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Table 1 Three implementation case studies

From: PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice

Implementation study

Innovation

Recipients

Context

Facilitation

Implementation outcomes

1. Improving the identification and management of chronic kidney disease (CKD) in primary care

Starting point: existing data indicating prevalence levels of CKD in the local population were lower than would be expected

National clinical guideline presenting evidence-based recommendations for identifying and managing CKD

Stakeholder group convened to consider the evidence and the local population data; identified 2 targets for improvement

General practice teams recruited to participate in an improvement collaborative; each team required to have multi-disciplinary membership

Sponsorship from senior leaders in the primary health care setting

Some resistance encountered at a local level, e.g. from practice colleagues who did not recognise CKD as a priority, were uncomfortable disclosing to patients or did not feel sufficiently involved

Practices were working to a pay-for-performance system; CKD was part of this system; hence, there was an incentive to improve

Wider changes occurring in relation to the organisation and management of general practice

Facilitation teams set up, comprising a mix of internal and external novice, experienced/expert facilitators, supported by clinical leaders and project managers

Facilitation methods used included collaborative learning events, local context assessment, Plan-Do-Study-Act (PDSA) cycles, audit and feedback, benchmarking of data and regular practice visits

Before and after study design

Recorded prevalence of CKD increased by 1.2 % in 30 participating practices (n = 1863 additional patients with CKD identified) compared to a national increase of 0.2 %

Management of blood pressure improved in line with national guidelines from 34 to 74 % (cohort 1) and 58 to 83 % (cohort 2)

[21]

2. Improving continence care in a nursing home setting

Starting point: 4 evidence-based recommendations for practice identified from an international clinical guideline by the project stakeholder group

Recommendations were discussed and reviewed by facilitators and a set of common audit criteria agreed

Facilitators were encouraged to establish improvement teams within the nursing home

Some difficulties in convincing colleagues that improvements in continence of long-term residents was possible

Input from continence nurse specialist

Use of patient stories to highlight the need/potential for improvement

Gate-keeper role of nursing home manager

Contextual challenges in a number of homes caused by change of management and reorganisation

Culture of managing incontinence rather than promoting continence

Positive impact of external inspection/accreditation

Internal novice facilitators trained and supported by external expert facilitators

Internal facilitators encouraged to partner with a buddy—some did and others did not

Majority of external support provided virtually

Facilitation methods: joint training, monthly teleconference meetings, audit and feedback and PDSA cycles

Cluster RCT showed no difference between control and intervention wards on primary outcome measure of overall compliance to continence recommendations [11, 85] but significant improvements on a number of secondary outcomes and 1 of the 4 specific recommendations

Internal evaluation demonstrated variable achievement of key audit targets by participating sites [45]

3. Improving nutritional care of older adults in an acute care setting

Starting point: evidence review to identify three interventions to be implemented as part of the project

Combined the three interventions (nutritional screening, nutritional supplements and red tray system) into an improvement bundle

Organisation wide approach adopted, with senior leadership support and communication strategy in place

Dietitians previously tried to introduce improvements but unable to secure buy-in

Formed part of an inter-disciplinary team in this project with involvement of other clinical colleagues and other departments such as catering and supplies

Contextual issues to be negotiated at an organisational level related to the infrastructure and resources required to enable implementation, e.g. providing fridges at ward level, financing the purchase of nutritional supplements, issues of supply and stock management

Experienced internal facilitators supported by external expert facilitators

Internal facilitators recruited ward level clinical champions to work with them

Facilitation methods: staff information and education programmes, audit and feedback

Stepped wedge RCT [86] demonstrated no difference in weight loss after 1 week between intervention and control wards

Improvement noted on key audit measures relating to nutritional screening, provision of nutritional supplements and use of red trays for patients requiring assistance with feeding [46]