Sibbald Shannon L, Van Asseldonk Rachelle, Cao Peiwen L, Law Benson
Faculty of Health Sciences, University of Western Ontario, London, Canada.
Department of Family Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada.
BMC Health Serv Res. 2021 Feb 12;21(1):134. doi: 10.1186/s12913-021-06100-4.
This study was a retrospective evaluation of an unsuccessfully implemented team-based, chronic disease management program, with an aim to understand more about implementation barriers. The program, the Chronic Disease Management Initiative (CDMI) was a new collaborative model of care for patients with COPD. It utilized customized health information and interactive tools, mainly smartphones, for ongoing disease management. The program's goal was to demonstrate that integrated team-based models of care could improve patient care, as well as reduce readmission rates and emergency department visits. The program planning for CDMI began in 2017, followed by the implementation and evaluation period in 2018. After a 10-month implementation period, the program was unable to enroll a sufficient number of patients to examine if there was an improvement in patient outcomes.
A retrospective case-study design using multiple data sources was used to gather feedback from participants involved in CDMI. Data collection occurred throughout planning and implementation and continued into early 2019. Semi-structured interviews were conducted, and transcripts were analyzed using NVivo 10 software. This was followed by content analysis.
Analysis revealed four key themes as barriers to CDMI's implementation: 1) lack of a needs assessment with key stakeholders; 2) lack of buy-in from medical staff; 3) inadequate patient engagement and; 4) contextual barriers. Planners did not conduct a proper needs assessment, nor include patients in the study design. In addition, there was insufficient consideration for how CDMI should be integrated into the usual COPD care plan, leading to confusion in roles and responsibilities. Poor communication between the implementation team and healthcare providers implementing the program, led to a lack of buy-in and engagement.
The key themes resonate with what is already known in the literature. This study supports the importance of using a theoretically grounded plan for implementation. Using a model only in the planning stages is insufficient even when an intervention is based on evidence to support higher quality care. It is imperative to consider practical and contextual factors of program implementation and their interactions. By detailing the 'failed implementation' of this intervention, we hope to share important lessons about the need to plan implementation processes early in program planning.
本研究是对一项未成功实施的基于团队的慢性病管理项目进行的回顾性评估，旨在更深入了解实施障碍。该项目即慢性病管理倡议（CDMI），是一种针对慢性阻塞性肺疾病（COPD）患者的新型协作式护理模式。它利用定制的健康信息和交互式工具（主要是智能手机）进行持续的疾病管理。该项目的目标是证明基于团队的综合护理模式可以改善患者护理，同时降低再入院率和急诊就诊次数。CDMI的项目规划始于2017年，随后在2018年进入实施和评估阶段。经过10个月的实施期后，该项目未能招募到足够数量的患者来检验患者结局是否有所改善。
采用回顾性案例研究设计，利用多个数据源收集参与CDMI的参与者的反馈。数据收集贯穿规划和实施过程，并持续到2019年初。进行了半结构化访谈，并使用NVivo 10软件对访谈记录进行分析。随后进行了内容分析。
分析揭示了CDMI实施的四个关键障碍主题：1）缺乏与关键利益相关者的需求评估；2）医务人员缺乏支持；3）患者参与不足；4）背景障碍。规划者没有进行适当的需求评估，也没有将患者纳入研究设计。此外，对于如何将CDMI纳入常规COPD护理计划考虑不足，导致角色和职责混乱。实施团队与实施该项目的医疗服务提供者之间沟通不畅，导致缺乏支持和参与。
这些关键主题与文献中已有的内容相呼应。本研究支持使用基于理论的实施计划的重要性。即使干预措施有证据支持更高质量的护理，仅在规划阶段使用模型是不够的。必须考虑项目实施的实际和背景因素及其相互作用。通过详细阐述该干预措施的“实施失败”，我们希望分享关于在项目规划早期就需要规划实施过程的重要经验教训。
