i. Outcome of implementation
Over two weeks, a redesigned perioperative workflow for the obstetric COVID-19 patient was successfully implemented within our L&D unit. The initial workflow draft was disseminated among clinical leaders and stakeholders and underwent one cycle of cognitive redesign. Prior to further refinement, planned testing or wide-scale dissemination amongst providers, its use was urgently requested by clinical leaders to assist in the management of our first live COVID-19 obstetric case. At this time, staff members involved in the case had no formal input into the design of the checklist or training in its use but were coached in real-time to work through the checklist elements. By following the sequence of the checklist, staff were able to safely perform the standard operating procedures, as indicated. Following our first live case, a formal debriefing with all members of the obstetric, anesthesia and perinatal team was conducted using video-conferencing, and specific steps were identified for checklist optimization. Subsequent checklist use, post-case debriefing and workflow redesign continued through a process of rapid cycling as described above. Following implementation, we report successful and consistent use of this new workflow for all obstetric COVID-19 perioperative cases (100% compliance) over the subsequent weeks to date. Feedback from frontline clinicians was that the checklist helped with ensuring proper use of PPE, created an environment of safety, and improved coordination and communication among the teams.
ii. Evaluation of checklist implementation
Evaluation of the implementation experience using CFIR demonstrated the significance of the following domains, when ranked in order of influence as facilitators of implementation success (expressed as a percentage of constructs within each domain): process (89%), innovation characteristics (88%,) inner setting (64%,) characteristic of individuals (40%) and the outer setting (0%). Constructs not applicable to this study included cosmopolitanism, organizational incentives and rewards, and external change agents.
Facilitators of implementation:
Constructs which positively influenced the implementation of this workflow redesign spanned all domains, except the outer setting. The domains of implementation process (Table 1) and innovation characteristics (Table 2) demonstrated the greatest proportion of facilitating constructs. Constructs within the inner setting which had a strong influence in facilitating implementation included the structural characteristics of the unit, the implementation climate (tension for change, compatibility, relative priority, goals and feedback) and the readiness for implementation (leadership engagement, available resources) (Table 3).
Barriers to implementation:
Several constructs were felt to negatively influence implementation in this study, in particular those from within the outer setting (Table 4). Additional barriers to implementation included the complexity of the innovation (innovation characteristics, Table 2), baseline culture, climate and communication (inner setting, Table 3) and personal attributes (characteristics of individuals, Table 5).
External pressures created by peer pressure, both locally and internationally, were evident as an early barrier to implementation. Local peer pressure created by a departmental policy within anesthesia on the appropriate personal protective equipment (PPE) resulted in general anxiety, disagreement and inconsistencies in inter-departmental guidance that impacted behaviors within the L&D unit and overall readiness for alignment. Furthermore, external influences from international peer groups, in particular communications from colleagues in China, Italy and other centers across the USA including the Center for Disease Control (CDC), demonstrated a considerable disconnect between the recommendations for care and clinical practice. This affected expectations and resulted in a delay of the shared mental model.
Constructs which demonstrated a change over time:
Evaluation of our implementation revealed some constructs which demonstrated a temporal change over time, the majority of which were within the inner setting (Table 3). At baseline, constructs such as communication, culture and learning climate initially acted as a barrier to implementation, but then progressed to become facilitators within the space of a few weeks.
With respect to this innovation, clear lines of communication and knowledge of where to access the most up to date information were not evident initially within the organization, which resulted in frustration. This was rectified over the course of implementation and communicated through the hospital’s COVID intranet. Further communication improvements at the local departmental levels, via intranet, email and teleconferencing permitted inter-professional collaborative work.
While the culture within the L&D unit was accustomed to the use of checklists, standard operating procedures, and iterative cycle improvement, additional internal forces such as recent staffing changes along with external pressures, fears and anxiety, were present that may have influenced the cohesion of the unit. Pre-existing egotism and individualism may have impacted the learning climate and further impacted implementation negatively. However, in view of the urgency of COVID-19, assistance outside of the L&D unit was sought and welcomed over the course of the implementation. Leaders within L&D valued the input of all inter-professional team members during the implementation period. Additionally, through the debrief mechanism, involved staff members felt like a valued partner in the change process.
Finally, within the outer setting, the patient’s needs and resources also shifted in influence over time (Table 4).