaborative sessions and coaching allowed participants to explore reliability, sensitivity to operations, anticipation and preparedness, and integration and learning, in addition to past harm, and move beyond a project and measurement oriented safety approach. Participants noted the importance of time dedicated to engaging stakeholders in talk about MMSF concepts and their significance to their settings, prior to moving to implementing the Framework into practice. While participants generally started with a small number of ways of integrating the MMSF into practice such as rounds or huddles, many teams continued to experiment with incorporating the MMSF into a range of practices. Participants reported changes in thinking about safety, discussions and behaviours, which were perceived to impact healthcare processes. However, participants also reported challenges to sharing the Framework broadly and moving beyond its surface implementation, and difficulties with its sustained and widespread use given misalignments with existing quality and safety processes.

CONCLUSION

The MMSF requires a dramatic departure from traditional safety strategies that focus on discrete problems and emphasise measurement. MMSF implementation requires extensive discussion, coaching and experimentation. Future implementation should consider engaging local leaders and coaches and an organisation or system approach to enable broader reach and systemic change.

Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study

OBJECTIVE

We aimed to increase the understanding of the scaling of de-implementation strategies by identifying the determinants of the process and developing a determinant framework.

DESIGN AND METHODS

This study has a mixed-methods design. First, we performed an integrative review to build a literature-based framework describing the determinants of the scaling of healthcare innovations and interventions. PubMed and EMBASE were searched for relevant studies from 1995 to December 2020. We systematically extracted the determinants of the scaling of interventions and developed a literature-based framework. Subsequently, this framework was discussed in four focus groups with national and international de-implementation experts. The literature-based framework was complemented by the findings of the focus group meetings and adapted for the scaling of de-implementation strategies.

RESULTS

The literature search resulted in 42 articles that discussed the determinants of the scaling of innovations and interventions. No articles described determinants specifically for de-implementation strategies. During the focus groups, all participants agreed on the relevance of the extracted determinants for the scaling of de-implementation strategies. The experts emphasised that while the determinants are relevant for various countries, the implications differ due to different contexts, cultures and histories. The analyses of the focus groups resulted in additional topics and determinants, namely, medical training, professional networks, interests of stakeholders, clinical guidelines and patients' perspectives. The results of the focus group meetings were combined with the literature framework, which together formed the supporting the scaling of de-implementation strategies (SPREAD) framework. The SPREAD framework includes determinants from four domains: (1) scaling plan, (2) external context, (3) de-implementation strategy and (4) adopters.

CONCLUSIONS

The SPREAD framework describes the determinants of the scaling of de-implementation strategies. These determinants are potential targets for various parties to facilitate the scaling of de-implementation strategies. Future research should validate these determinants of the scaling of de-implementation strategies.

How Do We Know Co-Created Solutions Work Effectively within the Real World of People Living with Dementia? Learning Methodological Lessons from a Co-Creation-to-Evaluation Case Study

Living Labs (LL) are a novel and potentially robust way of addressing real-life health challenges, especially within the dementia field. Generally, LLs focus on co-creating through implementing the quadruple helix partnership as a user-centric approach to co-creating. In the context of this paper, the users were people with dementia and their informal carers. LL are not necessarily environments that evaluate these co-created innovations within the real world. Considering this disconnect between co-creation and real-world evaluation, this paper, as a critical commentary, will reflect on the methodological lessons learnt during the development of an LL model aimed at addressing this discrepancy. The LL at Liverpool John Moores University (LJMU) was commissioned to co-create and then evaluate a new Dementia Reablement Service. The case study findings revealed that the Dementia Reablement Service had a positive impact on the quality of life of people with dementia, suggesting that the service is a catalyst for positive change. In addition, the critical learning from this case study highlights the potential role of LLs in seamlessly co-creating and then evaluating the co-created solution within the real world. A benefit of this way of working is that it provides opportunities for LLs to secure access to traditional research funding.

Identifying core strategies and mechanisms for spreading a national medicines optimisation programme across England-a mixed-method study applying qualitative thematic analysis and Qualitative Comparative Analysis

Background

Achieving widespread adoption of innovations across health systems remains a challenge. Past efforts have focused on identifying and classifying strategies to actively support innovation spread (replicating an innovation across sites), but we lack an understanding about the mechanisms which such strategies draw on to deliver successful spread outcomes. There is also no established methodology to identify core strategies or mechanisms which could be replicated with fidelity in new contexts when spreading innovations. We aimed to understand which strategies and mechanisms are connected with successful spread using the case of a national medicines optimisation programme in England.

Methods

The study applied a comparative mixed-method case study approach. We compared spread activity in 15 Academic Health Science Networks (AHSN) in England, applied to one innovation case, Transfers of Care Around Medicines (TCAM). We followed two methodological steps: (1) qualitative thematic analysis of primary data collected from 18 interviews with AHSN staff members to identify the strategies and mechanisms and related contextual determinants and (2) Qualitative Comparative Analysis (QCA) combining secondary quantitative data on spread outcome and qualitative themes from step 1 to identify the core strategies and mechanisms.

Results

We identified six common spread strategy-mechanism constructs that AHSNs applied to spread the TCAM national spread programme: (1) the unique intermediary position of the AHSN as “honest broker” and local networking organisation, (2) the right capacity and position of the spread facilitator, (3) an intersectoral and integrated stakeholder engagement approach, (4) the dynamic marriage of the innovation with local health and care system needs and characteristics, (5) the generation of local evidence, and (6) the timing of TCAM. The QCA resulted in the core strategy/mechanism of a timely start into the national spread programme in combination with the employment of a local, senior pharmacist as an AHSN spread facilitator.

Conclusions

By qualitatively comparing experiences of spreading one innovation across different contexts, we identified common strategies, causal mechanisms, and contextual determinants. The QCA identified one core combination of two strategies/mechanisms. The identification of core strategies/mechanisms and common pre-conditional and mediating contextual determinants of a specific innovation offers spread facilitators and implementers a priority list for tailoring spread activities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00364-5.

A qualitative study of hospital and community providers’ experiences with digitalization to facilitate hospital-to-home transitions during the COVID-19 pandemic

Background

The COVID-19 pandemic has triggered substantial changes to the healthcare context, including the rapid adoption of digital health to facilitate hospital-to-home transitions. This study aimed to: i) explore the experiences of hospital and community providers with delivering transitional care during the COVID-19 pandemic; ii) understand how rapid digitalization in healthcare has helped or hindered hospital-to-home transitions during the COVID-19 pandemic; and, iii) explore expectations of which elements of technology use may be sustained post-pandemic.

Methods

Using a pragmatic qualitative descriptive approach, remote interviews with healthcare providers involved in hospital-to-home transitions in Ontario, Canada, were conducted. Interviews were analyzed using a team-based rapid qualitative analysis approach to generate timely results. Visual summary maps displaying key concepts/ideas were created for each interview and revised based on input from multiple team members. Maps that displayed similar concepts were then combined to create a final map, forming the themes and subthemes.

Results

Sixteen healthcare providers participated, of which 11 worked in a hospital, and five worked in a community setting. COVID-19 was reported to have profoundly impacted healthcare providers, patients, and their caregivers and influenced the communication processes. There were several noted opportunities for technology to support transitions.

Interpretation

Several challenges with technology use were highlighted, which could impact post-pandemic sustainability. However, the perceived opportunities for technology in supporting transitions indicate the need to investigate the optimal role of technology in the transition workflow.

Supporting Rehabilitation of Rural Patients Receiving Total Knee Arthroplasty Through Physical Activity: Perceptions of Stakeholder Groups

Objective

To identify how patients with osteoarthritis waiting for and recovering from total knee arthroplasty (TKA) conceptualized and participated in physical activity behaviors in their rural setting and to gather perceptions of health care professionals and rehabilitation decision‐makers on the feasibility of a remotely led physical activity coaching intervention.

Methods

Using a qualitative descriptive study, we collected data from three stakeholder groups: patients waiting for or recovering from TKA (interviews), health professionals delivering a physical activity intervention to patients in the recovering cohort (focus group), and rehabilitation leaders involved in decision‐making at the local or provincial level (interviews).

Results

A total of 38 individuals provided their perspectives (25 patients, five health professionals, eight decision‐makers). Patients waiting for and recovering from surgery described the attributes of their rural environment that supported and restricted their ability to participate in physical activities. Patients recovering from TKA appreciated support for goal‐setting and problem‐solving during their rehabilitation. Health care professionals and decision‐makers commented on the benefits of the program's innovative use of relatively simple technology to support remotely delivered, personalized rehabilitation in rural settings.

Conclusion

This study adds to the limited voice of and about patients living with osteoarthritis who reside in rural settings and identifies facilitators and barriers to TKA rehabilitation in this population. Our findings highlight that it is important to consider the local context and the resources available to patients as they navigate living well with osteoarthritis.

Making Digital Health “Solutions” Sustainable in Healthcare Systems: A Practitioner Perspective

Digital health solutions have the potential to bring about great improvements in the delivery and quality of services in healthcare systems. In this paper, we draw on the extensive experience of NHS (National Health Service) England to develop a practitioner perspective on the challenges of effectively implementing and sustaining such solutions. We argue that a properly sustainable approach requires a shift in both thinking and practice when it comes to the spread and adoption of such technologies. Our thinking needs to shift from a focus on the technology itself to how we bring about the changes needed to deliver more efficient and effective care for patients. In practical terms, this means focussing on the changes involved to integrate digital health solutions into the delivery of services. In particular, it requires greater attention to the motivations, constraints and specific contexts that influence users and patients. The technical expertise of innovators therefore needs to be complemented by other forms of insight into change processes, including clinical and behavioral insight, process engineering and knowledge management. In this paper, we show how these different pillars of the NHS Sustainable Healthcare approach help to ensure the effective implementation and use of digital solutions. We draw out the implications of this approach for policy-makers in healthcare systems, highlighting the need to give greater attention and resources to the downstream challenges of implementing digital health solutions.

Domains and processes for institutionalizing evidence-informed health policy-making: a critical interpretive synthesis

BACKGROUND

While calls for institutionalization of evidence-informed policy-making (EIP) have become stronger in recent years, there is a paucity of methods that governments and organizational knowledge brokers can use to sustain and integrate EIP as part of mainstream health policy-making. The objective of this paper was to conduct a knowledge synthesis of the published and grey literatures to develop a theoretical framework with the key features of EIP institutionalization.

METHODS

We applied a critical interpretive synthesis (CIS) that allowed for a systematic, yet iterative and dynamic analysis of heterogeneous bodies of literature to develop an explanatory framework for EIP institutionalization. We used a "compass" question to create a detailed search strategy and conducted electronic searches to identify papers based on their potential relevance to EIP institutionalization. Papers were screened and extracted independently and in duplicate. A constant comparative method was applied to develop a framework on EIP institutionalization. The CIS was triangulated with the findings of stakeholder dialogues that involved civil servants, policy-makers and researchers.

RESULTS

We identified 3001 references, of which 88 papers met our eligibility criteria. This CIS resulted in a definition of EIP institutionalization as the "process and outcome of (re-)creating, maintaining and reinforcing norms, regulations, and standard practices that, based on collective meaning and values, actions as well as endowment of resources, allow evidence to become-over time-a legitimate and taken-for-granted part of health policy-making". The resulting theoretical framework comprised six key domains of EIP institutionalization that capture both structure and agency: (1) governance; (2) standards and routinized processes; (3) partnership, collective action and support; (4) leadership and commitment; (5) resources; and (6) culture. Furthermore, EIP institutionalization is being achieved through five overlapping stages: (i) precipitating events; (ii) de-institutionalization; (iii) semi-institutionalization (comprising theorization and diffusion); (iv) (re)-institutionalization; and (v) renewed de-institutionalization processes.

CONCLUSIONS

This CIS advances the theoretical and conceptual discussions on EIP institutionalization, and provides new insights into an evidence-informed framework for initiating, strengthening and/or assessing efforts to institutionalize EIP.

In It for the Long Haul: RE-AIM Evaluation of a Preschool Programme Implementing and Maintaining Adult-Initiated Motor Skill Development and Physical Activity across a Two-Year Period

Good motor skills (MS) are considered important for children's social, psychological and physical development and general physical activity (PA) levels. The Motor skill in Preschool study (MiPS) aimed to optimize children's MS through weekly PA sessions. The aim of this study is to use the RE-AIM framework to report the two-year implementation process of MiPS since the programme's initiation. Data were collected through a staff questionnaire based on the RE-AIM framework. Data were collected at three months, one year and two years after initiation. Results show that the pedagogical staff believes that the programme promotes MS in children. Implementation measures only showed medium to low fidelity concerning the core element of performing adult-initiated PA sessions with a duration of at least 45 min 4 days a week. The largest barrier was finding the time to plan these PA sessions. Still, the content of the PA sessions achieved high fidelity scores and the programme was deemed suitable for staff's everyday practice and in alignment with the stated pedagogical goals. The mandatory competence development course was highly valued as strong implementation support. It is notable that there is a large variation in the implementation among the preschools with some struggling more than others.

Factors influencing sustainability and scale-up of rural primary healthcare memory clinics: perspectives of clinic team members

Background

The aging of rural populations contributes to growing numbers of people with dementia in rural areas. Despite the key role of primary healthcare in rural settings there is limited research on effective models for dementia care, or evidence on sustaining and scaling them. The purpose of this study was to identify factors influencing sustainability and scale-up of rural primary care based memory clinics from the perspective of healthcare providers involved in their design and delivery.

Methods

Participants were members of four interdisciplinary rural memory clinic teams in the Canadian province of Saskatchewan. A qualitative cross-sectional and retrospective study design was conducted. Data were collected via 6 focus groups (n = 40) and 16 workgroup meetings held with teams over 1 year post-implementation (n = 100). An inductive thematic analysis was used to identify themes.

Results

Eleven themes were identified (five that influenced both sustainability and scale-up, three related to sustainability, and three related to scale-up), encompassing team, organizational, and intervention-based factors. Factors that influenced both sustainability and scale-up were positive outcomes for patients and families, access to well-developed clinic processes and tools, a confident clinic leader-champion, facilitation by local facilitators and the researchers, and organizational and leadership support. Study findings revealed the importance of particular factors in the rural context, including facilitation to support team activities, a proven ready-to-use model, continuity of team members, and mentoring.

Conclusions

Interdisciplinary models of dementia care are feasible in rural settings if the right conditions and supports are maintained. Team-based factors were key to sustaining and scaling the innovation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07550-0.

Capitalizing Upon Graduate Student Projects to Sustain Clinical Outcomes

As part of a clinical-academic partnership, graduate nursing students initiated evidence-based quality improvement projects in a large, metropolitan, 5-time Magnet®-designated pediatric hospital to encourage continuous innovation and evidence-based practice. This article describes the evolution and strategies used by leadership and staff to sustain the projects over time. Data collected by the organization report trended outcomes, highlight themes for success from graduate nursing students from 2017 through 2020, and report the implications for nurse executives.

Evaluation of a Dragons' Den-inspired symposium to spread primary health care innovations in Quebec, Canada: a mixed-methods study using quality-improvement e-surveys

BACKGROUND

On May 24, 2017, the Quebec College of Family Physicians held an innovation symposium inspired by the television show Dragons' Den, at which innovators pitched their innovations to Dragon-Facilitators (i.e., decision-makers) and academic family medicine clinical leads. We evaluated the effects of the symposium on the spread of primary health care innovations.

METHODS

We conducted a mixed-methods evaluation of the symposium. We collected data related to Rogers' innovation-decision process using 3 quality-improvement e-surveys (distributed between May 2017 and February 2018). The first survey evaluated spread outputs (innovation discovery, intention to spread, improvements) and was sent to all participants immediately after the symposium. The second evaluated short-term spread outcomes (follow-ups, successes, barriers) and was sent to innovators 3 months after the symposium. The third evaluated medium-term spread outcomes (spread, perceived impact) and was sent to innovators and clinical leads 9 months after the symposium. We analyzed the data using descriptive statistics, content analysis and joint display.

RESULTS

Fifty-one innovators, 66 clinical leads (representing 42 clinics) and 37 Dragon-Facilitators attended the symposium. The response rates for the surveys were 61% (82/134) for the immediate post-symposium survey of all participants; 68% (21/31) for the 3-month survey of innovators; and 49% (48/97) for the 9-month survey of clinical leads and innovators. Immediately after the symposium, clinical leads and Dragon-Facilitators reported a high likelihood of adopting an innovation (mean ± standard deviation 8.02 ± 1.63 on a 10-point Likert scale) and 87% (53/61) agreed that they had discovered innovations at the symposium. Nearly all innovators (95%, 20/21) intended to follow up with potential adopters. After 3 months, 62% (13/21) of innovators had followed up in some way. After 9 months, 72% of clinical leads (18/25) had implemented at least 1 innovation, and 52% of innovators (12/23) had spread or were in the process of spreading innovations.

INTERPRETATION

The innovation symposium supported participants in achieving the early stages of spreading primary health care innovations. Replicating such symposia may help spread other health care innovations.

Intuition and rationality in intrapreneurship and innovation outputs: The case of health professionals in primary health care

The aim of this article is to explore the role of cognitive styles and intrapreneurship in health professionals’ innovation outputs, as well the mediated effect of intrapreneurship between cognitive styles and innovation output. This study used the survey method of data collection, through a self-administered questionnaire. Partial least square structural equation modelling method was used to analyse the result of the sample of 209 professionals of primary health care providers in Northern Portugal. Our findings reveal that cognitive style plays a significant role in intrapreneurship and innovation outputs, which are mediated by intrapreneurship. In particular, health care professionals with the rational cognitive style are likely to be more of a intrapreneur and innovative as compared to those with a intuitive cognitive style. Promoting intrapreneurship is crucial for successful innovation outputs. This study reveals that an understanding of the cognitive style of the health care professionals can help managers allocate appropriate individuals to different healthcare tasks. Our primary contribution to theory has been to highlight the importance of cognitive styles in intrapreneurship and innovation within the context of primary health care organizations.

Initiating and integrating a personalized end of life care project in a community hospital intensive care unit: A qualitative study of clinician and implementation team perspectives

RATIONALE

The end of life (EOL) experience in the intensive care unit (ICU) can be psychologically distressing for patients, families, and clinicians. The 3 Wishes Project (3WP) personalizes the EOL experience by carrying out wishes for dying patients and their families. While the 3WP has been integrated in academic, tertiary care ICUs, implementing this project in a community ICU has yet to be described.

OBJECTIVES

To examine facilitators of, and barriers to, implementing the 3WP in a community ICU from the clinician and implementation team perspective.

METHODS

This qualitative descriptive study evaluated the implementation of the 3WP in a 20-bed community ICU in Southern Ontario, Canada. Patients were considered for the 3WP if they had a high likelihood of imminent death or planned withdrawal of life-sustaining therapy. Following the qualitative descriptive approach, semi-structured interviews were conducted with purposively sampled clinicians and implementation team. Data from transcribed interviews were analyzed in triplicate through qualitative content analysis.

RESULTS

Interviews with 12 participants indicated that the 3WP personalized and enriched the EOL experience. Interviewees indicated higher intensity education strategies were needed to enable spread as the project grew. Clinicians described many physical resources for the project but suggested more non-clinical project support for orientation, continuing education, and data collection. A majority of wishes focused on physical resources including keepsakes, which helped facilitate project spread when clinician capacity was attenuated by competing duties.

CONCLUSIONS

In this community hospital, ICU clinicians and implementation team members report perceived improved EOL care for patients, families, and clinicians following 3WP initiation and integration. Implementing individualized and meaningful wishes at EOL for dying patients in a community ICU requires adequate planning and time dedicated to optimizing clinician education. Adapting key features of an intervention to local expertise and capacity may facilitate spread during project initiation and integration.

Caught between HIV exceptionalism and health service integration: Making visible the role of public health policy in the scale-up of novel sexual health services

The role of contextual factors for program implementation is well-documented; however, their changing function throughout implementation phases is less established. We conducted an institutional ethnography to understand how structural conditions for scaling up initiatives are shaped by public health policy. We conducted 25 interviews with implementers of a comprehensive sexual health testing service in Canada, 21 meeting observations, and textual analyses of key policies and reports. Our analysis revealed a disjuncture between implementers' task of scaling up programming and the actualities of working within the discursive and material confines of policies premised on HIV exceptionalism and underfunded integrated health services.

Scaling Up Public Health Interventions: Engaging Partners Across Multiple Levels

Advancing the science of intervention scale-up is essential to increasing the impact of effective interventions at the regional and national levels. In contrast with work in high-income countries (HICs), where scale-up research has been limited, researchers in low- and middle-income countries (LMICs) have conducted numerous studies on the regional and national scale-up of interventions. In this article, we review the state of the science on intervention scale-up in both HICs and LMICs. We provide an introduction to the elements of scale-up followed by a description of the scale-up process, with an illustrative case study from our own research. We then present findings from a scoping review comparing scale-up studies in LMIC and HIC settings. We conclude with lessons learned and recommendations for improving scale-up research. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Closing the know-do gap for child health: UNICEF's experiences from embedding implementation research in child health and nutrition programming

UNICEF operates in 190 countries and territories, where it advocates for the protection of children’s rights and helps meet children’s basic needs to reach their full potential. Embedded implementation research (IR) is an approach to health systems strengthening in which (a) generation and use of research is led by decision-makers and implementers; (b) local context, priorities, and system complexity are taken into account; and (c) research is an integrated and systematic part of decision-making and implementation. By addressing research questions of direct relevance to programs, embedded IR increases the likelihood of evidence-informed policies and programs, with the ultimate goal of improving child health and nutrition.

This paper presents UNICEF’s embedded IR approach, describes its application to challenges and lessons learned, and considers implications for future work.

From 2015, UNICEF has collaborated with global development partners (e.g. WHO, USAID), governments and research institutions to conduct embedded IR studies in over 25 high burden countries. These studies focused on a variety of programs, including immunization, prevention of mother-to-child transmission of HIV, birth registration, nutrition, and newborn and child health services in emergency settings. The studies also used a variety of methods, including quantitative, qualitative and mixed-methods.

UNICEF has found that this systematically embedding research in programs to identify implementation barriers can address concerns of implementers in country programs and support action to improve implementation. In addition, it can be used to test innovations, in particular applicability of approaches for introduction and scaling of programs across different contexts (e.g., geographic, political, physical environment, social, economic, etc.). UNICEF aims to generate evidence as to what implementation strategies will lead to more effective programs and better outcomes for children, accounting for local context and complexity, and as prioritized by local service providers. The adaptation of implementation research theory and practice within a large, multi-sectoral program has shown positive results in UNICEF-supported programs for children and taking them to scale.

Sustainment of proactive physical therapy for individuals with early-stage Parkinson's disease: a quality improvement study over 4 years

Background

Implementation science frameworks aided the development of a new, evidence-based clinical physical therapy program. The purpose of this report is to describe the process of sustaining a clinical program in practice for over 4 years. We present a framework for integrating tools for sustainability with the Knowledge-to-Action model in the context of a proactive physical therapy (PAPT) program for individuals with early-stage Parkinson’s disease.

Methods

Sustainability of implementation strategies was addressed using the Dynamic Sustainability Framework and sustainability assessment tools. Repeated retrospective medical record reviews and phone interviews were used to evaluate the reach and adoption of the PAPT over 4 years. Characteristics of those who engaged with PAPT, implementation fidelity, and clinical effectiveness were assessed for year 1 and year 3. Sustainability was measured using RE-AIM, NHS Sustainability Model, and Clinical Sustainability Assessment Tool.

Results

Reach increased from 28 to 110 total patients per year and spread occurred from one to three sites. PAPT user age, sex, Hoehn and Yahr rating, time since diagnosis, and type of insurance were similar in year 1 and year 3 (p > 0.05). The program sustained its effect to help participants increase or maintain self-reported exercise (Y1, 95%; Y3, 100%). However, upon evaluation PAPT users in year 3 had longer time since symptom onset and worse UPDRS motor scores compared to the PAPT users in year 1 (p < 0.05). All sites sustained the core intervention components, with sustainability scores of 71/100 (± 9.9) on the NHS Sustainability Model and 6.1/7 (± 0.9) on the Clinical Sustainability Assessment Tool.

Conclusions

Integrating multiple sustainability models and assessments supported continued effectiveness, spread, and sustainment of PAPT for 4 years. Effective planning, anticipating common healthcare changes, and addressing sustainability determinants early in program implementation were essential aspects of long-term success.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00205-x.

Scaling Up a Community-Based Exercise Program for Women in Difficult Life Situations in Germany-The BIG Project as a Case-Study

Scaling up community-based participatory research (CBPR) remains challenging. This case-study reports on how, and under which conditions, a CBPR project aiming at promoting exercise among socially disadvantaged women (BIG) scaled up at four project sites. As part of BIG, researchers support city administrations in implementing a participatory project to reach socially disadvantaged women for exercise. The case study was conducted in winter 2020 in southern Germany and is based on a co-creative process involving city administrators and researchers. Following Kohl and Cooley's scaling up dimensions, scaling up BIG was investigated at the four sites using a mixed-method approach. Course registrations and offers were analysed, and qualitative interviews (n = 4) with administrative staff members were conducted and analysed using content analysis. The geographical coverage of exercise classes, the addressed groups, and the utilisation of participatory methods by city administrations are described. All four sites managed to scale-up project activities. Three of the four sites reported that further growth of the project was no longer possible due to limited resources. All sites attempted to reach a larger number of, and more diverse, women. One site managed to scale-up the use of participatory methods within the city administration. The following important facilitators for scaling up CBPR projects were reported: advertisements tailored to the needs of the addressed women, utilising participatory approaches, and equipping project coordinators with sufficient resources.

Nurses and midwives' experiences with peer-group clinical supervision intervention: A pilot study

AIM

This study aimed to evaluate differences in supervisees' understanding of clinical supervision and their perceptions of organisational functioning before and after engaging in peer-group clinical supervision.

BACKGROUND

Protected reflective time allows discussion of complex issues affecting health care. Peer-group clinical supervision is one model of clinical supervision that could facilitate this, but it is poorly understood.

METHODS

A pre-post intervention pilot study was performed. The intervention was delivered over a 12-month period. Data were collected using surveys on demographic and work-related factors and experience of clinical supervision pre- and post intervention.

RESULTS

Adaptability increased significantly between the pre- and post surveys. The post survey data showed finding time for clinical supervision scoring lowest with open-ended comments reinforcing this. The supervisees found the sessions to offer a safe place despite initial concerns.

CONCLUSION

The peer-group model of clinical supervision allowed supervisees to build a rapport and trust with their colleagues and share experiences.

IMPLICATIONS FOR NURSING MANAGEMENT

The benefits to participating in peer-group clinical supervision traversed the individual and organisation. These data support the implementation of such sessions while addressing workload and time pressures to aid participation.

Organizational perspectives on outdoor talking therapy: Towards a position of 'environmental safe uncertainty'

OBJECTIVES

There is growing support within the therapy professions for using talking therapy in alternative environments, such as outdoor spaces. The aim of the present study was to further understand how the organizational culture in clinical psychology may prevent or enable practitioners to step outside the conventional indoor consulting room.

DESIGN

Informed grounded theory methodology was used within a pragmatist philosophy.

METHODS

Participants (N = 15; nine male, six female) were identified using theoretical sampling. The sample consisted of experts and leaders within the profession of clinical psychology (e.g., heads of services, training programme directors, chairs of professional bodies, and developers of therapy models; M years in the profession = 34.80, SD = 9.77). One-to-one interviews and analysis ran concurrently over 9 months (April-December 2020). Mason's model of safe uncertainty was drawn upon to illuminate and organize themes.

RESULTS

The main themes comprised organizational factors that either support a practitioner in maintaining a position of curiosity and flexibility towards the environment where therapy is located ('environmental safe uncertainty'), or push them towards adopting a more fixed position ('environmental certainty'). Themes included influences from therapy traditions, accessibility of alternative environments, internalized risk, workplace subcultures, business models, biomedical approaches, and the COVID-19 pandemic.

CONCLUSIONS

Whether therapy is located in a consulting room, outdoors, clients' homes, or digitally, practitioners, clients, and services are encouraged to maintain a position of environmental safe uncertainty.

PRACTITIONER POINTS

The therapy process and outcomes are influenced by the physical environment in which talking therapy is situated. Practitioners have often remained fixed in their preferred therapy environment, such as the indoor consulting room, without exploring the potential benefits of alternative environments or involving the client in this decision-making (i.e., 'environmental certainty'). Outdoor environments, as well as other alternatives to the consulting room (e.g., digital, home visits, and public places), can support access to therapy, subsequent engagement, and therefore health care equity. Practitioners and clients are encouraged to adopt a position of 'environmental safe uncertainty', which is defined as having openness, critical curiosity, and collaboration regarding the therapy environment and the possibility of other environments being more conducive to therapy.