Characteristics of participants
One hundred sixty-five participants completed the interviews, among whom 110 were men; 78 were CPC directors. The average tenure among CPC directors was 21 years (range 15–26 years), whereas CPC coordinators had an intermediate term of 11 years (range 7–16 years). Over half of CPC coordinators had an attending title whereas nearly all CPC directors (81/87) had a chief title. Approximately 40% of CPC directors held master’s or doctoral degrees; the proportion was similar for CPC coordinators (Table 1).
Barriers and enablers
As Fig. 2 shows, we identified that 26 of the 39 CFIR constructs facilitated or impeded NCPCP implementation, covering five CFIR domains. Of these constructs, 3 were barriers, 14 were enablers, and 9 were both barriers and enablers. The five domains of the CFIR interacted with each other, providing a practical guide to systematically explore barriers and enablers in NCPCP implementation (Figure 2).
Characteristics of the intervention
Intervention sources
The intervention source indicated that the NCPCP was developed owing to both internal and external factors. From the perspective of hospitals, CPC accreditation fostered development of the cardiology discipline and multidisciplinary integration; this also reduced within-hospital medical disputes, improved the visibility and impact of the field, and attracted more patients. From the perspective of patients, through prehospital emergency and in-hospital resource integration, the treatment process for patients with chest pain was optimized, treatment time for those with ACS was shortened, and mortality and complications in patients with ACS were reduced. Government policies drove the external factors. Public hospitals were required to establish CPCs by the National Health Commission to the Provincial and Municipal Health Commission. For example, the Wuhan Health Commission required all tertiary hospitals to obtain CPC accreditation in 2017.
Three main reasons for participating the NCPC. First, the whole country, including the National Health Commission and the Provincial Health Commission, now administratively requires you to create CPCs. Second is the development of our disciplines. Third is from the people's point of view, CPCs emphasize early treatment, and various departments provide a green channel to facilitate patient consultation, thus ultimately benefiting the public. (Cardiology Chief, Chest Pain Center Director)
Evidence strength and quality
The evidence regarding the strength and quality of intervention has been a key determinant in implementation. The NCPCP has indeed improved the care quality for patients with ACS, with a substantial reduction in in-hospital mortality and a significant decrease in the incidence of complications, such as heart failure and arrhythmias. Through CPC establishment, hospitals have improved the diagnosis and treatment levels for ACS, thus enhancing the reputation and influence of these hospitals. Additionally, the CPC establishment lays a solid foundation for the accreditation of stroke centers, atrial fibrillation centers, and trauma centers in hospitals and provides a model from which to learn. Furthermore, the CPC establishment is important in raising the level of emergency care, awareness, and capability of the entire hospital.
Complexity
Complexity is crucial for influencing intervention implementation, and CPC directors and coordinators expressed concerns about the program’s complexity. Informants stated that the accreditation criteria and procedures are complex, and the preparation of materials, including developing flowcharts, is time-consuming, which is not conducive to establishing CPCs in primary hospitals. According to interviewees, variable entries such as time points are too demanding and cumbersome in the operation process, particularly the collection and reporting of case data for patients with chest pain, and these form-completion tasks increase the burden for medical staff. ACS discharge follow-ups and other requirements are also reportedly complex, and data availability is poor, resulting in less motivation among medical staff and fewer forms completed.
For those of us who work at the bottom, data reporting is usually a headache. I'm sure if you ask anyone, they'll tell you the same thing. The data issue, in my opinion, is the most difficult for us. (Cardiologist, Chest Pain Center Coordinator)
It implies that the more you complete, the more work you'll have to add to the local practitioner's schedule. We're all working for free, and these things don't immediately benefit us. Of course, filling out forms helps us be better at our job, but they're too time-consuming to complete. (Cardiology Chief, Chest Pain Center Director)
Interviewees stated that the accreditation criteria needs to be further simplified for different hospitals, especially for primary hospitals, and that capturing key indicators is sufficient.
Cost
The construction cost of a CPC includes purchasing equipment such as electrocardiography (ECG) equipment, troponin testers, and interventional equipment. Additionally, there are direct expenses such as salaries for the CPC’s data collection and form completion staff, and investment of time and energy by the cardiology department’s medical staff. For the department, this involves more indirect investment, such as staff time. CPC directors believed that CPC construction was cost-effective and worth promoting because of the positive social and economic benefits it achieved.
We didn't invest much money on this, only the time and effort that everyone put in throughout that period. (Cardiology Chief, Chest Pain Center Director)
Adaptability
To date, two versions of the CPC certification standard exist: the standard version for hospitals with percutaneous coronary intervention (PCI) capability and the basic version for hospitals without PCI capability. However, standardization of the CPC assessment standards has introduced new issues, such as the requirement regarding the bypass emergency ratio, which may lead to medical risks of misdiagnosis, and the requirement regarding in-hospital mortality, which may cause some hospitals to reject patients with severe conditions. Informants agreed that the standards for CPCs should be handled flexibly, following the actual situation of each hospital.
As with the earlier-mentioned issue of in-hospital mortality, the rate of in-hospital mortality sometimes exceeds the accreditation standards because the baseline is low in some hospitals. I believe there should be some flexibility for certain indicators to be combined according to the specific circumstances of each hospital. (Cardiology Chief, Chest Pain Center Director)
External settings
Patient needs and resources
ACS patient-level factors are substantial contributors to delays in care. Understanding patients’ needs and influencing factors effectively reduces patient delays and facilitates NCPCP implementation. Patient delays are primarily reflected in the time between onset of chest pain to first medical contact, and delays obtaining pre-surgery informed consent. CPC directors and coordinators emphasized that multilevel strategies should be used to reduce patient delays. Media outlets should increase favorable and active coverage of stents and other medical devices for patients with ACS to dispel common misconceptions. Expert resources should be fully exploited to reach the grassroots level so as to promote awareness of the importance of timely consultation. Finally, to improve patient trust, informed patient consent should be optimized at the hospital level.
The biggest obstacle to implementation is still in the prehospital stage. Some patients have problems with awareness about chest pain; for example, you know that chest pain is an urgent situation, but the patient does not at all. (Cardiology Chief, Chest Pain Center Director)
Cosmopolitanism
A crucial factor affecting NCPCP implementation and effectiveness is the proximity of hospitals and lower-level medical facilities to the prehospital emergency system. With diverse emergency system models and cooperation mechanisms between hospitals and emergency systems, the degree of linkage between prehospital emergency and in-hospital treatment are critical determinants impacting the clinical outcome of patients with ACS. For lower-level medical institutions, timely diagnosis and rapid referral are keys to effectively shortening treatment delays. Establishing an efficient out-of-hospital cooperation mechanism is a dilemma in the process of CPC accreditation. Interviewees stated that the answer to this problem requires a top-level design from the government.
I'd want to make it a one-stop model for prehospital and in-hospital emergencies. But why does prehospital emergency systems only send patients to some hospitals and not others? Some hospitals may have a good connection with 120; thus, patients are referred to these hospitals. (Cardiology Chief, Chest Pain Center Director)
We can only control ourselves, from the entrance to the hospital gate; we can only shorten in-hospital delays. As for how to build up the network in other hospitals, this may still need to be improved by the government. (Cardiology Chief, Chest Pain Center Director)
External policies and incentives
Government policies and financial support are crucial to the successful CPC establishment. Government support for CPC accreditation varies, and it frequently remains at the stage of issuing documentation, with no further evaluation, which has a limited promotional effect. Inversely, some district or county health commissions place a high value on CPC construction, making this a priority for the entire district/county and providing financial and policy support to improve the level of emergency care.
The attention of some Municipal Health Commissions given to CPCs is insufficient, and they merely stay in the stage of document issuing. The Health Commission lacks the sense of urgency required to implement CPC accreditation. (Cardiology Chief, Chest Pain Center Director)
CPCs directors highlighted the need for further strengthening of government support in the routine operation of CPCs, particularly health education for community members; the interface between hospitals and emergency systems; and the construction of chest pain emergency networks.
Peer pressure
Peer pressure promotes NCPCP implementation to some extent. Hospitals with relatively better comprehensive strength have been prompted to join the NCPCP with the CPC accreditation in hospitals that have weaker technical capabilities. Simultaneously, hospitals or cardiology departments have consolidated their academic status and disciplinary reputation on a national or local level through CPC accreditation. As neighboring hospitals continue to obtain CPC accreditation, non-accredited hospitals are faced with the dilemma of diminished attractiveness and patient flow, further encouraging them to join the NCPCP.
Our hospital, whether in terms of academics or reputation, definitely wants to integrate into the collective and build chest pain centers together. (Cardiologist, Chest Pain Center Coordinator)
Internal settings
Structural characteristics
Respondents reported that the organization’s structure and size plays an essential role in NCPCP implementation. Interviewees revealed that larger hospitals attach less importance to CPCs than smaller hospitals, especially larger general hospitals where patients with chest pain account for only 5% of all patients in the emergency department, making the initial CPC establishment relatively risky. The problem of mobility in the emergency department and other related departments can hamper NCPCP implementation. CPC directors suggested that staff mobility adversely affects several aspects, such as identifying and diagnosing atypical chest pain, and results in misreporting and omitting emergency data. However, this also reflects a lack of personnel training at CPCs in these hospitals.
What is the reason for the lack of training? It is because there is a lot of staff turnover in hospitals, with many recruits, including nursing staff, doctors, and housekeeping nurses. Hospital training for new staff in CPCs is insufficient. (Cardiology Chief, Chest Pain Center Director)
Networks and communications
One concept of the CPCs is to integrate hospital resources to provide timely treatment for patients with acute chest pain. CPC accreditation is a hospital-wide initiative, which requires the support and cooperation of related departments. During the interviews, we discovered that the emergency departments of most hospitals have shown some resistance to CPC construction, believing that a CPC is a matter for the cardiology department but that adds an extra workload to the emergency department. This resistance has had a significant impact on the process of promoting CPC accreditation.
Many departments may first believe that this is an issue of our cardiology department, and it is problematic for that department to initiate things like this. However, because of various forms of publicity, people are increasingly aware of the chest pain center, and that awareness has become more and more widespread. (Cardiologist, Chest Pain Center Coordinator)
Interviewees believed that the above problems could be solved in three ways: 1) improving communication with the emergency department so that emergency department staff understand the importance of CPC accreditation and its importance to the emergency department; 2) establishing a reward and punishment system at hospital level, and including routine CPC tasks in performance evaluation; 3) allowing the emergency department to fully participate in CPC accreditation and to reap the benefits, meaning that all patients with outpatient chest pain should go to the emergency department and start the process of chest pain evaluation in that department to increase its patient volume.
Implementation climate
From an endogenous perspective, hospitals that urgently need to improve the care quality for patients with ACS and reduce the occurrence of doctor–patient disputes by establishing a CPC are driven to join the NCPCP, and such hospitals have had a higher degree of fidelity to NCPCP interventions (tension for change). Some hospitals have provided incentives for staff in charge of data reporting. For example, the hospital provides approximately 100 RMB to medical staff in the emergency department, cardiology department, and catheterization department for completing a medical record form for high-risk patients with chest pain (organizational incentives and rewards). CPC coordinators review the completed data and penalize medical staff for any errors or omissions (goals and feedback). Some hospitals have established a performance appraisal system based on the CPC evaluation index for medical staff who perform emergency PCI procedures and the staff of radiology departments; rewards or penalties are determined based on whether the standards are met (organizational incentives and rewards, goals and feedback). The implementation of these measures facilitates NCPCP implementation and ensures the fidelity to and effectiveness of the intervention. By joining the NCPCP, young doctors have considerably enhanced their diagnosis and surgical abilities and gained professional pleasure and pride through continuous learning (learning climate).
CPC coordinators, particularly doctors in tertiary institutions, handle numerous specific activities in regular CPC operations, including data review and holding quality analysis meetings and case discussion, which have had a substantial impact on their everyday medical, research, and teaching tasks (compatibility). In response to these issues, CPC directors and coordinators highlighted the importance of enhancing the level of information technology to free up medical staff. Simultaneously, further simplifying the criteria for CPC-related meetings and documents is important to reduce the workload at the source.
Readiness for implementation
Implementation of the NCPCP has received strong support from hospitals, including leadership engagement from hospital level to department level. Directors of cardiology and emergency departments in some hospitals have been removed from their positions after failing CPC accreditation (leadership engagement). To successfully pass accreditation, hospitals have provided funding, equipment, and personnel to cardiology and emergency departments. However, informants stated that after passing CPC accreditation, hospital support in routine CPCs, including incentive funding and personnel training, begins to decrease gradually (available resources).
In preparation for accreditation, there was clear support at a hospital-wide level, and our vice president attended almost every meeting related to CPC accreditation. (Cardiology Chief, Chest Pain Center Director)
Characteristics of involved individuals
Knowledge and beliefs about the intervention
The recognition by medical staff of CPC effectiveness is an influential factor in promoting NCPCP implementation. Respondents perceived two effects of CPC establishment on patient treatment behavior among medical staff: first, more standardized treatment behavior, which effectively reduces the occurrence of missed diagnoses; second, more timely treatment, which effectively reduces the occurrence of cardiovascular-related complications in patients. Improved patient outcomes provide more intrinsic professional satisfaction to medical staff, motivating them to follow the NCPCP requirements in clinical practice.
I mean that the staff member can see his/her sense of achievement in doing something. They did save the patient, and this patient made an adequate recovery. The most important thing is that staff have a sense of accomplishment and satisfaction. (Cardiologist, Chest Pain Center Coordinator)
Self-efficacy
The NCPCP is a continuous quality improvement program that revolves around CPC certification. Hospitals have made concerted efforts in preparation for CPC accreditation, and key personnel, including CPC coordinators, have felt confident in successful accreditation. Additionally, the problems revealed during daily operations, including a lack of patient awareness, interfacing with the emergency system, and support for continuous operations, have required the support and participation of the government, community, and society.
Individual stages of change
Different departments and medical staff within the same department had different perspectives on the NCPCP. NCPCP implementation had an impact on patient treatment behavior among staff, which was the most difficult to change. However, as the NCPCP progressed, patients and hospitals benefited from it, identification with the NCPCP gradually strengthened among medical staff, and the interventions slowly became part of their routine. To promote change in treatment behaviors among medical staff, some hospitals have hired dedicated data reporters, which has further lowered the burden on medical staff and improved their recognition of the NCPCP.
The most significant barrier is that various people have varying levels of understanding of CPCs, and people continue to have different levels of engagement. However, we have become accustomed to it after doing it, and it has become a permanent working pattern. (Cardiologist, Chest Pain Center Coordinator)
Individual identification with the organization
Identification among medical staff with the hospital influences the level of commitment to the NCPCP. Some interviewees stated that the NCPCP has brought considerable social and economic benefit to the hospital. Medical staff have fully supported their hospital's decision to join the NCPCP and treat joining NCPCP as a personal responsibility.
Implementation process
Planning
A comprehensive and detailed implementation plan is a facilitator of NCPCP implementation. CPC directors indicated that hospitals that were interested in joining the NCPCP should focus on learning experiences and lessons from hospitals that have previously passed CPC accreditation. Hospitals should implement policies that facilitate the construction of CPCs and establish institutional assurances for CPC accreditation. The criteria for CPC accreditation should be clarified, and materials such as flow charts and clock unification for time points should be prepared following the standards. Training plays a vital role in NCPCP implementation, which includes training organized by national headquarters of the CPCs and provincial CPCs, training conducted at hospital level for relevant departments and all hospital staff, and training for community residents related to ACS. Finally, hospitals should concentrate on the prehospital setting and develop an effective interface mechanism with the prehospital emergency system and network hospitals.
Engaging
Building an executive team is critical to NCPCP implementation. The hospital president, who has overall responsibility; the chiefs of cardiology and emergency medicine, who are in charge of operations; and the chief of the medical administration office, who is in charge of coordination should be part of the CPC organizational architecture. However, leadership participation at the hospital level is insufficient, and supervision by government is also needed for CPCs to operate smoothly. CPC directors stated that the establishment of CPCs required the director of the cardiology department to have solid coordination and communication skills.
When we establish a CPC, the hospital director should be involved since more departments and employees are involved, and it is no longer a question of one person or a specific department. Second, we should rely on the government to closely monitor operational issues so that CPCs can function more efficiently. (Cardiology Chief, Chest Pain Center Director)
Executing
The most challenging aspect of NCPCP implementation was reported by respondents to be ensuring intervention fidelity in hospitals once a CPC had been accredited. Interviewees highlighted that some hospital leaders felt they had achieved their goals and support for CPC routine operations diminished after accreditation. Furthermore, a level of inertia existed among medical staff, including omissions when completing data forms for patients with chest pain. Reporting of chest pain patient data was still manual in most hospitals, with a low information technology penetration rate. The reasons for this include the high price of information systems and ineffective connection among the CPC data reporting system, hospital information system, and national CPC data reporting platform. Additionally, interviewees perceived inadequate implementation of CPC training, including training for new staff and for community-dwelling patients with chest pain. CPC directors emphasized the importance of the attitude and responsibility of the person in charge, and that CPC directors should promptly identify and address operational problems to achieve continuous quality improvement.
In our hospital, some leaders are still caught in not caring after obtaining certification. Some CPC signs are broken, and we've called to repair them. However, when calling from our level, the results are not very good. Some signs, such as a damaged lightbox, should be checked regularly. (Cardiology Chief, Chest Pain Center Director)
Reflecting and evaluating
Implementation of the NCPCP interventions is related to sustainability of the effect of CPC establishment. CPC directors proposed that self-inspection and external inspection be used to supervise the routine operation of CPCs. For hospital self-inspection, CPC directors felt that attention was needed regarding quality control and timely correction of deviations. The national headquarters of the CPCs should supervise the NCPCP implementation interventions in hospitals through unannounced visits and regular inspections. Governments can also act as a strong promoter of external assessment by organizing administratively binding CPC quality control centers.