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Table 1 Table of included studies

From: The barriers and facilitators influencing the sustainability of hospital-based interventions: a systematic review

Study
1. First author
2. Year (ref)
3. Design
4. Country
Aim
1. Aim
2. Focus
Study population and setting
1. Participants
2. Setting
Framework
1. Name
2. Category of implementation theory, model and framework
3. Theoretical visibility
1. Ament
2. 2017 [31]
3. QS
4. Netherlands
1. To explore key factors of the sustainability of two multidisciplinary hospital-based surgical care programs (ERAS and SSP).
2. Sustainability
1. MDT members (n = 26) incl. Surgeons, NP and nurses, 14 hospitals; 10/14 for ERAS, 4/14 for SSP
2. Surgical care
1. CFIR
2. Determinant framework
3. Level 5
1. Belizan
2. 2011 [32]
3. QS
4. South Africa
1. To understand the processes involved in initiating and implementing an audit programme, as well as factors contributing to the sustainability of the programme.
2. Implementation
1. Clinicians, regional and provincial coordinators, and other experienced stakeholders (n = 48)
2. Public hospitals
1. Stage-of-change conceptual framework
2. Classic theory
3. Level 5
1. Bergh [33]
2. 2014
3. MMS
4. South Africa
1. To systematically evaluate implementation status of facility-based kangaroo mother care services in four African countries
2. Non-sustainability
1. Key stakeholders incl. Government, program developers and coordinators, regulatory bodies, professional associa- tions, training and research institutions, health facilities, United Nations and other funding agencies, and non- governmental organizations involved in the improvement of newborn care or the implementation of KMC (n = 11–13/ country). Health facilities (n = 39; 3 teaching, 4 regional, 23 districts, 4 non profit, 1 rural, 4 health centres)
2. Health facilities in Malawi, Mali, Rwanda and Uganda
1. Implementation framework (6 stages)
2. Evaluation framework
3. Level 5
1. Bernstein
2. 2009 [34]
3. MMS
4. USA
1. Reports the dissemination and evaluation of SBIRT on systems of care in EDs using RE-AIM framework
2. Implementation
1. 24 participants incl. HPAs and their supervisors, clinicians, nurse managers, and ED directors
2. Five ED
1. Knowledge translation framework (RE-AIM)
2. Evaluation framework
3. Level 5
1. Bhanbhro
2. 2016 [35]
3. QS
4. UK
1. To explore the factors associated with variation between ‘units’ in sustaining the intended recovery-oriented practice during the recovery-focused staff training intervention (GetREAL)
2. Non-sustainability
1. Team on unit incl. Psychiatrist, psychologist and OT. Some exec management (ward manager, senior service manager, unit manager) attended ward training. Management support measured. Reaction of service users to intervention also reported. Three units: 2 hospital and 1 community, no. beds range: 15–31
2. Mental health rehabilitation units
1. CMO
2. Evaluation framework
3. Level 5
1. Bouamrane and Mair
2. 2014 [36]
3. QS
4. Scotland
1. To analyse the perspectives of key stakeholders involved in the rationalisation of surgical pre-assessment clinics (PACs) in NHS GGC and the integrated care pathway (ICP) design, development and implementation; identifying the complex sociotechnical factors that have influenced the successful adoption of the electronic preoperative ICP across NHS GGC in order to inform future implementations in this sphere
2. Implementation
1. 3 main stakeholder interviews: eForm 1: a member of the NHS GGC electronic patient record programme (EPR) eForm team involved in the development of design requirements and technical specifications for the preoperative ICP, −Anaesthetist 1: a consultant anaesthetist involved in the consensus process which led to development of the structured clinical content of the preoperative ICP, including the selection of guidelines underpinning the context dependant, adaptive behaviour of the eForm. -POA nurse 1: a senior nurse involved in the PCIP review of the NHS GGC PACs and the dissemination of information relating to the programme implementation across the health-board. In addition, the nurse was involved in the eForm user-testing, reporting user requirements and change requests to the eForm development team. 1 case study interviewing the service lead nurse and 3 nurses working in the clinic.
2. Acute Care hospital, pre-op clinics.
1. NPT
2. Implementation theory
3. Level 5
1. Brady
2. 2014 [37]
3. QI
4. USA
1. To increase the proportion of patients with acute haematogenous osteomyelitis admitted to the hospital medicine service who were discharged on oral antibiotics within 120 days.
2. Implementation
1. 12 hospital medicine faculty and 53 residents and medical students. Education targeted at medical faculty, residents, students. Wider aim was to increase rapid adoption of evidence-based decision making, and value in general paediatrics as a model of spread across city’s health care system and beyond.
2. Academic Children’s hospital
1. List of key drivers
(i) Knowledge and implementation of evidence for osteomyeltis treatment (ii) Local expert opinion and treatment (iii) Understanding among hospital medical team which patients need consults (iv) Physician ordering system and decision support for evidence-based care (v) Engagement of family and patient in shared decision making (vi) Physician feedback on performance and outcomes (identify and mitigate) (vii) Engagement of community physicians
2. Process model
3. Level 5
1. Bridges
2. 2017 [38]
3. QS
4. England
1. To more thoroughly investigate the process of implementing an intervention aimed at supporting the delivery of compassionate care by hospital teams; to identify and explain the extent to which CLECC was implemented into existing work practices and to identify how CLECC can be optimised to support sustained compassionate care delivery in acute settings.
2. Sustainability
1. Wards: older people (3), trauma and orthopaedics (1). Participants: 25- ward managers (4), deputy ward managers (2), staff nurses (8), healthcare assistants (7), senior hospital nurses (2), PDNs (2)
2. Four inpatient wards in 2 general hospitals
1. NPT
2. Implementation theory
3. Level 5
1. Campbell
2. 2011 [39]
3. QS
4. Canada
1. To understand how hospitals using the Ottawa Model for Smoking Cessation (OMSC) addressed sustainability, and determine if there were critical factors that should be addressed before expansion across Canada.
2. Sustainability
1. Six hospitals. One decision maker and one smoking cessation coordinator at hospital with 2 exceptions (1 DM at one hopsital and 2 DMs at one hospital). DMs held senior administrative roles such as director, clinical manager, chief nursing officer. SCCs were 4 unit nurses, 1 program manager and 1 dedicated SCC. Not all of these were involved in the initial program implementation.
2. Three general inpatient unit and 3 special care units
1. OMSC
2. Determinant framework
3. Level 5
1. Fleiszer
2. 2015 [40]
3. QS
4. Canada
1. How a nurse best practice guidelines (BPG) program was sustained over a long period of time in an acute healthcare centre: 1. How was program sustainability characterised? 2. What factors influenced sustainability? 3. How was the program sustained?
2. Sustainability
1. 14 organisational key informants (all registered nurses). 350 documents. 40 observations and exchanges. Nursing department level of the organisation. Acute academic health centre incorporating 6 hospital sites. Best practice guidelines (BPG) examined from executive level to front line level of the acute health centre.
2. Nursing department of an acute health centre
1. Developed their own conceptual framework proposing 3 charactieristics of sustainability (i.e. benefits, institutionalization and develoment) influences from 4 chacategories of factors (i.e. innovation, context, leadership and process) and relationships between characteristics and factors.
2. Determinant framework
3. Level 5
1. Fleiszer
2. 2016 [41]
3. QS
4. Canada
To understand how a nursing program was sustained over a long-term period in an acute healthcare center. 1. How was program sustainability characterized; 2. What were the factors that most influenced program sustainability; and 3. How was the program sustained over the long-term?
2. Sustainability
1. 4 inpatient nursing units. 25 interview participants. Sustainability examined at nursing department level of the health centre and then across 4 unit subcases. Looked at organizational/unit contexts
2. Hospital (a large tertiary/ quaternary urban academic health centre) As described in Fleiszer 2015.
1. Developed their own framework (as described in Fleizer 2015 paper)
2. Determinant framework
3. Level 5
1. Frykman
2. 2017 [42]
3. QS
4. Sweden
1. The aim of this study was to uncover the mechanisms influencing the sustainability of behavior changes following the implementation of teamwork at an ED
2. Sustainability
1. Participants for interviews: 2 physicians, 2 RNs, and 2 LPNs.
2.Emergency Department, Internal medicine at a university hospital
1. Integrated theoretical framework DCOM® Johnson et al. 2008 i
2. Implementation theory
3. Level 5
i. Johnson J, Dakens L, Edwards P, Morse N. SwitchPoints: Culture Change on the Fast Track to Business Success. John Wiley & Sons, Hoboken, NJ.
1. Glasgow
2. 2013 [43]
3. MMS
4. USA
To examine how a collection of survey measures of hospital characteristics related to QI success during a QI collaborative
2. Implementation
1. 100 hospitals. Survey 1: n = 130 participants, survey 2: n = 160 participants
2. Veterans hospitals providing inpatient care
1. General systems engineering model
2. Determinant framework
3. Level 5
1. Gould
2. 2016 [44]
3. QS
4. Wales
1. To explore the meaning of IPC ownership to health workers, and to evaluate the impact of an action plan to encourage IPC and IPC ownership throughout a National Health Service (NHS) health board in Wales, UK.
2. Implementation
1. 20 participants (7 doctors, 8 nurses, 3 general managers, 1 cleaner) and individuals involved in infection prevention and control
2. Acute care in four hospitals
1. NPT
2. Implementation theory
3. Level 4
1. Gramlich
2. 2017 [45]
3. QS
4. Canada
1. What are the barriers and enablers to ERAS implementation within a health system?
2. Implementation
1. 15 patients, 56 nurses, 13 clinical nurse educators, 1 unit clerk, 2 patient safety officers, 16 surgeons, 12 anaesthetists, 6 dietitians, 31 unit managers, 1 occupational therapist, 1 physiotherapist, 1 enterostomal therapist, 33 AHS (Alberta Health Services) managers, 6 site coordinators, 3 internal medicine doctors, 5 knowledge consultants, 3 pharmacists
2. Surgery units in 6 hospitals in the Alberta Health Services
1. TDF and QUERI
2. Determinant framework
3. Level 5
1. Green
2. 2017 [46]
3. QS
4. England
1. To identify factors that supported the successful implementation of two care bundles in the acute medical setting that used quality improvement methods.
2. Implementation
1. Data sources: progress review meetings and review reports and audio recordings of the review meetings
2.Acute medical unit/ward in 2 hospitals
1. CFIR
2. Determinant framework
3. Level 3
1. Hommel
2. 2017 [47]
3. QS
4. Sweden
1. To explore successful factors to prevent PUs in hospital settings.
2. Implementation
1. Six hospitals, 39 persons (managers, physicians, registered nurses, enrolled nurses with different kind of responsibilities)
2. Hospitals
1. PARIHS and Hsieh and Shannon (2005)i
2. Determinant framework
3. Level 3
i.Hsieh HF & Shannon SE. Three approaches to qualitative content analysis. 2005. Qualitative Health Research, 15, 1277–1287.
1. Hovlid
2. 2012 [48]
3. QS
4. Norway
1. Not explicitly stated but to explore factors contributing to sustained improvement
2. Sustainability
1. 20 (9 physicians, 7 nurses, 2 secretaries, 2 administrators)
2. Surgical departments (ophthalmology, general surgery, gynaecology, orthopaedics, ENT) at a District General Hospital
1. ELO
2. Process model
3. Level 3
1. Ilott
2. 2016 [49]
3. QS
4.England
1. To understand the processes, mechanism and outcomes associated with the spread and sustainability of a safety initiative
2. Sustainability
1. 7 wards (5 in hospitals, 2 in community). 22 front-line staff, 12 trainers.
2.see (3)
3.Data collected at the organisational and clinical level. There were senior managers with an organisation-wide remit. These are referred to as Education Strategic Leads (ESL) and Professional Strategic Leads (PSL). On the care pathways, there were Clinical Leads (CL), Education Leads (EL) and Trainers (T) who completed the train-the-trainer course.
4. Hospitals and community
1. Frameworks for spread and sustainability
2. Determinant framework
3. Level 5
1. Jangland and Gunningberg
2. 2017 [50]
3. MMS
4. Sweden
1. To conduct an evaluation of an implementation project on patient participation, using two specific research questions: How did the patients report their perception of quality of care, with a specific focus on patient participation after the implementation project? How did the nurse managers describe patient participation and their learning experience from the implementation project in the unit?
2. Non-sustainability
198 patients; The patients’ mean age was 61.6 years (range 23–92, SD 15.4), the gender distribution was even and the majority stayed in the surgical care unit between 2 and 6 days. 5 nurse managers (41 to 48 years of age (mean 45 years) and had held their position in their unit from 2 to 16 years (mean 6 years). They were all RNs (1–10 years’ experience; mean 8.5 years).
2. Surgical department in a large hospital
1. PARIHS
2. Determinant framework
3. Level 5
1. Matthew-Maich
2. 2013 [51]
3. QS
4. Canada
(1) What processes are involved in the implementation and uptake of the RNAO Breastfeeding BPG in three acute care hospitals? (2) What is the impact of
the BPG implementation and uptake for clients, nurses, other professionals, units, organizations and the broader system?
2. Sustainability
1. maternal-child units in three diverse acute care hospitals. 112 participants (54 mothers and 58 health professionals). 58 health professionals - 32 staff nurses, administrators and managers (7), lactation consultants (5), educators (5), physicians (3), midwives (3) and public health nurses (3).
2. Acute care hospital sites
1. SUNG
2. Implementation theory
3. Level 5
1. Mazzocato
2. 2012 [52]
3. MMS
4. Sweden
1. The objectives of the quantitative component were to track operational performance changes over time and to compare performance before and after the lean intervention. The objectives of the qualitative component were both to describe the lean intervention and to provide data to help us explain how the intervention worked based on four theoretical lean principles.
2. Implementation
1. n = 13 (1 resident, 3 senior physicians, 3 nurses, 1 coach, the director of the pediatric division, 2 first line managers, 2 administrative staff members)
2.Paediatric A&E at a hospital
4. Theoretical LEAN principles, empirically (derived by Spear and Boweni). According to these principles, LEAN (a) standardizes work and reduces ambiguity (b) connect people who are dependent on one another (c) creates seamless, uninterrupted flow of work through the process and (d) empowers staff to investigate process problems and to develop, test and implement countermeasures using a “scientific method”.
2. Determinant framework
3. Level 5
i.Spear S, Bowen HK. Decoding the DNA of the Toyota Production System. Harvard Business Review 1999, 77 (5):96–106.
1. McClung
2. 2017 [53]
3. QS
4.USA
1. To examine health care worker motivation for reducing HAI
2. Implementation
1. 10 respondents (6 physicians, 2 nurses, 1 nursing assistant, and 1 manager of environmental services, and the respondents came from a variety of departments, including internal medicine, critical care, hematology oncology, general surgery, and orthopedic surgery. Three physicians held administrative roles, including 2 within quality improvement efforts in the hospital. Two physicians held HAI champion roles, including surgical site infection, CAUTI, and CLABSI, whereas 1 physician with an administrative role also held a champion role. The nursing personnel, including the nursing assistant, also held similar champion roles in CDI and CAUTI).
2. Large academic research institution with 592 staffed beds and a level 1 trauma centre
1. CFIR
2. Implementation theory
3. Level 5
1. Mitchell
2. 2017 [54]
3. QS
4. USA
1. characterizes contextual factors influencing their decision-making process and motivations behind adaptations of the RED protocol and the impact of context and adaptations on implementation and sustainment of RED in these settings
2. Sustainability
1. 5 hospitals (suburban/urban, 2 suburban, 2 urban). 64 participants (11 senior leadership/executive, 22 clinical implementation team, 19 non-clinical implementation team, 9 non-RED staff, 3 community based partners)
2. Hospitals
1. Conceptual model of contextual factors
2. Determinant framework
3. Level 5
1.Naldemirci
2. 2017 [55]
3. QS
4.Sweden
1. To explore the deliberate and emergent strategies of key stakeholders to specific contextual challenges encountered when implementing the GPCC framework
2. Sustainability
1. 18 researchers, 17 healthcare practitioners (5 registered nurses, 4 assistant nurses, 4 ward managers, 4 physicians). Patients (20) who had recently been hospitalised.
2.Hospital wards
1. Mintzberg & Water’s taxonomy of types of strategiesi and NPT
2. Implementation theory
3. Level 3
i. Minzberg H, Walter, J. Of Strategies, Deliberate and Emergent. Strateg Manag J. 1985;6 (3):257–72.
1. Nordmark
2. 2016 [56]
3. QS
4. Sweden
1. The aim of this study was to explore the embedding and integration of the DPP from the perspective of registered nurses (RNs), district nurses (DNs) and homecare organizers (HCOs).
2. Implementation
1. Five hospital wards with the highest frequency of DPs were identified: geriatric/palliative, infection, surgical, orthopaedic and pulmonary medicine/ endocrinology- gastrology.12 Registered Nurses
2. Hospital wards
1. NPT
2. Implementation theory
3. Level 5
1. Parand
2. 2012 [57]
3. QS
4.UK
1. Offering strategies that are reported to promote sustainability of an organizational safety improvement programme: the UK Safer Patients Initiative (SPI)
2. Implementation
1. 34 coordinators of the Safer Patients Initiative Programme: 20 interviews at the end of the programme and 14 a year later. Focus on sustainability of intervention across the organisation
2. UK NHS Hospitals
1. Model for Improvement plus PDSA cycles
2. Process model
3. Level 5
1. Robert
2. 2011 [58]
3. MMS
4. England
1. To explore the local adoption, implementation and assimilation of an innovation into routine nursing practice by applying an evidence-based diffusion of innovations framework to a national quality improvement programme
2. Implementation
1. Survey: 150 responses, 56 project leaders/facilitators, 19 manager of the PW, 14 working in the PW most of the time, 70 either a ward manager/ sister/ charge nurse, staff nurse or matron. Case studies: 58
2. Acute hospitals
1. Adapted the model produced by Greenhalgh et al. (2005)i
2. Classic theory
3. Level 5
i. Greenhalgh T, Robert G, Bate SP, Macfarlane F & Kyriakidou O (2005) Diffusion of Innovations in Health Service Organisations. Blackwell, Oxford.
1. Rotteau
2. 2015 [59]
3. QS
4. Canada
1. To describe the hospital-based implementation teams’ experiences during program implementation, and the team’s perceptions of the key factors that influenced the program’s success or failure.
2. Implementation
1. 10 hospitals (6 with greatest improvement and 4 with least improvement), 52 participants (10 executive sponsors, 19 physician leads, 23 team leads)
2. Emergency Departments in hospitals with greatest (3 hospitals) and least (2 hospitals) improvement in wait times.
1. LEAN
2. Determinant framework
3. Level 2
1. Sanchez
2. 2014 [60]
3. QS
4. USA
1. To perform a qualitative examination of the medication reconciliation planning process in two healthcare organizations
2. Implementation
1. 13 interview respondents: 12 participating directly in the medication reconciliation planning process and one became involved after implementation was underway. Respondent roles: quality improvement (4), information technology (4), medication safety (3), and education (2). They had on average 5.9 (SD = 3.7) years of experience in their current position and all except one were present in their current position at the time the medication reconciliation implementation process had taken place. By professional training, there were four physicians, four nurses, four pharmacists, and one information technologist.
2. Large urban academic tertiary care center and an affiliated Veterans Affairs (VA) hospital in New York City
1. CFIR
2. Determinant framework
3. Level 4
1. Stacey
2. 2015 [61]
3. MMS
4.Canada
1. To evaluate a sustainable approach for implementing the lung transplant referral patient decision aid into clinical practice in adult cystic fibrosis (CF) clinics
2. Sustainability
1. 31 healthcare professionals (18 nurses, 12 physicians, 1 pharmacist)
2.Adult CF clinics within 8 different provincial healthcare systems in Canada (n = 18)
1. Knowledge-to-Action Framework
2. Process model
3. Level 5
1. White
2. 2011 [62]
3. QI
4. USA
1. To develop and implement a sustained medication reconciliation process to improve patient safety and compliance with Safety Goal 8.
2. Implementation
1. NA – obtained from weekly reports which merged admitting and registration information from the primary electronic medical record with data from the electronic medication reconciliation application.
2. Large urban paediatric academic medical centre
1. Model for improvement
2. Process model
3. Level 5
  1. Category of implementation theory, model and framework as defined in Nilsen (2015) [29] (Table 1, p3):
  2. Classic Theories: defined as theories that originate from fields external to implementation science, e.g. psychology, sociology and organizational theory, which can be applied to provide understanding and/or explanation of aspects of implementation;
  3. Determinant Frameworks: defined as types (also known as classes or domains) of determinants and individual determinants, which act as barriers and enablers (independent variables) that influence implementation outcomes (dependent variables). Some frameworks also specify relationships between some types of determinants. The overarching aim is to understand and/or explain influences on implementation outcomes, e.g. predicting outcomes or interpreting outcomes retrospectively;
  4. Evaluation frameworks: defined as those frameworks that specify aspects of implementation that could be evaluated to determine implementation success;
  5. Implementation theories: Theories that have been developed by implementation researchers (from scratch or by adapting existing theories and concepts) to provide understanding and/or explanation of aspects of implementation;
  6. Process models: Specify steps (stages, phases) in the process of translating research into practice, including the implementation and use of research. The aim of process models is to describe and/or guide the process of translating research into practice.
  7. Levels of theoretical visibility (see Bradbury-Jones 2014 [30]):
  8. Level 1 – Seemingly absent,
  9. Level 2 – Implied,
  10. Level 3 – Partially applied,
  11. Level 4 – Retrospectively applied,
  12. Level 5 – Consistently applied
  13. Key: CFIR Consolidated Framework for Implementation Research, CMO Context-Mechanism-Outcomes, DM Decision Maker, ED Emergency Department, ELO Evidence in the Learning Organization, ERAS Enhanced Recovery After Surgery program for colonic surgery, HPA health promotion advocates, KMC Kangaroo Mother Care, MDT multidisciplinary team; MMS mixed methods study, NA not applicable, NP nurse practitioners, NPT Normalisation Process Theory, OMSC Ottawa Model for Smoking Cessation, OT occupational therapist, PARiHS Promoting Action on Research Implementation Framework, PPIP Perinatal Problem Identification Programme, RE-AIM Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, QS qualitative study, QUERI Quality Enhancement Research Initiative, SSP short-stay program, SUNG Supporting the Uptake of Nursing Guidelines, TDF Theoretical Domains Framework