PGF dimensionsab | Category | Description | Concepts |
---|---|---|---|
WHY context | Intrinsic motivations | Personal beliefs of health care practitioners that leads to the implementation | Uniformity problem |
I. Stimuli for implementing cardiac risk scores | Educational support | ||
Research purposes | |||
Extrinsic motivations | Environmental and organizational pressure that leads to the implementation | (Inter) national guideline recommendations | |
Governmental pressure and regulatory demands: quality improvement program, recommendations of Dutch association of cardiology, audits of health care inspectorate | |||
Pressure hospital board | |||
Assessments by health care insurance companies | |||
HOW process | Implementation strategies | Interventions used to enhance or support the implementation process | Support and commitment staff |
II. Process of implementing cardiac risk scores | Clinical reminders: posters (passive), written and oral reminders (active) | ||
Data feedback | |||
Education: practical and theoretical | |||
Development project plan | |||
Appointment working committee | |||
Facilitators and barriers | Influential factors enhancing or hindering the implementation process | Facilitating factors | |
Innovation level: clinical relevance | |||
Practitioner level: commitment staff | |||
Organization level: management support, IT support | |||
Barriers | |||
Innovation level: administrative burden, complexity of underlying algorithm of risk score, loss of time | |||
Practitioner level: level of work experience, familiarization with new practices, lack of knowledge, lack of relevance | |||
Organization level: frequent staff rotation, high work load, lack of time, lack of management priority, lack of resources, fast update of guidelines, unexpected circumstances | |||
Sustainability | Interventions undertaken to sustain change in practices | Redesigning systems: integration of risk score(s) in existing electronic hospital systems, protocols or clinical pathways | |
Audit and feedback | |||
Appointment of champions | |||
WHAT content | Choice of risk score | Motivation for implementing cardiac risk score and its use in practice | Choice of risk score based on: purpose, availability relevant parameters, complexity, validity and available scientific evidence, recommendations of clinical guidelines, accordance own practices |
III. Perceptions of health care practitioners | |||
Use in practice: type of risk score (GRACE, TIMI, FRISC or HEART), intended users (interns, residents, less often cardiologist, nurse specialists), target group (patients with chest pain, unstable angina, non-ST-elevation myocardial infarction or acute coronary syndrome), location (emergency department, chest pain unit, coronary care unit) | |||
Unintended benefits and risks | Implementation effects in terms of benefits and risks for quality and safety of care | Expected benefits: improved uniformity, educational support, scientific benefits | |
Unintended benefits: support system, enhanced patient safety | |||
Risks: regulatory medicine | |||
Impact on treatment policies | Impact on physician’s decision-making process in terms of admission and treatment policies | Treatment policy: no consequence, conservative treatments (pharmacological), invasive treatments (cardiac catheterization or revascularization) | |
Admission policy: admission protocol, patient allocation, patient flow | |||
Effects on process of care | Effectiveness of cardiac risk score implementation | Current practice and variation in practice |