A realist evaluation to identify contexts and mechanisms that enabled and hindered implementation and had an effect on sustainability of a lean intervention in pediatric healthcare

Abstract

BackgroundIn 2012, the Saskatchewan Ministry for Health mandated a system-wide Lean transformation. Research has been conducted on the implementation processes of this system-wide Lean implementation. However, no research has been done on the sustainability of these Lean efforts. We conducted a realist evaluation on the sustainability of Lean in pediatric healthcare. We used the context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic to explain under what contexts, for whom, how and why Lean efforts are sustained or not sustained in pediatric healthcare.MethodsWe employed a case study research design. Guided by a realist evaluation framework, we conducted qualitative realist interviews with various stakeholder groups across four pediatric hospital units ‘cases’ at one acute hospital. Interview data was analyzed using an integrated approach of CMOc categorization coding, CMOc connecting and pattern matching.ResultsWe conducted thirty-two interviews across the four cases. Five CMOcs emerged from our realist interview data. These configurations illustrated a ‘ripple-effect’ from implementation outcomes to contexts for sustainability. Sense-making and staff engagement were prominent mechanisms to the sustainment of Lean efforts. Failure to trigger these mechanisms resulted in resistance. The implementation approach used influenced mechanisms and outcomes for sustainability, more so than Lean itself. Specifically, the language, messaging and training approaches used triggered mechanisms of innovation fatigue, poor ‘sense-making’ and a lack of engagement for frontline staff. The mandated, top-down, externally led nature of implementation and lack of customization to context served as potential pitfalls. Overall, there was variation between leadership and frontline staff’s perceptions on how embedded Lean was in their contexts, and the degree to which participants supported Lean sustainability.ConclusionsThis research illuminates important contextual factors and mechanisms to the process of Lean sustainment that can be applicable to those implementing systems changes. Future work is needed to continue to develop the science on the sustainability of interventions for healthcare improvement.

Contextual Factors and Mechanisms that Influence Sustainability: A Realist Evaluation of Two Provincially Scaled Evidence-Based Initiatives

“…Like previous research on sustainability (22) our ndings illustrate the important relationship and "ripple-effect" between implementation and sustainability; where there is a causal relationship between implementation processes and outcomes, and sustainability. We found that implementation factors and decisions made for implementation were critical to facilitating or hindering contexts for sustainability.…”

“…We followed the realist heuristic context (C) + mechanism (M) = outcome (O) con guration, whereby an intervention works or not (O), (CMOcs) because of the action of some underlying mechanism (M), which only comes into operation in particular contexts (C) (19,21). We followed the realist cycle of theory hypothesis generation, theory hypothesis observation and speci cation (19) according to realist terms previously detailed (22). The Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) II reporting standards were followed (23) (see additional le 1).…”

A realistic evaluation of evidence-based therapeutic processes in mental health services– Context-Mechanisms-Outcomes

“…This qualitative paper offers ways to address what work or not, when, why and for whom, under what circumstances to promote evidence-based therapeutic interaction in service provision (28,29). The therapeutic processes in mental health services have traditionally been tested and evaluated through middle-range theory (e.g.…”

Contextual Factors and Mechanisms that Influence Sustainability: A Realist Evaluation of Two Provincially Scaled Evidence-Based Initiatives

“…We followed the realist heuristic context (C) + mechanism (M) = outcome (O) con guration, whereby an intervention works or not (O), (CMOcs) because of the action of some underlying mechanism (M), which only comes into operation in particular contexts (C) (19, 21). We followed the realist cycle of theory hypothesis generation, theory hypothesis observation and speci cation (19) according to realist terms previously detailed (22). We followed the Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) II reporting standards and SQUIRE 2.0 checklist (23, 24) (additional le 1 & 2).…”