Eighty key dimensions were identified in the matrices developed in QSR International’s NVivo Pro version 11 software (NVivo) (see Additional file 1: Table S3), these were allocated into five categories: national health policy, regional and municipal policy and conditions, inter-organizational implementation projects (including five sub categories), experienced outcome, and professional skill and personal characteristics. These main categories were allocated into three higher order classifications: macro, meso and micro levels. The classifications, categories and sub-categories are presented in Fig. 1.
The category inter-organizational implementation projects at meso level was considered a core category where the subcategories describe a variety of factors affecting the actual implementation process. As the respondents act on the meso level, the data are more detailed in this level. First the macro and micro levels will be presented with barriers and facilitators affecting the internal processes and measures taken in the meso level.
Macro level
National health policy
The Norwegian healthcare system influenced the implementation of mobile radiography services in different ways, both as a barrier and a facilitator. Financial barriers and facilitators were most prominent. Managers experienced that the reimbursement system for specialized healthcare services was made for services provided in hospitals. The fee-for-service reimbursement for an x-ray examination was identical whether the service was provided in a hospital or in a nursing home. This was considered unfair by both hospital and municipal managers, because the resources used by the x-ray department were significantly higher per examination with the mobile service. Thus, the activity-based part of the funding was a barrier for mobile services. One hospital administrator said:
“The reimbursement system was not made for mobile services… It was made for an old-fashioned system in which things happen within four walls, such as in hospitals”.
The participants considered that the Coordination Reform facilitated mobile services by defining the principles for cooperation between hospitals and municipalities through contracts. In addition, the Reform allocated funding for projects. This funding facilitated projects. However, when this funding was no longer available, the participants experienced this as a barrier for new mobile radiography services. One municipal administrator said:
“The funding facilitated it [mobile radiography services]”.
Regional and municipal policy and conditions
Several barriers were identified at the regional and municipal levels. One barrier identified was organizational changes. In large reorganizations there was no time or money for innovation. In addition, both financial and structural barriers were identified. Mobile radiography represented a new way of cooperation and coordination across healthcare levels. Mobile radiography services are not part of ordinary primary care, and general radiography services are not usually mobile. Thus, municipalities or hospitals are not legally obligated to provide these services. This makes a mobile radiography service a different kind of healthcare service, and a new way of organizing and financing services. Thus, in municipalities, support from local politicians was important for money to be allocated in the budget. The process of gaining political support was time consuming and acted as a barrier. One nursing home manager said:
“This must also be supported at the chief municipal executive level. And when councilors change jobs or when new municipal councils come into power and so on, there is a risk that these kind of projects disappear, because they have such weird financing”.
Micro level
Experienced outcome
Most staff and managers had a positive attitude towards mobile radiography services. Participants said that a few physicians in nursing homes were sceptical to mobile radiography services because they considered that a clinical diagnosis was sufficient for these residents. So they regarded imaging tests as unnecessary. Most participants experienced that staff and managers considered imaging tests to be an important diagnostic tool for nursing home physicians, and that avoiding transfer to hospital was important for the residents. Mobile radiography was considered to increase the quality of the service for residents and family members. Also, the general quality of care in the nursing home was considered to be improved, because personnel did not need to spend time arranging for volunteers or family members to accompany residents to hospital for an x-ray, or to accompany residents themselves. One nursing home manager said:
“So here we are working with placing the patient in the centre, and thinking holistically about the patient. And this [mobile radiography] is very patient friendly. And I think that’s an important argument … It [mobile radiography] saves us a lot of frustration in relation to transportation, waiting for an ambulance, and finding someone to accompany the patient. It is much easier when we can just call and they say we’re coming rather than using family members or the volunteer centre”.
Professional skills and personal characteristics
The participants experienced that key personnel initiated, motivated or facilitated the service. These projects were mostly initiated by one person within the hospital or municipality. Without these enthusiasts the service may not have been implemented. One municipal manager said:
“We had a doctor who was enthusiastic, an elderly physician at the time, who was really into this [mobile radiography] …, she was very motivated and tried to persuade me to say that we had to have this”.
In the implementation process, the radiographers running the services had an important role in marketing and establishing good relations with the nursing home staff. One nursing home manager said:
“Those who come here are very nice, very helpful and very welcoming. It mean a lot that those who provide the treatment [mobile radiography] also think that this is a great service”.
Meso level
Collaborative implementation projects
The mobile radiography service needed to be defined and set up in cooperation between the hospital and the surrounding municipalities. This presented both administrative and practical challenges such as referral routines, communication, parking and adapting the vehicle. All areas established implementation projects led by the hospital, with managers from both the hospital and the collaborating municipalities. These projects involved deciding about purchases, organizing the service, marketing, and evaluating the service. One municipal administrator said:
“When the decision was made, when we decided, yes we will have a project, and we have the money, then we had to ensure that all the structures were in place first. So we established a project with a steering committee and project group”.
Economic aspects
Because the idea to implement mobile radiography services mostly came from one enthusiast, getting support from the top management in all the organizations was the greatest challenge. This support was necessary in order for money to be allocated in the budget in the organizations. One municipal administrator said:
“Perhaps the challenge with this kind of project was that it came from an enthusiast. It lacked anchorage in top management. It was a good project and it was nice to talk about it. But the lack of anchorage in top management made the funding a challenge”.
Because of the financial barriers at the macro level, most managers in hospitals and x-ray departments were not willing to invest in equipment, a vehicle and staff for the mobile service. The risk was considered high, because this was a new type of service that there was limited knowledge about and little experience of its use and efficiency. To overcome the financial barriers most of the projects applied for external funding and used contracts between the hospital and municipalities, as recommended by the Coordination Reform. This provided financial security and divided the costs between all the parties. The most common financial model used was one where the hospital covered 50% of the costs and the participating municipalities covered the other half of the costs. The division among the municipalities was usually calculated based on the number of inhabitants in the municipality. One hospital administrator said:
“For the part that was not externally funded, we agreed on a 50-50 economic model. The municipality covered half of the costs and the hospital trust covered the other half… This was really important for the hospital trust”.
However, developing and agreeing on contracts took a lot of resources and slowed down the implementation. In one area, the bureaucratic process of contracts was the main reason for not involving the municipalities financially. The manager from the x-ray department in this area said:
“If we had contracts with several municipalities, the contracts would need to be revised and kept up to date. We were not actually talking about much money, so the disadvantages of the bureaucracy outweighed the benefits”.
Collaborative culture
The participants from the municipalities experienced the x-ray department managers as respectful and grateful. All project members were highly committed and engaged in the project. Participants described a good collaborative culture within the project groups. They all wanted to increase the quality of the services for residents. Thus, they kept working despite the barriers. One nursing home manager said:
“You must have enthusiasm all the way, if not you will fail”.
In the area where the hospital covered all costs, cooperation was also important, not in order to gain support from the management in the municipalities, but to understand the needs of the nursing homes. The x-ray department manager in this area said:
“It was very important to involve them [the nursing home staff]. They could point out their needs and the importance of having x-ray as a diagnostic tool in the nursing home. I think that was very important”.
Planning an efficient service
Another important aspect in the implementation project was to tailor the service to the local demographics to ensure efficiency. Travel distances and traffic in the area were considered when planning the services. The population size needed for the service to be cost-effective was perceived differently in the different areas. In one area, two municipalities with just over 130,000 inhabitants was considered sufficient. However in another area, more than 300,000 inhabitants was considered to be necessary for the project to be cost-effective. However, all participants agreed that the service needed to be in an urban area. One hospital administrator said:
“This is a typical example of mobile services being cost-effective in densely populated areas, quite the opposite of what people think”.
To keep the service running all year with an appropriate response time, a group of radiographers rotating within the service was needed (2–7 in these projects). Keeping the service up and running was important for the quality and reputation of the service. If the services failed to arrive on time, the nursing homes would send residents to a hospital instead. In all areas the service was available on weekdays, daytime only. It was considered important that the examinations were done within the next day, because most examinations were semi-acute. One x-ray department manager said:
“We’ve said that these are semi-acute examinations. Our aim is to carry out the examination within the course of the next day, but it is not guaranteed, it’s one of those semi-acute services”.
To initiate the required treatment, the radiologists were required to report the examination on the same day and call the nursing home if there were any findings that required immediate action. If the nursing home physician was present when the examination was carried out, the images could be viewed on site as well. In addition, the radiographers communicated with the physician directly, or a radiologist by phone, if they suspected critical findings (e.g. fractures) in the images during the examination. One municipal administrator said:
“Yes, if you are at the bedside you get to see the image and that’s ok… we need the results quickly, we get the results mostly the same day. She [the radiographer] looks at the images there and then as well, and lets us know if there is anything special”.
It was planned to send referrals and reports electronically between the nursing homes and the hospitals. In addition, wireless transfer of images from the mobile unit to the hospital was planned in order to reduce reporting time. However, none of the projects had come so far. They experienced a combination of legal and procedural barriers for wireless image transfer. To avoid these barrier they used paper-based referrals and reports. In addition, they sat up connections for image transfer at places that were easily accessible outdoors in different hospitals, to transfer images via memory stick or cable. One x-ray department manager said:
“Transfer of images was also a challenge in other projects. We have not yet come so far either. So we are still working on this, and we have the money, but we haven’t got the solution up and running yet… Now we use a memory stick”.
Developing routines and procedures together
The participants described collaboration in development of a new service, routines and clinical procedures as important. In one area, routines were not discussed with the nursing home physicians prior to piloting the service. This made the implementation a bit chaotic. There were misunderstandings about referral routines and what types of examination it was possible to do in the nursing home. In the other areas, the target population and what types of x-ray examination to offer were discussed in the implementation projects. In addition, what kind of assistance the radiographers needed at the nursing home, and routines for referral, bookings and communication, were discussed. One x-ray department manager said:
“They [nursing home physicians and nurses] were involved in defining the service and talked about their needs in relation to the type of examinations they envisioned, how cooperation with the radiographer should be in the nursing home and with our radiologists here in relation to the results when we did not have wireless image transfer”.
Piloting and evaluating the service
After the period of planning and getting the equipment and a vehicle in place, the projects started a pilot where just a few nursing homes or municipalities were included. This made it possible to test equipment, to evaluate the facilities in the nursing homes, and for the radiographers to learn how to plan the day efficiently and gain experience in working alone in a mobile service. The x-ray equipment needed to fit safely in the vehicle, and the vehicle needed to be maintained. Further, the x-ray equipment needed to be designed for transportation into and within the nursing home. In addition, there was a need for sufficient power supply in close proximity to the residents’ rooms. One nursing home manager said:
“So there was talk of testing to be able to deploy this [mobile radiography services] in a sensible way. We tested it in two municipalities first”.
The pilot was also used for marketing. It was vital to make the service known to the nurses, physicians and managers, and to build networks. It was important to give information to the physicians who were the referrers and the nurses who were the ones who would contact the physician for a medical examination. Otherwise, no-one would use the service. One radiographer was responsible for visiting all the nursing homes to present the service and the new routines. In addition, the service was publicized in the newspapers. One x-ray department manager said:
“We thought that it was important to have one designated person in the service who would drive around and establish contact with the nursing homes. It was important to have continuous dialogue, to get them to use us [the mobile radiography service]”.
The participants experienced evaluation during the pilot as important. The projects used feedback and surveys from physicians, nursing home staff and radiographers in their evaluation. In addition, statistics were discussed in the project meetings as a management tool. This would help to increase the use of the service and improve the quality. One x-ray municipal administrator said:
“We received regular reports from the project manager, showing how much the service was used. This was a good parameter for asking questions in our own organization: Why are we not using mobile radiography? And we could compare ourselves with others. This has been a good tool”.
In summary, the barriers at the macro level were identified as the national reimbursement system, and large organizational changes. At the meso level, the main barriers identified were gaining support from the top management to get resources for the project with the process of making contracts, lack of management across healthcare levels, lack of electronic communication and wireless image transfer. In order to overcome these barriers, the implementation projects used different measures such as external funding and contracts, piloting, collaboration and manual communication procedures.