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Table 4 Barriers to the implementation of the ACS QUIK toolkit intervention

From: Implementation and acceptability of a heart attack quality improvement intervention in India: a mixed methods analysis of the ACS QUIK trial

Barriers Data source Description Context, conditions, and consequences
Individual level
 Time and staffing constraints (frequent change in hospital nursing staff) Interview Limited nursing staff and physicians available at the hospital and frequent change in nursing staff Limited staff availability and frequent turnover in nursing staff affected continuity in delivering the toolkit intervention components and hence, its overall effect on patient outcomes could have been affected.
 Inadequate understanding of the quality improvement programs Interview Physicians did not fully understand the difference between drug trials and quality improvement translation trials. Because of lack of physicians’ awareness of quality improvement programs, the approach to the implementation of toolkit intervention suffered and there was inadequate response to audit reports.
Organizational level
 Technological constraint: electronic case report forms and audit report relying on internet access Interview Access to uninterrupted internet services was not available at all hospitals Due to slow internet access, there were lags in data entry and in accessing audit reports.
 High patient volumes and lack of inter-department coordination/ communication Interview High patient volumes and lack of coordination/communication between emergency unit, medicine department, and coronary care unit Due to high patient volumes, physicians or support staff could not explain the patient educations materials including tobacco cessation, cardiac rehabilitation in as much detail as possible. Also, lack of coordination/support from various departments hindered the full implementation and delivery of toolkit intervention components, including changes to the clinical flow of patients with acute myocardial infarction.
 Lack of adequate training to the support staff Survey Physicians expressed that additional training to support staff could lead to improved delivery of toolkit intervention. Additional training to support staff on regular intervals was sought and received by the site physicians to improve delivery of toolkit intervention to account for frequent turnover of support staff.
 Low patient enrolment rates Interview Few hospitals could not use audit reports in meaningful ways due to low patient enrolment rates, including low consent rates. Since the audit report summarized the hospital-level performance and measures based on patient data entered in the system, sites that enrolled few patients did not have meaningful indicators in the audit report.