Conceptualising contexts, mechanisms and outcomes for implementing large-scale, multisite hospital improvement initiatives: a realist synthesis

Abstract

DesignRealist synthesis.Study backgroundLarge-scale hospital improvement initiatives can standardise healthcare across multiple sites but results are contingent on the implementation strategies that complement them. The benefits of these implemented interventions are rarely able to be replicated in different contexts. Realist studies explore this phenomenon in depth by identifying underlying context–mechanism–outcome interactions.ObjectivesTo review implementation strategies used in large-scale hospital initiatives and hypothesise initial programme theories for how they worked across different contexts.MethodsAn iterative, four-step process was applied. Step 1 explored the concepts inherent in large-scale interventions using database searches and snowballing. Step 2 identified strategies used in their implementation. Step 3 identified potential initial programme theories that may explain strategies’ mechanisms. Step 4 focused on one strategy-theory pairing to develop and test context–mechanism–outcome hypotheses. Data was drawn from searches (March–May 2020) of MEDLINE, Embase, PubMed and CINAHL, snowballed from key papers, implementation support websites and the expertise of the research team and experts. Inclusion criteria: reported implementation of a large-scale, multisite hospital intervention. RAMESES reporting standards were followed.ResultsConcepts were identified from 51 of 381 articles. Large-scale hospital interventions were characterised by a top–down approach, external and internal support and use of evidence-based interventions. We found 302 reports of 28 different implementation strategies from 31 reviews (from a total of 585). Formal theories proposed for the implementation strategies included Diffusion of Innovation, and Organisational Readiness Theory. Twenty-three context–mechanism–outcome statements for implementation strategies associated with planning and assessment activities were proposed. Evidence from the published literature supported the hypothesised programme theories and were consistent with Organisational Readiness Theory’s tenets.ConclusionThis paper adds to the literature exploring why large-scale hospital interventions are not always successfully implemented and suggests 24 causative mechanisms and contextual factors that may drive outcomes in the planning and assessment stage.

Turning evidence into action using a senior friendly hospital framework and a collaborative network

“…The latter enabling teams to select and adapt improvements to best fit their hospital's context, reduce reactance to top-down control and maximize opportunity for innovation that may be particularly important in multi-hospital/ unit initiatives. 26,29 In linking these two features SFH ACTION may be unique amongst applications of CNM and multi-hospital interventions in the care of seniors. 46,47 Despite methodological limitations including non-random cohort assignment, reliance on subjective measures, and the absence of control groups, clinical outcome measures, or cost effectiveness data, results suggest that SFH ACTION achieved its objectives and can inform process improvement specialists, health system leaders, hospital administrators, and unit managers who are building more senior friendly hospitals.…”

“…The latter enabling teams to select and adapt improvements to best fit their hospital’s context, reduce reactance to top-down control and maximize opportunity for innovation that may be particularly important in multi-hospital/unit initiatives. 26,29 In linking these two features SFH ACTION may be unique amongst applications of CNM and multi-hospital interventions in the care of seniors. 46,47…”

“…We think that the SFH Framework allowed us to limit attrition in this complex intervention by being respectful of the need for contextual variation. Participants did not want to leave the network and when competing priorities are no longer a distraction 26 to healthcare systems, a re-energized network can support more senior friendly improvements informed by the rich diversity of the collaborative’s innovations. In this regard, alternatives to the SFH Framework that have emerged internationally 48,49 might serve the value of contextual adaptation in their settings.…”

“…The framework served as the foundation for a system-wide survey of senior friendly care practices in all of Ontario Canada's publicly funded, nonpaediatric hospitals. 23 Survey responses suggested a readiness to improve senior friendly care that was tempered by a recognized obstacle to practice improvement [24][25][26] -a gap between the clinical skills of staff and those skills needed to lead Quality Improvement (QI). The survey also revealed that needs varied across the respondents diverse environments which ranged from small rural hospitals to large urban science centres.…”

Real Talk: A Realist Dialogic Approach in a Realist Evaluation

“…In order to illustrate our argument and expand our explanatory reach, we draw on the observations, reflections and tools used in our realist evaluation on the implementation and scaling of a large-system value-based program to transform a complex health system (Long et al, 2022; Sarkies et al, 2020a). LBVC is one of several programs designed to scale and support change based on the principles of ‘value-based healthcare’ in NSW, Australia.…”