Abstract and Introduction
Abstract
Objective. To gain insight into which factors impede, and which facilitate, the implementation of a complex multi-component improvement initiative in hospitalized older patients.
Design. A qualitative study based on semi-structured interviews. The three dimensions of Pettigrew and Whipp's theoretical framework, namely, Process, Content and Context, were used to undertake a structured data analysis.
Setting. The study was conducted in 19 Dutch hospitals implementing the Frail Elderly Project.
Participants. Sixty-five members of staff, including physicians, nurses and members of the policy team.
Intervention. The Frail Elderly Project, a Dutch quality improvement program, aims to decrease adverse events in frail older hospitalized people by implementing screening instruments and interventions targeting delirium, falls, malnutrition and physical impairment.
Main Outcome Measures. The management of the process of implementation, participants' opinions of the program elements and contextual factors which influence the implementation.
Results. Barriers to implementation included two process factors (insufficient involvement of clinicians and lack of time), two content factors (having divergent objectives and concerns about recommended program elements) and two contextual factors (a lack of knowledge of delirium and minimal insight into the purposes and effects of the program). Facilitating factors included one process factor (leadership), one content factor (flexibility in choosing methods) and two contextual factors (the program's guidance and the use of digital patient records).
Conclusion. We identified the barriers and the factors which facilitate implementing complex multi-component improvement programs concerning care for older patients. These barriers must be resolved in future improvement programs in order to ensure successful implementation.
Introduction
Older persons are substantial consumers of hospital care. In Dutch hospitals in 2010, the proportion of people aged 75 years or older who were admitted to hospital was 16.9%, compared with 7.8% of the population aged 50–55 years, 9.5% of those aged 55–65 years and 13.0% of the patients in the age group 65–75 years. However, the prognosis for functional recovery in daily activities is poor in many hospitalized older patients and previous studies indicate that adverse events in hospitals are more common among older patients. There is also evidence that adverse events in older inpatients are more often preventable than those in younger patients. What makes this even more dramatic is that older people represent a large proportion of the patient population worldwide. Furthermore, this is predicted to increase substantially within the next few decades. In the Netherlands for example, the percentage of people aged 65 years or older increased from 13.6% in 2000 to 15.3% in 2010 and is expected to reach almost 26% by 2040. Therefore, older patients are an important target group for initiatives to improve patient safety.
In recent years, many large-scale quality improvement programs were developed worldwide, such as the 100,000 Lives Campaign in the United States, the safer patients initiative (SPI) in the UK and the Better Faster program in the Netherlands. Consequently, there has been extensive literature about the implementation of such programs. However, these programs paid little specific attention to the older population and the implementation of complex multi-component improvement projects for older hospitalized patients is hardly or poorly evaluated. Proper evaluations of such projects are important since previous studies have indicated a large gap between evidence-based knowledge and clinical practice. Although many projects have been developed to support hospitals to improve care, the implementation is often a task required of the hospitals themselves. In this article, we attempt to analyze, structurally, the implementation of the Frail Elderly Project, a current evidence-based, multi-component Dutch quality improvement initiative aimed at the older population (Box 1 and Table 1 ). In this way, we hope to gain insight into which factors impede, and which factors facilitate, implementation.
Our research questions are guided, therefore, by the three dimensions of Pettigrew and Whipp's theoretical framework: the 'Process', the 'Content' and the 'Context' of strategic change. These have been used in health care research several times previously. The process dimension concerns how, and to what extent, implementation is achieved. In addition, the content dimension assesses the choice of program elements and evaluates which objectives are reached according to the stakeholders. Finally, the context dimension concerns how internal and external factors influence implementation. All three dimensions should be taken into account in order to achieve a good understanding of the implementation of a complex intervention.
We used this framework in this article in order to evaluate the implementation of the Frail Elderly Project. As a result, the research questions that will be answered are:
How did Dutch hospitals implement the Frail Elderly Project and to what extent did they succeed? (Process)
What are the stakeholders' objectives and assumptions regarding the Frail Elderly Project, and what is their opinion of the different elements of the program? (Content)
Which contextual factors influence the implementation? (Context)