Setting
Healthcare professionals and implementation experts participated in this study. Both groups were involved in a two-year half-time post-initial scientific master’s programme (subsequent to an initial master’s) on quality improvement in healthcare. The program trains healthcare professionals with an academic background to become leaders in the evidence-based improvement of healthcare quality and safety. Professionals are enrolled in 12 interactive learning modules (see Figure 1, which shows the core elements of the master’s programme). The implementation experts are teachers and supervisors in these modules and have different specialties, such as leadership or patient involvement in quality improvement. Professionals work intensively on their personal (leadership) development in quality improvement through portfolios and coaching. Together, these educational interventions support professionals to lead and perform a QIP at their workplace during their master’s programme. Because these QIPs are carried out in the context of a teaching programme, they are to some extent standardised (e.g., all professionals receive methodological support, all QIPs are performed in a hospital setting and are led by healthcare professionals, and all theses are evaluated using the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines(16)), making them valuable sources for the development of this tool.
Year 1: knowledge and skills
Interactive modules:
1–2: Introduction 3: Patient centered care 4: Effective care 5: Implementation of quality improvement 6–7: Safe care 8: Efficient care 9: Scientific research in quality improvement
From a quality improvement project idea to a plan
Personal (leadership) development using portfolios and coaching
Year 2: Skills, distance learning, workplace learning and peer coaching
Interactive modules:
10: Transboundary care 11–12: Leadership track 1 and 2
Leading a quality improvement project
Free electives based on personal learning goals
Longitudinal learning paths: Interprofessional learning, lifelong learning and patient involvement
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Figure 1. Elements of the Dutch two-year post-initial master’s on Quality and Safety in Healthcare
Design
We used a mixed-methods design(17) to develop the tool. First, we performed a cross-sectional study using an online survey among healthcare professionals from the master’s programme, in which they were asked about the determinants they experienced during the performance of their QIP. We subsequently performed semi-structured interviews with implementation experts about 1) how healthcare professionals can be assisted to analyse the determinants of our tool within their QIP and 2) how healthcare professionals can tackle the barriers or use the facilitators identified in their improvement project. We used the Strengthening of Reporting of Observational Studies in Epidemiology guidelines (STROBE) and the Consolidated Criteria for Reporting Qualitative Research guidelines (COREQ) when designing our study. For more details, see additional files 1 and 2 [see Additional file 1 and 2].
Part 1: Survey
Development
Two cohorts of healthcare professionals following the master’s programme (N = 41) were asked to fill in an online survey about the determinants they experienced during the performance of their QIP. They were retrospectively asked to express the five most important experienced facilitators and five most important experienced barriers. See additional file 3 for the complete survey (in Dutch) [see Additional file 3].
We developed a pre-specified list of facilitators and barriers from which healthcare professionals could chose their determinants for their top five facilitators and top five barriers.
This list was based on two existing models of determinants: MUSIQ(4) and the TICD model(2). To the best of our knowledge, MUSIQ is the only model that includes determinants relevant to team-level quality improvement in our context, while the TICD model is based on a systematic review of other determinant frameworks, not including MUSIQ. We therefore assume that the combination of both models provides an overview of all unique determinants.
First, the researcher (AvT) combined the two models to gain an insight into the unique and overlapping determinants. For the MUSIQ model, we used the questionnaire that was developed to measure contextual determinants(18). For the TICD model, we used the TICD tool that was developed to facilitate the use of the model(2). The researcher (AvT) and one member of the research team (HW) scored all determinants (57 TICD determinants, 39 MUSIQ determinants) by three criteria: relevance (the determinant should be of relevance for performing an improvement project in healthcare), applicability (the determinant should be applicable across various relevant settings and types of improvement project) and recognition (the determinant must be easily understood by healthcare professionals)(2). Of the selected determinants, 32 came from the MUSIQ questionnaire, 22 from the TICD tool and five were identified in both tools. Two determinants were formulated by discussion with the research group based on their relevance to our context. We formulated all the included determinants as both facilitators and barriers, resulting in two lists of 61 determinants each. A flowchart of the selection process can be found in Figure 2.
Figure 2. Flow diagram of selection process of determinants in the pre-specified list used in the survey
The translation and adaptation of the determinants for the questionnaire was completed by researcher AvT. The list was extensively discussed with the entire research group. The determinants were organised according to the MUSIQ model levels: those of the external environment, organisation, microsystem and QI team. We also added two levels from the TICD model: the level of the patient and of the QIP.
Procedure
In 2014–2018, a total of 46 healthcare professionals with backgrounds in various medical and nursing specialties participated in the first two cohorts of the master’s programme. We included all healthcare professionals who started performing a QIP during their master’s. Professionals who dropped out of the programme and did not begin a QIP and those who explicitly stated that they did not want to participate were not recruited. In total, 41 healthcare professionals were recruited by e-mail to participate. A reminder was sent two weeks after the first invitation. Participation in this survey was voluntary. Informed consent was implied by the overt action of completing the online questionnaire after reading the information letter.
In the survey, professionals were retrospectively asked to name the five facilitators and five barriers they experienced as most important in their QIP. Professionals could select determinants in two ways; choosing from the pre-specified list of facilitators and barriers and/or naming self-experienced determinants that were not included in this list. The questionnaire could be completed in approximately 10 minutes.
Analyses
For the analyses, the participants’ self-experienced determinants were carefully evaluated by the researcher (AvT) to assess whether they could be merged with determinants in the pre-specified list or with determinants reported by other participants. Self-experienced determinants with the same meaning as a prespecified determinant were accommodated within this determinant. Self-experienced determinants with the same meaning as another self-experienced determinant were combined, sometimes leading to a reformulation of the self-experienced determinant. The combined determinants were discussed with another member of the research team until consensus was reached (HW and/or HC).
A priority score was calculated for each of the top-five determinants named by the respondents. This score consisted of the sum of the ranking in the top five (i.e., a determinant ranked in first place scored five points, a determinant ranked fifth place scored one point), multiplied by the number of times a determinant was placed in a top five by professionals. Determinants with a priority score ≥ 20 were included in our tool.
Part 2: Interviews
Questions
We received further information about determinants with a priority score ≥ 20 from the implementation experts using semi-structured interviews. The interview guideline consisted of open-ended questions about how healthcare professionals could be assisted to analyse determinants, use facilitators and confront barriers when performing a QIP. We also asked for general comments on the tool. The interview guide was pilot-tested with a member of the research team (HC) and adapted where necessary.
Procedure
We recruited 29 implementation experts from eight Dutch universities. They all had a teaching role in the master’s programme and possessed different expertise regarding the implementation of QIPs. We used purposive sampling to select implementation experts with varied expertise in implementing QIPs. All 29 implementation experts were approached by e-mail to participate, and were provided with information about the goal of the study. After a week, a reminder was sent. Those implementation experts who agreed to participate were contacted by the primary researcher (AvT) to schedule a date for the interview. Oral consent was recorded. The primary researcher interviewed all implementation experts. All interviews were audio-taped and field notes were made.
During the interview, implementation experts were asked to choose two facilitators and two barriers from the list of determinants with a priority score ≥ 20, on which they wanted to provide input. Input was based on the implementation experts’ theoretical knowledge and practical experiences with QIPs. As an increasing number of interviews were held, it became clear that some determinants had received more input than others. Therefore, as we conducted more interviews, we asked implementation experts if they could also advise on the determinants which had previously received less input.
Analyses
All interviews were transcribed verbatim by the primary researcher (AvT), and from each transcript an extensive summary was made to facilitate the analyses. The transcript summaries were analysed in pairs using principles from thematic analyses(19). The primary researcher (AvT) analysed all summaries and two researchers (HW and HC) with implementation expertise also analysed half of the summaries each. This involved carefully reading the summaries before discussing the meaning of the input to identify and develop themes, which were reformulated into suggestions for analysing and addressing the determinants in the tool.