Health care transformation in a resource-limited environment: exploring the determinants of a good climate for change

Tessa A van Boekholt,1 Ashley J Duits,2–4 Jamiu O Busari5,6 1Department of Public Health, United Nations High Commissioner for Refugees Uganda Operation, Arua, Uganda; 2Department of Medical Education, St. Elisabeth Hospital, Willemstad, Curaçao; 3Institute for Medical Education, University Medical Center Groningen, Groningen, The Netherlands; 4Red Cross Blood Bank Foundation, Willemstad, Curaçao; 5Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, University of Maastricht, Maastricht, The Netherlands; 6Department of Pediatrics, Zuyderland Medical Center, Heerlen, The Netherlands Purpose: In a continued effort to improve the health care services, a project was set up to develop and implement a care pathway for the effective management of pressure ulcers in the St Elisabeth Hospital in Curaçao, the Dutch Caribbean. To ensure the effective implementation of our intervention, we decided to investigate what factors define the implementation climate of a health care institution within a resource-limited environment. Methods: We used a participatory tool approach in this study, where a mixed team of health professionals worked on two parts of a health improvement project, namely: 1) workforce leadership development through a clinical leadership training program; and 2) health care quality improvement through the pressure ulcer care pathway development. In-depth interviews were held with ten participants to gain insight into their experiences of the implementation climate in the hospitals and inductive analysis was used to identify the (sub)themes. Results: Identified themes that described the implementation climate included: 1) the attitude of staff toward policy changes; 2) vision of the organization; 3) collaboration; 4) transparency and communication; 5) personal development; and 6) resources. These factors were interrelated and associated with several potential consequences such as loss of motivation among staff, loss of creativity to solve issues, the emergence of the feeling “us” vs “them”, short-term solutions to problems, and a sense of suspicion/frustration among staff members. Conclusion: From this study, positive subconstructs for a favorable implementation climate in a hospital organization were lacking and those that were identified were suboptimal. The inability to satisfy all the subconstructs seemed to be the consequence of insufficient resources and infrastructure within the current health system. A favorable implementation climate in a resource-limited environment is closely tied to the availability of health care resources and infrastructure. Keywords: care pathway, implementation, health care, leadership, Caribbean, pressure ulcer, interprofessional collaboratio