What risks to sustainability are identified throughout care bundle implementation and how can they be addressed? A mixed methods case study

Abstract

ObjectivesDespite national guidance on how to identify and treat heart failure (HF), variation in HF care persists across UK hospitals. Care bundles have been proposed as a mechanism to deliver reliable optimal care for patients; however, specific challenges to sustain care bundles in practice have been highlighted. With few studies providing insight into how to design or implement care bundles to optimise sustainability, there is little direction for practitioners seeking to ensure long-term impact of their initiatives. This study explores the sustainability risks encountered throughout the implementation of a HF care bundle (HFCB) and describes how these challenges were addressed by a multidisciplinary team (MDT) to enhance sustainability over time.DesignA longitudinal mixed method case study examined the HFCB improvement initiative from September 2015 to August 2018. A standardised sustainability tool was used to collect perceptions of sustainability risks and actions throughout the initiative. Observations, key-informant interviews and documentary analysis were conducted to gain in-depth understanding of how the MDT influenced sustainability through specific actions. A qualitative database was developed using a consolidated sustainability framework to conduct thematic analysis. Sustainability outcomes were explored 1-year post funding to ascertain progress towards sustainment.ResultsThe MDT identified six sustainability challenges for the HFCB: infrastructure limitations, coding reliability, delivery consistency, organisational fit, resource stability and demonstrating impact. The MDT undertook multiple actions to enhance sustainability, including: (1) developing a business case to address infrastructure limitations; (2) incorporating staff feedback to increase bundle usability; (3) establishing consistent training; (4) increasing reliability of baseline data; (5) embedding monitoring and communication; and (6) integrating the bundle into current practices.ConclusionThrough the description of challenges, actions and learning from the MDT, this study provides practical lessons for practitioners and researchers seeking to embed and sustain care bundles in practice.

Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review

“…From a theoretical perspective, the empirically evidenced mechanisms (figure 2) uncovered in this review provide new insight into existing sustainability frameworks with specific relevance to hospital settings 17–20. The identified factors spanning before, during and after change implementation narrow an empirical gap in understanding the activities required to enhance sustainability 50. In particular, the factors and mechanisms beyond active implementation extend our understanding of the identified limits of current frameworks of change implementation in healthcare 41–43.…”

“…[17][18][19][20] The identified factors spanning before, during and after change implementation narrow an empirical gap in understanding the activities required to enhance sustainability. 50 In particular, the factors and mechanisms beyond active implementation extend our understanding of the identified limits of current frameworks of change implementation in healthcare. [41][42][43] Additionally, this review elaborates on the mechanisms optimising the fit between the intervention and context.…”

“…Greater challenges exist in attaining sustained improvement and meaningful change from organisational change 39 47–49. The identified gap above with limited current understanding of improvement sustainability19 29 50 creates an investigation opportunity with a particular focus on hospital context.…”

Effect of implementing a heart failure admission care bundle on hospital readmission and mortality rates: interrupted time series study

“…Particular attention was paid to the long-term success of the initiative, and a separate study conducted to explore risks to sustainability. 16 Throughout the initiative, the team used the Web Improvement Support for Healthcare platform to collate, store and analyse data. 17 …”

Identifying value in healthcare transformation initiatives: an evaluation of an approach to benefits realisation

“…Benefits measurement of initiatives that did not implement during the funded period of the project may be further challenged where further funding is required to sustain them. 8 Additionally, healthcare transformation projects often comprise a large diversity of stakeholders, of who those…”