Analysing implementation in Acute Stroke and Patient Initiated Clinics (ASPIC)

Background

It is difficult to generalise what approach to take when implementing improvements and new practice in healthcare due to differences in service context, meaning what works to change practice in one place may work partially or not at all in another. These differences may relate to personnel, organisational culture or structure, financial considerations, physical constraints and styles or absence of leadership, for example, or some combination of these. We do not need to reinvent the implementation wheel every time we work with a new organisation or team, because although each setting is unique there are similarities across settings that allow established approaches to be employed, if we are able to understand the contextual differences and how to approach them.

We seek to help understand differences in context across two SW AHSN/PenCLAHRC-supported interventions. Each intervention has been piloted and has already been shown to be effective and acceptable, these are:

1. Emergency treatment of acute ischaemic stroke

Work has been carried out at a single site and is ready to be implemented across the region. An ethnographic study of the processes involved in implementing the stroke project will be conducted, which will involve interviews with individuals involved in the project, observations and analysis of documents.

2. Patient-initiated clinics (PICs)

PICs have been implemented in rheumatology and will now be applied in other clinics across the same site. Additional support will be provided to the existing ethnographic evaluation and implementation support that forms part of the PICs project by joint working with the qualitative researcher and some additional purposeful interviews.

A comparative analysis of implementation will enable a synthesising of insights across both projects. This will inform the identification of lessons learnt from these two efforts to spread improvements and implement changes in healthcare.

Project aims and objectives

The project aim is to understand differences in context and generate in-depth insights into the implementation processes of these two SW AHSN- and CLAHRC-supported projects to increase the uptake of changes in health care practice.

Our objectives:

• To study and gain in-depth insights into the critical barriers and facilitators to achieving the desired changes in practice across the different implementation contexts within each project.
• To then use the in-depth insights gained to inform the potential development of a tool to support future similar projects

Project activity

An ethnographic study of the two projects, guided by an implementation science framework: the Consolidated Framework for Implementation Research. Often implementation and improvement studies rely on retrospective approaches or participants’ reports of experience rather than direct observation. Our strategy combines a retrospective analysis with a prospective one.

With the appropriate ethical approvals and access our approach included undertaking:

• Semi-structured interviews with individuals involved in the project delivery and service provision (clinicians, managers, researchers, operational modellers, improvement support and steering group members)
• Observation of selected formal and informal meetings and events, along with shadowing of the work of selected project team members
• Analysis of relevant project, policy, guidance and procedural documents
• Co-analysis of data

Insights from both projects will be synthesised so common and contrasting barriers and facilitators to implementation of change in practice can be considered.

Anticipated outputs

• Implementation understanding and support:
• Improve understanding within both the SW AHSN and NIHR CLAHRC South West Peninsula of methods of effective improvement and implementation.
• Deliver a workshop to share and discuss insights and recommendations.
• Report on the implementation of the two projects with details of what has worked and what has not in relation to the differences in context found at each site.
• Inform the development of a tool (e.g. lessons learnt, guidance, checklist) to facilitate future implementation.

Research

• Article(s) written for peer-reviewed academic publications.
• Present at national forums on how we have improved our success in implementing change in applied healthcare setting.

Outputs

Presentation at the SW AHSN workshop on 30th November 2016 (pdf)

News Story: PenCLAHRC presents at SW AHSN ‘Sharing Best Practice’ Conference 2016

News Story: Using Implementation Science to drive health care change: The ASPIC project

The team have also written an article for the Implementation Science Team’s blog: Understanding the Rollercoaster of contextual influences on the spread of practices.