Exploring the complexity of the implementation determinants of human papillomavirus vaccination in Africa through a systems thinking lens: A rapid review

A rapid review was conducted to explore the implementation determinants of human papillomavirus (HPV) vaccination in the World Health Organization African Region and describe their dynamic relationship. PubMed and Google Scholar were searched in October 2023 to find relevant literature. A total of 64 published studies that reported factors affecting HPV vaccination were identified. Analysis of identified factors yielded 74 implementation determinants of HPV vaccination across the five domains of the Consolidated Framework for Implementation Research (CFIR): two (2.70%) were in the innovation domain, seven (9.46%) were in the outer setting domain, 14 (18.92%) were in the inner setting domain, 37 (50%) were in the individual domain and 14 (18.92%) were in the implementation process domain. A causal loop diagram of these implementation determinants revealed four balancing and seven reinforcing loops. Applying systems lens promoted a more holistic understanding of the implementation determinants of HPV vaccination, exposing leverage points for interventions.

Research and Practice in Quality Improvement and Implementation Science: The Synergy for Change Model

BACKGROUND

Nurses play an essential role in the achievement of quality depicted by the Quintuple Aim to improve clinical outcomes, patient experience, equity, provider well-being, and reduction of costs. When quality gaps occur, practice change is required and is facilitated by quality improvement (QI) and implementation science (IS) methods. QI and IS research are required to advance our understanding of the mechanisms that explain how evidence is implemented and improvements are made.

PROBLEM

Despite past efforts of the evidence-based practice and QI movements, challenges persist in sustaining practice improvements and translating research findings to direct patient care.

APPROACH

The purpose of this article is to describe the Synergy for Change Model that proposes that both QI and IS research and practice be used to accelerate improvements in health care quality.

CONCLUSIONS

Recognizing the synergy of QI and IS practice and research will accelerate nursing's contributions to high-quality and safe care.

Implementation of Complex Suicide Prevention Interventions: Insights into Barriers, Facilitators and Lessons Learned

INTRODUCTION

Effective suicide prevention interventions are infrequently translated into practice and policy. One way to bridge this gap is to understand the influence of theoretical determinants on intervention delivery, adoption, and sustainment and lessons learned. This study aimed to examine barriers, facilitators and lessons learned from implementing complex suicide prevention interventions across the world.

METHODS AND MATERIALS

This study was a secondary analysis of a systematic review of complex suicide prevention interventions, following updated PRISMA guidelines. English published records and grey literature between 1990 and 2022 were searched on PubMed, CINAHL, PsycINFO, ProQuest, SCOPUS and CENTRAL. Related reports were organized into clusters. Data was extracted from clusters of reports on interventions and were mapped using the updated Consolidated Framework for Implementation Research.

RESULTS

The most frequently-reported barriers were reported within the intervention setting and were related to the perceived appropriateness of interventions within settings; shared norms, beliefs; and maintaining formal and informal networks and connections. The most frequently reported facilitators concerned individuals' motivation, capability/capacity, and felt need. Lessons learned focused on the importance of tailoring the intervention, responding to contextual needs and the importance of community engagement throughout the process.

CONCLUSION

This study emphasizes the importance of documenting and analyzing important influences on implementation. The complex interplay between the contextual determinants and implementation is discussed. These findings contribute to a better understanding of barriers and facilitators salient for implementation of complex suicide prevention interventions.

Leaders' experiences of embedding a simulation-based education programme in a teaching hospital: an interview study informed by normalisation process theory

There is limited research on the experiences of people in working to embed, integrate and sustain simulation programmes. This interview-based study explored leaders' experiences of normalising a simulation-based education programme in a teaching hospital. Fourteen known simulation leaders across Australia and North America were interviewed. Semi-structured interviews were analysed using reflexive thematic analysis sensitised by normalisation process theory, an implementation science theory which defines 'normal' as something being embedded, integrated and sustained. We used a combined social and experiential constructivist approach. Four themes were generated from the data: (1) Leadership, (2) business startup mindset, (3) poor understanding of simulation undermines normalisation and (4) tension of competing objectives. These themes were interlinked and represented how leaders experienced the process of normalising simulation. There was a focus on the relationships that influence decision-making of simulation leaders and organisational buy-in, such that what started as a discrete programme becomes part of normal hospital operations. The discourse of 'survival' was strong, and this indicated that simulation being normal or embedded and sustained was still more a goal than a reality. The concept of being like a 'business startup' was regarded as significant as was the feature of leadership and how simulation leaders influenced organisational change. Participants spoke of trying to normalise simulation for patient safety, but there was also a strong sense that they needed to be agile and innovative and that this status is implied when simulation is not yet 'normal'. Leadership, change management and entrepreneurship in addition to implementation science may all contribute towards understanding how to embed, integrate and sustain simulation in teaching hospitals without losing responsiveness. Further research on how all stakeholders view simulation as a normal part of a teaching hospital is warranted, including simulation participants, quality and safety teams and hospital executives. This study has highlighted that a shared understanding of the purpose and breadth of simulation is a prerequisite for embedding and sustaining simulation. An approach of marketing simulation beyond simulation-based education as a patient safety and systems improvement mindset, not just a technique nor technology, may assist towards simulation being sustainably embedded within teaching hospitals.

Variation in Evidence-Based Practices Among Youth-Serving Residential Treatment Facilities

BACKGROUND

Residential treatment is among the most intensive and expensive settings for children with behavioral health challenges; yet, the extent to which evidence-based practices are used in these settings is unknown.

AIM

The purpose of this study was to describe the extent which family therapy, case management, telehealth, peer support, and family psychoeducation are provided in residential treatment using data from the National Mental Health Services Survey (N-MHSS). Organizational factors-region, ownership, payment, licensing/accreditation, and facility size-were examined in relation to evidence-based practices to understand disparities in care.

METHODS

This was a secondary analysis of publicly available data from the 2018 N-MHSS. A subpopulation was created consisting of residential facilities that served children (N = 576). Descriptive statistics were used to describe the sample, and Cohen's h was calculated to determine patterns of evidence-based practice utilization.

RESULTS

Evidence-based practices from most to least prevalent were family therapy (76%), family psychoeducation (74%), case management (71.1%), telehealth (17.2%), and peer support (8.7%). The provision of evidence-based practices was not evenly distributed. There were primarily small to moderate differences by organizational factors, including region (i.e., Northeast, Midwest), ownership status (i.e., for-profit), payment type (i.e., self-pay, private insurance), licensing/accreditation (Department of Family and Children Services), and facility capacity (>251 clients served per year).

CONCLUSION

Findings demonstrate a need for research-practice partnerships to determine the barriers that prevent effective evidence-based practices from being implemented in the residential treatment setting.

A qualitative examination on the implementation of participatory "A"rt-based activity on "Health" of older community-dwellers: what worked for the Singapore A-Health Intervention?

Introduction

Art and museum-based interventions are gaining increasing recognition for their potential as low-risk activities for older adults, offering numerous physical, cognitive, and emotional benefits. However, there remains a dearth of knowledge regarding the science of implementation as well as the factors and processes that contribute to their effectiveness from the perspectives of intervention participants.

Methods

The current research draws on the qualitative evaluation data obtained from a larger mixed-method randomized control trial that evaluated a standardized Participatory "A"rt-Based Activity On "Health" of Older Community-Dwellers-the Singapore A-Health Intervention. Adopting a participatory action research approach, the primary objective is to critically examine the lived experiences and health impact of the Singapore A-Health Intervention with a secondary objective to uncover strategies for optimized implementation outcomes. All 56 participants who completed the intervention filled out a program evaluation survey and a nested sample of 30 participants completed a series of acceptability focus groups.

Results

Descriptive analyses of the program evaluation survey data revealed that 96.2% of participants were satisfied with the overall experience of the Singapore A-Health intervention (M = 9.00, SD = 1.76), reported that the intervention positively impacted their quality of life (M = 8.90, SD = 1.43), and social wellbeing (M = 8.92, SD = 1.43). Thematic analysis with a grounded theory approach on the qualitative focus group data revealed three interrelated themes detailing how the Singapore A-Health Intervention contributed to positive health and wellbeing outcomes (1. A-Health Experience, 2. Wellbeing Outcomes, 3. Enabling Factors) and nine subthemes (1a. Intellectual Stimulation, 1b. Positive Stress, 1c. Peer Interaction, 2a. Interpersonal Bonds, 2b. Personal Growth, 2c. Mindful Living, 3a. Integrated Support, 3b. Session Design, 3c. Mode of Engagement).

Discussion

This investigation provides important insights to the Singapore A-Health intervention's effectiveness for enhancing wellbeing among older adults, as well as the factors that enable successful program implementation. These findings offer a culturally unique perspective on the benefits of art and museum interventions, while underscoring the imperative need for strong partnership and collaborations among community stakeholders in supporting the health and wellbeing of ageing populations.

Supporting translation of research evidence into practice-the use of Normalisation Process Theory to assess and inform implementation within randomised controlled trials: a systematic review

BACKGROUND

The status of randomised controlled trials (RCTs) as the 'gold standard' for evaluating efficacy in healthcare interventions is increasingly debated among the research community, due to often insufficient consideration for implementation. Normalisation Process Theory (NPT), which focuses on the work required to embed processes into practice, offers a potentially useful framework for addressing these concerns. While the theory has been deployed in numerous RCTs to date, more work is needed to consolidate understanding of if, and how, NPT may aid implementation planning and processes within RCTs. Therefore, this review seeks to understand how NPT contributes to understanding the dynamics of implementation processes within RCTs. Specifically, this review will identify and characterise NPT operationalisation, benefits and reported challenges and limitations in RCTs.

METHODS

A qualitative systematic review with narrative synthesis of peer-reviewed journal articles from eight databases was conducted. Studies were eligible for inclusion if they reported sufficient detail on the use of NPT within RCTs in a healthcare domain. A pre-specified data extraction template was developed based on the research questions of this review. A narrative synthesis was performed to identify recurrent findings.

RESULTS

Searches identified 48 articles reporting 42 studies eligible for inclusion. Findings suggest that NPT is primarily operationalised prospectively during the data collection stage, with limited sub-construct utilisation overall. NPT is beneficial in understanding implementation processes by aiding the identification and analysis of key factors, such as understanding intervention fidelity in real-world settings. Nearly three-quarters of studies failed to report the challenges and limitations of utilising NPT, though coding difficulties and data falling outside the NPT framework are most common.

CONCLUSIONS

NPT appears to be a consistent and generalisable framework for explaining the dynamics of implementation processes within RCTs. However, operationalisation of the theory to its full extent is necessary to improve its use in practice, as it is currently deployed in varying capacities. Recommendations for future research include investigation of NPT alongside other frameworks, as well as earlier operationalisation and greater use of NPT sub-constructs.

TRIAL REGISTRATION

The protocol for this systematic review was accepted for public registration on PROSPERO (registration number: CRD42022345427) on 26 July 2022.

Hospital organizational change: The importance of teamwork culture, communication, and change readiness

Background

Hospital organizational change can be a challenging time, especially when staff do not feel informed and ready for the change to come. A supportive workplace culture can mitigate the negative effects allowing for a smooth transition during hospital organizational change. In this paper, we test an exploratory path model by which teamwork culture influences staff attitudes in feeling informed and ready for change, and which are ultimately related to reduced staff burnout. We also examined different types of change communication, identifying the channels that were perceived as most useful for communicating organizational change.

Methods

In 2019, a cross-sectional online and paper-based survey of all staff (clinical and non-clinical) was conducted at a hospital undergoing major organizational change in Sydney, Australia. The survey included items regarding teamwork culture, communication (feeling informed, communication channels), change readiness (appropriateness, change efficacy), and burnout. With a sample size of 153 (62% clinical staff), regression and path analyses were used to examine relationships between variables.

Results

The total effects between teamwork culture and burnout was significant [β (Total) = -0.37, p < 0.001) and explained through a serial mediation. This relationship was found to be mediated by three factors (feeling informed, appropriateness of change and change efficacy) in a full mediation. Further, change readiness (appropriateness of change and change efficacy) mediated the relationship between feeling informed and burnout. The most useful channels of change communication included face-to-face informal communication, emails, and a newsletter specifically about the change.

Conclusion

Overall, the results supported the predicted hypotheses and were consistent with past research. In the context of large hospital change, staff with a positive teamwork culture who feel informed are more likely to feel change-ready, heightening the chances of successful organizational change and potentially reducing staff burnout. Understanding the pathways on how culture and communication related to burnout during organizational change provides an explanatory pathway that can be used to heighten the chances of a smooth change transition with minimal disruption to staff and patient care.

Frailty nurse and GP-led models of care in care homes: the role of contextual factors impacting Enhanced health in care homes framework implementation

BACKGROUND

The Enhanced Health for Care homes (EHCH) framework is an innovative response to provide more proactive, preventative approaches to care for residents living in care homes. It involves co-producing a shared vision with primary care. As part of EHCH a UK clinical commissioning group supported GP's in two localities to implement their preferred delivery approach involving a new Frailty Nurse-led (FN-led) model in care homes alongside an existing General Practitioner-led (GP-led) model. This paper focuses on implementation of the new FN-led model.

METHODS

A qualitative study design was adopted. Forty-eight qualitative semi-structured interviews were undertaken across six care home sites in a Northern locality: three implementing the FN-led and three engaged in an existing GP-led model. Participants included residents, family members, care home managers, care staff, and health professionals working within the EHCH framework.

RESULTS

Two overarching themes were generated from data analysis: Unanticipated implementation issues and Unintended consequences. Unsuccessful attempts to recruit Frailty Nurses (FN) with enhanced clinical skills working at the desired level (UK NHS Band 7) led to an unanticipated evolution in the implementation process of the FN-led model towards 'training posts'. This prompted misaligned role expectations subsequently provoking unexpected temporary outcomes regarding role-based trust. The existing, well understood nature of the GP-led model may have further exacerbated these unintended consequences.

CONCLUSION

Within the broader remit of embedding EHCH frameworks, the implementation of new FN roles needed to evolve due to unforeseen recruitment issues. Wider contextual factors are not in the control of those developing new initiatives and cannot always be foreseen, highlighting how wider factors can force evolution of planned implementation processes with unintended consequences. However, the unintended consequences in this study highlight the need for careful consideration of information dissemination (content and timing) to key stakeholders, and the influence of existing ways of working.

Key success factors for the implementation of quality management systems in developing countries

Background

Despite the tremendous progress made in advancing laboratory medicine in low- and middle-income countries (LMICs), inadequate quality management systems (QMSs) remain a problem and barrier to provision of reliable laboratory services in resource-limited settings. Therefore, it is useful to study the experience of medical laboratories in LMICs that have successfully implemented QMS.

Aim

This review identified key success factors (KSFs) for medical laboratories in LMICs implementing QMS in accordance with the International Organization for Standardization standard 15189 as a pathway to improving laboratory quality.

Methods

Applying Preferred Reporting Items for Systematic Reviews procedures, we conducted a targeted search of studies from LMICs published between 2012 and 2022 to identify KSFs. Thirty-two out of 952 references retrieved were considered relevant and included in this review. Grounded theory was used to extract key features of the included studies to derive KSFs.

Results

Ten KSFs for medical laboratories striving to implement QMS were identified and described. These KSFs were integrated to create a model of success for laboratory QMS implementation. The model consists of three underlying factors, namely preparing for change, resource availability, and effective project management, each comprising three separate KSFs. Institutional commitment was identified as the core of the model and is integral to ensuring the quality of laboratory services.

Conclusion

Laboratories planning to implement a QMS can benefit from understanding the KSFs demonstrated in this study as this would help them to identify the necessary changes to implement and set realistic expectations about the outcomes of QMS implementation.

The effect of virtual specialist conferences between endocrinologists and general practitioners about type 2 diabetes: study protocol for a pragmatic randomized superiority trial

BACKGROUND

To support the primary care sector in delivering high-quality type 2 diabetes (T2D), literature reviews emphasize the need for implementing models of collaboration that in a simple and effective way facilitate clinical dialogue between general practitioners (GPs) and endocrinologists. The overall aim of the project is to evaluate if virtual specialist conferences between GPs and endocrinologists about patients living with T2D is clinically effective and improves diabetes competences and organization in general practice in comparison to usual practice.

METHODS

A prospective, pragmatic, and superiority RCT with two parallel arms of general practices in the Municipality of Aarhus, Denmark. All general practices are invited (n = 100). The intervention runs for 12 months and consists of four virtual conferences between endocrinologists and an individual general practice. Before the first conference, an introductory webinar teaches GPs about how to use an IT-platform to identify and manage T2D patients. The main analysis (month 12) concerns the difference between the intervention and control arm. It is expected that the virtual conferences at the patient level will improve adherence to international recommendations on diabetes medication for T2D patients and improve the risk profile with a reduction in glycated haemoglobin, blood pressure, and cholesterol. The study design allows for identifying a significant difference between the intervention (n = 15) and control group (n = 15) regarding the three primary clinical outcomes with a power of 0.8870-0.9941. At the general practice level, it is expected that general practitioners and practice staff in the intervention group will improve self-reported diabetes competence and organization. The control arm will get the intervention when the primary intervention ends (months 12-24), and the intervention arm transitions to a maintenance phase.

DISCUSSION

The potential of virtual conferences is yet to be fully tapped because of methodological limitations. Studies have also not yet systematically evaluated virtual conferences in the context of chronic care using a high-quality research design. Given the nature of this real-life intervention, general practitioners and endocrinologists cannot be blinded to their allocation to either the intervention or comparison arm.

TRIAL REGISTRATION

ClinicalTrials.gov, United States National Institutes of Health trial ID: NCT05268081. Registered on 4 March 2022.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The development of the concept of return-on-investment from large-scale quality improvement programmes in healthcare: an integrative systematic literature review

BACKGROUND

Return on Investment (ROI) is increasingly being used to evaluate financial benefits from healthcare Quality Improvement (QI). ROI is traditionally used to evaluate investment performance in the commercial field. Little is known about ROI in healthcare. The aim of this systematic review was to analyse and develop ROI as a concept and develop a ROI conceptual framework for large-scale healthcare QI programmes.

METHODS

We searched Medline, Embase, Global health, PsycInfo, EconLit, NHS EED, Web of Science, Google Scholar using ROI or returns-on-investment concepts (e.g., cost-benefit, cost-effectiveness, value). We combined this terms with healthcare and QI. Included articles discussed at least three organisational QI benefits, including financial or patient benefits. We synthesised the different ways in which ROI or return-on-investment concepts were used and discussed by the QI literature; first the economically focused, then the non-economically focused QI literature. We then integrated these literatures to summarise their combined views.

RESULTS

We retrieved 10 428 articles. One hundred and two (102) articles were selected for full text screening. Of these 34 were excluded and 68 included. The included articles were QI economic, effectiveness, process, and impact evaluations as well as reports and conceptual literature. Fifteen of 68 articles were directly focused on QI programme economic outcomes. Of these, only four focused on ROI. ROI related concepts in this group included cost-effectiveness, cost-benefit, ROI, cost-saving, cost-reduction, and cost-avoidance. The remaining articles mainly mentioned efficiency, productivity, value, or benefits. Financial outcomes were not the main goal of QI programmes. We found that the ROI concept in healthcare QI aligned with the concepts of value and benefit, both monetary and non-monetary.

CONCLUSION

Our analysis of the reviewed literature indicates that ROI in QI is conceptualised as value or benefit as demonstrated through a combination of significant outcomes for one or more stakeholders in healthcare organisations. As such, organisations at different developmental stages can deduce benefits that are relevant and legitimate as per their contextual needs.

TRIAL REGISTRATION

Review registration: PROSPERO; CRD42021236948.

Too much theory and not enough practice? The challenge of implementation science application in healthcare practice

BACKGROUND

Implementation science (IS) should contribute to maintaining high standards of care across healthcare systems and enhancing care practices. However, despite the evident need for greater and more rapid uptake and integration of evidence in practice, IS design and methodology fall short of the needs of effective translation.

AIM

In this paper we examine what it is about IS that makes it so appealing for effective uptake of interventions in routine practice, and yet so difficult to achieve. We propose a number of ways that implementation scientists could build mutual relationships with healthcare practitioners and other stakeholders including public members to ensure greater shared care practices, and highlight the value of IS training, collaborative educational events, and co-designed research.

DISCUSSION

More consideration should be given to IS applications in healthcare contexts. Implementation scientists can make a valuable contribution by mobilizing theory and improving practice. However, goals for an evidence-based system may be more appropriately achieved through greater outreach and collaboration, with methods that are flexible to support rapid implementation in complex adaptive systems. Collective learning and mutual trust can be cultivated by embedding researchers into healthcare services while offering greater opportunities for practitioners to learn about, and engage in, implementation research.

CONCLUSION

To bridge the worlds of healthcare practice and IS, researchers could be more consistent in the relationships they build with professionals and the public, communicating through a shared language and co-joining practical approaches to effective implementation. This will build capacity for improved collaboration and foster respectful, interdisciplinary relationships.

Knowledge, attitudes and preferences regarding reproductive genetic carrier screening among reproductive-aged men and women in Flanders (Belgium)

Through carrier screening couples at-risk of conceiving a child with an autosomal recessive or X-linked condition can be identified prior to conception. The aim of this study was to assess knowledge, attitudes and preferences regarding reproductive genetic carrier screening (RGCS) among reproductive-aged men and women in Flanders (Belgium). Women and men of reproductive age visiting their pharmacist were invited to answer a self-administered questionnaire. Prior to filling in the questionnaire, participants were asked to read an information leaflet explaining some key concepts about RGCS. Our sample included 387 individuals of reproductive age, of which 68.5% were female and 31.5% were male. Most of the participants were below 34 years old (72.9%), didn't have children (68.6%) and were currently in a relationship (69.1%). Offering RGCS to couples that want to have children was found acceptable by 86% of participants. However, fewer participants would consider RGCS for themselves in the future (61%). We observed a positive correlation between attitude score/knowledge score and the intention to have RGCS. Half of the participants (50.9%) preferred the disclosure of individual test results. Most of participants indicated that RGCS should be offered through the gynecologist (81.1%), followed by the GP (71.5%) and the Centre for Human Genetics (64.8%). About 68.9% of participants were willing to pay out-of-pocket for an RGCS test. We recommend that RGCS should ideally be implemented through a tailored implementation strategy whereby individual needs and preferences can be taken into account.

The Voices of Stakeholders Involved in Precision Medicine: The Co-Design and Evaluation of Qualitative Indicators of Intervention Acceptability, Fidelity and Context in PRecISion Medicine for Children With Cancer in Australia

We report a novel approach of amalgamating implementation outcomes of acceptability and fidelity alongside context as a new way of qualitatively evaluating implementation outcomes and context of a precision medicine intervention. A rapid qualitative online proforma was co-designed with stakeholders and sent to a purposive sample of healthcare professionals involved in an early-phase clinical trial intervention. Data were analysed using Framework Analysis. A total of 24 out of 68 proformas were returned. Although some participants raised concerns about drug medication access issues, the main intervention was well accepted and understood across professional groups. Comprehension was enhanced through exposure to specialist multidisciplinary meeting arrangements. In conclusion, a rapid data collection tool and framework are now available to assess readily measurable, qualitative indicators of acceptability, fidelity of receipt and contextual fit within the dynamic precision medicine context.

Academic health science centre models across the developing countries and lessons for implementation in Indonesia: a scoping review

OBJECTIVE

To describe models of academic health science centres (AHSCs) across developing countries, in order to inform AHSC development in Indonesia.

DESIGN

Scoping review with systematic methods.

DATA SOURCES

Ovid MEDLINE, ProQuest Central, Wiley online library, Scopus and Web of Sciences were searched for relevant publications from 1 January 2015 to 1 December 2020. 'Grey literature' was hand searched by targeted website searches, Google searches, as well as personal communication held with stakeholders in Indonesia specifically. Relevant articles regarding AHSCs in developing countries are included. The review would be synthesised to focus on the purpose, structure and core activities of AHSCs. Strategies for success were also considered.

RESULTS

Twenty-six recognised AHSCs in developing countries were identified, located in Asia (n=13), Europe (n=1), South America (n=7) and Africa (n=5). Innovation, health system improvement and enhancement in academic capacity were the common visions. Most centres are functionally integrated and university-led. Most AHSCs include community health services to complement primary stakeholders such as academic institutions and hospitals. Limited information was identified regarding patient and public involvement and workforce capacity building. Five AHSCs have been piloted in Indonesia since 2018, integrating universities, academic hospitals and provincial health offices. However, information regarding their core activities and successes is limited.

CONCLUSIONS

The review suggests that limited published data are available on AHSC models in developing countries, but they still provide important insight into AHSC development in Indonesia. Innovation and health systems strengthening are the common visions. Functional integration with university leadership is the most common model of governance. Other than universities and hospitals, community health centres, research centres and regional health offices are common partners. There is a little description of community engagement and workforce capacity building.

World guidelines for falls prevention and management for older adults: a global initiative

BACKGROUND

falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present.

OBJECTIVES

to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries.

METHODS

a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting.

RECOMMENDATIONS

all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations.

CONCLUSIONS

the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

An international study on implementation and facilitators and barriers for parent‐infant closeness in neonatal units

Importance

Parent‐infant closeness and active parent participation in neonatal care are important for parent and infant health.

Objective

To give an overview of current neonatal settings and gain an in‐depth understanding of facilitators and barriers to parent‐infant closeness, zero‐separation, in 19 countries.

Methods

Neonatal intensive care unit (NICU) professionals, representing 45 NICUs from a range of geographic regions in Europe and Canada, were purposefully selected and interviewed June–December 2018. Thematic analysis was conducted to identify, analyze and report patterns (themes) for parent‐infant closeness across the entire series of interviews.

Results

Parent‐infant separation during infant and/or maternity care is very common (42/45 units, 93%), despite the implementation of family integrated care (FICare) practices, including parent participation in medical rounds (17/45, 38%), structured education sessions for parents (16/45, 36%) and structured training for healthcare professionals (22/45, 49%). NICU professionals encountered four main themes with facilitators and barriers for parent‐infant closeness on and between the hospital, unit, staff, and family level: Culture (jointly held characteristics, values, thinking and behaviors about parental presence and participation in the unit), Collaboration (the act of working together between and within different levels), Capacities (resources and policies), and Coaching (education to acquire and transfer knowledge and skills).

Interpretation

Implementing parent‐infant closeness in the NICU is still challenging for healthcare professionals. Further optimization in neonatal care towards zero‐separation and parent‐infant closeness can be achieved by enforcing the ‘four Cs for Closeness’: Culture, Collaboration, Capacities, and Coaching.

Global Experiences of Community Responses to COVID-19: A Systematic Literature Review

Objective

This study aimed to conduct a systematic review of the global experiences of community responses to the COVID-19 epidemic.

Method

Five electronic databases (PubMed, Embase, CINAHL, ScienceDirect, and Web of Science) were searched for peer-reviewed articles published in English, from inception to October 10, 2021. Two reviewers independently reviewed titles, abstracts, and full texts. A systematic review (with a scientific strategy for literature search and selection in the electronic databases applied to data collection) was used to investigate the experiences of community responses to the COVID-19 pandemic.

Results

This review reported that community responses to COVID-19 consisted mainly of five ways. On the one hand, community-based screening and testing for Coronavirus was performed; on the other hand, the possible sources of transmission in communities were identified and cut off. In addition, communities provided medical aid for patients with mild cases of COVID-19. Moreover, social support for community residents, including material and psychosocial support, was provided to balance epidemic control and prevention and its impact on residents' lives. Last and most importantly, special care was provided to vulnerable residents during the epidemic.

Conclusion

This study systematically reviewed how communities to respond to COVID-19. The findings presented some practical and useful tips for communities still overwhelmed by COVID-19 to deal with the epidemic. Also, some community-based practices reported in this review could provide valuable experiences for community responses to future epidemics.

How can the healthcare system deliver sustainable performance? A scoping review

BACKGROUND

Increasing health costs, demand and patient multimorbidity challenge the sustainability of healthcare systems. These challenges persist and have been amplified by the global pandemic.

OBJECTIVES

We aimed to develop an understanding of how the sustainable performance of healthcare systems (SPHS) has been conceptualised, defined and measured.

DESIGN

Scoping review of peer-reviewed articles and editorials published from database inception to February 2021.

DATA SOURCES

PubMed and Ovid Medline, and snowballing techniques.

ELIGIBILITY CRITERIA

We included articles that discussed key focus concepts of SPHS: (1) definitions, (2) measurement, (3) identified challenges, (4) identified solutions for improvement and (5) scaling successful solutions to maintain SPHS.

DATA EXTRACTION AND SYNTHESIS

After title/abstract screening, full-text articles were reviewed, and relevant information extracted and synthesised under the five focus concepts.

RESULTS

Of 142 included articles, 38 (27%) provided a definition of SPHS. Definitions were based mainly on financial sustainability, however, SPHS was also more broadly conceptualised and included acceptability to patients and workforce, resilience through adaptation, and rapid absorption of evidence and innovations. Measures of SPHS were also predominantly financial, but recent articles proposed composite measures that accounted for financial, social and health outcomes. Challenges to achieving SPHS included the increasingly complex patient populations, limited integration because of entrenched fragmented systems and siloed professional groups, and the ongoing translational gaps in evidence-to-practice and policy-to-practice. Improvement strategies for SPHS included developing appropriate workplace cultures, direct community and consumer involvement, and adoption of evidence-based practice and technologies. There was also a strong identified need for long-term monitoring and evaluations to support adaptation of healthcare systems and to anticipate changing needs where possible.

CONCLUSIONS

To implement lasting change and to respond to new challenges, we need context-relevant definitions and frameworks, and robust, flexible, and feasible measures to support the long-term sustainability and performance of healthcare systems.

Conceptualising contexts, mechanisms and outcomes for implementing large-scale, multisite hospital improvement initiatives: a realist synthesis

DESIGN

Realist synthesis.

STUDY BACKGROUND

Large-scale hospital improvement initiatives can standardise healthcare across multiple sites but results are contingent on the implementation strategies that complement them. The benefits of these implemented interventions are rarely able to be replicated in different contexts. Realist studies explore this phenomenon in depth by identifying underlying context-mechanism-outcome interactions.

OBJECTIVES

To review implementation strategies used in large-scale hospital initiatives and hypothesise initial programme theories for how they worked across different contexts.

METHODS

An iterative, four-step process was applied. Step 1 explored the concepts inherent in large-scale interventions using database searches and snowballing. Step 2 identified strategies used in their implementation. Step 3 identified potential initial programme theories that may explain strategies' mechanisms. Step 4 focused on one strategy-theory pairing to develop and test context-mechanism-outcome hypotheses. Data was drawn from searches (March-May 2020) of MEDLINE, Embase, PubMed and CINAHL, snowballed from key papers, implementation support websites and the expertise of the research team and experts.

INCLUSION CRITERIA

reported implementation of a large-scale, multisite hospital intervention. RAMESES reporting standards were followed.

RESULTS

Concepts were identified from 51 of 381 articles. Large-scale hospital interventions were characterised by a top-down approach, external and internal support and use of evidence-based interventions. We found 302 reports of 28 different implementation strategies from 31 reviews (from a total of 585). Formal theories proposed for the implementation strategies included Diffusion of Innovation, and Organisational Readiness Theory. Twenty-three context-mechanism-outcome statements for implementation strategies associated with planning and assessment activities were proposed. Evidence from the published literature supported the hypothesised programme theories and were consistent with Organisational Readiness Theory's tenets.

CONCLUSION

This paper adds to the literature exploring why large-scale hospital interventions are not always successfully implemented and suggests 24 causative mechanisms and contextual factors that may drive outcomes in the planning and assessment stage.

Rethinking Blood Testing in Pediatric Cancer Patients: A Quality Improvement Approach

Introduction:

The overuse of blood tests burdens the healthcare system and can detrimentally impact patient care. Risks of frequent blood sampling include infection and clinician-induced anemia, which can negatively impact patients and their families. Pediatric cancer patients are particularly vulnerable as they are immunocompromised with a small blood volume. Four blood tests had become a daily practice. Therefore, we aimed to reduce the number of blood tests taken per bed day within the inpatient pediatric cancer unit by 15% within 8 months.

Methods:

This quality improvement project combined several strategies to reduce test frequency and empower clinicians on the rationale for blood test ordering. Recommendations were developed collaboratively presented in a summary table. Targeted behavior-change methodology built engagement and momentum for the change. All clinicians were challenged to STOP and THINK about why a test is necessary for each patient. The primary outcome measure was the frequency of the tests taken per bed day. Frequency was compared between pre- and postimplementation plus follow-up periods across 2019–2021.

Results:

26,941 blood tests were captured in 1,558 admissions. The intervention led to an overall blood test reduction of 37% over 8 months. Liver Function Tests were the standout, with a 52% decrease in test frequency.

Conclusions:

A strategy incorporating education and culture change, combined with clear guidance on testing frequency, significantly reduced the ordering frequency of blood tests without increased patient harm.

Implementing the use of objective medication adherence data in routine clinical practice via the digital CFHealthHub platform: situation analysis and strategy development using the theoretical domains framework

Background

Preventative inhaled treatments preserve lung function and reduce exacerbations in cystic fibrosis (CF). Self-reported adherence to these treatments is over-estimated. An online platform (CFHealthHub) has been developed with patients and clinicians to display real-time objective adherence data from dose-counting nebulisers, so that clinical teams can offer informed treatment support.

Methods

In this paper, we identify pre-implementation barriers to healthcare practitioners performing two key behaviours: accessing objective adherence data through the website CFHealthHub and discussing medication adherence with patients. We aimed to understand barriers during the pre-implementation phase, so that appropriate strategy could be developed for the scale up of implementing objective adherence data in 19 CF centres.

Thirteen semi-structured interviews were conducted with healthcare practitioners working in three UK CF centres. Qualitative data were coded using the theoretical domains framework (TDF), which describes 14 validated domains to implementation behaviour change.

Results

Analysis indicated that an implementation strategy should address all 14 domains of the TDF to successfully support implementation. Participants did not report routines or habits for using objective adherence data in clinical care. Examples of salient barriers included skills, beliefs in consequences, and social influence and professional roles. The results also affirmed a requirement to address organisational barriers. Relevant behaviour change techniques were selected to develop implementation strategy modules using the behaviour change wheel approach to intervention development.

Conclusions

This paper demonstrates the value of applying the TDF at pre-implementation, to understand context and to support the development of a situationally relevant implementation strategy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00263-9.

A Roadmap to Implementing Venous Thromboembolism Risk Stratification and Mitigation

INTRODUCTION

Venous thromboembolism (VTE) is a life-threatening postoperative complication that carries high morbidity and mortality for plastic surgery patients. In 2011, the American Society of Plastic Surgeons recommended the adoption of a VTE risk stratification and mitigation; however, successful implementation of VTE prophylaxis protocols has not been well described. To address and reduce the VTE burden at our academic center, a risk assessment protocol was implemented for patients undergoing outpatient plastic surgery procedures.

METHOD

All patients who received outpatient plastic surgery between August 2018 and July 2019 were eligible for the VTE modified Caprini risk assessment screening. Sampling of practice patterns was done by chart review from the first week of each month. The study was divided into 3 phases to assess the relationship of screening compliance rates with each protocol change. Compliance was defined as completion of VTE Caprini screening with documentation in patients' charts.

RESULTS

Over the 12-month study period, 277 patients met the inclusion criteria. From August to November 2018 (phase 1), patients were screened at the initial clinic visit with an average compliance rate of 11.1%. In December 2018 (phase 2), patients were screened on the day of surgery, with an average compliance rate of 47.1%. From January to July 2019 (phase 3), surgeons recorded the numerical Caprini score into the patient's electronic medical record with a subsequent compliance rate of 61.3%. The overall compliance during the 12 months was 44.8%. The median calculated Caprini score for this population was 4 (range, 1-7).

CONCLUSIONS

Standardization of VTE risk assessment is vital for patient safety and outcomes. Successful implementation and long-term protocol sustainability are not a simple goal. In this study, protocol compliance greatly improved after tailoring the guidelines to the specific institutional needs and workflow. These results reinforce the importance of continuous protocol review and modification to ensure optimal departmental buy-in and sustainability.

Rationalised premedication practice for blood product transfusions: A single-centre quality initiative

AIM

Blood and platelets are scarce resources that are an essential part of the supportive care for paediatric cancer patients. There are many inherent risks involved with transfusions including acute transfusion reactions (ATRs). Following an initial ATR, prophylactic medications are commonly given prior to subsequent transfusions. However, there are risks with medication administration as well as negative implications for the health system. Our aim was to prevent the automatic prescribing of premedications prior to blood and platelet transfusions for ATRs. We hypothesised this would not increase the risk of harm.

METHODS

Our intervention was to eliminate automatic prescribing of intravenous corticosteroids and intravenous promethazine prior to a transfusion. This was approached through a behaviour change model and the implementation of recommended prescribing guidelines. Three Plan Do Study Act (PDSA) cycles refined the guidelines to align with clinicians' needs and build support through co-design. Data gathered on individual patients receiving transfusions and reaction rates during the trial were compared to international data.

RESULTS

A total of 100 patients received a transfusion during the trial. Eleven patients either had a previous reaction or experienced their first reaction during this time. All patients followed the guidelines and had either no premedication or an oral antihistamine premedication. There were no breakthrough reactions using oral antihistamines. The overall reaction rate was 1.33%, which aligns with the reported data on ATRs internationally.

CONCLUSION

A restricted prescribing approach to pharmaceutical cover prior to blood and platelet transfusions can be implemented effectively in a paediatric cancer population, without an increase in the risk of harm to the patients.

The Impact of Integrated Support and Context on Treatment Implementation and Child Outcomes Following Behavioral Consultation

Assuring treatment plan implementation following consultation is critically important because implementation is strongly related to outcomes. Treatment implementation has been hypothesized to be influenced by both the nature of the follow-up support provided and contextual variables. However, studies to date have not examined both issues while directly measuring implementation. This study examined treatment implementation following consultation for 48 teachers in public schools who had referred a student for intervention services in a randomized clinical field trial. Participating teachers in the experimental group received Integrated Support (IS). IS includes social influence, planning, and performance feedback elements. IS was compared to weekly follow-up meetings alone. Treatment implementation and child outcomes were markedly superior for IS as compared to weekly follow-up. Three school climate factors were found to be correlated with treatment implementation for the IS group, but not the weekly follow-up group. Participants rated treatment implementation, treatment acceptability, and consultant effectiveness positively and similarly across conditions. The implications of these findings for future work examining school culture, consultation and intervention are discussed.

Advancing Diagnostic Safety Research: Results of a Systematic Research Priority Setting Exercise

BACKGROUND

Diagnostic errors are a major source of preventable harm but the science of reducing them remains underdeveloped.

OBJECTIVE

To identify and prioritize research questions to advance the field of diagnostic safety in the next 5 years.

PARTICIPANTS

Ninety-seven researchers and 42 stakeholders were involved in the identification of the research priorities.

DESIGN

We used systematic prioritization methods based on the Child Health and Nutrition Research Initiative (CHNRI) methodology. We first invited a large international group of expert researchers in various disciplines to submit research questions while considering five prioritization criteria: (1) usefulness, (2) answerability, (3) effectiveness, (4) potential for translation, and (5) maximal potential for effect on diagnostic safety. After consolidation, these questions were prioritized at an in-person expert meeting in April 2019. Top-ranked questions were subsequently reprioritized through scoring on the five prioritization criteria using an online questionnaire. We also invited non-research stakeholders to assign weights to the five criteria and then used these weights to adjust the final prioritization score for each question.

KEY RESULTS

Of the 207 invited researchers, 97 researchers responded and 78 submitted 333 research questions which were then consolidated. Expert meeting participants (n = 21) discussed questions in different breakout sessions and prioritized 50, which were subsequently reduced to the top 20 using the online questionnaire. The top 20 questions addressed mostly system factors (e.g., implementation and evaluation of information technologies), teamwork factors (e.g., role of nurses and other health professionals in the diagnostic process), and strategies to engage patients in the diagnostic process.

CONCLUSIONS

Top research priorities for advancing diagnostic safety in the short-term include strengthening systems and teams and engaging patients to support diagnosis. High-priority areas identified using these systematic methods can inform an actionable research agenda for reducing preventable diagnostic harm.

Developing a tool to monitor knowledge translation in the health system: results from an international Delphi study

BACKGROUND

It is generally accepted that evidence-informed decision making contributes to better health system performance and health outcomes, yet we are lacking benchmarks to monitor the impact of national health information systems (HIS) in policy and practice. Hence in this study, we have aimed to identify criteria for monitoring Knowledge Translation (KT) capacity within countries.

METHODS

We conducted a web-based Delphi with over 120 public health professionals from 45 countries to reach agreement on criteria to monitor KT at the level of national HIS. Public health professionals participated in three survey rounds, in which they ranked 85 preselected criteria and could suggest additional criteria.

RESULTS

Experts working in national (public) health agencies and statistical offices, as well as in health policy and care agreed on 29 criteria which constitute the Health Information (HI)-Impact Index. The criteria cover four essential domains of evaluation: the production of high-quality evidence, broad access and dissemination, stakeholder engagement and knowledge integration across sectors and in civil society. The HI-Impact Index was pretested by officials working in ministries of health and public health agencies in eight countries; they found the tool acceptable and user-friendly.

CONCLUSIONS

The HI-Impact Index provides benchmarks to monitor KT so that countries can assess whether high-quality evidence can be easily accessed and used by the relevant stakeholders in health policy and practice, by civil society and across sectors. Next steps include further refining the procedure for conducting the assessment in routine, and sharing experiences from HIS evaluations using the HI-Impact Index.

Understanding implementation science from the standpoint of health organisation and management: an interdisciplinary exploration of selected theories, models and frameworks

Purpose

As a discipline, health organisation and management is focused on health-specific, collective behaviours and activities, whose empirical and theoretical scholarship remains under-utilised in the field of implementation science. This under-engagement between fields potentially constrains the understanding of mechanisms influencing the implementation of evidence-based innovations in health care. The aim of this viewpoint article is to examine how a selection of theories, models and frameworks (theoretical approaches) have been applied to better understand phenomena at the micro, meso and macro systems levels for the implementation of health care innovations. The purpose of which is to illustrate the potential applicability and complementarity of embedding health organisation and management scholarship within the study of implementation science.

Design/methodology/approach

The authors begin by introducing the two fields, before exploring how exemplary theories, models and frameworks have been applied to study the implementation of innovations in the health organisation and management literature. In this viewpoint article, the authors briefly reviewed a targeted collection of articles published in the Journal of Health Organization and Management (as a proxy for the broader literature) and identified the theories, models and frameworks they applied in implementation studies. The authors then present a more detailed exploration of three interdisciplinary theories and how they were applied across three different levels of health systems: normalization process theory (NPT) at the micro individual and interpersonal level; institutional logics at the meso organisational level; and complexity theory at the macro policy level. These examples are used to illustrate practical considerations when implementing change in health care organisations that can and have been used across various levels of the health system beyond these presented examples.

Findings

Within the Journal of Health Organization and Management, the authors identified 31 implementation articles, utilising 34 theories, models or frameworks published in the last five years. As an example of how theories, models and frameworks can be applied at the micro individual and interpersonal levels, behavioural theories originating from psychology and sociology (e.g. NPT) were used to guide the selection of appropriate implementation strategies or explain implementation outcomes based on identified barriers and enablers to implementing innovations of interest. Projects aiming to implement change at the meso organisational level can learn from the application of theories such as institutional logics, which help elucidate how relationships at the macro and micro-level have a powerful influence on successful or unsuccessful organisational action. At the macro policy level, complexity theory represented a promising direction for implementation science by considering health care organisations as complex adaptive systems.

Originality/value

This paper illustrates the utility of a range of theories, models and frameworks for implementation science, from a health organisation and management standpoint. The authors’ viewpoint article suggests that increased crossovers could contribute to strengthening both disciplines and our understanding of how to support the implementation of evidence-based innovations in health care.

Building capacity from within: qualitative evaluation of a training program aimed at upskilling healthcare workers in delivering an evidence-based implementation approach

Translating evidence into complex health systems is an ongoing challenge. Building the capacity of healthcare workers in behavioral and implementation science methods may facilitate the use of evidence-based implementation approaches, leading to sustainable and effective translation. The aim was to describe the development, contents and evaluation of a training workshop aimed at upskilling hospital-embedded staff to deliver an evidence-based implementation approach. The Hide and Seek Project (HaSP) is a cluster randomized controlled trial testing two implementation approaches for improving hereditary cancer referral at eight Australian hospitals. Healthcare workers were recruited as “Implementation Leads” and trained via a one-day workshop—TRAining in evideNce-baSed ImpLementATion for hEalth (TRANSLATE). The purpose of TRANSLATE was to upskill Implementation Leads in the delivery of HaSP, as well as implementation science methods more broadly. Implementation Leads participated in semi-structured evaluation interviews, which were analyzed using inductive thematic analysis. Nine Implementation Leads from various professional backgrounds completed the training. Four key themes were identified: (i) training day reactions, (ii) learning, (iii) implementation barriers and facilitators, and (iv) building health system capacity for implementation. Participants reported high levels of satisfaction, and anticipated that the knowledge and skills may be useful in the future. We describe a novel training program focused on the delivery of evidence-based implementation within health systems. Guided by insights from this study, methods to deliver the training on a larger scale and across different contexts are being explored. The prolonged impact of TRANSLATE will be further evaluated at trial completion.

Trial registration: ANZCTR, ACTRN12618001072202. Registered on June 27, 2018

Identifying barriers and facilitators to implementation of community-based tuberculosis active case finding with mobile X-ray units in Lima, Peru: a RE-AIM evaluation

OBJECTIVES

Identify barriers and facilitators to integrating community tuberculosis screening with mobile X-ray units into a health system.

METHODS

Reach, effectiveness, adoption, implementation and maintenance evaluation.

SETTING

3-district region of Lima, Peru.

PARTICIPANTS

63 899 people attended the mobile units from 7 February 2019 to 6 February 2020.

INTERVENTIONS

Participants were screened by chest radiography, which was scored for abnormality by computer-aided detection. People with abnormal X-rays were evaluated clinically and by GeneXpert MTB/RIF (Xpert) sputum testing. People diagnosed with tuberculosis at the mobile unit were accompanied to health facilities for treatment initiation.

PRIMARY AND SECONDARY OUTCOME MEASURES

Reach was defined as the percentage of the population of the three-district region that attended the mobile units. Effectiveness was defined as the change in tuberculosis case notifications over a historical baseline. Key implementation fidelity indicators were the percentages of people who had chest radiography performed, were evaluated clinically, had sputum samples collected, had valid Xpert results and initiated treatment.

RESULTS

The intervention reached 6% of the target population and was associated with an 11% (95% CI 6 to 16) increase in quarterly case notifications, adjusting for the increasing trend in notifications over the previous 3 years. Implementation indicators for screening, sputum collection and Xpert testing procedures all exceeded 85%. Only 82% of people diagnosed with tuberculosis at the mobile units received treatment; people with negative or trace Xpert results were less likely to receive treatment. Suboptimal treatment initiation was driven by health facility doctors' lack of familiarity with Xpert and lack of confidence in diagnoses made at the mobile unit.

CONCLUSION

Mobile X-ray units were a feasible and effective strategy to extend tuberculosis diagnostic services into communities and improve early case detection. Effective deployment however requires advance coordination among stakeholders and targeted provider training to ensure that people diagnosed with tuberculosis by new modalities receive prompt treatment.

Mind the gap - Evaluation of the promotion initiatives for implementation of the GLA:D® back clinician courses

BACKGROUND

Translation of research into practice is a methodological challenge. The GLA:D® Back program was initiated to implement evidence-based care for people with low back pain inspired by GLA:D® (Good Life with osteoArthritis in Denmark) that has succeeded in implementing evidence-based care for knee and hip osteoarthritis. This study evaluates the spread and reach of promotion initiatives for GLA:D® Back clinician courses, and the adoption of the GLA:D® Back intervention in clinical practice.

METHODS

Pre-defined success criteria addressed; i) spread; achievement of intended promotion activities (e.g. social media), ii) reach; recruitment of clinicians with certain profiles (e.g. gender balance). Adoption was defined as patient enrollment in the GLA:D® Back registry by course participants. Univariate and multivariate logistic regression was used to investigate associations between adoption and clinician characteristics.

RESULTS

Most clinicians signed up based on information from colleagues (22%). Pre-defined goals for reach, except one, was obtained. 23% (140) of clinicians initiated the GLA:D® Back program in clinical practice within <90 days of course participation; mainly physiotherapists (p < 0.001). The odds ratio for starting GLA:D® Back patient care in a chiropractic setting was 7.4 [2.5; 21.4], indicating that physiotherapists employed by chiropractors mostly handled the intervention.

CONCLUSION

Future promotion strategies should recognize the influence of colleagues and professional networks. Converting clinician courses into patient care was mostly adopted physiotherapists. Although, evaluation processes were less useful in this study, future evaluation of health care processes has potential to inform the implementation of new models in future studies.

Implementation Science and Nutrition: From Research to Practice

Implementation science (IS) is a young field that seeks to minimize the gap between what we know and what we practice, otherwise known as the "know-do gap." Recently, IS has focused on research that expedites the dissemination of evidence-based knowledge, accelerates the translation of interventions to improve knowledge gaps, shrinks healthcare disparities, enhances care of complex medical conditions, and narrows variation in clinical practice and policy. This article seeks to review theoretical frameworks of IS and demonstrate how IS can be utilized to improve nutrition care. Specific examples in this article include implementation of initiatives to improve documentation of malnutrition, increase provision of oral nutrition supplements, increase use of Enhanced Recovery After Surgery protocols, and increase energy and protein delivery. Clinical nutrition is a growing field with more and more research findings pointing to new therapies. In implementing these new therapies, practitioners should recognize the complex system present in healthcare and lean on IS findings to speed implementation and more rapidly improve clinical outcomes.

Key components influencing the sustainability of a multi-professional obstetric emergencies training programme in a middle-income setting: a qualitative study

BACKGROUND

Multi-professional obstetric emergencies training is one promising strategy to improve maternity care. Sustaining training programmes following successful implementation remains a challenge. Understanding, and incorporating, key components within the implementation process can embed interventions within healthcare systems, thereby enhancing sustainability. This study aimed to identify key components influencing sustainability of PRactical Obstetric Multi-Professional Training (PROMPT) in the Philippines, a middle-income setting.

METHODS

Three hospitals were purposively sampled to represent private, public and teaching hospital settings. Two focus groups, one comprising local trainers and one comprising training participants, were conducted in each hospital using a semi-structured topic guide. Focus groups were audio recorded. Data were analysed using thematic analysis. Three researchers independently coded transcripts to ensure interpretation consistency.

RESULTS

Three themes influencing sustainability were identified; attributes of local champions, multi-level organisational involvement and addressing organisational challenges.

CONCLUSIONS

These themes, including potential barriers to sustainability, should be considered when designing and implementing training programmes in middle-income settings. When 'scaling-up', local clinicians should be actively involved in selecting influential implementation champions to identify challenges and strategies specific to their organisation. Network meetings could enable shared learning and sustain enthusiasm amongst local training teams. Policy makers should be engaged early, to support funding and align training with national priorities.

A review of implementation frameworks to operationalize health technology assessment recommendations for medical technologies in the Singapore setting

BACKGROUND

Methodologies of health technology assessment (HTA) for medical technologies are well established; yet, operational frameworks that enable appropriate uptake of HTA recommendations into routine clinical practice are lacking. This review aims to identify the key themes needed to guide the planning and implementation of HTA subsidy decisions for medical technologies such as diagnostics, medical devices, and services and to monitor their impact on a complex multipayer healthcare system like Singapore.

METHODS

A literature search of implementation frameworks was conducted up to 20 December 2020 and was documented in a flow diagram. A thematic analysis of the evidence base was performed using the Braun and Clark approach to identify key themes, from which an implementation framework suitable for Singapore's healthcare system could be developed.

RESULTS

The searches yielded forty-four articles for review, from which twenty themes were identified. The top ten themes constituted the key themes of implementation essential for local adaptation and were categorized into five domains: implementation strategy, organizational support, stakeholder engagement, information dissemination, and implementation outcomes and evaluation. These domains provide operational guidance to methodically identify gaps to facilitate sustainable implementation of HTA-informed medical technology subsidy decisions.

CONCLUSION

A robust and adaptable implementation of HTA-informed subsidy decisions is crucial to optimize its intended impact of improving patient outcomes per dollar spent. The key themes of an implementation framework should capture the important aspects of organizational feasibility to ensure successful adoption in a complex multipayer healthcare system like Singapore.

How to do no harm: empowering local leaders to make care safer in low-resource settings

In a companion paper, we showed how local hospital leaders could assess systems and identify key safety concerns and targets for system improvement. In the present paper, we consider how these leaders might implement practical, low-cost interventions to improve safety. Our focus is on making immediate safety improvements both to directly improve patient care and as a foundation for advancing care in the longer-term. We describe a 'portfolio' approach to safety improvement in four broad categories: prioritising critical processes, such as checking drug doses; strengthening the overall system of care, for example, by introducing multiprofessional handovers; control of known risks, such as only using continuous positive airway pressure when appropriate conditions are met; and enhancing detection and response to hazardous situations, such as introducing brief team meetings to identify and respond to immediate threats and challenges. Local clinical leaders and managers face numerous challenges in delivering safe care but, if given sufficient support, they are nevertheless in a position to bring about major improvements. Skills in improving safety and quality should be recognised as equivalent to any other form of (sub)specialty training and as an essential element of any senior clinical or management role. National professional organisations need to promote appropriate education and provide coaching, mentorship and support to local leaders.

Implementation Science: Application of Evidence-Based Practice Models to Improve Healthcare Quality

BACKGROUND

Translating research into practice is complex for clinicians, yet essential for high quality patient care. The field of implementation science evolved to address this gap by developing theoretical approaches to guide adoption and sustained implementation of practice changes. Clinicians commonly lack knowledge, time, and resources of how evidence-based practice (EBP) models can guide implementation, contributing to the knowledge-to-practice gap.

AIM

This paper aimed to equip clinicians and other healthcare professionals with implementation science knowledge, confidence, and models to facilitate EBP change in their local setting and ultimately improve healthcare quality, safety, and population health outcomes.

METHODS

The field of implementation science is introduced, followed by application of three select models. Models are applied to a clinical scenario to emphasize contextual factors, process, implementation strategies, and outcome evaluation. Key attributes, strengths, opportunities, and utilities of each model are presented, along with general resources for selecting and using published criteria to best fit clinical needs. Partnerships between implementation scientists and clinicians are highlighted to facilitate the uptake of evidence into practice.

LINKING EVIDENCE TO ACTION

Knowledge of implementation science can help clinicians adopt high-quality evidence into their practices. Application-oriented approaches can guide clinicians through the EBP processes. Clinicians can partner with researchers in advancing implementation science to continue to accelerate the adoption of evidence and reduce the knowledge-to-action gap.

Health practitioners' perceptions of the barriers and enablers to the implementation of reproductive genetic carrier screening: A systematic review

Background

As interest in reproductive genetic carrier screening rises, with increased availability, the role of healthcare practitioners is central in guiding uptake aligned with a couples' values and beliefs. Therefore, practitioners' views on implementation are critical to the success of any reproductive genetic carrier screening programme.

Aim

To explore healthcare practitioners' perceptions of the barriers and enablers to implementation.

Materials & Methods

We undertook a systematic review of the literature searching seven databases using health practitioner, screening and implementation terms returning 490 articles.

Results

Screening led to the inclusion of 26 articles for full‐text review. We found three interconnected themes relating to reproductive genetic carrier screening: (i) use and impact, (ii) practitioners' beliefs and expectations and (iii) resources.

Discussion

Barriers and enablers to implementation were present within each theme and grouping these determinants by (a) community for example lack of public interest, (b) practitioner for example lack of practitioner time and (c) organisation for example lack of effective metrics, reveals a preponderance of practitioner barriers and organisational enablers. Linking barriers with potential enablers leaves several barriers unresolved (e.g., costs for couples) implying additional interventions may be required.

Conclusion

Future research should draw on the findings from this study to develop and test strategies to facilitate appropriate offering of reproductive genetic carrier screening by healthcare practitioners.

What is already known?

Availability of reproductive genetic carrier screening is rising.

Screening is often focused on ethnically specific conditions or for those with a family history of disease.

Commonly, carriers do not have family history of disease.

What does this review add?

Identifies practitioner barriers to implementation of reproductive genetic carrier screening, for example, beliefs and expectations.

Matches identified practitioner barriers to enablers to implementation.

Highlights where additional implementation support is required, for example, lack of practitioner confidence.

How to Ensure Referral and Uptake for COPD Rehabilitation - Part 2: A Case of Integrated Care on How to Translate Findings of Cross-Sectorial Workflow to Improve Cross-Sectorial Rehabilitation

Background:

Patients with chronic obstructive pulmonary disease (COPD) can greatly benefit from rehabilitation initiatives, but referral to rehabilitation is sparse. Before we initiated activities to ensure hospital referrals for prevention initiatives at the municipality, we investigated referral patterns and relevant factors in the cross-sectorial workflow.

Objective:

To ensure referral to municipality COPD rehabilitation, by simplifying the referral procedures, and by facilitating relational coordination across the two health care settings.

Methods:

We simplified the referral procedure by initiating all referrals to contain standard wording, all send to the same electronic location, and assuring that all patients were referred to the same initial interview. We facilitated cross-sectorial relational coordination by establishing local- and cross-sectional network groups. We monitored the network groups, and send questionnaires to obtain knowledge of network activities. We used indicators to measure the cross-sectorial quality and questionnaires to measure the patient experienced quality.

Results:

We detected flaws in the referral system that meant that several referrals were neglected. Based on knowledge and experiences the networks called for adjustments. This led to adjustments in patient inclusion and data collection.

Conclusion:

We succeeded in simplifying referral procedures and facilitated cross-sectorial relational coordination. We had to make ongoing adjustments of procedures, information, content, population and data infrastructure.in simplifying referral procedures and facilitated cross-sectorial relational coordination. We had to make ongoing adjustments of procedures, information, content, population and data infrastructure.

Implementing Goals-of-Care Conversations: Lessons From High- and Low-Performing Sites From a VA National Initiative

CONTEXT

The Veterans Health Administration (VA) National Center for Ethics in Healthcare implemented the Life-Sustaining Treatment Decisions Initiative, including policy and practice standards, clinician communication training, a documentation template, and central implementation support to foster advance care planning via goals-of-care conversations for seriously ill veterans in 2014, spreading nationally to other Veterans Health Affairs (VA) sites in 2017.

OBJECTIVES

Our goal was to describe the range of early implementation experiences among the pilot sites, and compare them with spread sites that implemented LSTDI about two years later, identifying cross-site best practices and pitfalls.

METHODS

We conducted semistructured interviews with 32 key stakeholders from 12 sites to identify cross-site best practices and pitfalls related to implementation.

RESULTS

Three primary implementation themes emerged: organizational readiness for transformation, importance of champions, and time and resources needed to achieve implementation. Each theme's barriers and facilitators highlighted variability in success based on complexity in terms of vertical hierarchy and horizontal cross-role/cross-clinic relationships.

CONCLUSION

Learning health care systems need multilevel interdisciplinary implementation approaches to support communication about serious illness, from broad-based system-level training and education to build communication skills, to focusing on characteristics of successful individual champions who listen to critics and are tenacious in addressing concerns.

Improving patient safety during intrahospital transportation of mechanically ventilated patients with critical illness

Aim

Intrahospital transportation (IHT) of patients under mechanical ventilation (MV) significantly increases the risk of patient harm. A structured process performed by a well-prepared team with adequate communication among team members plays a vital role in enhancing patient safety during transportation.

Design and implementation

We conducted this quality improvement programme at the intensive care units of a university-affiliated medical centre, focusing on the care of patients under MV who received IHT for CT or MRI examinations. With the interventions based on the analysis finding of the IHT process by healthcare failure mode and effects analysis, we developed and implemented strategies to improve this process, including standardisation of the transportation process, enhancing equipment maintenance and strengthening the teamwork among the transportation teammates. In a subsequent cycle, we developed and implemented a new process with the practice of reminder-assisted briefing. The reminders were printed on cards with mnemonics including ‘VITAL’ (Vital signs, Infusions, Tubes, Alarms and Leave) attached to the transportation monitors for the intensive care unit nurses, ‘STOP’ (Secretions, Tubes, Oxygen and Power) attached to the transportation ventilators for the respiratory therapists and ‘STOP’ (Speak-out, Tubes, Others and Position) attached to the examination equipment for the radiology technicians. We compared the incidence of adverse events and completeness and correctness of the tasks deemed to be essential for effective teamwork before and after implementing the programme.

Results

The implementation of the programme significantly reduced the number and incidence of adverse events (1.08% vs 0.23%, p=0.01). Audits also showed improved teamwork during transportation as the team members showed increased completeness and correctness of the essential IHT tasks (80.8% vs 96.5%, p<0.001).

Conclusion

The implementation of reminder-assisted briefings significantly enhanced patient safety and teamwork behaviours during the IHT of mechanically ventilated patients with critical illness.

Using implementation science to develop and implement a guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty

Introduction: Guidelines and consensus statements do not support routine preoperative testing for asymptomatic bacteriuria (ASB) prior to elective arthroplasty. Despite this, urine testing remains commonplace in orthopaedic practice. This mixed methods stepwise quality improvement project aimed to develop and implement a guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty within a single centre. Methods: Step 1 - description of current practice in preoperative urine testing prior to arthroplasty within a single centre; Step 2 - examination of the association between preoperative urine culture and pathogens causing prosthetic joint infection (PJI); Step 3 - co-design of a guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty; Step 4 - implementation of a sustainable guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty. Results: Retrospective chart review showed inconsistency in mid-stream urine (MSU) testing prior to elective arthroplasty (49 % preoperative MSU sent) and in antimicrobial prescribing for urinary tract infection (UTI) and ASB. No association was observed between organisms isolated from urine and joint aspirate in confirmed cases of PJI. Co-design of a guideline and decision support tool supported through an implementation strategy resulted in rapid uptake and adherence. Sustainability was demonstrated at 6 months. Conclusion: In this stepwise study, implementation science methodology was used to challenge outdated clinical practice, achieving a sustained reduction in unnecessary preoperative urine testing for ASB prior to elective arthroplasty.

Leaders' perspectives on learning health systems: a qualitative study

Background

Integrated utilisation of digital health data has the power to transform healthcare to deliver more efficient and effective services, and the learning health system (LHS) is emerging as a model to achieve this. The LHS uses routine data from service delivery and patient care to generate knowledge to continuously improve healthcare. The aim of this project was to explore key features of a successful and sustainable LHS to inform implementation in an Academic Health Science Centre context.

Methods

We purposively identified and conducted semi-structured qualitative interviews with leaders, experienced in supporting or developing data driven innovations in healthcare. A thematic analysis using NVivo was undertaken.

Results

Analysis of 26 interviews revealed five themes thought to be integral in an effective, sustainable LHS: (1) Systematic approaches and iterative, continuous learning with implementation into healthcare contributing to new best-practice care; (2) Broad stakeholder, clinician and academic engagement, with collective vision, leadership, governance and a culture of trust, transparency and co-design; (3) Skilled workforce, capability and capacity building; (4) Resources with sustained investment over time and; (5) Data access, systems and processes being integral to a sustainable LHS.

Conclusions

This qualitative study provides insights into the elements of a sustainable LHS across a range of leaders in data-driven healthcare improvement. Fundamentally, an LHS requires continuous learning with implementation of new evidence back into frontline care to improve outcomes. Structure, governance, trust, culture, vision and leadership were all seen as important along with a skilled workforce and sustained investment. Processes and systems to optimise access to quality data were also seen as vital in an effective, sustainable LHS. These findings will inform a co-designed framework for implementing a sustainable LHS within the Australian healthcare and Academic Health Science Centre context. It is anticipated that application of these findings will assist to embed and accelerate the use of routine health data to continuously generate new knowledge and ongoing improvement in healthcare delivery and health outcomes.

How can we monitor the impact of national health information systems? Results from a scoping review

Background

National health information (HI) systems provide data on population health, the determinants of health and health system performance within countries. The evaluation of these systems has traditionally focused on statistical practices and procedures, and not on data use or reuse for policy and practice. This limits the capacity to assess the impact of HI systems on healthcare provision, management and policy-making. On the other hand, the field of Knowledge Translation (KT) has developed frameworks to guide evidence into practice.

Methods

A scoping review of the KT literature to identify the essential mechanisms and determinants of KT that could help monitor the impact of HI systems.

Results

We examined 79 publications and we identified over 100 different KT frameworks but none of these were focused on HI systems per se. There were specific recommendations on disseminating evidence to stakeholders at the institutional and organizational level, and on sustaining the use of evidence in practice and the broader community setting.

Conclusions

We developed a new model, the HI-Impact framework, in which four domains are essential for mapping the impact of national HI systems: (i) HI Evidence Quality, (ii) HI System Responsiveness, (iii) Stakeholder Engagement and (iv) Knowledge Integration. A comprehensive impact assessment of HI systems requires addressing the use of HI in public health decision-making, health service delivery and in other sectors which might have not been considered previously. Monitoring Stakeholder Engagement and Knowledge Integration certifies that the use of HI in all policies is an explicit point of assessment.

Avoiding unnecessary hospitalisation for patients with chronic conditions: a systematic review of implementation determinants for hospital avoidance programmes

Background

Studies of clinical effectiveness have demonstrated the many benefits of programmes that avoid unnecessary hospitalisations. Therefore, it is imperative to examine the factors influencing implementation of these programmes to ensure these benefits are realised across different healthcare contexts and settings. Numerous factors may act as determinants of implementation success or failure (facilitators and barriers), by either obstructing or enabling changes in healthcare delivery. Understanding the relationships between these determinants is needed to design and tailor strategies that integrate effective programmes into routine practice. Our aims were to describe the implementation determinants for hospital avoidance programmes for people with chronic conditions and the relationships between these determinants.

Methods

An electronic search of four databases was conducted from inception to October 2019, supplemented by snowballing for additional articles. Data were extracted using a structured data extraction tool and risk of bias assessed using the Hawker Tool. Thematic synthesis was undertaken to identify determinants of implementation success or failure for hospital avoidance programmes for people with chronic conditions, which were categorised according to the Consolidated Framework for Implementation Research (CFIR). The relationships between these determinants were also mapped.

Results

The initial search returned 3537 articles after duplicates were removed. After title and abstract screening, 123 articles underwent full-text review. Thirteen articles (14 studies) met the inclusion criteria. Thematic synthesis yielded 23 determinants of implementation across the five CFIR domains. ‘Availability of resources’, ‘compatibility and fit’, and ‘engagement of interprofessional team’ emerged as the most prominent determinants across the included studies. The most interconnected implementation determinants were the ‘compatibility and fit’ of interventions and ‘leadership influence’ factors.

Conclusions

Evidence is emerging for how chronic condition hospital avoidance programmes can be successfully implemented and scaled across different settings and contexts. This review provides a summary of key implementation determinants and their relationships. We propose a hypothesised causal loop diagram to represent the relationship between determinants within a complex adaptive system.

Trial registration

PROSPERO 162812 

Increasing the uptake of vitamin D supplement use in Australian residential aged care facilities: results from the vitamin D implementation (ViDAus) study

BACKGROUND

Adequate (≥800 IU/day) vitamin D supplement use in Australian residential aged care facilities (RACFs) is variable and non-optimal. The vitamin D implementation (ViDAus) study aimed to employ a range of strategies to support the uptake of this best practice in participating facilities. The aim of this paper is to report on facility level prevalence outcomes and factors associated with vitamin D supplement use.

METHODS

This trial followed a stepped wedge cluster, non-randomised design with 41 individual facilities serving as clusters pragmatically allocated into two wedges that commenced the intervention six months apart. This multifaceted, interdisciplinary knowledge translation intervention was led by a project officer, who worked with nominated champions at participating facilities to provide education and undertake quality improvement (QI) planning. Local barriers and responsive strategies were identified to engage stakeholders and promote widespread uptake of vitamin D supplement use.

RESULTS

This study found no significant difference in the change of vitamin D supplement use between the intervention (17 facilities with approx. 1500 residents) and control group (24 facilities with approx. 1900 residents) at six months (difference in prevalence change between groups was 1.10, 95% CI - 3.8 to 6.0, p = 0.6). The average overall facility change in adequate (≥800 IU/day) vitamin D supplement use over 12 months was 3.86% (95% CI 0.6 to 7.2, p = 0.02), which achieved a facility level average prevalence of 59.6%. The variation in uptake at 12 months ranged from 25 to 88% of residents at each facility. In terms of the types of strategies employed for implementation, there were no statistical differences between facilities that achieved a clinically meaningful improvement (≥10%) or a desired prevalence of vitamin D supplement use (80% of residents) compared to those that did not.

CONCLUSIONS

This work confirms the complex nature of implementation of best practice in the RACF setting and indicates that more needs to be done to ensure best practice is translated into action. Whilst some strategies appeared to be associated with better outcomes, the statistical insignificance of these findings and the overall limited impact of the intervention suggests that the role of broader organisational and governmental support for implementation should be investigated further.

TRIAL REGISTRATION

Retrospectively registered (ANZCTR ID: ACTRN12616000782437 ).

An overview of healthcare improvement: unpacking the complexity for clinicians and managers in a learning health system

Given the pace of technological advancement and government mandates for healthcare and system transformation, there is an imperative for change. Health systems are highly complex in their design, networks and interacting components, and experience demonstrates that change is very challenging to enact, sustain and scale. Policy-makers, academics and clinicians all need better insight into the nature of this complexity and an understanding of the evidence-base that can support healthcare improvement (HCI), or quality improvement, interventions and make them more effective in driving change. The evidence base demonstrates the vital role of clinical engagement and leadership in HCI, and it is imperative that clinicians engage to improve front-line healthcare. The literature on HCI is vast, applies different and inconsistent terminology and encompasses often loosely defined and overlapping concepts. An increasingly broad range of disciplines has contributed to the available evidence base, but often discipline-specific perspectives frame these contributions. Available literature can also be overly driven by the generation of theoretical concepts and the advancement of academic understanding. It does not necessarily primarily provide focussed and pragmatic insights to guide and inform frontline practice. We aim to address these issues by summarising theories, frameworks, models and success factors for improvement in complex health systems to assist clinicians and others to engage and lead change. We integrate the field of HCI into the learning health system highlighting the key role of the clinician. We seek to inform stakeholders; clinicians and managers to guide the planning, enacting, sustaining and scaling of HCI.