Implementation challenges to patient safety in Guatemala: a mixed methods evaluation

Abstract

BackgroundLittle is known about factors affecting implementation of patient safety programmes in low and middle-income countries. The goal of our study was to evaluate the implementation of a patient safety programme for paediatric care in Guatemala.MethodsWe used a mixed methods design to examine the implementation of a patient safety programme across 11 paediatric units at the Roosevelt Hospital in Guatemala. The safety programme included: (1) tools to measure and foster safety culture, (2) education of patient safety, (3) local leadership engagement, (4) safety event reporting systems, and (5) quality improvement interventions. Key informant staff (n=82) participated in qualitative interviews and quantitative surveys to identify implementation challenges early during programme deployment from May to July 2018, with follow-up focus group discussions in two units 1 year later to identify opportunities for programme modification. Data were analysed using thematic analysis, and integrated using triangulation, complementarity and expansion to identify emerging themes using the Consolidated Framework for Implementation Research. Salience levels were reported according to coding frequency, with valence levels measured to characterise the degree to which each construct impacted implementation.ResultsWe found several facilitators to safety programme implementation, including high staff receptivity, orientation towards patient-centredness and a desire for protocols. Key barriers included competing clinical demands, lack of knowledge about patient safety, limited governance, human factors and poor organisational incentives. Modifications included use of tools for staff recognition, integration of education into error reporting mechanisms and designation of trained champions to lead unit-based safety interventions.ConclusionImplementation of safety programmes in low-resource settings requires recognition of facilitators such as staff receptivity and patient-centredness as well as barriers such as lack of training in patient safety and poor organisational incentives. Embedding an implementation analysis during programme deployment allows for programme modification to enhance successful implementation.

Applying a systems lens to understand patient safety effectiveness in low-and-middle-income countries

“…To date, the evidence on how to effectively improve patient safety in LMICs is limited and although we can infer lessons from high-income countries (HICs), there are meaningful differences between HICs and LMICs that require careful study. The study by Hall et al 1 in this issue of BMJ Quality & Safety, which used implementation science methods to study what helped or hindered the roll-out of a patient safety programme in Guatemala, is therefore a welcome addition to this evidence base. 1 Based on the findings from Hall et al, 1 and the growing focus in the field of implementation science to analyse mechanisms by which implementation strategies work (or do not work), we argue that patient safety endeavours globally should consider systems-level barriers and explicitly include tailored strategies to overcome them.…”

“…The study by Hall et al 1 in this issue of BMJ Quality & Safety, which used implementation science methods to study what helped or hindered the roll-out of a patient safety programme in Guatemala, is therefore a welcome addition to this evidence base. 1 Based on the findings from Hall et al, 1 and the growing focus in the field of implementation science to analyse mechanisms by which implementation strategies work (or do not work), we argue that patient safety endeavours globally should consider systems-level barriers and explicitly include tailored strategies to overcome them. 2 LMICs have unique contextual factors that require interventions to be adapted, rather than directly transported from HICs.…”

“…Mixed-methods implementation science studies like those employed in Hall et al ’s paper1 are particularly helpful for increasing our understanding of how to translate systems thinking into real-world practice. Hall et al 1 used the Consolidated Framework for Implementation Research (CFIR)3 to identify facilitators and barriers for implementation and inform the optimisation of patient safety implementation strategies in Guatemala.…”

“…Mixed-methods implementation science studies like those employed in Hall et al ’s paper1 are particularly helpful for increasing our understanding of how to translate systems thinking into real-world practice. Hall et al 1 used the Consolidated Framework for Implementation Research (CFIR)3 to identify facilitators and barriers for implementation and inform the optimisation of patient safety implementation strategies in Guatemala. They evaluated implementation determinants acting across multiple levels, including the individual, inner organisational context, and external environment which led to several insights related to the overall health system and context.…”

“…While the CFIR framework proved to be a helpful tool in the Hall et al 1 study for identifying individual determinants, many existing implementation science theories, models and frameworks fail to consider the characteristics of the overall health system within which a discrete implementation strategy is embedded. For example, the current Expert Recommendations for Implementing Change compilation of implementation strategies has generated a list of 73 discrete implementation strategies that can be adopted for patient safety 4.…”