Barriers and facilitators to implementing priority inpatient initiatives in the safety net setting

Abstract

Background: Safety net hospitals, which serve vulnerable and underserved populations and often operate on smaller budgets than non-safety net hospitals, may experience unique implementation challenges. We sought to describe common barriers and facilitators that affect the implementation of improvement initiatives in a safety net hospital, and identify potentially transferable lessons to enhance implementation efforts in similar settings. Methods: We interviewed leaders within five inpatient departments and asked them to identify the priority inpatient improvement initiative from the last year. We then conducted individual, semi-structured interviews with 25 stakeholders across the five settings. Interviewees included individuals serving in implementation oversight, champion, and frontline implementer roles. The Consolidated Framework for Implementation Research informed the discussion guide and a priori codes for directed content analysis. Results: Despite pursuing diverse initiatives in different clinical departments, safety net hospital improvement stakeholders described common barriers and facilitators related to inner and outer setting dynamics, characteristics of individuals involved, and implementation processes. Implementation barriers included (1) limited staffing resources, (2) organizational recognition without financial investment, and (3) the use of implementation strategies that did not adequately address patients' biopsychosocial complexities. Facilitators included (1) implementation approaches that combined passive and active communication styles, (2) knowledge of patient needs and competitive pressure to perform well against non-SNHs, (3) stakeholders' personal commitment to reduce health inequities, and (4) the use of multidisciplinary task forces to drive implementation activities. Conclusion: Inner and outer setting dynamics, individual's characteristics, and process factors served as implementation barriers and facilitators within the safety net. Future work should seek to leverage findings from this study toward efforts to enact positive change within safety net hospitals.

Management Strategies to Promote Follow-Up Care for Incidental Findings: A Scoping Review

“…Conversely, enhanced templates and restructured workflow or communication pathways automated use of guidelines. Prior research suggests that passive and nonautomated strategies to educate or remind clinicians often result in inconsistent adoption of the desired behavior change [32,33], whereas automated strategies streamline and standardize radiologists' decisionmaking processes [34,35].…”

“…1 [32] Cost of enhanced reporting, communication and clinical pathway model 1 [35] Clinician preference for enhanced radiology reports 1 [29] (continued) Increased clinician understanding of IF significance 1 [29] Increased clinician confidence in carrying out recommended follow-up care 1 [29] Phase 4: Patient or family member is informed of findings, recommendations (n ¼ 5). Percent of patient records with documented communication about the IF between a clinician and the patient 2 [23,34] Mode of communicating IF results to patient (eg, letter, telephone call, clinical visit)…”

“…1 [32] Patient satisfaction with clinician explanation of IF results and care plan 1 [32] Phase 5: Patient's PCP or another responsible physician is informed of findings, recommendations (n ¼ 1). Percent of patient records with documented communication about the IF between the ordering clinician and the PCP 1 [34] Phase 6: Follow-up care is delivered (n ¼ 8).…”

“…Percent of patient records with documented communication about the IF between the ordering clinician and the PCP 1 [34] Phase 6: Follow-up care is delivered (n ¼ 8). Percent patients with documented treatment, follow-up, or referral in patient chart 2 [22,24] Percent of patients that receive follow-up surveillance imaging 2 [23,32] Percent of patients with new IFs detected in follow-up surveillance imaging 1 [26] Percent of follow-up surveillance imaging studies recommended by the interpreting radiologist 1 [23] Percent of patients that complete specialty provider visits or received nonimaging follow-up surveillance (eg, hormonal testing in the setting of incidental adrenal masses)…”

“…1 [26] Percent of guideline concordant vs discordant follow-up care delivered 6 [24,25,28,29,31,32] Percent of guideline discordant follow-up care that results in over-or undermanagement 5 [25,28,29,31,32] Patient satisfaction with IF care management 1 [32] Phase 7: Incidentaloma is resolved (n ¼ 5). Percent of patients lost to follow-up care 1 [31] Percent of IFs that remain under observation 1 [35] Percent of patients with definitive diagnosis (eg, neoplastic, inflammatory, benign)…”