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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]