In this study, we developed a tool of 12 prioritised facilitators and nine prioritised barriers based on the experienced importance according to healthcare professionals performing QI initiatives in practice. For every determinant in the tool, , suggestions on how to analyse and address these determinants are provided . This tool can be used before, during and after the implementation of a QI initiative to guide discussion on which determinants s are important to consider. The tool therefore helps healthcare professionals to learn from failures and successes, which can be used in future initiatives . Most facilitators in our tool are at the level of the department, while most barriers are at the organisational level. We identified support from the departmental management staff as the most important facilitator, while lacking the proper time to perform an initiative was the most important barrier. Methods for analysing and addressing each determinant are provided, based on interviews with implementation experts. Although not every determinant can be directly influenced by professionals, good communication with stakeholders, keeping the project small and learning from implementation are important overall recommendations for performing QI initiatives .
Differences with other determinant models
In contrast to most determinant models in the literature, our tool makes an explicit distinction between barriers and facilitators. We assume that the presence of a determinant during implementation does not necessarily have to be equally as helpful as its absence would be prohibitive, and vice versa. By analysing the professionals’ top five most important experienced facilitators and barriers, we conclude that this assumption is valid because we found that determinants that are experienced as most important facilitators were different than determinants that are experienced as most important barriers. Our tool therefore contains separate lists of prioritised facilitators and barriers. We hope that this distinction supports professionals in making more informed choices on which facilitators to use and which barriers to address during the implementation of an QI initiative.
Because identifying determinants is the first step to challenge or use determinants, we not only include a list of prioritised facilitators and barriers but also provide practical suggestions on how to analyse determinants, use facilitators and address barriers. Current determinant models = often fail to provide a link between determinants and the strategies to address them(8, 15, 16). A recent study of which implementation strategies in the ERIC model would best address contextual barriers from the CFIR found that respondents had varying opinions regarding which implementation strategies best addressed each contextual barrier(12). This result can be explained by the fact that professionals chose implementation strategies without fully understanding the determinant and that most implementation strategies are limited in their specification, poorly described and ‘package’ approaches consisting of multiple poorly understood elements(21). Our tool first helps to address these concerns by including suggestions how to analyse the determinants. By applying those analysing methods, there will be a better understanding of the determinant leading to more informed choices on selecting implementation strategies. Thereby, the practical suggestions in our tool to address the determinants are different to those of other implementation strategies in that they are concrete and focus on one specific determinant. Future research should strengthen our suggestions to address the determinants by enhancing the evidence for these suggestions. Also linking specific behavioural change strategies, based on theoretical constructs, to the determinants in our tool would be a valuable future step. . .
Reflection on the barriers and facilitators in the tool
We identified receiving sufficient support from management as the most important facilitator . Support from management helps to formally confirm an initiative , for example by integrating it in the policy statements of the department(22) or by providing resources(19). In an exploratory analysis of the MUSIQ model, researchers found that microsystem determinants (e.g., department-level factors) have direct effects on the success of QI initiatives(19). Microsystem leadership (similar to our determinant ‘management support of department’) was not found have a direct influence on success; however, this determinant was found to be directly influenced by QI team leadership, which in turn had one of the strongest direct effects on measures of success. Our tool is based on the experiences of QI team leaders, who, it could be argued, are highly influenced by their departmental management team.
Analysis of the MUSIQ model also found that most determinants related to the QI team had a direct effect on success because this team is responsible for guiding the implementation(19). Our results also show that facilitators at the level of the QI team were most often reported in professionals’ top 5 but were not included in our tool due to their priority score (< 20). This result could mean that the various individual determinants related to the QI team are independently not experienced as most important but that these determinants together could make the total synergistic importance of this domain very high. Future research on this tool should study how and why the QI team is important in the performance of a QI initiative.
By providing a tool of prioritised facilitators and barriers with practical suggestions for how to analyse and address determinants, we intend to help healthcare professionals to have structured discussions regarding which determinants are important to consider during different moments in the implementation process of the QI initiative. . Using the tool prior to the implementation can help to identify potential barriers and facilitators to implementation, , adapt the initiative before implementation and consider how learning can be supported.. During implementation, our tool can serve to monitor the implementation and to identify and address determinants. After implementation, the tool can help to reflect upon which determinants influenced the implementation. Although we recommend to use our tool during different phases of the implementation, we did not take into account that the experienced importance of determinants will vary throughout the lifetime of a QI imitative in the development of the tool. We recommend future research to ask professionals at different moments during the implementation of the initiative which determinants they experience as most important.
Our determinants are prioritised based on the experiences ofhealthcare professionals who were leading a QI initiative in the hospital setting. It is assumed that the higher the priority score, the more important this determinant is in the implementation of the initiative . However, as every initiative is unique and every context is different, it’s not definite that the determinants we found will also reflected in other contexts or initiatives. It’s therefore important that QI teams have a structured discussion about the determinants in our tool to discuss whether the determinants are reflected in their context.
Although the science of measuring determinants is immature(1), the column ‘analysis’ in the tool will be helpful for this task. During those discussions professionals should also think about other possible determinants that are important in their context and add them to this tool. Additional file 4 which provides all determinants that were ranked in professionals’ top five, could support these discussions.
Knowing which determinants could potentially influence the implementation does not mean that the determinant can be addressed by healthcare professionals.; interviews with implementation experts showed that some determinants lie beyond the control of healthcare professionals. An organisational culture supportive of QI is an example of a facilitator, but is difficult to influence directly and in the short term by healthcare professionals. However, this does not imply that these determinants should be fully ignored by healthcare professionals. We recommend professionals to give priority on addressing the determinants that lie within their control yet at the same time do not lose sight on the determinants beyond their control(33). First addressing the determinants within practitioners’ control will help to build motivation and commitment to the QI initiative. These ‘early wins’ could also help to address or use the determinants that are beyond their influence by stimulating the organization to influence those determinants. Also, these determinants that lie beyond practitioners’ control should be kept on the horizon, knowing that they won’t change quickly but by the use of adaptive leadership behaviours and other strategies small steps in the right direction can be obtained
Because our tool is one of the first that includes the sphere of influence, we recommend more research on which determinants can be influenced by whom and under which circumstances.
Our study has several limitations. The first limitation has to do with the context dependency of our tool, limiting the generalizability. The QI initiatives s at the basis of this study were performed within the context of an educational programme, making the results susceptible to selection bias. It is possible that healthcare professionals performing a QI initiative outside the context of an educational programme will experience different determinants. Although this possibility, our initiatives are performed using the principles from experiential learning which means that real-life experiences in the context relevant to learners own future career are used, making the difference with initiatives performed outside the educational context relatively small(34, 35). Thereby, all of the included improvement initiatives are performed within the Dutch hospital setting. We propose future research to test this tool in other contexts, to see whether the determinants we found are also experienced as most important in those contexts. Also, our tool is based on a small number of QI initiatives (N = 28), which may further limit its generalisability. The initiatives were performed in a wide range of hospitals across the Netherlands however, including all academic hospitals in the country. Another limitation is that there could be a potential bias in the participants ‘top 5 barriers and facilitators. Respondents could have identify the easier well-known determinants more easy and overlooked the less known determinants that could potentially have a greater impact. However , we tried to minimalize this bias by letting participants choose determinants from our pre-specified list of determinants which included also the less obvious determinants.
Finally, our tool has not been prospectively validated. Further evaluation and modification is needed, including feedback from a broad range of healthcare professionals about their experiences with the tool. This tool is not a finished product and will benefit from further adjustments and developments.