Introduction A recent WHO multi-country study on maternal and newborn health concluded that there was no evidence of an association between high coverage with essential interventions and reduced mortality in health care facilities, or improvement in other outcomes.1 According to Horton the missing ingredient in this relation is quality of care.2 Quality improvement in healthcare has adopted techniques mainly from industries such as manufacturing and has been used widely in Europe and US. However, evidence of success of these techniques in healthcare is not very conclusive, especially in low and middle-income countries. There have been limited efforts to critically analyse the techniques used in quality improvement interventions. One of the main challenges in evaluating quality improvement is the complexity of the interventions themselves and the complex nature of the systems in which they are implemented. Robust evidence regarding quality improvement interventions for resource poor settings is generally lacking.
The MaiKhanda trial looked at the effect of QI interventions and community women's groups on maternal and newborn mortality in 3 central districts in Malawi.3 The impact evaluation measuring effect on newborn mortality for the QI interventions, using a cluster RCT approach, remained inconclusive. We use a Theory-Based Evaluation (TBE) approach to understand why improvement interventions undertaken by MaiKhanda for new-born care did not show an effect. Absence of effect could be attributed to a failure of theory, a failure of implementation, an evaluation failure or a combination of these.
Our primary objective was to understand the mechanisms by which the QI interventions worked (or not) and explore the interaction between the various factors that mediated the lack of effect on neonatal mortality that was observed in the cluster randomized control trial.
Methods Our research strategy consisted of developing a post-hoc Theory of Change, consolidating and synthesizing all the available evidence using an appropriate framework, and analysing the program and implementation theory using theory based approaches to evaluation.
Data synthesis was conducted using the Consolidate Framework for Implementation Research (CFIR).4 The synthesis takes into consideration the various reports and documents accumulated through the life of the project and complements the process evaluation studies conducted during the same period. In doing so, it draws a picture of the intervention with a multi-dimensional perspective, which provides insights into the evolution of the project. The framework is very comprehensive covering 5 major domains and a range of constructs, not all of which were included in our study. As this was post-hoc analysis, the choice of constructs was based on the availability of data rather than prioritizing the key constructs to consider.
CFIR helps to produce structured and comprehensive data that is then used for analysing the program theory in relation to the intervention outcome. The program theory thus generated for the MaiKhanda intervention is compared with the program theories of the Michigan Keystone Project, which used similar collaborative methods to successfully reduce their central venous line blood stream infections in 106 participating ICUs.5 The rationale for such a comparison is that while the interventions per se are very unique and specific to their context, the program theories underlying the use of collaborative methods in both the interventions is the same and therefore comparable. Theories offer a higher level of abstraction that can be comparable across different settings.6
Results The key finding from analysis of the program theory is that similar intervention strategies that triggered successful mechanisms for improvement in the Keystone Project failed to generate such mechanisms in MaiKhanda project.
The Model for Improvement used in MaiKhanda was built around Deming's improvement theory7 and Roger's diffusion of innovation theory.8 The former theory considers improvement as a product of subject matter knowledge and profound knowledge. Subject matter knowledge on essential and emergency newborn care was generally lacking among health care providers in Malawi. Similarly, understanding variations within the health systems is an acquired skill. While the implementing partners, provided ample opportunities for the Malawian health system to learn the Institute for Healthcare Improvement (IHI) model for improvement, in general, QI teams lacked capacity to collate data and analyse the variations between the health facilities. QI was a fairly new concept in Malawi and MaiKhanda's attempts to embed it within existing health system was limited by challenges of the health systems context, MaiKhanda's own organizational transition and QI and clinical capacity of health care providers.
The main challenge for MaiKhanda was to simultaneously implement and sustain the various change packages it had introduced in the different facilities. While there were isolated instances of successful intervention activities within MaiKhanda, it did not build enough momentum to generate mechanisms across a critical mass of the facilities that would eventually result in improved newborn outcomes. This can be attributed to the implementation strength, context and complexity of MaiKhanda's interventions. This is explored further using the implementation theory.
Implementation was based on diffusion theories where better performing facilities were to act as role models for other facilities to emulate. The cRCT design for measuring impact evaluation required a random allocation of the improvement facilities and this conflicted with innovation diffusion theories, which prescribed a gradual organic spread of the interventions by strategically engaging the innovators and early adapters.
Limitations of the evaluation design notwithstanding, the implementation strength characterized by the dose, duration, intensity and specificity of the intervention was sub-optimal.
Implementation strength is not the only factor triggering an intervention mechanism and cannot be measured independent of the intervention complexity or the intervention context. For example, MaiKhanda struggled to show an effect of its interventions, despite having a long pre-intervention period to refine its interventions, while the Michigan study produced results within 18 month period. This could be because of other factors related to intervention complexity such as the long implementation chain for intervention delivery, the subjective perception of the agency (QI teams) regarding QI and contextual factors such as organizational readiness, the health systems context, QI team capacity to deliver QI interventions and MaiKhanda's own internal capacity.
Human agency is at the heart of implementation and the intervention required a continuous and prolonged time and effort, than was anticipated, to engage and train the health facility QI teams on the improvement model.
One of the key factors affecting the uptake of strategies was MaiKhanda's positioning within the health system and the degree of influence it could exert on other actors. This factor has a significant role to play in country where projects are donor supported and perhaps also donor driven. The period of the intervention also saw MaiKhanda going through a period of rapid organizational transition, which affected intervention implementation on the ground. Furthermore, MaiKhanda's own understanding of QI concepts was evolving gradually and this coupled with its long implementation chain, influenced the subjective understanding of the QI teams regarding QI concepts. Health facility staff also lacked the necessary skills and knowledge related to management of newborn health.
Limited resources within the health facilities meant that gains achieved in some aspects of the intervention could not be sustained in the long run. External contextual factors such as fuel shortages contributed to poor implementation. Changes in policy such as government ban on TBAs, affected intervention uptake and resulted in an increase in health facility deliveries, overwhelming the already under-resourced staff capacity in the health facilities. It is conceivable that quality improvement was not on top of their priority list. But, ‘motivation’ to be involved in QI Collaboratives remained high. In resource constrained settings, ‘motivation’ can be influenced by the lure of personal incentives (such as per diems for attending workshops and meetings) as much as individual's commitment to broader social gains (ie reduction in newborn case fatality rates in their facility). The improvement model was competing against other existing models and it was difficult to get enough stakeholder commitment to the prescribed model as there were huge expectations fuelled by the poverty and poor governance structures and a culture of “perdiemitis” was prevalent in Malawian health care system.9
Discussion As is evident from the study, a single research method will not be able to provide justice to evaluation of a complex set of factors that influence newborn outcomes. We propose a research strategy that includes developing a Theory of Change, followed by evaluation of the program theory, measuring implementation strength, analysing implementation theory and comparing this in relation to the outcomes of the intervention observed through the impact evaluation. The results arising from such a comprehensive evaluation will contribute to the growth of improvement science with the accumulation of knowledge and explanation rather than being just a bedrock of observational facts.
More generally, we propose that design, implementation and evaluation of QI activities, particularly in resource-poor settings, should consider five key principles i.e it should include whole systems thinking, accountability, participatory approach, should be evidence-based and adapt innovative methods.10
Introduction: Implementation science is a foundational field within the broader scope of research and practice focused on implementing change that will improve quality and safety in primary health care. A great deal of attention has been paid over the past few decades to developing and refining frameworks and strategies for implementing best practices in this sector, with the overarching goal of achieving the Institute for Healthcare Improvement's Triple Aim.1 However, despite the importance of frameworks and strategies to enhance the meaningful uptake of best practices in service of these inter-related quality improvement goals, large-scale in-depth studies of the implementation process have been rare.
Primary health care is considered one of the most challenging sectors of health systems in which to promote improvement and change.2 However, it is arguably the health system sector with the highest potential to catalyze transformational changes in the health of certain populations, especially for those with the most complex health and social care needs. Meeting the needs of these patients has proven to be a “wicked” problem,3 raising the importance of strategies to achieve community-based integrated primary health care that can provide the wide range of necessary services in an efficient, high quality, and safe manner. We contend that the challenge of implementing such integrated primary health care constitutes the most important contemporary challenge for improving quality and safety in health care.
The purpose of our research program was to (a) synthesize frameworks of the implementation of best practices in primary health care using meta-narrative methods, (b) complete 9 organizational case studies of the implementation of integrated community-based primary health care in 3 jurisdictions (Ontario and Quebec in Canada, and New Zealand), and (c) compare the findings of the meta-narrative review with our organizational case study findings to strengthen and advance the field of implementation science. Our overarching research question was: “What conceptual and practical advancements in implementation science offer the greatest potential to improve quality and safety in primary health care?”
Methods: In this study a large international research team collaborated to complete 9 interdisciplinary organizational case studies,4 focused on the implementation of community-based integrated primary health care (CBPHC). The research team consists of patients, carers, inter-professional clinician-scientists, policymakers, anthropologists, economists, health services researchers, and health policy researchers. Exemplary cases of organizations that have successfully integrated CBPHC were sampled from Ontario, Quebec and New Zealand, and mixed-methods case studies were completed focusing on 4 analytic levels: Patient/carer, health care providers, organizations, and policies. Methods included qualitative interviews (n >200), surveys (n >50), and document review (n >50) across all 9 cases. Analysis follows the method of framework analysis 5 using NVIVO qualitative data management software, and will continue through to early 2017. We report on early findings in this abstract.
In parallel to the organizational case studies, our research team completed a meta-narrative review of frameworks for implementing best practices in primary health care. The meta-narrative review followed the methods outlined by Greenhalgh et al (2005),6 which was most suited to clarifying our topic given its heterogeneous disciplinary nature. Under the guidance of a specialist librarian, we searched Medline, Pubmed, CINAHL, and the Cochrane Library from 2003–2016 to identify existing reviews of literature that addressed frameworks and theories (and related conceptual guides) for implementing best practices pertinent to primary health care. These publications were reviewed for quality, and data was extracted and analyzed following the meta-narrative approach.
Results: The organizational case studies include extensive data from a wide variety of stakeholders involved in the implementation of high quality integrated, community-based primary health care for older people with complex needs. In this abstract we focus specifically on data that illustrates gaps in the broader literature summarized in our meta-narrative review.
Our meta-narrative review identified five distinct storylines, representing the transition of the implementation science literature across the following spectrum: (1) the generation of theoretical constructs to describe implementation, (2) identifying the many factors that influence implementation, (3) developing new comprehensive frameworks to guide implementation, (4) applying and testing existing frameworks, and (5) clarifying the effectiveness of interventions within particular frameworks. These different foci of frameworks for implementation science were developed across a variety of disciplinary and theoretical perspectives.
Despite the drive for comprehensiveness in the articles included in our meta-narrative review, our organizational case studies have identified a number of key themes excluded from existing literature on frameworks guiding implementation of best practices in primary health care:
The salience of organizational vision: Our case study findings suggest that health care organizations across the three jurisdictional settings establish coherent visions that embody their strategic directions as organizations. Senior managers then work to make these visions manifest in the everyday practice of health care providers within the organization, providing a highly salient influence on the structure and delivery of primary health care. Although “organizational context” is addressed in some frameworks for implementation science, the salience of this coherent organizational vision for health care providers was not reflected in the findings of our meta-narrative review.
The centrality of interpersonal relationships: Inter-personal relationships between managers, health care providers, and patients were found to be a central mechanism by which best practices were implemented in our case studies. The centrality of relationships came to light through our focus on community-based integrated primary health care, wherein “working together” is a fundamental component of integration. However, the impact of personal commitment to others and the role of relationships in collaboration illustrate the importance of these relationships in “spreading” practices across a given organization. The importance of relationships was not reflected in the findings of our meta-narrative review.
The mandatory inclusion of the patient perspective: Our case study findings pointed to the importance of listening to patients and their unpaid carers; many patients explained how their priorities and concerns were simply different from those of their formal health care providers. In this way, although efforts to better integrate primary health care appeared to be successful by other metrics, patients did not perceive their care to be better “integrated”. Instead, many found their most important needs remained unmet. This finding illustrates the importance of thinking critically about the ultimate goals of implementation initiatives. If the goal of the implementation of best practices is to better meet patients' needs (thereby helping to improve population health), then the patient perspective must be central.
Discussion: These findings illustrate important gaps in the broader implementation science literature that require attention if the field's impact on quality and safety in primary health care is to grow. Three implications, mapped onto our three key findings, should be emphasized:
First, the ad hoc presentation of “best practice implementation initiatives” into busy primary health care settings might conflict with longstanding organizational visions, where local histories and ways of working often take precedence over new initiatives seeking to change practices. It is our assessment that previous literature has underestimated the salience of coherence between clinical practice and organizational vision in the implementation of practice change in health care. Future efforts should seek to better align new best practices with existing organizational visions, and/or situate implementation initiatives within longer term efforts to help organizations evolve their visions effectively toward system-wide improvements.
Second, although interpersonal relationships cannot be engineered, ignoring their relevance in implementation initiatives will only continue to result in failed implementation. Relationships create micro-systems of accountability between individuals, and enable coordination in work practices that is simply not possible through formal systems of inter-organizational collaboration. Embracing trusting, interpersonal relationships between managers, providers, patients and carers, and creating opportunities in which these relationships can be established and grow is essential in the implementation of new ways of practicing within and between organizations.
Finally, patients and carers must be involved in the development of best practices at the health system level from the very beginning. Too many health system improvement interventions are developed without due consideration of whether such interventions will have a meaningful impact on patient experience or population health. An iterative process of piloting and encouraging feedback and re-design of health system improvements is essential to the meaningful integration of patient perspectives into the overall improvement of quality and safety in health care.
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Understanding the impact of a QI intervention on newborn mortality in 3 central districts in Malawi: a post-hoc theory-based evaluation
Declaration of competing interests This research is funded by the Canadian Institutes of Health Research and the Health Research Council of New Zealand.
Competing interests None.
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