Implementation study | Innovation | Recipients | Context | Facilitation | Implementation outcomes |
---|---|---|---|---|---|
1. Improving the identification and management of chronic kidney disease (CKD) in primary care | Starting point: existing data indicating prevalence levels of CKD in the local population were lower than would be expected National clinical guideline presenting evidence-based recommendations for identifying and managing CKD Stakeholder group convened to consider the evidence and the local population data; identified 2 targets for improvement | General practice teams recruited to participate in an improvement collaborative; each team required to have multi-disciplinary membership Sponsorship from senior leaders in the primary health care setting Some resistance encountered at a local level, e.g. from practice colleagues who did not recognise CKD as a priority, were uncomfortable disclosing to patients or did not feel sufficiently involved | Practices were working to a pay-for-performance system; CKD was part of this system; hence, there was an incentive to improve Wider changes occurring in relation to the organisation and management of general practice | Facilitation teams set up, comprising a mix of internal and external novice, experienced/expert facilitators, supported by clinical leaders and project managers Facilitation methods used included collaborative learning events, local context assessment, Plan-Do-Study-Act (PDSA) cycles, audit and feedback, benchmarking of data and regular practice visits | Before and after study design Recorded prevalence of CKD increased by 1.2 % in 30 participating practices (n = 1863 additional patients with CKD identified) compared to a national increase of 0.2 % Management of blood pressure improved in line with national guidelines from 34 to 74 % (cohort 1) and 58 to 83 % (cohort 2) [21] |
2. Improving continence care in a nursing home setting | Starting point: 4 evidence-based recommendations for practice identified from an international clinical guideline by the project stakeholder group Recommendations were discussed and reviewed by facilitators and a set of common audit criteria agreed | Facilitators were encouraged to establish improvement teams within the nursing home Some difficulties in convincing colleagues that improvements in continence of long-term residents was possible Input from continence nurse specialist Use of patient stories to highlight the need/potential for improvement Gate-keeper role of nursing home manager | Contextual challenges in a number of homes caused by change of management and reorganisation Culture of managing incontinence rather than promoting continence Positive impact of external inspection/accreditation | Internal novice facilitators trained and supported by external expert facilitators Internal facilitators encouraged to partner with a buddy—some did and others did not Majority of external support provided virtually Facilitation methods: joint training, monthly teleconference meetings, audit and feedback and PDSA cycles | Cluster RCT showed no difference between control and intervention wards on primary outcome measure of overall compliance to continence recommendations [11, 85] but significant improvements on a number of secondary outcomes and 1 of the 4 specific recommendations Internal evaluation demonstrated variable achievement of key audit targets by participating sites [45] |
3. Improving nutritional care of older adults in an acute care setting | Starting point: evidence review to identify three interventions to be implemented as part of the project Combined the three interventions (nutritional screening, nutritional supplements and red tray system) into an improvement bundle | Organisation wide approach adopted, with senior leadership support and communication strategy in place Dietitians previously tried to introduce improvements but unable to secure buy-in Formed part of an inter-disciplinary team in this project with involvement of other clinical colleagues and other departments such as catering and supplies | Contextual issues to be negotiated at an organisational level related to the infrastructure and resources required to enable implementation, e.g. providing fridges at ward level, financing the purchase of nutritional supplements, issues of supply and stock management | Experienced internal facilitators supported by external expert facilitators Internal facilitators recruited ward level clinical champions to work with them Facilitation methods: staff information and education programmes, audit and feedback | Stepped wedge RCT [86] demonstrated no difference in weight loss after 1Â week between intervention and control wards Improvement noted on key audit measures relating to nutritional screening, provision of nutritional supplements and use of red trays for patients requiring assistance with feeding [46] |