Barriers and facilitators to implementing priority inpatient initiatives in the safety net setting.
ABSTRACT: Background:Safety net hospitals, which serve vulnerable and underserved populations and often operate on smaller budgets than non-safety net hospitals, may experience unique implementation challenges. We sought to describe common barriers and facilitators that affect the implementation of improvement initiatives in a safety net hospital, and identify potentially transferable lessons to enhance implementation efforts in similar settings. Methods:We interviewed leaders within five inpatient departments and asked them to identify the priority inpatient improvement initiative from the last year. We then conducted individual, semi-structured interviews with 25 stakeholders across the five settings. Interviewees included individuals serving in implementation oversight, champion, and frontline implementer roles. The Consolidated Framework for Implementation Research informed the discussion guide and a priori codes for directed content analysis. Results:Despite pursuing diverse initiatives in different clinical departments, safety net hospital improvement stakeholders described common barriers and facilitators related to inner and outer setting dynamics, characteristics of individuals involved, and implementation processes. Implementation barriers included (1) limited staffing resources, (2) organizational recognition without financial investment, and (3) the use of implementation strategies that did not adequately address patients' biopsychosocial complexities. Facilitators included (1) implementation approaches that combined passive and active communication styles, (2) knowledge of patient needs and competitive pressure to perform well against non-SNHs, (3) stakeholders' personal commitment to reduce health inequities, and (4) the use of multidisciplinary task forces to drive implementation activities. Conclusion:Inner and outer setting dynamics, individual's characteristics, and process factors served as implementation barriers and facilitators within the safety net. Future work should seek to leverage findings from this study toward efforts to enact positive change within safety net hospitals.
Project description:<h4>Background</h4>Blunt chest injury can lead to significant morbidity and mortality if not treated appropriately. A blunt chest injury care bundle was to be implemented at two sites to guide care.<h4>Aim</h4>To identify facilitators and barriers to the implementation of a blunt chest injury care bundle and design strategies tailored to promote future implementation.<h4>Methods</h4>1) A mixed-method survey based on the theoretical domains framework (TDF) was used to identify barriers and facilitators to the implementation of a blunt chest injury care bundle. This survey was distributed to 441 staff from 12 departments across two hospitals. Quantitative data were analysed using SPSS and qualitative using inductive content analysis. 2) The quantitative and qualitative results from the survey were integrated and mapped to each of the TDF domains. 3) The facilitators and barriers were evaluated using the Behaviour Change Wheel to extract specific intervention functions, policies, behaviour change techniques and implementation strategies. Each phase was assessed against the Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects or safety and Equity (APEASE) criteria.<h4>Results</h4>One hundred ninety eight staff completed the survey. All departments surveyed were represented. Nine facilitators and six barriers were identified from eight domains of the TDF. Facilitators (TDF domains) were: understanding evidence-informed patient care and understanding risk factors (Knowledge); patient assessment skills and blunt chest injury management skills (Physical skills); identification with professional role (Professional role and identity); belief of consequences of care bundle (Belief about consequences); provision of training and protocol design (Environmental context and resources); and social supports (Social influences). Barriers were: not understanding the term 'care bundle' (Knowledge); lacking regional analgesia skills (Physical skills); not remembering to follow protocol (Memory, attention, and decision processes); negative emotions relating to new protocols (Emotions); equipment and protocol access (Environmental context and resources). Implementation strategies were videos, education sessions, visual prompt for electronic medical records and change champions.<h4>Conclusions</h4>Multiple facilitators and barriers were identified that may affect the implementation of a blunt chest injury care bundle. Implementation strategies developed through this process have been included in a plan for implementation in the emergency departments of two hospitals. Evaluation of the implementation is underway.
Project description:BACKGROUND:Clean Cut is a six month, multi-modal, adaptive intervention aimed at reducing surgical infections through improving six critical perioperative processes: 1) handwashing/skin preparation, 2) surgical gown/drape integrity, 3) antibiotic administration, 4) instrument sterility, 5) gauze counts, and 6) WHO Surgical Safety Checklist use. The aim of this study was to elucidate themes across Clean Cut implementation sites in Ethiopia to improve implementation at future hospitals. METHODS:We conducted semi-structured interviews of 20 clinicians involved in Clean Cut at four hospitals. Participation was limited to Clean Cut team members and included surgeons, anesthetists, operating room (OR) nurses, ward nurses, OR managers, quality improvement personnel, and hospital administrators. Audio recordings were transcribed and coded using qualitative software. A codebook was inductively and iteratively derived between two researchers, tested for inter-rater reliability, and applied to all transcripts. We conducted thematic analysis to derive our final qualitative results. RESULTS:The interviews revealed barriers and facilitators to the implementation of Clean Cut, as well as strategies for future implementation sites. Key barriers included material resource limitations, feelings of job burden, existing gaps in infection prevention education, and communication errors during data collection. Common facilitators included strong hospital leadership support, commitment to improved patient outcomes, and organized Clean Cut training sessions. Future strategies include resource assessments, creating a sense of responsibility among staff, targeted training sessions, and incorporating new standards into daily routine. CONCLUSIONS:The findings of this study highlight the importance of engaging hospital leadership, providers and staff in quality improvement programs, and understanding their work contexts. The identified barriers and facilitators will inform future initiatives in the field of perioperative infection prevention.
Project description:BACKGROUND:The number of patient portals is rising, and although portals can have positive effects, their implementation has major impacts on the providing health care institutions. However, little is known about the organizational factors affecting successful implementation. Knowledge of the specific barriers to and facilitators of various stakeholders is likely to be useful for future implementations. OBJECTIVE:The objective of this study was to identify the barriers to and facilitators of patient portal implementation facing various stakeholders within hospital organizations in the Netherlands. METHODS:Purposive sampling was used to select hospitals of various types. A total of 2 university medical centers, 3 teaching hospitals, and 2 general hospitals were included. For each, 3 stakeholders were interviewed: (1) medical professionals, (2) managers, and (3) information technology employees. In total, 21 semistructured interviews were conducted using the Grol and Wensing model, which describes barriers to and facilitators of change in health care practice at 6 levels: (1) innovation; (2) individual professional; (3) patient; (4) social context; (5) organizational context; and (6) economic and political context. Two researchers independently selected and coded quotes by applying this model using a (deductive) directed content approach. Additional factors related to technical and portal characteristics were added using the model of McGinn et al, developed for implementation of electronic health records. RESULTS:In total, we identified 376 quotes, 26 barriers, and 28 facilitators. Thirteen barriers and 12 facilitators were common for all stakeholder groups. The facilitators' perceived usefulness (especially less paperwork) was mentioned by all the stakeholders, followed by subjects' positive attitude. The main barriers were lack of resources (namely, lack of staff and materials), financial difficulties (especially complying with high costs, lack of reimbursements), and guaranteeing privacy and security (eg, strict regulations). Both similarities and differences were found between stakeholder groups and hospital types. For example, managers and information technology employees mainly considered guaranteeing privacy and security as a predominant barrier. Financial difficulties were particularly mentioned by medical professionals and managers. CONCLUSIONS:Patient portal implementation is a complex process and is not only a technical process but also affects the organization and its staff. Barriers and facilitators occurred at various levels and differed among hospital types (eg, lack of accessibility) and stakeholder groups (eg, sufficient resources) in terms of several factors. Our findings underscore the importance of involving multiple stakeholders in portal implementations. We identified a set of barriers and facilitators that are likely to be useful in making strategic and efficient implementation plans.
Project description:Implementation of handoff as part of TeamSTEPPS initiatives for improving shift-change communication is examined via qualitative analysis of on-site interviews and process observations in 8 critical access hospitals. Comparing implementation attributes and handoff performance across hospitals shows that the purpose of implementation did not differentiate between high and low performance, but facilitators and barriers did. Staff involvement and being part of the "big picture" were important facilitators to change management and buy-in.
Project description:Background:Several frameworks have been developed to identify essential determinants for healthcare improvement. These frameworks aim to be comprehensive, leading to the creation of long lists of determinants that are not prioritised based on being experienced as most important. Furthermore, most existing frameworks do not describe the methods or actions used to identify and address the determinants, limiting their practical value. The aim of this study is to describe the development of a tool with prioritised facilitators and barriers supplemented with methods to identify and address each determinant. The tool can be used by those performing quality improvement initiatives in healthcare practice. Methods:A mixed-methods study design was used to develop the tool. First, an online survey was used to ask healthcare professionals about the determinants they experienced as most facilitating and most hindering during the performance of their quality improvement initiative. A priority score was calculated for every named determinant, and those with a priority score ? 20 were incorporated into the tool. Semi-structured interviews with implementation experts were performed to gain insight on how to analyse and address the determinants in our tool. Results:The 25 healthcare professionals in this study experienced 64 facilitators and 66 barriers when performing their improvement initiatives. Of these, 12 facilitators and nine barriers were incorporated into the tool. Sufficient support from management of the department was identified as the most important facilitator, while having limited time to perform the initiative was considered the most important barrier. The interviews with 16 experts in implementation science led to various inputs for identifying and addressing each determinant. Important themes included maintaining adequate communication with stakeholders, keeping the initiative at a manageable size, learning by doing and being able to influence determinants. Conclusions:This paper describes the development of a tool with prioritised determinants for performing quality improvement initiatives with suggestions for analysing and addressing these determinants. The tool is developed for those engaged in quality improvement initiatives in practice, so in this way it helps in bridging the research to practice gap of determinants frameworks. More research is needed to validate and develop the tool further.
Project description:<h4>Objective</h4>To describe core principles and processes in the implementation of a navigated care program to improve specialty care access for the uninsured.<h4>Study setting</h4>Academic researchers, safety-net providers, and specialty physicians, partnered with hospitals and advocates for the underserved to establish Project Access-New Haven (PA-NH). PA-NH expands access to specialty care for the uninsured and coordinates care through patient navigation.<h4>Study design</h4>Case study to describe elements of implementation that may be relevant for other communities seeking to improve access for vulnerable populations.<h4>Principal findings</h4>Implementation relied on the application of core principles from community-based participatory research (CBPR). Effective partnerships were achieved by involving all stakeholders and by addressing barriers in each phase of development, including (1) assessment of the problem; (2) development of goals; (3) engagement of key stakeholders; (4) establishment of the research agenda; and (5) dissemination of research findings.<h4>Conclusions</h4>Including safety-net providers, specialty physicians, hospitals, and community stakeholders in all steps of development allowed us to respond to potential barriers and implement a navigated care model for the uninsured. This process, whereby we integrated principles from CBPR, may be relevant for future capacity-building efforts to accommodate the specialty care needs of other vulnerable populations.
Project description:The aim of this study was to identify the characteristics of morbidity and mortality conferences (MMCs) associated with the implementation of patient health-care quality and safety improvement initiatives.We conducted an observational study of MMCs and followed up improvement initiatives for 1 year. Data on MMC baseline characteristics were abstracted using document analysis and observation of a meeting in three university hospitals in France (Grenoble, Nice, and Cochin [Paris] hospitals). Fifty-nine MMCs were included in medical (n?=?24), surgical (n?=?21), and anesthesiology and/or intensive care (n?=?14) departments. An effectiveness index was computed by summing a composite score for each initiative pertaining to the MMC.Overall, 282 initiatives were identified in 42 MMCs. During the follow-up period, 215 initiatives (76%) were totally or partially implemented and the impact was evaluated for 73 (26%). An effectiveness index higher than the median (i.e., ?10) was associated with a standardized presentation of cases (81% versus 29%, p <0.001), recording of improvement initiatives (94 versus 57, p?=?0.001), the existence of an annual activity report (94% versus 68%, p?=?0.01), the prior dissemination of a meeting agenda (71% versus 36%, p?=?0.007), longer meeting duration (109 versus 80 min, p?=?0.005), anesthesiology and/or intensive care specialty (39% versus 7%, p?=?0.02), a theme-focused MMC (29% versus 4 %, p?=?0.01), and a thorough analysis of failures (58% versus 25%, p?=?0.01).This study suggests that the implementation of improvement initiatives relates to MCC characteristics. Recommendations for developing more effective patient safety-oriented MMCs can be proposed.
Project description:<h4>Background</h4>The barriers to uptake of guidelines underscore the importance of going beyound the mere synthesis of evidence to tailoring the synthesized evidence into local contexts and situations. This requires in-depth exploration of local factors. This project aimed to assess contextual barriers and facilitators to the implementation of a guideline developed to reduce HIV-related stigma and discrimination (SAD) in the Ethiopian healthcare setting.<h4>Methods</h4>A descriptive qualitative research study was conducted using a semi-structured interview guide informed by the Registered Nurses Association of Ontario (RNAO) framework. The interview was conducted among a purposive sample of seven key informants from Jimma University and Jimma Zone HIV Prevention and Control Office. The interviews were transcribed, coded and analysed using Atlas ti version 7.5 software packages.<h4>Results</h4>Guideline attributes, provider-related factors and organizational and practice-related were identified as factors that can potentially affect the implementation of the guideline. The presence of expert patients were identified as agents for guideline implementation, whilst regular health education programs in addition to initiatives related to service quality improvement, were identified as suitable platforms to assist with the implementation of this guideline. Study participants recommended that the guideline should be disseminated through multidisciplinary team (MDT) meetings, gate keepers such as opinion leaders and unit heads, one-to-five networks and mentorship programs, as well as training, workshops and posters. The current study also indicated that continuous monitoring, evaluation and mentorship are critical elements in the integration of the guideline into the system of the hospital.<h4>Conclusions</h4>This study identified that guideline implementation can make use of existing structures and pathways such as MDT meetings, service quality improvement initiatives, one-to-five networks, training and workshops. Teamwork and partnership with stakeholders should be strengthened to strengthen facilitators and tackle barriers related to the implementation of the guideline. Effective implementation of the guideline also requires establishing an implementation structure. Moreover, indicators developed to track the implementation of stigma reduction guideline should be integrated into mentorship, MDT meetings and evaluation programs of the hospital to improve performance and to assist data collection on implementation experiences.
Project description:BACKGROUND:Acute kidney injury in hospital patients is common and associated with reduced survival and higher healthcare costs. The Tackling Acute Kidney Injury (TAKI) quality improvement project aimed to reduce mortality rates in patients with acute kidney injury by implementing a multicomponent intervention comprising of an electronic alert, care bundle and education in five UK hospitals across a variety of wards. A parallel developmental evaluation using a case study approach was conducted to provide the implementation teams with insights into factors that might impact intervention implementation and fidelity. The qualitative element of the evaluation will be reported. METHODS:29 semi-structured interviews with implementation teams across the five hospitals were carried out to identify perceived barriers and enablers to implementation. Interviews were taped and transcribed verbatim and Framework analysis was conducted. RESULTS:Interviews generated four 'barriers and enablers' to implementation themes: i) practical/contextual factors, ii) skills and make-up of the TAKI implementation team, iii) design, development and implementation approach, iv) staff knowledge, attitudes, behaviours and support. Enablers included availability of specialist teams (e.g. educational teams), multi-disciplinary implementation teams with strong leadership, team-based package completion and proactive staff. Barriers were frequently the converse of facilitators. CONCLUSIONS:Despite diversity of sites, a range of common local factors-contextual, intervention-based and individual-were identified as potential barriers and enablers to fidelity, including intervention structure/design and process of/approach to implementation. Future efforts should focus on early identification and management of barriers and tailored optimisation of known enablers such as leadership and multidisciplinary teams to encourage buy-in. Improved measures of real-time intervention and implementation fidelity would further assist local teams to target their support during such quality improvement initiatives.
Project description:BACKGROUND:Despite the high and rising burden of chronic kidney disease (CKD) in South Asia, factors that influence access to CKD care at the community level have not been studied previously, especially in the rural areas. We conducted a mixed methods study and interviewed key stakeholders to explore the views and experiences of key stakeholders, and identify barriers and potential facilitators that influence access to CKD care at the primary care level in rural India. METHODS:A total of 21 stakeholders participated in the study. We conducted 15 in-depth interviews on a purposive sample of stakeholders (CKD patients, healthcare providers and health planners) and one focus group discussion with 6 community health workers. The interviews were audio-recorded and transcribed verbatim. We employed the Lévesque's framework for access to care to base interview guides and structure the initial codes. By inductive and deductive approaches, thematic analysis was undertaken using QSR NVivo version 11. RESULTS:The major patient-level barriers to CKD care as reported by the most patients and healthcare providers was poor knowledge and awareness of CKD. Health system-level barriers included shortages of skilled healthcare professionals and medicines, fragmented referrals pathways to the specialists at the hospitals with inadequate follow up care. Many patients and healthcare providers, when asked about areas for improving access to CKD care, reported educational initiatives to increase awareness of CKD among healthcare providers and patients, provision of CKD related supplies, and a systems-level approach to care coordination including task shifting by engaging community health workers in CKD care, as potential facilitators. CONCLUSIONS:We identified several barriers to access CKD care at the primary care level in rural India that need urgent attention. Targeted CKD screening programs and CKD specific educational initiatives may improve awareness of CKD. Additionally, primary care infrastructure needs to be strengthened for CKD care, ensuring trained staff, availability of essential diagnostics and medications, and creating efficient referral pathways for quality CKD care.