Barriers to successful implementation of a clinical pathway for CHF

Organizational Barriers to and Facilitators of the Successful Implementation and Sustainability of the Supporting and Enhancing NICU Sensory Experiences (SENSE) Program

IMPORTANCE

The Supporting and Enhancing NICU Sensory Experiences (SENSE) program is an evidence-based intervention that promotes daily, positive sensory exposures for infants in the neonatal intensive care unit (NICU). Understanding program implementation across sites may aid in optimizing strategies for uptake of the program and subsequently improve outcomes for infants and families.

OBJECTIVE

To investigate health care professionals' perceptions of implementing the SENSE program.

DESIGN

The SENSE Program Implementation Survey was developed using Proctor et al.'s model and the BARRIERS scale to probe organizational practices across sites worldwide.

SETTING

Survey distributed to 211 hospitals with a SENSE program license obtained before March 2020.

PARTICIPANTS

One hundred fourteen NICU personnel (response rate = 54%).

OUTCOMES AND MEASURES

The survey sought to understand barriers and facilitators, adaptations during implementation, and associated costs.

RESULTS

Of the 53% (n = 57 of 107) of respondents who had implemented the SENSE program, many (n = 14; 31%) experienced quick timing (<1 mo) to use, including spread to nearly all infants in their NICU within 6 mo (n = 18; 35%). Most reported the program was used to educate families ≤3 days of birth (n = 20/59; 34%). Most of the sensory interventions in the program were performed by parents (n = 38; 67%) and therapists (n = 44; 77%). Barriers and facilitators at the organizational and individual levels were identified. No additional staff were hired to implement the program.

CONCLUSIONS AND RELEVANCE

Given perceived successes and challenges, strategic enhancement of implementation can inform future administrations of the SENSE program. Plain-Language Summary: This study provides occupational therapists who are interested in implementing the SENSE program (Supporting and Enhancing NICU Sensory Experiences) with an understanding of common barriers, facilitators, costs, and adaptations, which can be used to advocate for program implementation in NICUs to improve outcomes for preterm infants worldwide.

"I'll leave that to the case managers." Healthcare Service Providers' Perceptions of Organizational Readiness for Change in a Randomized Controlled Trial-A Qualitative Analysis Exploring Implementation Success

Up to 50% of unsuccessful implementations of organizational change are due to a lack of organizational readiness for change (ORC). This qualitative study aims to investigate the experiences of occupational physicians (OPs) and staff of test and training centers (ETTCs) with team effectiveness in the context of ORC. The change setting is the implementation of a new occupational health program in a multicentric randomized controlled trial for musculoskeletal disorders (MSD) in Germany. Two rounds of expert interviews with OPs (1st round: n = 10, 2nd round: n = 13) and one round of expert interviews with ETTCs (n = 9) were conducted and analyzed with a deductive-inductive procedure. The focus of the analysis was the assessment of change commitment and change efficacy, as well as their influence on general ORC on a collective level according to Weiner's model (2009). Differential critical assessment of change by the care providers led to a missing collective change commitment and consequently to a missing organizational change commitment. Main inhibiting factors include lacking feedback about (e.g., recruitment) success, limited time resources of and narrow communication between responsible study staff, along with a low rate of utilization and limited adherence of the study population. Main facilitators include standardized procedures and documentation along with easy-access digital tools. Researchers may use the findings to improve the development of new intervention studies, especially in a randomized setting.

Barriers Perceived by Managers and Clinical Professionals Related to the Implementation of Clinical Practice Guidelines for Breastfeeding through the Best Practice Spotlight Organization Program

International institutions facilitate the contact of health professionals to evidence-based recommendations for promoting exclusive breast feeding (BF). However, the achievement of good rates of exclusive BF is still far from the optimum. The intention of the present work is to determine the barriers identified by managers and health professionals involved in the implementation and sustainability of Clinical Practice Guidelines (CPG) for breastfeeding under the auspices of the Best Practice Spotlight Organization program. A qualitative research study was carried out. The participants were managers, healthcare assistants, nurses, midwives, pediatricians and gynecologists. Semi-structured interviews were conducted which were transcribed and analyzed using the six steps of thematic analysis. Twenty interviews were conducted, which defined four major themes: (1) Lack of resources and their adaptation; (2) Where, Who and How; (3) Dissemination and reach of the project to the professionals; and (4) The mother and her surroundings. This research identifies the barriers perceived by the health professionals involved in the implementation, with the addition of the managers as well. Novel barriers appeared such as the ambivalent role of the midwives and the fact that this CPG is about promoting health. The efforts for promoting the implementation program should be continuous, and the services should be extended to primary care.

Brain Trauma Foundation Guideline Compliance: Results of a Multidisciplinary, International Survey

BACKGROUND

Brain Trauma Foundation (BTF) guidelines reflect evidence-based best practices in management of traumatic brain injury. The aim of this study was to examine self-reported physician compliance and predictors of compliance related to BTF guidelines.

METHODS

We conducted an international, multidisciplinary survey examining self-reported adherence to BTF guidelines and multiple factors potentially affecting adherence. We also surveyed intracranial pressure monitoring practices.

RESULTS

Of 154 physician respondents, 15.9% reported their institutions "always" follow BTF guidelines and 72.2% reported that they follow them "most of the time." Personal volume of traumatic brain injury cases and years in practice were not significantly related to adherence. Reported adherence varied significantly in association with respondent's institutional trauma level (P = 0.0010): 17.3% of practitioners at level I, 13.0% at level II, and 0% at level III trauma centers reported "always" following guidelines. Reported adherence to guidelines also varied significantly in association with provider specialty (P = 0.015) and institutional volume of severe traumatic brain injury cases (P = 0.008). Regarding intracranial pressure monitoring practices, 52% of respondents used external ventricular drains, 21% used intraparenchymal monitors, and 27% had no preference (P < 0.001). Of respondents not routinely using external ventricular drains, 36% claimed to "always" follow guidelines. There was no apparent association between type of intracranial pressure monitoring used and reported guideline adherence.

CONCLUSIONS

Few respondents reported their institutions "always" follow BTF guidelines. General surgeons and providers at high-volume level I trauma centers were more likely to comply with guidelines. Differences in survey responses based on provider and institutional characteristics may help target educational efforts.

Hospital-based interventions: a systematic review of staff-reported barriers and facilitators to implementation processes

BACKGROUND

Translation of evidence-based interventions into hospital systems can provide immediate and substantial benefits to patient care and outcomes, but successful implementation is often not achieved. Existing literature describes a range of barriers and facilitators to the implementation process. This systematic review identifies and explores relationships between these barriers and facilitators to highlight key domains that need to be addressed by researchers and clinicians seeking to implement hospital-based, patient-focused interventions.

METHODS

We searched MEDLINE, PsychInfo, Embase, Web of Science, and CINAHL using search terms focused specifically on barriers and facilitators to the implementation of patient-focused interventions in hospital settings. To be eligible, papers needed to have collected formal data (qualitative or quantitative) that specifically assessed the implementation process, as experienced by the staff involved.

RESULTS

Of 4239 papers initially retrieved, 43 papers met inclusion criteria. Staff-identified barriers and facilitators to implementation were grouped into three main domains: system, staff, and intervention. Bi-directional associations were evident between these domains, with the strongest links evident between staff and intervention.

CONCLUSIONS

Researchers and health professionals engaged in designing patient-focused interventions need to consider barriers and facilitators across all three identified domains to increase the likelihood of implementation success. The interrelationships between domains are also crucial, as resources in one area can be leveraged to address barriers in others. These findings emphasize the importance of careful intervention design and pre-implementation planning in response to the specific system and staff context in order to increase likelihood of effective and sustainable implementation.

TRIAL REGISTRATION

This review was registered on the PROSPERO database: CRD42017057554  in February 2017.

A process mining-based investigation of adverse events in care processes

This paper proposes the Clinical Pathway Analysis Method (CPAM) approach that enables the extraction of valuable organisational and medical information on past clinical pathway executions from the event logs of healthcare information systems. The method deals with the complexity of real-world clinical pathways by introducing a perspective-based segmentation of the date-stamped event log. CPAM enables the clinical pathway analyst to effectively and efficiently acquire a profound insight into the clinical pathways. By comparing the specific medical conditions of patients with the factors used for characterising the different clinical pathway variants, the medical expert can identify the best therapeutic option. Process mining-based analytics enables the acquisition of valuable insights into clinical pathways, based on the complete audit traces of previous clinical pathway instances. Additionally, the methodology is suited to assess guideline compliance and analyse adverse events. Finally, the methodology provides support for eliciting tacit knowledge and providing treatment selection assistance.

A Method to Evaluate Critical Factors for Successful Implementation of Clinical Pathways

OBJECTIVE

Clinical pathways (CPs) have been viewed as a multidisciplinary tool to improve the quality and efficiency of evidence-based care. Despite widespread enthusiasm for CPs, research has shown that many CP initiatives are unsuccessful. To this end, this study provides a methodology to evaluate critical success factors (CSFs) that can aid healthcare organizations to achieve successful CP implementation.

DESIGN

This study presents a new approach to evaluate CP implementation CSFs, with the aims being: (1) to identify CSFs for implementation of CPs through a comprehensive literature review and interviews with collaborative experts; (2) to use a filed study data with a robust fuzzy DEMATEL (the decision making trial and evaluation laboratory) approach to visualize the structure of complicated causal relationships between CSFs and obtain the influence level of these factors.

PARTICIPANTS

The filed study data is provided by ten clinical experts of a Chinese hospital.

RESULTS

23 identified CSF factors which are initially identified through a review of the literature and interviews with collaborative experts. Then, a number of direct and indirect relationships are derived from the data such that different perceptions can be integrated into a compromised cause and effect model of CP implementation.

CONCLUSIONS

The results indicate that the proposed approach can systematically evaluate CSFs and realize the importance of each factor such that the most common causes of failure of CP implementation could be eliminated or avoided. Therefore, the tool proposed would help healthcare organizations to manage CP implementation in a more effective and proactive way.

Clinical Pathway Analytics

Recently, medical informatics researchers have focused on supporting standardized activity coordination patterns that structure complex multi-disciplinary interventions. While the designed clinical pathways are aimed to improve the provided healthcare, this paper demonstrates that the care process of individual patients can significantly deviate from the standardized path. Examining the deviations in the individual care processes might result in the further enhancement of the provided quality of care, the evaluation of adverse events or the identification of suboptimal use of resources. This paper presents an optimal combination of process analytics for extracting valuable medical and organizational information from real-world care processes. The authors elaborate an extensive case study based on these process analytics on a series of oncological care processes.

Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems

OBJECTIVES

To sustain an argument that harnessing the natural properties of sociotechnical systems is necessary to promote safer, better healthcare.

METHODS

Triangulated analyses of discrete literature sources, particularly drawing on those from mathematics, sociology, marketing science and psychology.

RESULTS

Progress involves the use of natural networks and exploiting features such as their scale-free and small world nature, as well as characteristics of group dynamics like natural appeal (stickiness) and propagation (tipping points). The agenda for change should be set by prioritising problems in natural categories, addressed by groups who self select on the basis of their natural interest in the areas in question, and who set clinical standards and develop tools, the use of which should be monitored by peers. This approach will facilitate the evidence-based practice that most agree is now overdue, but which has not yet been realised by the application of conventional methods.

CONCLUSION

A key to health system transformation may lie under-recognised under our noses, and involves exploiting the naturally-occurring characteristics of complex systems. Current strategies to address healthcare problems are insufficient. Clinicians work best when their expertise is mobilised, and they flourish in groupings of their own interests and preference. Being invited, empowered and nurtured rather than directed, micro-managed and controlled through a hierarchy is preferable.

Re-mapping client journeys and professional identities: a review of the literature on clinical pathways

OBJECTIVES

To explore the growing use of clinical pathways by nurses and midwives, their impact on client care, and the potential consequences of widespread pathway utilisation for the professional identity and knowledge base of nursing and midwifery.

METHODS

A keyword search was performed within CINAHL and PubMed for the period 1995-2006 to identify relevant material, and article bibliographies were examined to identify relevance references. Thirty-nine publications were selected for inclusion in the analysis on the basis that they offered the most original account of the development of pathways or their effectiveness, or because they provided useful theoretical concepts. A thematic analysis of the selected articles was undertaken.

RESULTS

The review identified four main themes: the multiple aims of clinical pathways; the process of initial development; pathway implementation in practice, and the impacts of pathways on client care, professional identities, and the nature of written documentation. Clinical pathways have multiple aims, including standardising practice, levering external evidence into local health care work, and improving interprofessional co-ordination. The review found limited evidence of pathways' impact on client care, but the existing research suggests that they may be most suitable for predictable, routinised surgical procedures. Key concepts, such as variance and audit were found to be poorly defined. Clinical pathways appear to achieve many of their effects at the development stage and the reshaping of professional interactions.

CONCLUSIONS

Given their widespread adoption and valorisation as tools of evidence-based practice, the dearth of evidence for clinical pathways should raise concerns. Clinical pathways may have significant impacts on nursing and midwifery as professions, both through redrawing professional identities and boundaries, and transforming the ways in which nurses and midwives document care. The impact of standardised pathways on professional ideologies which emphasise individualised care, and clinical autonomy will require long-term programmes of research.

Clinical Practice Guideline Adherence Before and After Implementation of the HEARTFELT (HEART Failure Effectiveness & Leadership Team) Intervention

HEART Failure Effectiveness & Leadership Team (HEARTFELT) is a multifaceted intervention designed to improve adherence with the American College of Cardiology/American Heart Association practice guidelines for heart failure (HF). The purpose of this study was to assess differences in clinician adherence with clinical practice guidelines before and after implementation of HEARTFELT. A quasi-experimental, untreated control group design with separate pretest/posttest samples was employed at a community hospital in Connecticut. The untreated historical control group included patients aged 65 years or older with HF and a nonequivalent comparison group of patients with stroke. The posttest samples included patients with the diagnosis of HF and stroke admitted after implementation of the HEARTFELT intervention. The HEARTFELT intervention included automated pathway in electronic medical record (order sets, interdisciplinary plan of care, self-management plan), access to evidence for clinicians and patients, HF self-management education tools, and ongoing discipline-specific feedback regarding adherence. Data were analyzed using parametric and nonparametric methods. The HEARTFELT intervention significantly improved clinician adherence with addressing all self-management categories in the electronic medical record (P = .000) and adherence with self-management education given to the patient in writing at discharge (P = .000). There were no significant differences in adherence with medical interventions (P = .39). While guideline adherence is associated with less practice variation and improved processes, methods of integration into practice in community hospital settings have been largely unexplored. The multifaceted HEARTFELT intervention is promising for its potential to integrate evidence at the point of care, to reduce unwarranted variation in practice, and ultimately to improve the outcomes of individuals with HF.

Developing an Outcome-based Multidisciplinary Care Planning Tool

Multidisciplinary care planning is required for patients in acute care settings. A task force was charged by the Vice President of Patient Care to develop and implement a multidisciplinary care planning tool. This article outlines the process used and includes examples of the tool and outcomes to date. This major change project resulted in the development of a successful tool, a successful Joint Commission on Accreditation of Healthcare Organization survey, and new opportunities for outcome-based care planning.

Inpatient heart failure treatment from the patient's perspective

OBJECTIVE

The objective of this study was 2-fold: (1) to identify particular opportunities for improvement in patient-centered care of heart failure patients and (2) to suggest strategies for service quality improvement focusing on those areas.

SAMPLE

A national cross-sectional sample of survey data from diagnostic-related group 127 patients was collected between December 1, 2001, and November 30, 2003. Data were split into two 12-month samples to compare results over time. The 2002 sample included 5224 patients treated at 220 hospitals; the 2003 sample included 6531 patients treated at 269 hospitals.

METHOD

A standardized mail-out/mail-back methodology was used to collect data from random samples of patients within 5 days of discharge.

RESULTS

For both samples, the ranking of service issues was highly similar, with the same 4 areas emerging as the foremost priorities: patient involvement in decision making, staff response to concerns voiced during the hospital stay, staff sensitivity to the inconvenience of heart failure and hospitalization, and emotional/spiritual support. Improvement in these 4 service areas should be associated with the greatest increases in patient satisfaction and quality of care for heart failure patients.

CONCLUSIONS

Adequately addressing these patient needs should increase patient satisfaction and quality of care for heart failure patients.