Barriers and facilitators to improving services what have we learnt - - PowerPoint PPT Presentation

Barriers and facilitators to improving services – what have we learnt about implementing change?

Jo Day and Carol Massey 21st July 2016

CLAHRC South West Peninsula (PenCLAHRC)

Background

• The often documented chasm between ‘knowing’ and ‘doing / improving’

health services and the importance of contextual factors.

• ASPIC Study: Our aim is to generate in-depth insights across the

implementation and improvement processes of two SW AHSN / PenCLAHRC projects: Stroke Thrombolysis Pathway and Patient Initiated Clinics in the South West

• Stroke Quality Improvement Manager: Worked collaboratively - SCN,

PenCLAHRC, SW AHSN and Trusts to: promote quality improvement of the Thrombolysis pathway and develop understanding of key factors affecting quality improvement and implementation

CLAHRC South West Peninsula (PenCLAHRC)

Methodology

Focused Ethnography:

• “focus on a distinct issue or shared experience in cultures or sub-cultures

in specific settings rather than entire communities” (Cruz & Higginbottom 2013, p.36).

• Suitable for health care research as a pragmatic and efficient way to

capture data on a topic of importance.

CLAHRC South West Peninsula (PenCLAHRC)

Methodology

Implementation Science:

• Consolidated Framework for Implementation Research (CFIR) by Damschroder et

al (2009).

• Developed by consolidating constructs found in other published implementation

theories, models and frameworks:

• 5 domains – intervention characteristics, inner and outer setting,

characteristics of individuals, process

• 41 constructs
• An overarching model that aims to help assess what works, where and why

across multiple contexts. Used to inform design and analysis of the study.

CLAHRC South West Peninsula (PenCLAHRC)

Data

ASPIC Study 41 project related documents 45 observations of meetings & Trust visits, formal / informal conversations c.39 hrs 12 interviews - Trusts and Steering Group

CLAHRC South West Peninsula (PenCLAHRC)

Insight 1: Outer context

Patient Needs & resources

Moving towards implementation and improvement

• Potential for patient

harm

• Not a ‘risk free’

treatment

• Benefits of improving
• utcome of patients

quality of life and their disability

• Seeing the benefit of

the treatment for patients after

CLAHRC South West Peninsula (PenCLAHRC)

Insight 2: Inner context

Implementation Climate: Relative Priority

Moving towards implementation and improvement

• Focus on other wider

priorities such as bed management, finance, Success Regime

• Priority for

improvement on another part of the stroke pathway

• External attention e.g.

CQC aid prioritising improvement

• Perceived as

important to do at this point in time and have energy and time to devote to it

CLAHRC South West Peninsula (PenCLAHRC)

Insight 3: Inner context

Culture

Moving towards implementation and improvement

• Trust supportive of

making improvements – in words and action

• Board has a good

awareness of stroke

• Where managers and

clinicians tend not to coalesce to make improvements

• Limited resource,

money or time put towards service improvement

CLAHRC South West Peninsula (PenCLAHRC)

Insight 4: Inner context

Readiness for Implementation: Leadership Engagement

Moving towards implementation and improvement

• Team Stability
• ‘Our patients are

different’

• Person
• Position
• Process
• Project Drivers
• Catalyst

CLAHRC South West Peninsula (PenCLAHRC)

Improvement Leadership

• Engaging others as partners
• Developing and achieving a shared focus / vision
• Create a supportive environment for creative thinking
• Challenge assumptions – in a positive way
• Appreciate a variety of perspectives
• Develop processes that inspire and enable everyone to participate
• Make time for reflection

CLAHRC South West Peninsula (PenCLAHRC)

Additional challenges

• It will probably be harder and longer than you think - ‘be prepared for

the unexpected’. Links to reflection and stepping back.

• The influence of (his)story - ‘soft’ knowledge / intelligence as well as

‘hard’ measures. The ‘nature’ of each organisation is different.

• Recurring need to reinvent the (innovation) wheel and understanding

how improvements may work. Evidence in one’s ‘own back yard’.

• Improvement support – how able to network and learn from others

CLAHRC South West Peninsula (PenCLAHRC)

Implications & reflections

• Possibilities offered by the FE method and CFIR for gaining insights

into the role of context in implementation and improvement processes.

• Our analysis confirms the mediating influence of a dynamic context

and the importance of leadership. A future challenge is to understand the combined influence of factors.

• Identify transferable insights for future efforts that are useful for those

trying to close the ‘knowing-doing’ gap

Thank you for listening!