Facilitating knowledge exchange between health-care sectors, organisations and professions: a longitudinal mixed-methods study of boundary-spanning processes and their impact on health-care quality

An integrated primary care service to reduce cardiovascular disease risk in people with severe mental illness: Primrose-A - thematic analysis of its acceptability, feasibility, and implementation

BACKGROUND

Cardiovascular disease among patients with severe mental illness in England is a major preventable contributor to premature mortality. To address this, a nurse and peer-coach delivered service (Primrose-A) was implemented in three London general practices from 2019 (implementation continued during COVID-19). This study aimed to conduct interviews with patient and staff to determine the acceptability of, and experiences with, Primrose-A.

METHODS

Semi-structured audio-recorded interviews with eight patients who had received Primrose-A, and 3 nurses, 1 GP, and 1 peer-coach who had delivered Primrose-A in three London-based GP surgeries were conducted. Reflexive thematic analysis was used to identify themes from the transcribed interviews.

FINDINGS

Overall, Primrose-A was viewed positively by patients and staff, with participants describing success in improving patients' mental health, isolation, motivation, and physical health. Therapeutic relationships between staff and patients, and long regular appointments were important facilitators of patient engagement and acceptance of the intervention. Several barriers to the implementation of Primrose-A were identified, including training, administrative and communication issues, burden of time and resources, and COVID-19.

CONCLUSIONS

Intervention acceptability could be enhanced by providing longer-term continuity of care paired with more peer-coaching sessions to build positive relationships and facilitate sustained health behaviour change. Future implementation of Primrose-A or similar interventions should consider: (1) training sufficiency (covering physical and mental health, including addiction), (2) adequate staffing to deliver the intervention, (3) facilitation of clear communication pathways between staff, and (4) supporting administrative processes.

Implementing standardised flow: navigating operational and professional dependencies

Purpose

The purpose of this study had two aims: (1) to extend insight regarding the challenges of implementing standardised work, via care pathways, in a healthcare setting by considering interactions with other operational (i.e. resource sharing, portfolio alignment) and professional (i.e. autonomous expertise) dependencies and (2) to develop novel insights regarding a specific flow mechanism, the stroke nurse practitioner, a form of flow “pilo” or guide.

Design/methodology/approach

This was a longitudinal case study of implementing the acute stroke care pathway in a National Health Service hospital in England based on 185 hours of non-participant observations and 68 semi-structured interviews. Archival documents were also analysed.

Findings

The combined flow, operational and professional dependency lens extends operations management understanding of the challenge of implementing standardised work in healthcare. One observed practice, the process pilot role, may be particularly valuable in dealing with these dependencies but it requires specific design and continuous support, for which the authors provide some initial guidance.

Research limitations/implications

The research was a single case study and was focussed on a single care pathway. The findings require replication and extension but offer a novel set of insights into the implications of standardised work in healthcare.

Originality/value

In addition to confirming that a multidependency lens adds conceptual and practical insight to the challenges of implementing standardised work in a healthcare setting, the findings and recommendations regarding flow “pilots” are novel. The authors' analysis of this role reveals new insights regarding the need for continued improvisation in standardised work.

Health professionals' experiences of tuberculosis cohort audit in the North West of England: a qualitative study

OBJECTIVES

Tuberculosis cohort audit (TBCA) was introduced across the North West (NW) of England in 2012 as an ongoing, multidisciplinary, systematic case review process, designed to improve clinical and public health practice. TBCA has not previously been introduced across such a large and socioeconomically diverse area in England, nor has it undergone formal, qualitative evaluation. This study explored health professionals' experiences of the process after 1515 cases had been reviewed.

DESIGN

Qualitative study using semistructured interviews. Respondents were purposively sampled from 3 groups involved in the NW TBCA: (1) TB nurse specialists, (2) consultant physicians and (3) public health practitioners. Data from the 26 respondents were triangulated with further interviews with key informants from the TBCA Steering Group and through observation of TBCA meetings.

ANALYSIS

Interview transcripts were analysed thematically using the framework approach.

RESULTS

Participants described the evolution of a valuable 'community of practice' where interprofessional exchange of experience and ideas has led to enhanced mutual respect between different roles and a shared sense of purpose. This multidisciplinary, regional approach to TB cohort audit has promoted local and regional team working, exchange of good practices and local initiatives to improve care. There is strong ownership of the process from public health professionals, nurses and clinicians; all groups want it to continue. TBCA is regarded as a tool for quality improvement that improves patient safety.

CONCLUSIONS

TBCA provides peer support and learning for management of a relatively rare, but important infectious disease through discussion in a no-blame atmosphere. It is seen as an effective quality improvement strategy which enhances TB care, control and patient safety. Continuing success will require increased engagement of consultant physicians and public health practitioners, a secure and ongoing funding stream and establishment of clear reporting mechanisms within the public health system.