Identification of factors that support successful implementation of care bundles in the acute medical setting: a qualitative study

Background Clinical guidelines offer an accessible synthesis of the best evidence of effectiveness of interventions, providing recommendations and standards for clinical practice. Many guidelines are relevant to the diagnosis and management of the acutely unwell patient during the first 24–48 h of admission. Care bundles are comprised of a small number of evidence-based interventions that when implemented together aim to achieve better outcomes than when implemented individually. Care bundles that are explicitly developed from guidelines to provide a set of related evidence-based actions have been shown to improve the care of many conditions in emergency, acute and critical care settings. This study aimed to review the implementation of two distinct care bundles in the acute medical setting and identify the factors that supported successful implementation. Methods Two initiatives that had used a systematic approach to quality improvement to successfully implement care bundles within the acute medical setting were selected as case studies. Contemporaneous data generated during the initiatives included the review reports, review minutes and audio recordings of the review meetings at different time points. Data were subject to deductive analysis using three domains of the Consolidated Framework for Implementation Research to identify factors that were important in the implementation of the care bundles. Results Several factors were identified that directly influenced the implementation of the care bundles. Firstly, the availability of resources to support initiatives, which included training to develop quality improvement skills within the team and building capacity within the organisation more generally. Secondly, the perceived sustainability of changes by stakeholders influenced the embedding new care processes into existing clinical systems, maximising their chance of being sustained. Thirdly, senior leadership support was seen as critical not just in supporting implementation but also in sustaining longer-term changes brought about by the initiative. Lastly, practitioner incentives were identified as potential levers to engage junior doctors, a crucial part of the acute medical work force and essential to the initiatives, as there is currently little recognition or reward for involvement Conclusions The factors identified have been shown to be supportive in the successful implementation of care bundles as a mechanism for implementing clinical guidelines. Addressing these factors at a practitioner and organisational level, alongside the use of a systematic quality improvement approach, should increase the likelihood that care bundles will be implemented successfully to deliver evidence based changes in the acute medical setting

What we have learned about policy-research linkage from providing a rapid response facility for international healthcare comparisons to the Department of Health in England

In this paper we reflect on our experience of providing a rapid response facility for international healthcare policy comparisons to the English Department of Health. We examine the challenges of developing sustained relationships with policy officials while providing an 'on-demand' service in an environment with high turnover of policies and staff. It may be easier for policy makers to draw on researchers in such a setting than for researchers to foster 'linkage and exchange' relationships with policy makers. Under the facility, knowledge transfer has mostly been from researchers to policy officials, affording us little insight into the policy process or the impact of our work

Advice on commissioning external academic evaluations of policy pilots in health and social care: a discussion paper

This discussion document aims to provide guidance to those thinking of initiating policy pilots and commissioning or requesting others to commission their evaluations. It addresses a number of issues that are specific to policy piloting and that need to be considered before selecting pilot sites and commissioning evaluation. Much advice on evaluation today is focused on advocating the adoption of specific study designs – especially randomised controlled trial (RCTs). While RCTs will be relevant to consider for specific purposes, as we discuss below, they may well not be the best option for the evaluation of policy pilots. We therefore aim to encourage consideration of a range of evaluation designs so as to capitalise fully on the opportunities for learning from policy piloting but, more importantly, to encourage more thinking about other aspects of commissioning evaluations of policy pilots. The advice is primarily designed for national level staff involved in policy making, programme management, monitoring and analysis, and responsible for initiating policy-relevant pilots and commissioning their evaluations

Explaining the persistent dominance of the Greek medical profession across successive health care system reforms from 1983 to the present

The Greek medical profession played an important role at the start of the Greek National Health System (NHS) in 1983 and became intrinsic to its later development. In particular, junior hospital doctors firmly established their position and rights as a result of the new NHS. Using archival sources and interviews with elite participants, this article investigates the specific patterns of power and influence that Greek NHS doctors have exerted from the establishment of the Greek NHS through the latest major attempt at reform in 2001 to the present. Hospital doctors, in particular, have been able consistently to resist any health care system reforms that might affect their dominant position. Their unchallenged position in the system derives from both the particularities of the Greek state and society (in particular, the former’s founding institutional arrangements and the latter’s clientelistic social relations) and the key role that junior doctors played in the early stages of the Greek NHS. As a result, the system is highly path dependent in that the initial implementation of the NHS during the 1980s ensured that subsequent reforms consistently favored the self-interest of medical doctors. Though challenges to the unaccountable power of the medical profession have emerged in Greece following the financial crisis of 2009, including the beginnings of a popular critique of the medical profession, it is too soon to tell whether these will succeed in bringing about significant change

New Zealand's new health sector reforms: back to the future?

New Zealand attracted much international attention in the late 1980s and 1990s for its radical economic and social reforms. This reforming tendency shows no signs of abating. In late 1999 the national (conservative) government was replaced by a Labour led coalition, which is rapidly and significantly changing the way publicly financed health services are organised. Before the general election, Labour had criticised the national government's quasimarket system for its narrow focus on the production of services rather than the improvement of health, for having fragmented a public service, for fostering inappropriate commercial behaviour, for increasing transaction costs, and for lacking local democratic input. These problems were attributed to the "corporate model" of public hospital provision and a single, national purchasing agency. Both will now be replaced with a system promoted as allowing greater community "voice" in health sector decision making and "putting the public back into the public health system." This paper reviews New Zealand's experience with the quasimarket model and appraises the rationale for another round of structural change. We identify challenges policymakers face in achieving their goals, consider the general lessons provided by New Zealand's frequent U-turns in policy, and offer a set of criteria against which the new system might be assessed

Interpretations of referral appropriateness by senior health managers in five PCT areas in England: a qualitative investigation

AIM: To explore interpretations of "appropriate" and "inappropriate" elective referral from primary to secondary surgical care among senior clinical and non-clinical managers in five purposively sampled primary care trusts (PCTs) and their main associated acute hospitals in the English National Health Service (NHS). METHODS: Semi-structured face-to-face interviews were undertaken with senior managerial staff from clinical and non-clinical backgrounds. Interviews were tape-recorded, transcribed and analysed according to the Framework approach developed at the National Centre for Social Research using N6 (NUD*IST6) qualitative data analysis software. RESULTS: Twenty-two people of 23 approached were interviewed (between three and five respondents per PCT and associated acute hospital). Three attributes relating to appropriateness of referral were identified: necessity: whether a patient with given characteristics was believed suitable for referral; destination or level: where or to whom a patient should be referred; and quality (or process): how a referral was carried out, including (eg, investigations undertaken before referral, information contained in the referral and extent of patient involvement in the referral decision. Attributes were hierarchical. "Necessity" was viewed as the most fundamental attribute, followed by "destination" and, finally, "quality". In general, but not always, all three attributes were perceived as necessary for a referral to be defined as appropriate. CONCLUSIONS: For senior clinical and non-clinical managers at the local level in the English NHS, three hierarchical attributes (necessity, appropriateness of destination and quality of referral process) contributed to the overall concept of appropriateness of referral from primary to secondary surgical care

Policy experiments: Investigating effectiveness or confirming direction?

In England, ‘policy experiments’ are largely synonymous with the use of randomized controlled trials (RCTs) to test whether one policy ‘works’ better than another. While advocacy of the use of RCTs in public policy presents this as relatively straightforward, even common sense, the reality is different, as shown through analysis of three high profile policy pilots and their evaluations undertaken in health and social care in England in the mid/late 2000s. The RCTs were expected to confirm the direction of policy by resolving any remaining uncertainty about the effectiveness of the chosen path and their existence was used largely as instruments of persuasion. The findings from the analysis of the three pilots confirm the continuing relevance of Campbell’s 1969 insight that governments struggle to experiment in the scientific sense and explain the limited effect of these policy experiments on policy decisions