Scaling-up Shared Decision Making in Multidisciplinary Osteoarthritis Care Teams: A Qualitative Study Using the Consolidated Framework for Implementation Research With Three Demonstration Sites

Abstract

BackgroundDespite the development of theory-driven frameworks to guide implementation strategies, their application thus far has largely been limited to evaluating effectiveness within specific contexts. This study describes the use of these frameworks to inform a scale-up strategy for shared decision making (SDM) implementation across a state-wide government-funded health program. MethodsTailored SDM strategies were implemented in three multidisciplinary osteoarthritis care teams over a 3-6 month period during 2019-20 in New South Wales, Australia. Staff interviews occurred across 3 timepoints based on the Organisational Readiness for Change Scale, the Theoretical Domains Framework and the Preparation for Decision-Making (PreP-DM) Scales. Patient interviews based on the PreP-DM were also completed. A hybrid inductive-deductive thematic analysis was followed by mapping the results to the Consolidated Framework for Implementation Research (CFIR) and the OMERACT core domains for SDM. Finally, a ranked list of Expert Recommendations for Implementing Change (ERIC) was derived using a published tool.Results47 interviews were conducted with 18 staff along with 20 interviews with patients. We identified 39 themes for SDM implementation across the five CFIR domains: 1) Interventions need to be flexible to align with different clinical workflows and busy clinics; 2) Outer Settings such as senior managers should formally endorse SDM and clinical protocols and standards need to better align with an SDM approach; 3) Inner Setting teams need early engagement, role clarification and communities of practice in SDM; 4) Individuals are strongly motivated by better patient outcomes and need SDM training and support; and 5) Processes such as patient-reported measures and feedback along with adequate resourcing were key. Recommended strategies therefore focussed on Stakeholder Engagement, Evaluative and Iterative Strategies, Education and Training and Adaptation/Tailoring to the Context. Skills in the identification of decision points, values clarification and deliberation were particularly challenging for staff.ConclusionsTheory-driven scale-up strategies can be developed using qualitative research within demonstration sites. By combining the CFIR and TDF frameworks and prior mapping to the ERIC strategies, health system and program planners can obtain a relevant and evidence-informed roadmap for implementation across complex health systems.