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The implementation of change model adds value to value-based healthcare: a qualitative study.

ABSTRACT: BACKGROUND:Value-based healthcare (VBHC) is a concept that focuses on outcome measurement to contribute to quality improvement. However, VBHC does not offer a systematic approach for implementing improvement as implementation science does. The aim is to, firstly, investigate the implementation of improvement initiatives in the context of VBHC and secondly, to explore how implementation science could be of added value for VBHC and vice versa. METHODS:A case study with two cases in heart care was conducted; one without the explicit use of a systematic implementation method and the other one with the use of the Implementation of Change Model (ICM). Triangulation of data from document research, semi-structured interviews and a focus group was applied to evaluate the degree of method uptake. Interviews were held with experts involved in the implementation of Case 1 (N = 4) and Case 2 (N = 7). The focus group was held with experts also involved in the interviews (N = 4). A theory-driven qualitative analysis was conducted using the ICM as a framework. RESULTS:In both cases, outcome measures were seen as an important starting point for the implementation and for monitoring change. Several themes were identified as most important: support, personal importance, involvement, leadership, climate and continuous monitoring. Success factors included intrinsic motivation for the change, speed of implementation, complexity and continuous evaluation. CONCLUSION:Application of the ICM facilitates successful implementation of quality- improvement initiatives within VBHC. However, the practical use of the ICM shows an emphasis on processes. We recommend that monitoring of outcomes be added as an essential part of the ICM. In the discussion, we propose an implementation model that integrates ICM within VBHC.

SUBMITTER: Zipfel N

PROVIDER: S-EPMC6728951 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ObjectiveTo explore how residents experienced the application of the Positive Health dialogue tool (PH-tool) during outpatient consultations and its influence on the delivery of value-based healthcare (VBHC).DesignQualitative study using non-participant observations of outpatient consultations during which residents used the PH-tool, followed by longitudinal individual, semistructured interviews. To analyse the data from observations and interviews, observational form notes' summarisation and categorisation, and an iterative-inductive thematic approach was used.ParticipantsEight residents-five from the ear, nose, and throat-department and three from the gastroenterology-hepatology-department-were selected through convenience sampling, accounting for 79 observations and 79 interviews.ResultsResidents had bivalent experiences with using the PH-tool. Residents discussed three main benefits: a gained insight into the individual patient's context and functioning, a changed dynamics in resident-patient communication, and an increased awareness regarding value in terms of patient-related outcomes and healthcare costs. Three barriers became apparent: doubts regarding the PH-tool's relevance and scope, boundaries of superspecialised medical professionals, and a lack of demarcation in clinical practice.ConclusionThe PH-tool use can be beneficial for residents during outpatient consultations with new patients and follow-up in cases of multidimensional problems, particularly in cases of chronic conditions and generalist care. In these situations, the tool yielded valuable patient information beyond physical health, helped foster patient engagement, and enabled tailoring the treatment plan to individual patients' needs. On the other hand, the PH-tool was not a good fit for simple problems, clearly demarcated help requests, periodic follow-up consultations, or verbose patients. In addition, it was not suitable for superspecialised care, because it yielded an abundance of general information. For particular patients and problems, using the PH-tool seems a promising strategy to increase VBHC delivery. Nevertheless, further research and detailing is needed to better align the PH-tool's broad intent and clinical practice.

Project description:BACKGROUND:Healthcare organisations are complex social entities, comprising of multiple stakeholders with differing priorities, roles, and expectations about how care should be delivered. To reach agreement among these diverse interest groups and achieve safe, cost-effective patient care, healthcare staff must navigate the micropolitical context of the health service. Micropolitics in this study refers to the use of power, authority, and influence to affect team goals, vision, and decision-making processes. Although these concepts are influential when cultivating change, there is a dearth of literature examining the mechanisms through which micropolitics influences implementation processes among teams. This paper addresses this gap by exploring the role of power, authority, and influence when implementing a collective leadership intervention in two multidisciplinary healthcare teams. METHODS:The multiple case study design adopted employed a triangulation of qualitative research methods. Over thirty hours of observations (Case A?=?16, Case B?=?15) and twenty-five interviews (Case A?=?13, Case B?=?12) were completed. An in-depth thematic analysis of the data using an inductive coding approach was completed to understand the mechanisms through which contextual factors influenced implementation success. A context coding framework was also employed throughout implementation to succinctly collate the data into a visual display and to provide a high-level overview of implementation effect (i.e. the positive, neutral, or negative impact of contextual determinants on implementation). RESULTS:The findings emphasised that implementing change in healthcare teams is an inherently political process influenced by prevailing power structures. Two key themes were generated which revealed the dynamic role of these concepts throughout implementation: 1) Exerting hierarchical influence for implementation; and 2) Traditional power structures constraining implementation. Gaining support across multiple levels of leadership was influential to implementation success as the influence exercised by these individuals persuaded follower engagement. However, the historical dynamics of each team determined how this influence was exerted and perceived, which negatively impacted some participants' experiences of the implementation process. CONCLUSION:To date, micropolitics has received scant attention in implementation science literature. This study introduces the micropolitical concepts of power, authority and influence as essential contextual determinants and outlines the mechanisms through which these concepts influence implementation processes.

Project description:BackgroundSuicide risk prediction models derived from electronic health records (EHR) are a novel innovation in suicide prevention but there is little evidence to guide their implementation.MethodsIn this qualitative study, 30 clinicians and 10 health care administrators were interviewed from one health system anticipating implementation of an automated EHR-derived suicide risk prediction model and two health systems piloting different implementation approaches. Site-tailored interview guides focused on respondents' expectations for and experiences with suicide risk prediction models in clinical practice, and suggestions for improving implementation. Interview prompts and content analysis were guided by Consolidated Framework for Implementation Research (CFIR) constructs.ResultsAdministrators and clinicians found use of the suicide risk prediction model and the two implementation approaches acceptable. Clinicians desired opportunities for early buy-in, implementation decision-making, and feedback. They wanted to better understand how this manner of risk identification enhanced existing suicide prevention efforts. They also wanted additional training to understand how the model determined risk, particularly after patients they expected to see identified by the model were not flagged at-risk and patients they did not expect to see identified were. Clinicians were concerned about having enough suicide prevention resources for potentially increased demand and about their personal liability; they wanted clear procedures for situations when they could not reach patients or when patients remained at-risk over a sustained period. Suggestions for making risk model workflows more efficient and less burdensome included consolidating suicide risk information in a dedicated module in the EHR and populating risk assessment scores and text in clinical notes.ConclusionHealth systems considering suicide risk model implementation should engage clinicians early in the process to ensure they understand how risk models estimate risk and add value to existing workflows, clarify clinician role expectations, and summarize risk information in a convenient place in the EHR to support high-quality patient care.

Project description:We assessed the context in which a hip Fracture Liaison Service was implemented. We conducted semi-structured interviews with 21 key informants at two time points to understand organizational readiness, facilitators, and barriers to change. We identified strategies important to successful implementation, particularly in the context of change fatigue.PurposeFracture Liaison Service (FLS) is effective for secondary fracture prevention. Two hospital sites implemented FLS for hip fracture patients, 50?+ years, in Alberta, Canada. We assessed organizational readiness, facilitators, and barriers to change to better understand the context in which the FLS was implemented to inform its potential spread provincially.MethodsWe recruited individuals involved in FLS implementation at provincial and site levels to participate in telephone interviews at baseline and 16 months post-implementation. Interviews were transcribed and analyzed using thematic content analysis. In addition, site-level participants were invited to complete the Organizational Readiness to Implement Change tool at baseline.ResultsWe conducted 33 semi-structured interviews (20 at baseline; 13 at post-implementation) with 21 key informants. Participants included managers (24%), FLS physicians/clinical nurses (19%), operational/leadership roles (19%), physicians/surgeons (14%), pharmacists (10%), nurse practitioners (10%), and social work (5%). Seventeen site-level participants completed the ORIC tool at baseline; all participants scored high (71%) or neutral (29%). We found that the use of several strategies, including demonstrating value, providing resources, and selecting appropriate sites, were important to implementation, particularly in the context of change fatigue. Participants perceived the FLS as acceptable and there was evidence of facilitated learning rather than simply monitoring implementation as intended.ConclusionsAn effective change management approach neutralized change fatigue. This approach, if maintained, bodes well for the potential spread of the FLS provincially if proven effective and cost effective. Change readiness assessment tools could be used strategically to inform the spread of the FLS to early adopter sites.

Project description:BackgroundEffective implementation processes play a central role in health care organizations and affect the care of patients. Managers are pivotal in facilitating the use of new practices, but their experience and how it affects the implementation outcome are still largely unknown. In the field of disability health care in particular, managers experiences have scarcely been investigated. Therefore, the aim of this study is to explore managers' experiences of the implementation process when transferring new practices into disability health care settings.MethodsSemi-structured individual telephone interviews were conducted with managers at disability health care organizations in four administrative regions in central Sweden. A total of 23 managers with formal managerial responsibility from both public and private health care were strategically selected to be interviewed. The interviews were analysed using reflexive thematic analysis with an inductive approach.ResultsThe analysis resulted in two themes about factors influencing the implementation process: firstly, Contextual factors set the agenda for what can be achieved, which highlighted aspects that hinder or enable the implementation process, such as internal and external conditions, the workplace culture, the employees and managers' attitudes and openness to change: secondly, Leadership in the winds of change, which described the challenges of balancing managerial tasks with leading the change, and the importance of a leadership that involves the participation of the employees.ConclusionsThis study explored how and to what extent managers address and manage the implementation process and the many associated challenges. The findings highlight the importance of leadership support and organizational structure in order to transfer new practices into the work setting, and to encourage an organizational culture for leading change that promotes positive outcomes. We suggest that identifying strategies by focusing on contextual factors and on aspects of leadership will facilitate implementation processes.Trial registrationThe SWAN (Structured Water Dance Intervention) study was retrospectively registered on April 9, 2019 and is available online at ClinicalTrials.gov (ID: NCT03908801).

Project description:INTRODUCTION:Translating scientific advances in genomic medicine into evidence-based clinical practice is challenging. Studying the natural translation of genomics into 'early-adopting' health system sectors is essential. We will (a) examine 29 health systems (Australian and Melbourne Genomics Health Alliance flagships) integrating genomics into practice and (b) combine this learning to co-design and test an evidence-based generalisable toolkit for translating genomics into healthcare. METHODS AND ANALYSIS:Twenty-nine flagships integrating genomics into clinical settings are studied as complex adaptive systems to understand emergent and self-organising behaviours among inter-related actors and processes. The Effectiveness-Implementation Hybrid approach is applied to gather information on the delivery and potential for real-world implementation. Stages '1' and '2a' (representing hybrid model 1) are the focus of this protocol. The Translation Science to Population Impact (TSci Impact) framework is used to study policy decisions and service provision, and the Theoretical Domains Framework (TDF) is used to understand individual level behavioural change; both frameworks are applied across stages 1 and 2a. Stage 1 synthesises interview data from 32 participants involved in developing the genomics clinical practice systems and approaches across five 'demonstration-phase' (early adopter) flagships. In stage 2a, stakeholders are providing quantitative and qualitative data on process mapping, clinical audits, uptake and sustainability (TSci Impact), and psychosocial and environmental determinants of change (TDF). Findings will be synthesised before codesigning an intervention toolkit to facilitate implementation of genomic testing. Study methods to simultaneously test the comparative effectiveness of genomic testing and the implementation toolkit (stage 2b), and the refined implementation toolkit while simply observing the genomics intervention (stage 3) are summarised. ETHICS AND DISSEMINATION:Ethical approval has been granted. The results will be disseminated in academic forums and used to refine interventions to translate genomics evidence into healthcare. Non-traditional academic dissemination methods (eg, change in guidelines or government policy) will also be employed.

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The implementation of change model adds value to value-based healthcare: a qualitative study.

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