Table 3 Key organisational factors and implications for the design and delivery of the intervention
Domains | Factors | Implications for intervention components |
|---|---|---|
The intervention | Guideline-based intervention low compatibility with medical culture; good compatibility with nursing culture | Suggest nurses have the “main” lead role; suggest more training tasks to be done by nurses as well as use of actual tool |
Potential for reinvention needed (e.g. to reflect available resources) | Specify minimum local training; local opinion leaders determine how, by whom and when training is delivered. Communicate 3 recommended practices; EDs decide whether a pathway/protocol is developed from recommendations | |
Changes need to be observable to keep momentum/commitment | Audit and feedback component [note: considered not feasible] | |
Needs clear, unambiguous advantage over current practice | Communicate the evidence underpinning recommendations and health consequences | |
High complexity of cross-unit change | Communicate 3 recommended practices; EDs determine how to integrated practice with care processes/pathways | |
System readiness for innovation | Relatively low tension for change/perceptions of collective change commitment for “acute part of management” (generally not perceived as in need of change) | Present baseline figures [note: considered not feasible]. Stress health impact for patients post discharge |
Mixed tension for change for management of longer-term symptoms (higher change commitment, but relatively low change efficacy) | Select different messages for different audiences | |
Management driven agenda perceived to be very time-focused and not necessarily focused on high quality management from patient perspective | Communicate to senior leaders in stakeholder meeting the fact that the tool is very quick and may lead to shorter stay for patients in the ED | |
Implementation processes (change management practices) | Influence within social networks, not across (particularly in medical professions) | Identify multidisciplinary local opinion leader team (medical and nursing). Provide directors with a description of the types and characteristics of people suited to the role) |
Different professions have own systems in place for organising and communicating changes | Local opinion leaders determine the best way to communicate to staff | |
Visible multidisciplinary leadership, use of ‘stable forces’ | Include in local opinion leader training information about being ‘the constant reminder’ and the importance of leading by example | |
Respected (informal) leaders | Provide ED Director with a description of characteristics of informal leaders | |
System antecedents for innovation | High turnover rates generally perceived to hamper implementation due to constant loss of tacit knowledge | Local opinion leaders deliver training and ensure training is provided to staff on different shifts. Provide ‘back-up’ materials (e.g. presentations with script) that local opinion leaders can distribute to staff unable to attend face-to-face training. Encourage local opinion leaders to integrate training and tools into work processes (e.g. materials for new staff). Involve stable workforce (consultants and nurses). Design brief training sessions that can be repeated regularly |
Little organisational slack, stretched environment | Provide EDs with reimbursement and communicate this in recruitment materials | |
ED perceived to be open to change in general, positive culture in relation to change (relatively positive history of change) | Non-modifiable factor—included in process evaluation | |
Stretched and hectic ED environment not conducive to learning and reflection | Design brief training sessions that can be fitted in easily and repeated often | |
Constantly changing team-structure brings challenges to team-based learning | Include training on learning across professions in Train-the-Trainer day [note: unlikely to be feasible for local sessions] | |
Lack of routine monitoring and feedback (as well as systems to support this); predominately reactive approaches to problem solving | Non-modifiable factor—included in process evaluation | |
Coordination between various quality systems still very manual | Non-modifiable factor | |
Outer context | Being subspecialty at the entry-point of the hospital means many specialties have requests with respect to the management if they were to admit patients under their care | Organise stakeholder meetings and encourage discussions with stakeholders in the hospital |
Raise topic again later in project when thinking about sustaining the changes | ||
Absence of agreed cross-unit pathways/protocols | Encourage early discussions with range of stakeholders to maximise chances of sustaining the changes | |
Agreement between different specialties generally difficult to organise | Encourage early discussions with range of stakeholders to maximise chances of sustaining the changes | |
Accountability metrics very finance driven | Non-modifiable factor | |
Financial systems focus on local costs; no entire patient care journey through the system; perceived absence of follow-up facilities | Communicate 3 recommended practices; EDs determine how to integrate practice with the care processes/pathways |