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Abstract
Background Health and social care standards have been widely adopted as a quality improvement intervention. Standards are typically made up of evidence-based statements that describe safe, high-quality, person-centred care as an outcome or process of care delivery. They involve stakeholders at multiple levels and multiple activities across diverse services. As such, challenges exist with their implementation. Existing literature relating to standards has focused on accreditation and regulation programmes and there is limited evidence to inform implementation strategies specifically tailored to support the implementation of standards. This systematic review aimed to identify and describe the most frequently reported enablers and barriers to implementing (inter)nationally endorsed standards, in order to inform the selection of strategies that can optimise their implementation.
Methods Database searches were conducted in Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), SocINDEX, Google Scholar, OpenGrey and GreyNet International, complemented by manual searches of standard-setting bodies’ websites and hand searching references of included studies. Primary qualitative, quantitative descriptive and mixed methods studies that reported enablers and barriers to implementing nationally or internationally endorsed standards were included. Two researchers independently screened search outcomes and conducted data extraction, methodological appraisal and CERQual (Confidence in Evidence from Reviews of Qualitative research) assessments. An inductive analysis was conducted using Sandelowski’s meta-summary and measured frequency effect sizes (FES) for enablers and barriers.
Results 4072 papers were retrieved initially with 35 studies ultimately included. Twenty-two thematic statements describing enablers were created from 322 descriptive findings and grouped under six themes. Twenty-four thematic statements describing barriers were created from 376 descriptive findings and grouped under six themes. The most prevalent enablers with CERQual assessments graded as high included: available support tools at local level (FES 55%); training courses to increase awareness and knowledge of the standards (FES 52%) and knowledge sharing and interprofessional collaborations (FES 45%). The most prevalent barriers with CERQual assessments graded as high included: a lack of knowledge of what standards are (FES 63%), staffing constraints (FES 46%), insufficient funds (FES 43%).
Conclusions The most frequently reported enablers related to available support tools, education and shared learning. The most frequently reported barriers related to a lack of knowledge of standards, staffing issues and insufficient funds. Incorporating these findings into the selection of implementation strategies will enhance the likelihood of effective implementation of standards and subsequently, improve safe, quality care for people using health and social care services.
- Health services research
- Implementation science
- Standards of care
- Healthcare quality improvement
- Patient safety
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Health services research
- Implementation science
- Standards of care
- Healthcare quality improvement
- Patient safety
WHAT IS ALREADY KNOWN ON THIS TOPIC
Health and social care standards are quality improvement interventions in health systems. Existing literature relating to standards has focused on accreditation and regulation programmes and there is limited evidence to inform implementation strategies to support the implementation of standards.
WHAT THIS STUDY ADDS
This review provides empirical evidence on factors that influence the implementation of (inter)nationally endorsed standards. Key enablers identified related to available support tools, education and shared learning. Key barriers related to a lack of knowledge of standards, staffing issues and insufficient funds.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Researchers, policy makers and service providers can infer from these findings which influencing factors apply to their own context. Findings from this review can inform decision making when selecting strategies that can be effective in supporting implementation of (inter)nationally endorsed standards.
Introduction and background
Reports of substandard care exist across health systems globally.1 2 It has been estimated that only 60% of healthcare is delivered according to best evidence and health systems waste approximately 30% of health expenditures.1 3 In addition, 10% of service-users experience medical harm or adverse events globally.1 3 Publications such as Crossing the Quality Chasm by the Institute of Medicine4 and Caring for Quality in Health by the Organisation for Economic Co-operation and Development5 have encouraged the adoption of quality systems to strengthen healthcare delivery and improve patient safety.
Setting standards for health and social care services is a well-recognised lever to improving quality and safety in health systems. Health and social care standards (referred to as standards hereafter) typically consist of evidence-based statements (based on evidence of all grades from expert consensus to meta-analyses) that describe an outcome or process of providing safe, high-quality, person-centred care.6 Implementation of standards promotes quality assurance, guides delivery of appropriate care, reduces variation in service provision, and sets out the care that service-users can expect to receive.7
Health systems globally adopt different approaches to setting standards whereby standards vary from statutory requirements to supportive quality improvement approaches. Standards may be promulgated through laws, regulation, private accreditation or certification or endorsement of professional organisations. They may be enforced or encouraged through licensure, regulatory inspection, certification or private accreditation recognition. However, standards by themselves do not bring about improvements in practice. They require multilevel service activities and efforts from stakeholders at multiple levels across diverse services. For standard-setting bodies to learn how to support services to effectively implement standards, there is a need to examine the implementation process. This begins with gaining an understanding of what, why and how standards are implemented in real world health and social care services. A comprehensive understanding will also inform strategies that can enhance implementation and subsequently improve the quality and safety of care delivery.8
Existing systematic reviews relating to standards, all pertain to accreditation or regulation programmes.9–17 There is a gap in synthesising literature relating to the broader field of standards and more specifically relating to the implementation of standards. Furthermore, implementation scientists have highlighted that limited evidence exists to inform the selection and tailoring of implementation strategies for any interventions.8 They have recommended assessing enablers and barriers that influence the implementation process as a first step in selecting appropriate implementation strategies.8 18 This paucity of evidence for both standards and implementation strategies makes it difficult to determine effective implementation strategies specifically for standards. Therefore, we conducted a systematic review and meta-summary to synthesise the existing empirical literature, describing the most frequently reported enablers and barriers that influence implementation of (inter)nationally endorsed health and social care standards.
Methods
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines19 were followed in conducting this systematic review and meta-summary (online supplemental appendix 1).
Supplemental material
A protocol detailing the methodological plan has been published on HRB (Health Research Board) Open Research.20 Deviation from the protocol did not occur. The methods are summarised below in brief.
Search strategy
The following database searches took place in November 2020 and were updated in November 2021: Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), SocINDEX, Google Scholar, OpenGrey and GreyNet International. In addition, manual searches of targeted websites belonging to relevant standard-setting bodies and hand searching the references used in included studies were conducted in February 2021. Keywords for the search were informed by the SPICE (Setting, Perspectives, Interest phenomenon of, Comparison, Evaluation) framework and were; ‘healthcare’, ‘social care’, ‘standards’, ‘enabler’, ‘barrier’, ‘implementation’ (online supplemental appendix 2). Time and language limits were not applied. Records retrieved were imported into the Covidence systematic management software and duplicates were automatically removed.21 One reviewer (YK) paired with a second reviewer (NO’R/LO’C/JH) to independently screen titles and abstracts based on the inclusion and exclusion criteria (online supplemental appendix 3). Articles selected for full-text screening were screened by two reviewers (YK, NO’R/LO’C/JH) independently. Any discrepancies with decisions during the screening stages were resolved through discussion or inviting a third reviewer (NO’R/LO’C/JH) to review until consensus was reached.
Supplemental material
Study selection criteria
Empirical qualitative, quantitative descriptive and mixed methods studies were included. Systematic reviews and scoping reviews were excluded but the reference lists of relevant reviews were screened for potential studies fitting the inclusion criteria. The phenomenon of interest was factors reported as facilitating (enablers) and hindering (barriers) implementation of standards that were (inter)nationally endorsed. Standards are statements that ‘describe best evidence to achieve quality, safe, and person-centred care’.20 Terminological inconsistencies with ‘standards’ posed challenges in ascertaining if the implementation object was specifically standards or, for example, guidelines. Nonetheless, researchers acting as the second and third reviewers were subject matter experts in standards and alongside careful discussion, a mutual interpretation of what ‘standards’ were was achieved, thus reaching consensus on the application of the eligibility criteria.
Data extraction
Data items from included studies were extracted and populated into two data extraction tables in Microsoft Excel. The first table included general characteristics of the studies and the second table was used to categorise the data as enablers or barriers. These data were descriptive portions of text extracted verbatim from the results and discussion sections of the studies. These descriptive portions were second order constructs representing the author’s descriptions, discussions, interpretations, statements and ideas pertaining to the primary data collected.22 23 Two reviewers (YK, NO’R/LO’C/JH) independently extracted these data.
Quality assessment
According to Sandelowski et al, any finding relevant to the research aim enhances the synthesis of the empirical findings.24 Thus, all studies were included in the synthesis, irrespective of any quality concerns. Methodological quality was assessed using the Critical Appraisal Skills Programme tool25 for qualitative studies, Joanna Briggs Institute Critical Appraisal Tools26 for quantitative studies and The Mixed Methods Appraisal Tool27 for mixed methods studies. One study used a one group post-test design.28 A quality appraisal tool specifically for this study design was not sourced and the generic Evidence-based Librarianship critical appraisal checklist29 was used. Two researchers independently (YK, NO’R/LO’C/JH) completed the quality appraisals and assessed studies for concerns with methodological limitations. The methodological assessments were used to inform the Confidence in Evidence from Reviews of Qualitative research (CERQual) component ‘methodological limitations.’
Data synthesis
Sandelowski’s meta-summary approach was applied to synthesise the descriptive findings from the included studies.22 24 An inductive approach was adopted and facilitated the identification of ‘real-world’ experiences. As part of the meta-summary, minor edits were made to the verbatim data populated in the second data extraction table to facilitate understanding. An example of minor edits included: ‘Poor or patchy QS11[Quality Standard 11] implementation was often attributed to weak communication between healthcare professionals in different sectors or settings’30 (p272) was edited to read: Poor or patchy implementation was often attributed to weak communication between healthcare professionals in different sectors or settings. These data were uploaded to QRS International’s NVivo V.12 software programme and organised into their overarching category of being an enabler or a barrier. Data with similar meanings were combined to create descriptions of the underlying data. Preliminary thematic statements were developed using these descriptions and then grouped into themes. A codebook was created from NVivo V.12 that consisted of preliminary themes, thematic statements and descriptions with associated data. The codebook was crosschecked against the original data for comprehensiveness and accurate reflection of the data by two researchers (YK, JH).
The contributions of enablers, barriers and individual studies to the overall findings were quantified using frequency effect size (FES) and intensity effect size (IES). The FES represents the prevalence of each enabler or barrier relative to all studies reporting enablers or barriers.24 The FES was calculated by dividing the total number of studies reporting on an enabler or barrier by the total number of studies reporting on all enablers or barriers.24 Studies (where there were multiple associated publications) with identical setting and population were counted once in the FES calculations. The IES represents the contribution of each study to all enablers and barriers identified.24 The IES was calculated by dividing the number of findings (enablers or barriers) in a study by the number of findings (enablers or barriers) identified across all studies.24
Assessment of confidence in evidence
The Grades of Recommendation, Assessment, Development, and Evaluation-CERQual approach was used to assess confidence in the identified enablers and barriers.31–35 The overall assessment was based on the researchers in pairs, independently judging (YK, LO’C/JH) each of the four CERQual components until consensus was reached. CERQual components comprise: methodological limitations which factored in the quality assessments conducted on the primary studies; relevance of data from the primary studies supporting the findings, for example, how applicable were the data to the context within the review question; coherence assessed if the fit between the data from the primary studies and the findings was clear and logical; adequacy of the data related to the degree of richness as well as quantity of the data supporting the findings. Concerns were assessed as ‘no concerns’, ‘minor concerns’, ‘moderate concerns’ and ‘serious concerns’ in relation to each component. These assessments were used to enhance usability of findings by giving weight to the credibility and potential impact of each enabler and barrier in the implementation process. All enablers and barriers began with high confidence and were graded down to moderate or low if any concerns existed in relation to the CERQual components.31 High, moderate or low confidence was based on the judgement that the finding was highly likely, likely, or possibly a reasonable representation of an enabler or barrier to implementing standards.36
Results
The initial search yielded 4072 records with 4042 records retrieved from database searches and 30 records retrieved from other methods (figure 1). Two hundred and thirty reports were sought for full-text review as they fulfilled the criteria or a decision could not be made based on title and abstract alone. Despite extensive efforts, including contacting the authors and the publishing journals, six records could not be retrieved. Following full-text screening, 37 papers were deemed eligible for inclusion in the meta-summary synthesis. The main reasons for excluding studies were: research did not examine health and/or social care standards; not pertaining to implementation of standards; wrong type of study, for example, study protocols. Three papers were identified as being part of one study.37–39 These were crosschecked by a second reviewer (NO’R) to confirm identical setting and population and were counted as one study thereafter.
Preferred Reporting Items for Systematic review and Meta-Analysis diagram for factors that influence the implementation of (inter)nationally endorsed health and social care standards.
Of the 35 studies included, 9 originated from the USA,40–48 8 from Australia,49–56 5 from the UK,28 30 57–59 4 from the Netherlands,60–63 2 from Iran64 65 and 1 from each of Bangladesh,66 Brazil,67 Croatia,68 Ethiopia,69 Jordan,70 Republic of South Africa37–39 and WHO regions (including 180 countries).71 The majority of studies used quantitative methods (n=21)28 40–43 46 48 50 51 55–59 61 62 64 65 67 68 71 with questionnaires, followed by qualitative methods using mainly focus groups and interviews as data collection approaches (n=9).30 37–39 45 47 52–54 60 70 There were five mixed methods studies that used focus groups, interviews, observations and surveys for data collection.44 49 63 66 69 One mixed methods study adopted a three-step process using an assessment of causality, rapid review and case study design.66 As such, only the qualitative component (case study) was included in the synthesis and quality appraisal.66 Studies examined healthcare standards (n=30),28 30 37–44 46 47 50–53 56–71 social care standards (n=2),45 48 health and mental healthcare standards (n=2),49 55 and health and social care standards (n=1).54 The standards ranged from cross-system standards (n=1),71 ‘WHO Child Growth Standards’ to whole system standards (n=8 of which 2 were examined in more than one paper),37–39 42 49 53–55 65 69 72 for example ‘National Safety and Quality Health Service Standards’ to standards for specific conditions (n=26),28 30 41 43–48 50–52 54 56–64 66–68 70 for example ‘Delirium Clinical Care Standard’. The included studies represented the analysis of 847 documents, for example, patient charts and notes and, 13 679 participants. Of this 13 679 sample, 308 represented individuals at system level, for example, government representatives and academic professionals, 1920 were service-users and the remainder consisted of individuals working at service management and front-line level (online supplemental appendix 4).
Quality appraisal
Nineteen included studies were assessed as having no methodological limitations,28 30 43 46 49 50 53–56 60 61 63–68 71 14 had minor37–42 44 45 48 52 57 58 62 70 and 4 had moderate methodological limitations47 51 59 69 (online supplemental appendix 5). Quantitative studies with cohort and descriptive cross-sectional designs were mainly assessed as having no methodological limitations. The main reasons for minor to moderate methodological limitations across studies included: poor reporting of sampling and outcome measures in quantitative studies; poor reporting on reflexivity, ethical considerations and rigour of analysis in qualitative studies; poor reporting on the integration of findings, divergences between study designs and unclear rationale for using a mixed methods approach in mixed methods studies.
Confidence in the findings
We had high confidence in 16 enablers, moderate confidence in 4 and low confidence in 2 enablers (table 1). We had high confidence in 16 barriers, moderate confidence in 6 and low confidence in 2 barriers (table 2). Our concerns were mainly with methodological limitations and adequacy of data as reported in studies (online supplemental appendix 6). Reasons for downgrading adequacy of data were concerns relating to a low number of studies reporting the finding and studies with low numbers of participants. Downgrading for relevance occurred where a study took place in a jail or prison setting, as this was deemed only partially relevant to our research question. Coherence did not feature as a concern throughout the assessments.
Themes, thematic statements and descriptions of enablers to implementing (inter)nationally endorsed health and social care standards with level of confidence in the evidence* reporting the enablers
Themes, thematic statements and descriptions of barriers to implementing (inter)nationally endorsed health and social care standards with level of confidence in the evidence* reporting the barriers
Meta-summary findings
For enablers to implementing standards, six themes with 22 thematic statements were generated from 322 findings extracted from 31 studies (table 1). For barriers, six themes with 24 thematic statements were generated from 376 findings extracted from 35 studies (table 2).
The FES for thematic statements describing enablers ranged from 10% to 55% (online supplemental table 3). Themes containing thematic statements with the highest FES were: services have key staff who will lead and share knowledge of the standards (theme 2); services have accessible training, support tools and monitoring practices (theme 6). The FES for thematic statements describing barriers ranged from 6% to 63% (online supplemental table 4). Themes containing thematic statements with the highest FES were: services work in silos, have limitations with staffing and knowledge of standards (theme 2); services have poor access to resources and funding (theme 4). One study contributed a large proportion of findings for both enablers (IES=77%) and barriers (IES=75%).49 The majority of studies (n=25) had an IES between 21% and 46%.
Thematic statements and their associated themes are discussed below.
Theme 1
Enabler: Standards are adaptable and relevant in day-to-day practice.
Barrier: Standards have limited adaptability.
Theme 1 described the adaptability of standards and relevance in practice. Studies reported that standards were adaptable when they were simplified and tailored for implementation (FES 16%, high confidence) and relevant for application in practice (FES 12%, high confidence).
Standards had limited adaptability when there was heterogeneity across healthcare services and their geographical locations (FES 20%, high confidence). Language used in standards was described as medical oriented, which made standards difficult to embed in practice (FES<10%, moderate confidence). Standards did not always fit neatly with legislation, accreditation or regulatory frameworks and this did not support effective implementation (FES<10%, moderate confidence).
Theme 2
Enabler: Services have key staff who will lead and share knowledge of the standards.
Barrier: Services work in silos, have limitations with staffing and knowledge of standards.
Theme 2 focused on knowledge and staff. Studies reported that shared knowledge and interprofessional collaborations enabled collective efforts with implementation of standards (FES 45%, high confidence) and knowledge of the standards were fundamental to implementation (FES 26%, high confidence). Active involvement from managers by providing leadership and commitment was reported as assisting with implementation (FES 26%, high confidence). The availability of staff was identified as a key enabler and studies referred to key staff as champions, role models, designated personnel or care coordinators (FES 52%, moderate confidence).
A lack of knowledge, awareness and understanding of the standards was the most frequently reported barrier (FES 63%, high confidence). The gap in knowledge related to the rationale for standards, their content, expectations and knowledge of available support tools. Staffing constraints were reported as a barrier, which resulted in issues such as an increase in transient staff (FES 46%, high confidence). Other barriers reported were: managers who do not support staff with consistent processes or onsite presence (FES 23%, moderate confidence); services taking a monodisciplinary approach resulting in a lack of shared knowledge (FES 20%, moderate confidence); staff not consistently involved in implementation (FES 11%, moderate confidence).
Theme 3
Enabler: Services collaborate with people using services.
Barrier: Services and service-users have misconceptions about healthcare and support.
Theme 3 described the role of the service-user in implementation of standards. Collaborations and partnerships with patients, family and carers were reported as improving care delivery (FES=16%, high confidence). The availability of appropriate supports for service-users assisted with implementing standards (FES=13%, high confidence).
Barriers included service-users having misconceptions about healthcare due to a lack of knowledge on service delivery and healthcare needs (FES 23%, high confidence). Care and support that was patient-focused resulted in families and carers experiencing challenges accessing supports for themselves (FES 23%, high confidence). Healthcare professionals reported concerns that they would harm relationships with patients if they raised sensitive issues as recommended in some standards (FES 11%, high confidence).
Theme 4
Enabler: Services have access to resources.
Barrier: Services have poor access to resources and funding.
Theme 4 described the availability of adequate resources such as supplies, equipment and screening systems which were required to incorporate the standards into practice (FES 39%, high confidence). The allocation of sufficient budgets to services (FES 10%, low confidence) and maintenance of infrastructures were reported as facilitating implementation (FES 10%, low confidence).
Conversely, limited supply of equipment, medical supplies and materials impeded implementation (FES 40%, high confidence). Reasons for limited supply were described as a lack of availability or, distribution and allocation issues. Other barriers such as insufficient funds resulted in shortages in supplies, poor maintenance of equipment and infrastructure. Standards had cost implications that led to competing tenders for safety and quality projects (FES 43%, high confidence). Infrastructural issues were described as limited physical space, old structures and service size (FES 26%, moderate confidence).
Theme 5
Enabler: Services promote quality improvements and value staff in doing so.
Barrier: Services experience resistance to change due to cultural practices.
Theme 5 set out organisational cultures and practices that influenced implementation of standards. Enabling factors comprised a culture of quality improvement such as: capacity building and staff engagement (FES 32%, high confidence); recognising staff for their efforts (FES 19%, high confidence); credibility that standards were an impetus to safety and quality improvements (FES 19%, high confidence).
Barriers related to entrenched cultures that resisted change because standards were perceived as a burden (FES 40%, high confidence). Studies reported that there was insufficient time to implement standards (FES 40%, high confidence) as time spent on standards meant time away from other competing projects, resulting in variation in implementing standards (FES 20%, high confidence). Unclear accountability systems resulted in a misunderstanding of roles and responsibilities with standards (FES 17%, high confidence). A culture where staff did not perceive the standards as the norm for high quality care was also reported as hindering implementation (FES <10%, low confidence).
Theme 6
Enabler: Services have accessible training, support tools and monitoring practices.
Barrier: Services have a lack of training, support tools and consistent monitoring processes.
Theme 6 described strategies that facilitated implementation of standards. The availability of support tools (FES 55%, high confidence), training courses (FES 52%, high confidence) and accessible educational materials (FES 32%, high confidence) helped to implement standards. Studies referred to support tools as standardised assessment tools, checklists, policies and guidelines. Descriptions of training courses across studies included targeted training, prequalification education, workshops and role-play sessions. Effective communication strategies such as newsletters, internal websites and academic journals promoted information about the standards (FES 10%, moderate confidence). Internal and external monitoring were motivating factors to implementation. Internal monitoring such as audit and feedback guided quality improvements (FES 32%, high confidence). External monitoring such as benchmarking, accreditation or regulation were motivators (FES 10%, high confidence).
Conversely, an absence of clear policies, guidelines, protocols and pathways (FES 29%, high confidence), and challenges with education and training (FES 31%, high confidence) acted as barriers to implementing standards. Challenges with education related to cost, time and backup capacity to replace staff, causing staff to become unreceptive to training. A lack of internal monitoring resulted in an inability to determine if implementation was effective (FES 20%, high confidence). Inconsistent external assessments resulted in low reliability and thus effected stakeholders’ perceptions of the credibility of the standards (FES <10%, low confidence).
Discussion
This systematic review synthesises the evidence from 35 primary studies. The meta-summary technique identified enablers and barriers based on prevalence across the literature and offers a focused thematic summary of the data which distinguishes it from other analytical methods where the generation of themes is determined by the researcher’s judgements.73 74 The most frequently reported enablers in which we had high confidence included services using support tools, accessible training courses and shared knowledge and interprofessional collaborations. The most frequently reported barriers in which we had high confidence included a lack of knowledge, awareness and understanding of what standards are and, services experiencing staffing constraints. A central concept underpinning these factors is knowledge of the standards themselves.
Influencing factors found in this review are bidirectional and are reflected in the literature on implementation, for example, Damschroder’s Consolidated Framework for Implementation Research75 and Greenhalgh’s Model of Diffusion in Service Organisations.76 In addition, this review incorporates new studies published since these frameworks were developed, expanding the research base and better allowing tacit knowledge to be made explicit. Enablers and barriers with low FES measurements were system-level factors that are described in the ‘outer context’ domains of the aforementioned frameworks. A less frequently reported enabler in which we had high confidence was services having external mandatory requirements, for example, accreditation. This is noteworthy considering 20 of the 35 studies examined standards that were part of accreditation or regulatory systems.37 40–42 44 45 47–57 64 65 67 Existing literature reports evidence to support external pressures from accreditation as assisting implementation of healthcare standards and the lack of such pressures as a hindering factor.77 Other less frequently reported barriers in which we had low to moderate confidence were standards not aligning well with legislation, accreditation or regulatory frameworks and services at risk of inconsistent external assessments regarding standards implementation. Three of four studies included in this review that identified system-level factors included people working at system level, for example, government representatives.49 53 54 66 Most studies in this review included people from service management and front-line staff in their samples suggesting a bottom-up perspective. Literature reports implementation science as primarily focusing on bottom-up approaches78 and policy implementation research typically focuses on system-level (top-down) approaches.79 Nilsen and Cairney reported a lack of recognition across implementation science for characteristics of the political and outer context environments in healthcare.79 This perhaps suggests a need for convergence between policy implementation research and implementation science to adopt a whole system approach to implementing standards.
Similarities in enablers and barriers reported across studies were evident regardless of the country where the study took place. For example, barriers such as staff constraints and insufficient funds were reported in low-income to middle-income38 66 and high income countries.50 63 In this review, we retrieved predominantly quantitative studies. Qualitative explorations are needed to gain an in-depth understanding of the extent to which an enabler or barrier is experienced.
Strengths and limitations
The meta-summary methodology enables a mixed research synthesis of the evidence from all study designs and thus a key strength of this review is methodological inclusivity. The FES is a useful metric to describe the prevalence of influencing factors across the literature and gives weight to their potential impact. This can assist with decision making on what enablers and barriers need to be addressed when developing implementation strategies. However, a critique of this metric is that it does not describe the scale at which factors have influence over implementation of standards or the interactions between the standards and their implementation in context.
The variation in standards examined in this review has captured the breadth of the literature relating to the implementation of (inter)nationally endorsed standards. This variation may pose challenges for researchers if transferring the enablers and barriers experienced in diverse health systems to their own situations, however, detailed descriptions of the methods and findings are presented.
Conclusion
Health and social care standards are complex interventions. The enablers and barriers described in this systematic review can be used to aid decision making on implementation strategies and support given by standard-setting bodies to health and social care services when they are implementing standards. Using Sandelowski’s meta-summary approach enabled presentation of these enablers and barriers in an accessible form given the large volume of data retrieved. The most prevalent identified factor across enablers and barriers was knowledge of standards. Implementation strategies that focus first and foremost on increasing knowledge and understanding of standards, are likely to be effective.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
This work was conducted as part of the Structured Population health, Policy and Health-services Research Education (SPHeRE) programme (Grant No. SPHeRE/2019/1). Yvonne Kelly has conducted this work as part of a PhD studentship that is funded by the Health Information and Quality Authority (HIQA).
References
Supplementary materials
Supplementary Data
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Footnotes
Contributors YK: conceptualisation, data curation, formal analysis, investigation, methodology, software, project administration, validation, visualisation, writing—original draft preparation, writing—review and editing. NO’R: resources, supervision, validation, writing—review and editing. RF: funding acquisition, resources. LO’C: conceptualisation, supervision, validation, visualisation, writing—review and editing. JH: conceptualisation, methodology, supervision, validation, visualisation, writing—review and editing, guarantor.
Funding This study was funded by Health Information and Quality Authority (no award/grant number).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.