Between October 2023 and February 2024, participants, coaches and executives were interviewed face-to-face, over the phone or video conference by MB (n = 31) (Table 1). Each interview took on average 28 minutes. Three group interviews were conducted by MB using the same questions with: participants (n = 2, 20 minutes); coaches (n = 6, 80 minutes); and executives (n = 2, 18 minutes).
Table 1
Interview Participant demographics
| Interview participant groups | | N |
| CIP009 executives | | 6 |
| CIP009 coaches | | 9 |
| CIP009 participants | | 16 |
| Participant clinical experience (Range 2–40 years)* | 10 years or less | 2 |
| | 11–20 years | 6 |
| | 21 years or more | 4 |
| Participant Profession | Nurse | 5 |
| | Doctor | 7 |
| | Allied Health Professional | 4 |
| *4 participants did not report their length of clinical experience |
Five CIP009 team meetings were observed, typically comprised of five team members and stakeholders plus a coach, each running for an hour on average, and one faculty meeting was observed, also an hour long. Teams typically discussed project progress, challenges, and made action plans for next steps. The midpoint presentations were observed (4.5 hours), as well as the graduation session (4.5 hours) and field notes were taken. Each team presented their progress at each of these sessions. CIP009 Faculty and team documents were reviewed (n = 78), such as: the training agenda, slides and notes, and recordings of guest lectures, midpoint and graduation presentation slides, recruitment and registration documents, support resources, team meeting agendas and minutes, project plans, project specific outlines of length of stay data, and draft protocols, training and presentation evaluation data. Analysis of these data enabled the characterisation of the program, along with the identification of key strengths and challenges associated with CIP009.
Characterisation of the SALHN CIP009 program
CIP background
Since 2018, nine iterations of the CIP have been delivered, supporting over two hundred internal CQI projects over that timeframe. This has increased organisational awareness of the program, approaching a critical mass of staff having graduated from past CIPs, or with experience as CIP project stakeholders. The CIP is historically a 6-month CQI program delivered to staff which includes training sessions around the SALHN 8 step methodology(5), and continuous support from CIP coaches and Faculty. Participants present project progress to their cohort at a midpoint presentation and at the graduation session (Table 2).
CIP009 design
In preparation for CIP009, 12 CIP project topics were selected and codesigned by hospital Division and CIP executives based on metrics such as high rates of admission, readmission, or length of stay. Project topics were designed to include at least two hospital Divisions involved in the patient care continuum, facilitating collaboration across the organisation. The CIP Faculty then conducted preliminary data analysis of the projects to gather baseline data and background information to justify and prepare each project for the 12 teams (Table 2).
CIP009 recruitment
CIP009 participants were typically nominated by their Heads of Units and Divisions and assigned to a CIP009 team. Project team members (doctors, nurses and allied health professionals) were multidisciplinary, with varying levels of seniority, from multiple divisions across SALHN. Each team was led by at least one CIP coach and some with an additional shadow coach in training. Team members were introduced to their coach by the Director of CIP and presented with the preliminary analysis and justification for the project topics (Table 2).
CIP009 training and support
CIP009 participants were provided with 3.5 days of training about CQI methodology and key objectives of CIP009 (Table 2). Participants were provided with resources to support the development of these skills. Sessions were delivered as seminars by the Faculty and senior executives, including shared experience of past CIP projects, and group workshops focused on practical cases. During and following the training sessions, teams initiated the CIP 8-step continuous improvement process, to identify, define and address their project issue. The most commonly reported data collection methods teams utilised included audits, electronic medical record analysis, observations and staff and patient surveys. The projects aimed to increase patient flow across micro-systems, with the intention of improving hospital-wide patient flow through the reduction in patient admission, readmission, length of stay and unwarranted clinical variation.
The CIP009 teams were guided by improvement coaches, and the Faculty. Coaches played a project management role, accessing, conducting and supporting data analysis, providing expert CQI advice, and developing outputs such as presentations and protocols through face-to-face and virtual support. CIP009 teams met with their coaches regularly to discuss the project design and implementation plan. Coaches had a range of clinical backgrounds and CQI experience. All were graduates of a past CIP course and had shadowed another coach supporting a previous CIP team. Coaches received in-house training and mentoring, and regularly collaborated in Faculty brainstorming sessions to discuss CIP009 projects.
In light of the complexity of projects, the Faculty and coaching support provided to CIP009 project teams was extended from a six-month program to over 18-months to enable teams to complete the SALHN 8 steps with wraparound support (Table 2). As a result, at the time of the evaluation, teams were still in the diagnostic and planning phases, and had not completed the SALHN 8 steps. Teams had typically refined the problem, conducted analysis including development of a cause-and-effect diagram, and identified outcomes to be measured.
Table 2
Key CIP009 Project Milestones
| CIP009 Project Milestones: |
| Preparation: |
| • CIP009 projects (n = 12) were codesigned with clinical directors and SALHN division leadership |
| | Team | Topic |
| | 1 | Shorter Stays, Better Journeys: Improving back pain care |
| | 2 | Alcohol presentations to ED |
| | 3 | Preventing Delirium on 4D |
| | 4 | Not just a failing heart |
| | 5 | Standardising SALHN Mental Health Care Pathways for Clinical Presentations of Borderline Personality Disorder |
| | 6 | Reducing short stay Undifferentiated abdominal pain admissions |
| | 7 | Improving the patient flow processes at Southern Adelaide Palliative Care Services |
| | 8 | Toe-Tal Improvement: Ramping Up Care for Patients with Diabetic Foot Infection |
| | 9 | Future of Falls in Elderly at FMC |
| | 10 | Bringing AIR (Acute Illnesses of the Respiratory Tract/System) in and out of Flinders Paediatrics |
| | 11 | ED to Emergency Extended Care Unit Pathway |
| | 12 | PV bleeding presentations to ED |
| • CIP009 participants were nominated by division executives |
| • Pre-training data analysis and project preparation conducted by coaches to justify projects to teams |
| • Team introductions by director of CIP, preliminary analysis of projects discussed |
| Commencement of CIP009: |
| • CIP training days (March 2023) including project team groupwork with coaches. |
| | Training day (hours) | Topics |
| | Training day 1 (4.5h) | Introduction to the ‘Towards Zero Ramping: Improving organisational capability through standardisation’ International Guest lectures-A Personal Journey in Acute Care Improvement |
| | Training day 2 (8.5h) | Welcome from the Minister for Health and wellbeing Standardisation in clinical practice – reducing unnecessary variation Project pathways-Introduction of teams and project streams Continuous Improvement Principles Group Activity Continuous Improvement Program – 8 step Improvement Framework Diagnostic Tools (1) Breaking down the problem, focus on process mapping, tracking Work as imagined, work as done Allocation of small groups Part 1: draft milestones & stakeholders for process map (breakout rooms) |
| | Training day 3 (8.5h) | Human Factors – The Influence on Healthcare Quality Measuring for Improvement Lessons learnt from protocol development over 20 years Small Group Work Part 2: further analysis of pathway and identify key steps/milestones (breakout rooms) Asking why Diagnostic Tools (2) Understand what to work on (tally sheets, brainstorming, Ishikawa, multi voting, Pareto charts) Consumer involvement- The value of having consumers on projects Small Group Work Part 3: discuss diagnostic plan (direct observations, plan mapping meeting, measure & mission statement) |
| | Training day 4 (7.5h) | Data Clinician interface Ethics Approval Group Work – Part 3 continued: diagnostics: what will you do tomorrow? How to Publish Your Project Evidence: SALHN CI Sustainability Plan your Work, Work your Plan! Ready to Launch |
| • Teams initiated the SALHN 8 step continuous improvement framework process |
| | Step | Task |
| | 1 | Define the Problem |
| | 2 | Breakdown the Problem |
| | 3 | Set a Target/Mission Statement |
| | 4 | Root Cause Analysis |
| | 5 | Improvement planning |
| | 6 | Implementation |
| | 7 | Evaluate/Assess Impact |
| | 8 | Continuous Improvement |
| • Continuous Support: CIP009 Project teams were provided with continuous support from coaches and Faculty (approximately 4 hours of support each week per team, via team meetings, data collection and analysis) |
| • Stakeholder Engagement To further elucidate the root causes of selected problems, CIP009 participants recruited stakeholders to provide clinical insight and local knowledge to the problem-solving process through brainstorming and process mapping |
| • Midpoint Report back session (June 2023) (4.5 hours) The project teams presented their progress at a midpoint report back session, and received feedback from the CIP009 teams, coaches, and Faculty. The hospital CEO and other SALHN executive attended these sessions and provided feedback to teams |
| • Graduation Report back session (October 2023) (4.5 hours) The teams presented their progress to their CIP009 peers, coaches, Faculty and executive at their graduation ceremony, demonstrating their use of the 8 step CIP framework to design and implement a service improvement. Most teams had not completed the 8 steps by this point. They had refined the problem, conducted analysis including development of a cause-and-effect diagram, and identified outcomes to be measured |
| • Planned ‘Where are you now?’ report back session (October 2024) The teams will present their progress and receive feedback from peers and executive. |
| • Planned Sustainability following graduation (continuous support from the Faculty anticipated until project completion in June 2024) At intervention stage, teams report progress to executives and consumer adviser committees, for accountability and sustainability |
Thematic analysis of data identified seven key themes highlighting key challenges and strengths of CIP009 implementation within the SALHN setting: Four of the themes were focused on strengths of CIP009 implementation and captured concepts like: flattened hierarchy; wrap-around support from coaches; vested interests; and senior clinical change agents. Three themes were focused on key challenges of CIP009 implementation and included: individual workloads; issues in the way teams worked together; and training shortcomings (Fig. 1). Exemplar quotes (n = 36) from more than two thirds of interviewees are presented in Table 3 (22/31. 71%), including 21 quotes from CIP009 participants (n = 11/16, 69%), 8 quotes from coaches (n = 7/9, 71%) and 7 quotes from executives (n = 4/6, 67%).
CIP009 Strengths
Overwhelmingly, participants were positive about CIP009, and the improvements they had achieved in their teams. Four themes and subthemes were identified as strengths of CIP009 that facilitated the implementation of the projects (Fig. 1). Exemplar quotes are presented in Table 3.
Theme 1: CIP framework and culture embedded in the psyche of the SALHN organisation
Key strengths of CIP009 included the flexible, adaptive, agile and transferable nature of the CIP methodology and the predetermined and clear nature of the projects. This enabled coaches to do preparation work identifying key literature and baseline data to present to teams and facilitated efficient problem definition and change implementation. The report back presentation sessions at midpoint and graduation were seen as an opportunity to learn from other teams and celebrate successes. Presentation deadlines held teams accountable, and the extended timeframe of CIP009 support facilitated progress of projects. Participants valued the protected time for training, away from clinical duties, to immerse themselves in the CQI topics (Quote 1). Many felt additional protected time would accelerate project progress.
Achieving stakeholder buy-in and project engagement was considered essential to change, facilitated through coach support and networking. Participants valued the multidisciplinary and cross-divisional collaboration (particularly with ED), facilitated by CIP009, both in the composition of the teams, and engagement with stakeholders during brainstorming sessions and protocol development. This enabled teams to develop a clearer understanding of the patient journey end-to-end (Quote 2) and strengthen professional networks (Quote 3). Consumer involvement in projects was considered important but only utilised across some projects.
SALHN was perceived to be moving towards critical mass regarding CIP training saturation, with awareness and engagement with CIP increasing exponentially (Quote 4). CIP has built a culture of inquiry over time, across SALHN, with continuous improvement ideas perceived to be embedded in the organisational psyche (Quote 5). The use of a standardised, adaptive and evidence-based framework to develop targeted improvements that is simple to follow and adapt to local problems, was valued.
The SALHN CIP training builds improvement capacity and capability by teaching participants the skills to independently design and implement improvement projects. CIP009 however, had an outcome-focused strategic direction imposed upon the projects, with greater coaching support provided to facilitate and expedite progress of improvement projects. CIP009 was focused on organisational capacity building, efficiency and reducing waste, built on the foundation of organisation-wide CIP awareness and use of a common CQI language. This facilitated engagement with stakeholders who were already familiar with CIP (Quote 6). Participants valued the overarching hospital priority-aligned strategic approach used to address network-wide wicked problems (Quote 7) and the non-prescriptive combined top-down and bottom-up nature of CIP009. While executives nominated and codesigned the broad selection of CIP009 topics, clinicians at the patient interface valued their ownership over the design and implementation of the improvement projects (Quote 8).
CIP has established avenues for ongoing accountability and sustainability of the improvement projects through regular reporting to committees and executives. However, few CIP participants commented on mechanisms for sustainability and accountability, possibly reflecting the early stages of the SALHN 8 step framework that they had reached.
The CIP Faculty and program instilled a culture of flattened hierarchy, enabling participants to confidently engage with and discuss ideas across the team, enhancing collaboration. This was established through role modelling with coaches demonstrating humble enquiry and negotiation techniques as methods to constructively challenge current practices, and support change adoption (Quote 9).
The CIP009 training sessions held off site were considered well-structured with interesting in-depth content. The theory and reference to the literature throughout the training content was generally well regarded, and participants felt the framework was applicable across disciplines. Many participants valued the lectures from the expert presenters (including international guests), the small group activities and the real-life examples of past CIP projects presented by alumni and coaches. These examples of learned experience, alongside the SALHN 8 step framework, were useful to shift mindsets around continuous improvement methodology (Quote 10). The team building benefits of the face-to-face sessions, and opportunities to network with other teams, coaches and participants, as well as provision of training resources were also valued.
Theme 2: The benefits of support from a dedicated, internal improvement faculty
Participants were complimentary about the large and experienced Faculty and leadership supporting the 12 CIP009 projects, and the breadth of knowledge coaches demonstrated (Quote 11). CIP Faculty executives played a key role as gatekeepers of coach workload to protect coach capacity to support CIP009 teams. The increased provision of coach support for CIP009, relative to past CIPs, resulted in a perceived higher standard of project outcomes.
The continuous and resourced nature of Faculty CIP009 support was invaluable and seen to minimise the workload burden on CIP009 participants and ensure projects progressed. The internal nature of the Faculty meant the coaches could provide indispensable organisational knowledge-based advice (Quote 12). The Faculty also advocated for improvement changes that required policy escalation or changes to workflow and helped to navigate occasional challenging dynamics across divisions, as neutral stakeholders.
Faculty staff who were embedded within executive teams and divisions, wielded influence to engage executives with change initiatives. High executive and leadership awareness, understanding and support of the CIP009 projects across SALHN was perceived to facilitate improvements, staff buy in, and minimise governance barriers. Participants also felt that executive attendance at the CIP009 training and presentation days increased recognition of and institutional support for their improvement initiatives. Similarly, ED leadership support of projects validated improvement programs and facilitated staff buy-in.
Coaches and Faculty staff were considered to be a key strength of the CIP009 program demonstrating enthusiasm, commitment and belief in the value of each project (Quote 13). Coach support was respectful and encouraging, but not prescriptive (Quote 14). Coach clinical knowledge was another key strength perceived to facilitate project progress. Coaches aimed to provide a standardised approach to project support and facilitation, and the Faculty team promoted a culture of support and beneficence through their training, resources and coaching, which facilitated engagement with stakeholders.
The extensive wrap-around support from coaches who were embedded in teams was considered a key strength of CIP009 (Quote 15). This included data sourcing and analysis, proactive project management, and output development such as protocols and preparation of presentations. This reduced the burden on participants (Quote 16) and freed up participant time to provide expert clinical advice on the improvement design and implementation. The coaches led the teams through the 8-step continuous improvement framework, providing structured guidance and feedback and preventing teams from jumping to solutions. The coaches who were embedded in Divisions were considered particularly helpful as they had pre-established relationships with staff, facilitating stakeholder engagement with the projects, as well as having greater clinical understanding of the project. Coaches were considered experts in improvement, with their process knowledge helpful to guide feasible intervention design and facilitate change. Coaches were also seen to have strong professional networks which were useful to progress interventions.
Coaches coordinated regular meetings and communication between team members to maintain project momentum and hold team members accountable, without overburdening them. Team members valued these often-weekly meetings, particularly the flexible nature of the hybrid face-to-face and virtual meetings, and clear communication about expectations, task setting and virtual communication when they were unable to attend in real time.
Theme 3: The advantages of an enthusiastic participant disposition and incentives
Individual team members’ disposition was considered to have an impact on project progress, with an appetite for change, and respect and belief in CIP009 to achieve change being valuable characteristics. Participants, naturally, began the CIP009 course with varying skills and experience, but their capacity to be open to feedback and to show initiative was beneficial. The CIP009 process helped participants gain insight into the contributing factors of their project problem, which were often different to what they expected. Project progress was best supported by team members who managed their time to complete project tasks and meet with their teams regularly, by prioritising other work commitments. Past CIP participants had often become continuous improvement advocates themselves after graduating from CIP (Quote 17).
There were various incentives identified to complete the CIP009 project including: a shared vision of beneficence and developing capability to improve patient support end-to-end; benefits to career progression; continuing professional development (CPD) points; easing workflow demands for staff; learning how to break down problems and design and implement effective feasible solutions; opportunities to network and collaborate with consultants to improve processes; gaining new perspectives on patient journeys from team members; supporting teammates; and opportunities for publication. Almost all participants reported a vested interest in the improvement being delivered effectively, with many projects being seen as impactful and meaningful to the team members.
Theme 4: Effective teams and team composition
Team cohesion and collaboration in the teams were important factors, ensuring that participants felt solutions to the identified problems were not imposed upon them, but generated together. The composition of team members was important, with value seen in having a balance between expertise from more senior medical staff, and members with capacity to do the work, with the later role predominantly falling to nursing and allied health-based team members (Quote 18). However, these staff often reported not having time to ‘do’ the work on top of their clinical workloads. The more senior participants were seen as change agents who facilitate change adoption, particularly through medical and surgical staff engagement. The multidisciplinary nature of teams was seen as a strength of CIP009. Familiarity with team members was also considered valuable, with pre-existing rapport facilitating smoother teamwork. Ensuring the team members were engaged and positive about the project was important, as was engaging the right stakeholders, particularly those from ED, to provide input and new perspectives.
CIP009 Challenges
This iteration of the CIP program had a focus on improving patient flow in comparison to past capability building CIPs. CIP is firmly embedded within SALHN culture, with CIP language common across SALHN, and leadership support facilitated through executive, and senior staff involvement in the CIP training and projects. Despite these factors, challenges persist. The thematic analysis identified three themes that represented challenges of CIP009 (Fig. 1). Exemplar quotes are presented in Table 3.
Theme 5: Workforce and Organisation-level challenges of improvements
Limited time and capacity to engage in the project was the most commonly reported organisational-level challenge for CIP009 teams. Competing priorities and clinical duties limited opportunities to meet and coproduce the work. Some felt that the timing of their improvement project implementation was impeded by other priorities that detracted from stakeholder engagement with the projects, such as accreditation. Participants talked about the importance of teams being ready, mature and capable for CIP009 and how if the team was in crisis-mode, from other stressors like workforce issues or seasonal demand, this was seen to detract from their ability to conduct improvement projects effectively (Quote 19). Workforce capacity and operational demand challenges included balancing annual leave, staff capacity with seasonal fluctuations in operational demand, and workforce shortages (Quote 20). Fitting the additional workload of CIP009 into daily workflow was challenging for many and created additional pressure. This was alleviated to some extent by the extensive wraparound support provided by coaches (Quote 21). Many participants noted that there was no sanctioned time to engage with the projects, other than the training days, mid-point and graduation sessions. They posited that additional protected time from clinical duties to immerse themselves in the project would facilitate the implementation of each improvement project (Quote 22). The timeframe of CIP009 (despite the extension) was perceived by many as too brief to progress through the SALHN 8 steps and achieve the types of improvements that had been designed, increasing pressure on participants (Quote 23).
Another frequently discussed challenge was the poor access to electronic patient data and poor data quality (due to documentation variation) to support the improvement process. Access to data for both baseline problem analysis, and monitoring of change was a challenge noted by many participants, and led to project delays, frustration, and increased workload for the coaches (Quote 24). Delays to technological infrastructure (ICT) improvement changes, limited physical infrastructure such as bed capacity for improvement projects, governance approval processes delays, and medico legal barriers (which were reportedly time consuming to navigate), were all thought to impeded project progress (Quote 25).
Theme 6: Team cohesion, logistics and stakeholder engagement challenges
Team-based challenges were predominantly around logistics with team members and stakeholders located across divisions and locations making it challenging to schedule project meetings. This resulted in poor momentum for some teams. Participants felt that the composition of their core teams could have had greater representation from different Divisions, specifically ED, and General Medicine (Quote 26). Participants posited that greater involvement of diverse stakeholders, especially those previously CIP trained, would have enabled a greater understanding of the improvement projects, and enhanced adoption of the changes.
Several participants and coaches discussed how challenging it was when there was unequal contribution, engagement and collaboration from team members. The composition of CIP009 teams was purposefully skewed toward more senior, executive, medical and surgical-specific staff who were perceived to be more time poor than their nursing and allied health counterparts. Utilisation of these individuals’ expertise and seniority meant that there was a greater reliance on coaches to provide the wrap around support (Quote 27).
Some participants discussed poor team cohesion and a lack of consensus to be a challenge to overcome as they progressed, particularly when the team lacked clarity around the definition of the problem they were provided with. Project complexity, including complex patient cohorts, made problem definition challenging, impacting the design and implementation of feasible improvements. Similarly, not having a prior relationship with their team members meant some felt less accountable to their team (Quote 28). Careful team and coach alignment, as well as trust and rapport between teams and the Faculty were important to ensure participants felt confident they would be supported to succeed.
Lack of engagement from stakeholders across the hospital (particularly surgical and medical-based clinicians and ED stakeholders) and resistance to change (Quote 29) were common challenges, which impacted the navigation, design and implementation of some improvement projects. Some participants reflected that it was difficult readjusting their thinking to the CIP009 framework to avoid jumping to solutions, and coaches noted that the expectation of participants to immediately generate solutions was challenging. Implementing projects and achieving behaviour change in a short timeframe was demanding, and depending on the project, required ongoing continuous support from coaches for an extended period of time to achieve desired outcomes. Implementation of projects was challenging, both in gaining stakeholder buy in and engagement and adoption of protocols, to achieve practice change and translation of evidence into practice. Several teams had not integrated consumer codesign into their improvement planning and design, and noted that this was an oversight, acknowledging the importance of consumer input as something that they would improve upon in future projects.
Theme 7: CIP009 training and support shortcomings
The length of the CIP009 3.5-day training sessions was perceived as too long for some staff to be away from clinical duties, with some staff feeling burdened if their roles were not backfilled (Quote 30). Some participants felt that lectures were too long, with some repetitive, redundant, superficial and disjointed content, and felt that the guest lectures were not given enough context to be relevant (Quote 31). Some team members were observed to not stay for the whole duration of the training days, supporting these concerns. Several participants felt that there was not enough group planning time with their team to progress their project, perhaps resulting in a missed opportunity to maximise momentum and enthusiasm from the training days (Quote 32). Similarly, some participants felt that they had limited team time with their coach during the training days, particularly when coaches were split across multiple teams, leaving some teams unsure how to proceed while waiting for their coach to return (Quote 33). Several participants noted that CIP009 projects were outcome focused rather than capability focused as past CIPs have been, with additional wrap around support from coaches meaning that the team members had fewer opportunities to practice the skills learnt in the CIP009 training course.
Communication about expectations of participant commitment was another challenge identified. Some participants felt presentation fatigue after presenting project results across multiple forums (the midpoint session, graduation day and to executive committees), suggesting they could record their presentations to reduce time away from clinical duties. Participants also noted that the lack of notice around the commencement of the CIP009 program and training days created scheduling conflicts with clinical commitments, increasing staff burden. As a result of limited communication, some participants felt they were being enrolled in the program as a result of poor performance and had negative reactions to being nominated by Divisional Directors and Heads of Departments. That quickly dissipated once they understood the purpose of the program and why their role was integral to the improvement project. Some felt the prescriptive nature of this process reduced their internal motivation, while others felt that such external support for the projects was motivating (Quote 34). Many participants felt that the rapid design and top-down selection of project problems by executive, rather than by each team impacted their engagement with the project initially, and limited opportunities for codesign with project team members. This resulted in some topics being seen as less valuable or meaningful to solve compared to others (Quote 35).
There was some scepticism noted about whether the CIP framework and 12 CIP009 projects would be able to impact patient flow and ramping in a significant way, with the sentiment that the CIP009 framework was useful for some projects, but not all (Quote 36). These participants highlighted that CIP was one of several methodologies being supported by the LHN working towards enhancing patient flow.
In terms of sustainability, several participants discussed how they had not yet set plans in place for ongoing monitoring and adjustment of their projects. This may be reflective of the stage the teams were at, still focused on problem clarification, solution generation and implementation at the time of interviews. There was, however, concern that projects would drop off the radar once Faculty coaching support was reduced, and competing priorities took over participants’ workloads, particularly for projects viewed as person dependent.
Table 3
Quotes representing the key strengths and challenges of CIP009
| | # | Quote and participant number (p) |
| Strengths | Theme 1: CIP framework and culture embedded in the psyche of the SALHN organisation |
| 1 | “That’s a really valuable thing for a clinical leader to be taken out of the environments [so] that they can just really focus on that.” (p31, CIP009 participant) |
| 2 | “One of the key, kind of, crucial, it was the culture piece as well, to say ‘Actually this is what’s happening in my piece of the world. But what’s happening over there in yours?’ And that has been probably one of the biggest things when I’ve gone to a lot of the process mapping etcetera, it’s just the team seeing an alternate view or alternate perspective of how that patient is managed.” (p6, executive) |
| 3 | “Meeting other people and you get to know a different group of people in the hospital who we may never cross paths with. So, I think that relationship stuff’s great.” (p19, CIP009 participant) |
| 4 | “We’ve had nine other CIPs where we’ve trained a lot of other people, like, I think in terms of the trust and the interest and the knowledge of the general workforce in terms of even just participating in mapping sessions, I do think that’s been a critical factor to the success of this one, in the sense of, you know, people trusting the process.” (p20, CIP009 coach) |
| 5 | “Lots of other people have bought into [CIP] culture over the years, and I think, we’re seeing the end product of multiple decades of that.” (p2, CIP009 participant) |
| 6 | “Everybody then knows the common language and it’s transferable into that building that culture of, you know, change management.” (p12, CIP009 participant) |
| 7 | “[We used] the CIP as a strategic plan to be able to look at involving clinicians at the patient-clinician interface to systematically fix ambulance ramping because we know that ambulance ramping is a symptom of delays across the entire quantum of care.” (p6, executive) |
| 8 | “Everybody jumped on board because we all had a common purpose, so that was fine. But I think the real strength of it is that you can, you know, yes, you may well be given an area, but you can really delve down what’s most important and really focus on that.” (p19, CIP009 participant) |
| 9 | “[The CIP faculty are] very good at, I think, challenging the way that some of the ED people think, and actually in reshaping that. But also, I guess empowering them to say what’s wrong and involving them in the process of improving it. Umm. So yeah, we love the CIP.” (p22, executive) |
| 10 | “I think the fact that the facilitators were able to relate past stories or past examples where the process had worked, it was really good. So, we knew that even if we were early on in the process and it wasn't, and it wasn't really clear what direction we were heading, we knew that we have people who were experienced in this, had gotten results and the process had worked for them. That was a key motivator throughout.” (p2, CIP009 participant) |
| Theme 2: The benefits of support from a dedicated, internal improvement faculty |
| 11 | “They're very experienced and they can see the wood for the trees, and I think that's really valuable.” (p23, executive) |
| 12 | “We have that capability that's in-house, we can network well with the process owners, and we can leverage that in a, in a very, very critical manner, comparative to other organisations. So, people who in in another situation, in comparison with other organisations, consultants would come from outside organisations like KPMG, EY, Deloitte, PwC. They would come, recommend and go, but they would not stay for the whole process. But I think we have from start to finish, end to end visibility, engagement.” (p16, CIP009 coach) |
| 13 | “We've got a lot riding on this, and the focus was patient flow and how we can actually make a difference with patient flow. And I think our reputations were on the line with this a little bit as well because we live and breathe this, and we I think every single one of us in this room 100% believes in the methodology. And we have a point to make now that this methodology can make a difference.” (p14, CIP009 coach). |
| 14 | “[Coach] was really good. Like, it's really nice to have someone who's so keen to drive, sort of, everything, but also be so positive as well. Actually, I never felt like I was being told what to do. Like, [coach] wasn’t condescending or anything. Like, the whole, like, CIP team in general have been really supportive, which has been, umm, I think encourages you to want to do more, like, quality improvement projects and, like, it sort of helped us prioritise quality improvement in, in along with our clinical load as well, if that makes sense. So, I think yeah, that would be the strength, would be definitely the facilitator.” (p21, CIP009 participant) |
| 15 | “I think the CIP team as a whole have been an amazing support for the ED this year, but they are very good at doing a wraparound support, I guess to take some of the smaller tasks away from us, you know, data collection. They’re very good at presenting the data analysis, and I think in trying to change the way that you think. I think as clinicians, we are good at jumping at problems and solutions very quickly. And I think, in slowing down that process, sometimes you really get the data you need to really understand the problem, which I think is really valuable.” (p22, executive) |
| 16 | “We know that our clinicians are doing this over and above their day jobs, yeah. And so, I think to actually have our support to know that the work could still progress without falling on their shoulders made a big, big difference.” (p5, CIP009 coach) |
| Theme 3: The advantages of an enthusiastic participant disposition and incentives |
| 17 | “A lot then go on to really become fierce advocates and do continue to do things because it becomes, they adopt this, this, as their way of doing business. And that really does assist in reaching a tipping point within the organisation of enough people to really do things at scale… one of the greatest things to initiate cultural change is to align people on an improvement journey.” (p17, executive) |
| Theme 4: Effective teams and team composition |
| 18 | “I think the strengths are the level of expertise of the people that are participating. The fact that it has support from the CEO here at [hospital], and you know high levels here at [hospital], it's definitely a priority that we're all interested in working towards, and people are very motivated to make change in that area. Especially people who have come on board from general medicine.” (p1, CIP009 participant) |
| | Theme 5: Workforce and Organisation-level challenges of improvements |
| 19 | “We've got, we've got a capability level that doesn't match what the CIP was trying to pull us to. [Our] NUM is absolutely stretched beyond capacity ... Does she have time to do this other extra thing? No. … So, if we set up our own CIP, we will set it at the level we need to set it at … we did feel a little bit like somehow this process was generating pressure and it was generating pressure in a way that wasn't always helpful.” (p29, CIP009 participant) |
| 20 | “So, I know there has been feedback in the past about, sort of, how slow some of these projects move. But I don't know how you could do that any differently in the environment that we're in. Yeah, because there’s such high staff turnover. People are on annual leave. People are on sick leave, like, it's just lots of moving parts.” (p30, CIP009 participant) |
| Challenges | 21 | “I think it has been hampered by workloads. Yeah, absolutely have, and it's sort of, it's, if you've got a bunch of people who are completely overloaded and barely hanging on by their fingernails, and then they have to go and do this other stuff on top, it really does wear people's goodwill right down, yeah. And so, I think there were moments where we were really hanging on by fingernails. … It's yet another stressor: we had accreditation; we had training, like the medical accreditation as well. This CIP has added significantly to the distress of people in this department.” (p29, CIP009 participant) |
| 22 | “I think it's been a significant workload, like around our clinical workload. It would have been nice to have some sanctioned time. We didn't get any sanctioned time.” (p1, CIP009 participant) |
| 23 | “My personal view is that [6 months] is too, too quick to, you know, and we did spread it to what it ended up being [many more] months. And I, my personal view is that, you know, at least a nine-month course would actually give that time… But I think that, you know, six months, like, with sick leave and people's annual leave, and you know, so it ends up not there in six months if people take some leave in between.” (p9, CIP009 coach)) |
| 24 | “We got told that we would get given datasets for this. And we waited so long, and we were losing so much time that in the end, like, I found some, like, work arounds to actually pull it manually. And it probably, it took hours and hours of my time, but at least I had something that I could then give the team to say, ‘What do you think?’. I know that it could have been done a lot more efficiently.” (p14, CIP009 coach) |
| 25 | “That's the other challenge is when we come up with some interventions and it's anything to do with EMR. It's a statewide EMR system. So, we need to make sure that every other LHN providing the same service actually want to invest in that as well. So, we'll put an improvement ticket in, but it takes years for anything to happen. So, that's probably another challenge and a barrier to implementation” (p8, CIP009 coach) |
| Theme 6: Team cohesion, logistics and stakeholder engagement challenges |
| 26 | “Initially in our, in our CIP, we did not have the emergency physicians. I mean, we are talking about [project topic] in emergency medicine and emergency department. And not having any representation from emergency was a bit hard. But even before we started the program, I approached the emergency medicine physicians who are keen to ma[ke] a patient journey through ED, quicker, easier, safer, providing them comprehensive assessment. So, the people who were keen, I already contacted them as well.” (p10, CIP009 participant) |
| 27 | “I think where we've lost capability build is we didn't have as many nurses, or we didn't have as many allied health, or other wrap around supports that would have been doing the course with them. But at the same time, I think what we did is we had a mindset change that this is the way we're going to approach problems within our units or Divisions. And this is also, ‘I'm then gonna provide the authority to release some of my junior staff to do in future’. So, I think, that was probably a good thing.” (p6, executive) |
| 28 | “I didn't know the team. Yeah, like, we were all strangers… When you don't have a personal relationship with someone in the team, you don't feel as accountable to them… If I'm working with my colleagues, they're my friends. Like, you don’t want to let them down… I think it was tricky trying to work with people that you've never worked with before.” (p30, CIP009 participant) |
| 29 | “But some of the barriers to that are, um, the teams that would be, um, overseeing those patients are quite resistant to change. They probably have quite a lot of change fatigue, and so when [our change initiative] was originally put through the senior consultants, they were like, ‘Absolutely not. No way’. So, there's potential that you may come up with an option for, you know, an alternative pathway and alternative location. But the barrier then may be, ‘No, we don't wanna change anything. Let's just leave it as it is’. So, it may be a very long-term solution that may take a lot of discussions and a lot of ongoing, and you know, mitigation strategies to say, ‘Oh, OK, the reason it would be a better option for patients is because we've engaged with consumers, and this is their feedback. This is a safety mechanism’.” (p7, CIP009 coach) |
| Theme 7: CIP009 Training and support shortcomings |
| 30 | “We had so many conflicting demands. And so, like, my phone was going constantly, you know, we had no cover. No one was covering our roles like so, taking three days off our normal jobs, it just meant that when we got back, we were swamped with so much work” (p12, CIP009 participant) |
| 31 | “I would say some of the material or lectures are redundant. And 3 1/2 days. Whether it's really that necessary to be that long is my main point and so personally, I mean, this is my opinion. I think it probably [could] be able to be condensed, the course into a maximum 1 1/2 days… even some of the lectures or guest lectures may not be all that necessary.” (p28, CIP009 participant) |
| 32 | “I think only a small amount of that time is dedicated to actually working on the actual problem. Like, you do little bits of it, but I wonder, if the teams, given they are actually together and the time’s already secured, would benefit from 1/2 day at the end or something to, um, really get the [project] kick started, going.” (p19, CIP009 participant). |
| 33 | “[I was] a bit unclear about what our task was. I probably would have wanted, maybe, more time with the coach. Because I know that the coaches had, like, multiple different teams. It would often be like set with the task and then you were sort of sitting down with strangers trying to complete a task you don't really understand. It would have been nice to have the coach there, sort of, driving that a little bit more so we had more of an understanding of what you're meant to be doing.” (p30, CIP009 participant) |
| 34 | “I rocked up at the course and I remember spending like the first two days, just being like, ‘What are these people talking about?... And there were lots of people, like I said, just thrown into it who didn't really want to do it…And I think the nature of the CIP009 was because we weren't a cohesive group that had come at it, like, chosen to, sort of, come at it together, I feel like that made it a lot harder. Like I've got colleagues who have done it before, and they've done it with their colleague with a really clear project in mind. So, you've got that, you've already got that buy-in. Like, they desperately want to be there, and they want to do it and they want to complete this project. That's why they signed up to it, whereas this was sort of thrust upon us a little bit more, so I feel like the coaches probably had to do more.” (p30, CIP009 participant) |
| 35 | “I must say, this year, because it was like, that focus on ramping and we got allocated our thing, it did, it wasn't the priority for me... I would have chosen a different priority.” (p29, CIP009 participant) |
| 36 | “I found, so that's why I think it was a little bit shallow, in that it was maybe asking for such a huge problem like ramping, you’ve gotta delve way deeper than the CIP course did…So, [CIP’s] really good for little problems, I think. Like, really good for some money saving, streamlining little problems that you would have on the wards or in outpatients or wherever.” (p24, CIP009 participant) |
The seven themes and subthemes representing determinants for CIP009 were deductively mapped against the five domains of the CFIR framework (Innovation, outer setting, inner setting, individual and implementation process)(31) (Table 4). Mapping these strengths and challenges against the theoretical framework reinforced how each subtheme was aligned with the different levels of determinants most likely to influence the implementation of CIP009 and the 12 CQI interventions. A large proportion of key strengths and challenges were mapped to the inner setting domain of the intervention relating to teams and culture.
Table 4
Strengths and challenges of CIP009 mapped against the CFIR domains (31).
| Themes | Subthemes of Key strengths and challenges associated with CIP009 implementation |
| Innovation domain Innovation Source, Evidence-Base, Relative Advantage, Adaptability, Trialability, Complexity, Design, Cost |
| Theme 1 CIP framework and culture embedded in the psyche of the organisation | • Strategic approach to capacity and capability building • Flexible and adaptive evidence-based program • Training strengths |
| Theme 2 The benefits of support from a dedicated, internal improvement Faculty | • An experienced internal faculty • Clinical directors and coaches embedded in divisions and within executive structures • Continuous wrap around support from knowledgeable and passionate coaches • Stable continuous support from an internal and well-resourced faculty |
| Theme 7 Training and support shortcomings | • Training shortcomings • Top-down and outcomes focus limiting codesign with staff • Scepticism related to complexity of issues |
| Outer setting domain Critical Incidents, Local Attitudes, Local Conditions, Partnerships & Connections, Policies & Laws, Financing, External Pressure |
| Theme 5 Workforce and organisation-level challenges of improvements | • Infrastructural and ICT challenges (medicolegal and governance approvals) • Data access and quality • Workforce capacity |
| Inner setting domain Structural Characteristics, Relational Connections, Communications, Culture, Tension for Change, Compatibility, Relative Priority, Incentive Systems, Mission Alignment, Available Resources, Access to Knowledge & Information |
| Theme 1 CIP framework and culture embedded in the psyche of the organisation | • Culture of flattened hierarchy • Accountability • Awareness of CIP and culture of enquiry Professional relationships, buy-in and engagement |
| Theme 2 The benefits of support from a dedicated, internal improvement Faculty | • Regular multimodal meetings with coaches and clear, respectful communication |
| Theme 3 The advantages of an enthusiastic participant disposition and incentives | • Shared vision of beneficence, and improving workflow and patient care end to end • Opportunities to collaborate across divisions and with consultants |
| Theme 4 Effective teams and team composition | • Team cohesion and collaboration • Multidisciplinary teams • Engagement with the right stakeholders • Senior team members as change agents • Balance of expertise and capacity to enact change |
| Theme 6 Team cohesion, logistics and stakeholder engagement challenges | • Team cohesion challenges • Team logistical challenges • Lack of stakeholder engagement and buy-in |
| Theme 7 Training and support shortcomings | • Communication issues |
| Individual domain – roles and characteristics High-level and Mid-level leaders, Opinion Leaders, Implementation (Impl) Facilitators, Impl Leads, Impl Team Members, Other Impl Support, Innovation Deliverers, Innovation Recipients, Need, Capability, Opportunity, Motivation |
| Theme 3 The advantages of an enthusiastic participant disposition and incentives | • Participant disposition, belief in the program and skill level • Enthusiasm to learn how to break down problems • Capacity to rearrange priorities to complete tasks • Vested interests to improve care and workflow • Gaining new perspectives on patient journeys • Professional incentives like CPD points and career progression |
| Theme 5 Workforce and organisation-level challenges of improvements | • Clinician workloads, competing priorities and time |
| Implementation process domain Teaming, Assessing Needs, Assessing Context, Planning, Tailoring Strategies, Engaging, Doing, Reflecting & Evaluating, Adapting |
| Theme 7 Training and support shortcomings | • Sustainability planning issues |
The key subthemes of the CIP009 were then collapsed into a more simplified structure of macro (hospital, outer setting), meso (teams, inner setting) and micro (individual) levels of the SALHN organisation, along with the key elements of the CIP009 program such as training and wraparound support from the Faculty. The fundamental elements of the CIP009 that were perceived to contribute to the implementation of CIP009 and its organisation-wide goal of improved patient flow and reduced ramping can be visualised in Fig. 2.