Measuring implementation: development of the implementation process assessment tool (IPAT).

BACKGROUND: Implementation science comprises a large set of theories suggesting interacting factors at different organisational levels. Development of literature syntheses and frameworks for implementation have contributed to comprehensive descriptions of implementation. However, corresponding instruments for measuring these comprehensive descriptions are currently lacking. The present study aimed to develop an instrument measuring care providers' perceptions of an implementation effort, and to explore the instrument's psychometric properties. METHODS: Based on existing implementation literature, a questionnaire was designed with items on individual and team factors and on stages of change in an implementation process. The instrument was tested in a Norwegian study on implementation of evidence based practices for psychosis. Item analysis, factor structure, and internal consistency at baseline were examined. RESULTS: The 27-item Implementation Process Assessment Tool (IPAT) revealed large variation between mean score of the items. The total scale scores were widely dispersed across respondents. Internal consistency for the total scale was high (Cronbach's alpha: .962), and all but one item contributed positively to the construct. The results indicated four underlying constructs: individual stages for behavioural change, individual activities and perceived support, collective readiness and support, and individual perceptions of the intervention. CONCLUSIONS: The IPAT appears to be a feasible instrument for investigating the implementation process from the perspective of those making the change. It can enable examination of the relative importance of factors thought to be essential for implementation outcomes. It may also provide ongoing feedback for leaders tailoring support for teams to improve implementation. However, further research is needed to detect the instrument's properties later in the implementation process and in different contexts. TRIAL REGISTRATION: ClinicalTrials.gov code NCT03271242 (retrospective registered September 5, 2017).

Quality collaboratives: lessons from research.

Quality improvement collaboratives are increasingly being used in many countries to achieve rapid improvements in health care. However, there is little independent evidence that they are more cost effective than other methods, and little knowledge about how they could be made more effective. A number of systematic evaluations are being performed by researchers in North America, the UK, and Sweden. This paper presents the shared ideas from two meetings of these researchers. The evidence to date is that some collaboratives have stimulated improvements in patient care and organisational performance, but there are significant differences between collaboratives and teams. The researchers agreed on the possible reasons why some were less successful than others, and identified 10 challenges which organisers and teams need to address to achieve improvement. In the absence of more conclusive evidence, these guidelines are likely to be useful for collaborative organisers, teams and their managers and may also contribute to further research into collaboratives and the spread of innovations in health care.

Evaluation of quality improvement programmes.

In response to increasing concerns about quality, many countries are carrying out large scale programmes which include national quality strategies, hospital programmes, and quality accreditation, assessment and review processes. Increasing amounts of resources are being devoted to these interventions, but do they ensure or improve quality of care? There is little research evidence as to their effectiveness or the conditions for maximum effectiveness. Reasons for the lack of evaluation research include the methodological challenges of measuring outcomes and attributing causality to these complex, changing, long term social interventions to organisations or health systems, which themselves are complex and changing. However, methods are available which can be used to evaluate these programmes and which can provide decision makers with research based guidance on how to plan and implement them. This paper describes the research challenges, the methods which can be used, and gives examples and guidance for future research. It emphasises the important contribution which such research can make to improving the effectiveness of these programmes and to developing the science of quality improvement.

Quality evaluation and indicator comparison in health care.

By 2005 all healthcare organizations in Europe will be required to take part in a quality evaluation scheme and to collect data about the quality of their service. Hospitals and doctors will need to prove they are safe--quality is no longer assumed. These were the predictions of a recent workshop of Nordic quality experts. The pressures to assess quality are increasing, and there are many assessment, certification, accreditation and measurement schemes in use. Which is best? What evidence is there that any have been effective? How should a hospital or region introduce such a scheme? There are many proponents for different schemes, and an increasing amount of experience to help answer these questions, but little research. This paper provides an overview for non-specialists of the different quality evaluation and indicator schemes for inspection and improvement. It draws on the experiences of quality specialists and leaders in each Nordic country who have applied the schemes in public hospitals and healthcare services. How a scheme is introduced and used may be more important than which particular scheme is chosen. This is one conclusion of the Nordic workshop. Other conclusions are that there is a need for clinicians to be involved, a need to balance simplicity and low cost with scientific validity and credibility with clinicians, and a need for research into different schemes to discover their costs and benefits in healthcare.

The Norwegian approach to integrated quality development.

The UK NHS quality proposals require all NHS organisations to develop an "integrated approach " to quality. In other countries, health care organisations are also working to ensure that the many different quality methods and systems used in health organisations do not duplicate or conflict with each other. The question this paper addresses is "what would an integrated approach to quality look like and how might managers and clinicians develop such an approach in their organisation?" The findings from the Norwegian total quality management experiment in six hospitals were that TQM could not be applied in its pure form in public health care services to ensure integration. The paper draws on this research to describe these hospitals' approach to integrate the different projects and systems which were stimulated by their initial quality programmes. The paper describes the "integrated quality development" approach which characterised these programmes.

The economics of quality--a practical approach.

How much time and money should we devote to quality activities? Will the results be worth the resources which we invest? How can we calculate the return on our quality investments? These questions are raised by managers, clinicians and policy-makers, but they are rarely answered, which may explain the loss of credibility of some quality activities. This paper gives examples of the cost of poor quality, describes and illustrates a simple method for quality costing, and discusses the economics of quality. It considers why there is little research and teaching about the subject, and proposes how managers and clinicians can take a more economically-informed approach to quality in public healthcare.

A team quality improvement sequence for complex problems.

To solve complex quality problems teams need to follow a systematic sequence of inquiry and action. In this article a practical description of a team quality improvement sequence (TQIS) is given based on the experience of the more successful teams in the Norwegian total quality management experiment. There are nine phases in the sequence and teams have the flexibility to choose the best quality methods for completing each phase. The strengths of the framework are in ensuring that personnel time is used cost effectively and that changes are made which result in measurable improvement. One limitation is that the framework has not been as widely tested as FOCUS-PDCA (find, organise, clarify, understand, select-plan, do, check, act) and other frameworks to which the TQIS framework is compared. It is proposed that if team projects are to be the main vehicle for quality improvement, then their work must be made more cost effective. The article aims to stimulate research into the conditions necessary for different quality teams to be successful in health care, and draws on the research to propose a "risk of team failure index" to improve the management of such teams.

Medical managers can make research-based management decisions.

The paper has three messages. First, doctors in management can use evaluation methods and research to make better management decisions and to manage projects. Second, health policy makers and managers can no longer afford not to make a greater use of evaluation in making and implementing decisions. Third, the model of evidence-based medicine is not appropriate for management decisions, but there are other approaches which can be used to develop evaluation-informed health management.

Would it work for us? Learning from quality improvement in Europe and beyond.

DEVELOPING QUALITY TRANSFER TECHNOLOGY AND TRANSFERABILITY ASSESSMENT: Transferring a method or an approach that works in one organization to another organization may not produce the same effect. The result in one setting is an effect of the method or approach working within that system, not just an effect of the method or approach alone. THE CONTEXT FOR QUALITY IMPROVEMENT (QI): To better understand QI activities in a particular country, five aspects of the QI context need to be considered--the health care system, social values, health reform, history of quality assurance, and the language and politics of quality. For example, differences in terminology, even within one region of a country, undermine transferability of quality approaches and methods. LEARNING FROM OTHERS' SOLUTIONS AND STRATEGIES: The methods used to learn from others can be improved by seeking out reports describing the context of the improvement, by carefully deciding which facilities to visit and which conferences and networking events to attend, and by developing skills in judging transferability and in adapting others' strategies. CONCLUSION: Similar changes in health care in most countries are creating a climate more conducive to QI methods than in the past, and there is more experience with these methods and there are more examples of their successful application. Learning from others has more benefits than finding solutions to one's own quality problems. By examining others' approaches to QI one may become aware of issues that have been ignored or that are latent problems in one's own organization.

Information for patients about health services: a review and future developments in the Nordic countries.

Patient power, consumerism and the information revolution are leading to more pressure on care givers to provide information to patients. There are many types of information about health services, treatments and health conditions which could be made available, and different ways of giving it to patients and of helping them to use the information. This paper considers the information which would help citizens to choose a provider, as well as the information which patients could use to take a greater part in treatment decisions and to manage their care, and discusses how it could be collected and provided to people. It reviews some of the research into what information people want, how they use it, the different systems which exist, and the problems and issues involved in helping patients to make more informed choices. Although the review is selective, some general themes emerge and suggest that nurses need to experiment with different approaches and to be at the forefront of developments in enabling patients to make use of the new information which is available.

Informed choice? Health service quality and outcome information for patients.

People need information to choose a physician, a hospital, or to take part in a decision about their treatment. There is little knowledge about what information people want or need to make these choices. Yet there is a growing view in Europe that more and better information should be available to the public about service quality and outcomes. This paper considers the collection, analysis and presentation of health service quality and outcome information for use by patients to make decisions about a provider and about a treatment. It considers why this subject is now a public health and policy issue in Europe, reviews experience in the USA and Europe to gathering and giving this information, and describes the technical, socio-political and ethical issues involved. It concludes that whilst advances have been made in overcoming the technical and cost problems, we do not yet know enough about the information which people want or can use to justify large scale publicity schemes. It proposes that global quality information about a hospital or other service as a whole is less useful. Progress is best made on a specialty or treatment basis, especially where there are large unexplained variations, and by involving patient groups in defining the information which patients with specific health conditions most value. It notes how these developments are leading to new types of collaboration between health workers and patients to increase both patient's and professional's knowledge of the course of an illness or treatment.

Medical participation in and leadership of quality programmes.

Notes that medical participation in organization-wide quality programmes and leadership of quality is commonly viewed as the key to a successful programme. Reviews and reports research into doctors' involvement in such programmes as distinct from doctors' involvement in medical quality activities. Reveals the lack of systematic evidence on the subject, suggests areas for future research, and summarizes what is known. Gives recommendations based on reported research and experience for quality training for doctors and how medical managers might engage their colleagues and other professions in quality programmes.

Beyond the public-private debate: the mixed economy of health.

Can or should private organisations provide public healthcare services? What is the scope for private finance in public healthcare services? This paper reviews some of the arguments for and against public or private ownership management and financing of public healthcare services. It concentrates on health services, where non-economic values and ethical questions are as important as the efficiency considerations, and on health purchasing or funding organisations. The paper describes the increasingly complex interrelationship and forms of competition between public and private providers, purchasers and financiers in the UK health sector. It argues that the simple private/public distinction never did describe well the many different forms of financing ownership and operation of health services in any country and is now a handicap to both scientific and lay policy debate about future options. It proposes a framework for describing the main forms of ownership and operations of health services and considers the future for health service purchasing and funding.

Fulfilling the need for a coordinated approach. Case management and community nursing.

Case management represents an alternative to the multidisciplinary team in coordinating community care. The case manager role is open to community nurses, among other disciplines, and offers an opportunity to combine management skills with clinical care.