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Table 2 Themes, categories and concepts

From: Understanding factors that influence the use of risk scoring instruments in the management of patients with unstable angina or non-ST-elevation myocardial infarction in the Netherlands: a qualitative study of health care practitioners’ perceptions

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

  1. aPettigrew & Whipp framework. bThe provided information cuts across more than one dimension.