In total, 16 semi-structured interviews were conducted. Participants were from different organisational levels, divided between 8 top leaders and mid managers, and 8 nurses from both sectors. All participants were relevant actors to the certification procedures. In order to ensure the anonymity of research subjects, the interviews were numbered according to the sequence in which they occurred and with an acronym according to the professional respondent role over the implementation process. Namely TL for top leaders, MM for mid managers and RN for registered nurses.
In addition, 83 observational hours were conducted over four separate weeks, and were divided between one of the three modules in the Med Rea sector, and two interventional rooms in the Dig Endo sector. The average age of interviewed nurses was 43 years old, with an average nine years’ work experience.
The following sections outline the data retrieved in this study; part I represents emerging elements over a certification implementation using QIT. Part II localises these components within the activity’s context, with different mobilisation mechanisms.
QIT analysis was conducted by aligning the tool’s components with actions from manager and leader interviews. An additional table file presents more details on results analysis [see Additional file1]. Results show that the majority of elements were captured by QIT components and action steps. For the first component “Develop an implementation team”, interviewees identified that the team in charge of certification implementation was well developed and structured, and this is benefits to the certification’s age in hospital since 1999. They mentioned as well that the implementation team embraced multidisciplinary actors from different institutional levels “Teams nowadays are well placed compared to the first procedure where we hadn’t any quality team within the establishment… the caregivers also are well integrated now” TL₁.
For the second “Foster supportive organisational climate and conditions”, interviewees mentioned several key elements for the successful implementation of certification at the level of professionals, such as the presence of the ‘referents of actions’. They are professionals, which have been chosen to assist in the process of implementation “The referent nurses of hygiene will decline the procedures and best practices on the level of teams” TL₁. It appears that they are adopting the role of champions. According to Miech et al., (2018), champion may emerge during an implementation process, sometimes as part of an intervention, sometimes as part of an implementation strategy, and at times neither; e.g. they thrive in the implementation environment (40). Other elements included the communication of procedural needs and benefits, and the professionals’ implication, this last have been revealed as well in the cited responsibilities by nurses. These were considered key actions that were helpful to avoid professional resistance to the intended change. Another element was enhancing accountability, which was identified by the presence of quality management system (QMS), the possibility to conduct a test period for the implemented action and finally the on-going meetings. In addition to the presence of an administrative support as working procedures, protocols etc … either in paper forms or electronic forms.
Another emerging component was “Receive knowledge and/or technical assistance”. This was identified as support for nurses’ practices “We define in prior the needed supports, which training, the needed technical support with the constructor himself or the provider…in general, there is a table for the learning curve that helps to find out, the fluidity of technic” MM₁. The implementation of certification occurs according to a programme, which is descend to the different departments and wards. That programme is developed based on national recommendations as identified by the HAS certification manual, and each sectors’ quality account. It defined a set of tasks corresponding to each standard objective, over predefined timelines (Dig. Endo action plan), and responded to the “Develop an implementation plan” component.
The fifth QIT component; “Practitioner-expert collaboration” this component was not applicable in the case of certification, because healthcare organisations rely on national recommendations defined by the HAS. For the “Evaluate the effectiveness of the implementation” component, interviewees identified quantitative and qualitative evaluation strategies, which were carried out differently, according to the intended action. This was based on evaluation; actors readjusted and improved implementation effectiveness “The ability to conduct a pre-test, an auto-evaluation and have feedback from each sectors, and see what we can do to improve because are important, the auto-evaluation allow to identify the missing things” TL₁.
In addition to these comments, top leaders also cited major barriers for the implementation of certification at the different wards of the studied hospital, such as a lack of organisational support, time, information, human resources, a generalised professional resistance and overall a challenging process.
This part of the study framed the identified components at the activity level. It incorporated previous analyses by explaining the different inter-relationships at the local context. This was based on triangulation between managers, nurse interviews and shadowed observations, all of which were aligned to TMT core components. An additional table file presents more details on results analysis [see Additional file 2].
The certification visit relies on a processes auditing approach supported by a patient tracer method (10). The HAS identifies healthcare system priorities, and each subject included a set of criteria and indicators (41), these standards define the quality programme of healthcare facilities as well as the policies and objectives to reach by the QMS (41). Hence, the higher goal of the healthcare system - defined by the care quality and patient safety- represents the ‘organising logics’ that determine the scoop of possible action and activities within facilities and shape it purpose. The primary mobilisation of certification procedures initiate within departments based on a list of priority actions elaborated previously through the quality account tool. This occurred via a set of actions steps according to each sector action plan “we have an action plan and a list of priority actions … and we contact the quality engineer once a year for this action plan” MM₁. The desired action is introduced to nurses by the proximity managers and/or by referent of action, this process reflects an ‘object formation’ mechanism, which is defined as “practices that create the objects of knowledge and practice and enrols them into projects” (37). Actions may have taken the form of new technologies and/or materials which supported practices, or interpretative repertoires such as protocol changes, policies, checklists and/or tractability documents. Through these, nurses translated recommendations and certification criteria, or other quality policies into practice. For example, in the Dig Endo sector, nurses were experimenting a new intervention, to identify the needed materials for the pre- and on-going intervention, they were using its working protocol as support for their preparations. The leader of change diffuses among nurses the needed change in the care process, its importance and benefits in terms of care quality and patient safety, in other words how it meets facility’s organisational logics, this reflects a ‘translation mechanism’. The last is defined as “practices that enable practice objects to be shared and differing viewpoints, local contingencies, and multiple interests to be accommodated in order to enable concerted action” (37). This was observed in nurses’ interviews; they are perceiving the importance of certification procedures for care quality, and patient safety, “the certification procedures are a progress and enhancement tools of things that can be improved in the process of patient care” RN₄. Healthcare systems by their very nature are dynamic and actions are changeable, thus, monitoring overall processes is important, particularly when implementing cross-sector processes or actions. It is essential to facilitate parallel actions pathways, and then ensure work harmonisation between different sectors. For example, in the Dig Endo sector, the implementation of checklist was intended for both units, with and without general anaesthesia (GA), the checklist was successfully integrated within GA unit, while it was not successfully working in the without GA unit. According to MM₁, the checklist was developed as a coordination sheet between the doctor and anaesthetist, however, in the without GA unit there is no anaesthetist, there is coordination between doctor and nurses. This created as result a lack in the tractability data. These feedbacks were used by the change leader, who worked with other transversal departments on a new version for the Dig Endo sector and other interventional sectors, such as interventional radiology. Changes were re-deployed and re-monitored to assess workability and acceptability amongst nurses. This ‘work articulation’ between multi-levels and sectors was fundamental. It occurred at team and departmental meetings, alongside the on-going monitoring of integrated changes. These key junctures relied on a shared culture and staff learning; they offered concrete actions by formalising workflow trajectories and ensuring work harmonisation and staff commitment. Evaluation of an implementation occurred continuously throughout the process; i.e. both formally and informally. It described the occurrence and positioning of implemented actions at end-user level/nurses, as well as the global organisation’s overview, this reflects a ‘reflexive monitoring’ mechanism; “We have monthly performance tables, which allows not only a quantitative evaluation, but also a qualitative evaluation… we have follow-up indicator tables, and we monitor monthly or once every semester, or annually, and also we have morbidity rates which are monitored every two months” MM₂. For example, in the Med Rea sector, nurses were using new intubation systems by tracing extubation rates, and were relaying their negative experiences at meetings. This feedback was considered a primary support in evaluating change feasibility and outcomes for patient care. Thus, nurses and managers sought to improve, “we return to our action plan and adjust, according to the adverse events” MM₁. This action mobilisation at the nurse level also depended on a ‘sense-making’ mechanism, which is defined as “practices through which actors interpreted, ordered, constructed and accounted for projects, and produced and reproduced institutions” (37). In the nursing field, nurses are actively engaged with certification procedures, e.g. they are involved in protocol preparation and validation, providing and sharing experiences, and contributing to auditing systems. By involving professionals in the process of implementation, actions and/or care processes take sense into their practices, this active engagement is valuable for an effective integration in the activity system. Professional active engagement provides meaning, and allows appropriate action mechanisms in the team. “It’s important that the caregivers understand the procedures; to make sense of its impact on patient care” TL₂.
These mobilisation mechanisms i.e. object formation, articulation, translation, sense-making and reflexive monitoring, have helped shape the different interrelationships between action, actors and context (37), leading to certification programme implementation at activity level. Finally, the interviewed leaders emphasised as well on the role of proximity managers and their ability to conduct a participative strategy over the process of implementation “the implementation depends on the proximity managers, this what we affirm between departments. So finally, there are the reality of the field and the ability of each manager to implement effectively” TL₂.