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Table 2 Implementation determinants of chronic condition hospital avoidance programmes

From: Avoiding unnecessary hospitalisation for patients with chronic conditions: a systematic review of implementation determinants for hospital avoidance programmes

CFIR domain CFIR construct Descriptive inductive themes Explanation of descriptive themes Example from text
Domain 1: characteristics of the intervention Design quality and packaging Intervention framing The way in which the intervention is presented to staff ‘One site found that presenting the bundle as best practice resulted in staff being more likely to engage with the project and more willing to complete the bundles.’ [47]
  Complexity/adaptability Timeliness of intervention Staff ability to adapt the timing of the intervention for maximum effectiveness ‘Most participants identified timely initiation of NIV as critical to the successful use of this intervention.’ [53]
  Relative advantage Advantage of intervention Patients’ perception of the advantage of the intervention versus an alternative ‘Patients felt that the non-face-to-face CCM program provided opportunities for personal health empowerment, including care plans. They acknowledged that care plans were individually designed based on their needs. Patients said their care managers spent long periods of time with them assessing their health needs and goals, and viewed this as a benefit to their health;’ [61]
  Adaptability Capacity to engage Factors influencing patients’ ability to fully participate in the intervention ‘One quarter of the individuals approached felt too sick or frail for any activity-related intervention.’ [52]
  Adaptability Patient interest and perception Patients’ willingness to participate in the intervention ‘The most common reason for declining participation (cited by four of eleven declining patients [36%]), was lack of interest in being responsible for managing their own insulin therapy given their acute illness.’ [50]
  Adaptability Psychosocial factors Issues relating to patients’ psychosocial needs and welfare ‘Social needs of eligible patients are complex and can complicate effective CCM service delivery.’ [61]
  Adaptability Complexity of clinical conditions influenced by patient complexity The influence of patients’ medical complexity on the intervention’s effectiveness ‘Complex clinical conditions challenge the effectiveness of CCM programs’ [61]
Domain 2: outer setting External policy and incentives External funding The presence of external financial incentives or other policies regarding reimbursement of organisations and health professionals ‘When the CQUIN was introduced there were financial penalties for non-completion which meant managers were more interested in encouraging staff to complete the bundle’ (Physiotherapist, group 1) [47].
  Cosmopolitanism Networks with external bodies The networking of the organisation with others ‘Some hospitals indicated that the networking and examples from other facilities were most helpful, specifically referring to listservs, face-to-face meetings, and webinars. Others indicated that online tools, resources, and access to subject matter experts were most helpful.’ [51].
Domain 3: inner setting Available resources Availability of resources Resources available to the organisation and health professionals, including equipment, training, staffing, and designated time for the intervention ‘Staff highlighted the need for … resourcing and regular training to facilitate QI.’ [55]
  Compatibility Compatibility and fit The fit between the intervention and the priorities and existing processes of health professionals and the organisation ‘Projects were often not integrated into the existing health-care field. The care that was offered within telemonitoring did not take into account the provided routine care.’ [58]
  Culture Engagement of interprofessional team Relationships between health professionals, including cooperation, communication, and trust ‘Nearly all participants noted the importance of interdisciplinary teamwork…Some participants also cited the importance of teamwork among respiratory therapists … two interviewees indicated that tension with nurses over conflicting priorities could be a barrier to keeping patients on NIV.’ [53]
  Leadership engagement Leadership influence The engagement and leadership styles of the organisation leaders ‘Evidence of leadership support is demonstrated by the investment of resources for education, training, and course and conference attendance…. Leaders were actively engaged in and had enduring enthusiasm for both project practices changes, which are currently ongoing.’ [59]
  Compatibility Alignment with organisation policies, procedures, and systems Procedural and system design issues impacting health professionals’ ability to implement ‘Several hospital policies were identified as relevant to NIV implementation. The most commonly mentioned policy was not restricting NIV initiation to the ICU… In many cases, participants indicated that they were unfamiliar with or did not know if their hospital had policies related to NIV.’ [53]
  Learning climate Staff autonomy The power and ability for health professionals to shape and control their work environment ‘Leadership promoted autonomy by … allowing staff to incorporate EBP, based upon individual unit needs and desires, versus dictating projects and priorities.’ [59]
Domain 4: characteristics of individuals Knowledge and beliefs about the innovation Staff buy-in Health professional engagement with, acceptance and willingness to work with the intervention ‘Nearly all participants highlighted the central role of clinician buy-in with statements indicating that clinicians are generally “on board” with NIV as preferential to intubation.’ [53]
  Self-efficacy Staff perceptions Health professional beliefs, motivations, and priorities relating to their work. Closely related to tension for change ‘It was often considered to be outside of the teams’ control and therefore solutions were not considered possible.’ [47]
Domain 5: processes Champions Champions The presence of staff members who are dedicated to promoting and advancing the intervention ‘One team stated that having a champion also allows for the project to be rolled out in new setting more smoothly as it allowed staff to learn from someone they already knew.’ [47]
  Engagement of innovation participants Engagement with key stakeholders The involvement of health professional and other stakeholders whose roles are well-positioned to advance the intervention ‘…care teams and patient care were enhanced by the inclusion of care coordinators.’ [61]
  Engagement of innovation participants Relationships with staff Patients’ ability to connect and communicate with staff ‘Many of the patients did not feel able to ask healthcare professionals, such as family doctors or specialists, questions about their HF symptoms… Some participants were willing to engage in self-recording their health measurements on a technological device if they were able to develop a connection with healthcare professionals…’ [56]
  Engagement of innovation participants Patient engagement The use of strategies by health professionals to attract and involve appropriate patients in the intervention ‘System leaders and health care providers expressed the utility of having the care coordinator on-site to enroll patients in non-face-to-face CCM during their visit to produce greater likelihood of patient acceptance of the co-pay and likelihood to consent to participation.’ [61]
  Reflecting and evaluating Monitor and feedback The presence of procedures to monitor and provide feedback to staff about the progress of the intervention ‘Participants at one hospital reported monthly meetings to review patients who failed NIV and attention to the number of days that patients were treated with NIV as an effort to improve NIV use.’ [53]
  Planning Planning The degree to which tasks involved for the intervention were developed with staff in advance of implementation ‘Best practices were identified by interviewees who had already implemented non-face-to-face CCM, including staffing models, which patients to enroll in the program, billing practices, and when and how to enroll patients.’ [61]
  1. EBP evidence-based practice, NIV non-invasive ventilation, CQUIN Commissioning for Quality and Innovation framework, QI quality improvement, UPC unit practice council, HF heart failure, ICU intensive care unit, CCM chronic care management