Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial)

Abstract

BackgroundImproving the quality and safety of perioperative care is a global priority. The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was a stepped-wedge cluster randomised trial of a quality improvement (QI) programme to improve 90-day survival for patients undergoing emergency abdominal surgery in 93 hospitals in the UK National Health Service.MethodsThe aim of this process evaluation is to describe how the EPOCH intervention was planned, delivered and received, at both cluster and local hospital levels. The QI programme comprised of two interventions: a care pathway and a QI intervention to aid pathway implementation, focussed on stakeholder engagement, QI teamwork, data analysis and feedback and applying the model for improvement. Face-to-face training and online resources were provided to support senior clinicians in each hospital (QI leads) to lead improvement. For this evaluation, we collated programme activity data, administered an exit questionnaire to QI leads and collected ethnographic data in six hospitals. Qualitative data were analysed with thematic or comparative analysis; quantitative data were analysed using descriptive statistics.ResultsThe EPOCH trial did not demonstrate any improvement in survival or length of hospital stay. Whilst the QI programme was delivered as planned at the cluster level, self-assessed intervention fidelity at the hospital level was variable. Seventy-seven of 93 hospitals responded to the exit questionnaire (60 from a single QI lead response on behalf of the team); 33 respondents described following the QI intervention closely (35%) and there were only 11 of 37 care pathway processes that > 50% of respondents reported attempting to improve. Analysis of qualitative data suggests QI leads were often attempting to deliver the intervention in challenging contexts: the social aspects of change such as engaging colleagues were identified as important but often difficult and clinicians frequently attempted to lead change with limited time or organisational resources.ConclusionsSignificant organisational challenges faced by QI leads shaped their choice of pathway components to focus on and implementation approaches taken. Adaptation causing loss of intervention fidelity was therefore due to rational choices made by those implementing change within constrained contexts. Future large-scale QI programmes will need to focus on dedicating local time and resources to improvement as well as on training to develop QI capabilities.EPOCH trial registrationISRCTN80682973 10.1186/ISRCTN80682973 Registered 27 February 2014 and Lancet protocol 13PRT/7655.Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0823-9) contains supplementary material, which is available to authorized users.

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

“…Our findings reveal that implementation of such an extensive care pathway was a more complex challenge than expected by our clinical community. It is important to interpret the results of this trial alongside those of the ethnographic study and process evaluation, 26,27 which together suggest that quality improvement programmes designed to implement complex care pathways require more resources, with dedicated time for clinical teams to focus on making change happen.…”

“…Our prospective ethnographic study and process evaluation are reported in full elsewhere. 26,27 The findings showed that teams reflected positively on the QI programme, in particular the practical nature of the activation and education meetings, and the opportunity to share ideas and learn from others as well as the utility of the online resources. However, staff in each of the six sites studied encountered multiple challenges as they attempted to improve patient care during the intervention period and often had little or no additional time in their job plans to accommodate this.…”

“…Detailed methods are presented in the full reports. 26,27 In this report, we summarise key themes to provide the perspective needed to interpret our main findings.…”

Quality improvement and emergency laparotomy care: what have we learnt from recent major QI efforts?

“…While the QI intervention did not impact upon patient survival, EPOCH provided vital learning about how we can and cannot improve patient care using large-scale QI programmes. 20,21 ELC was a large QI project funded by the Health Foundation, adopting implementation science to improve patient care. 7 The project was led by the Kent Surrey Sussex Academic Health Science Network ( www.kssahsn.net ) in 28 NHS hospitals, and used a quality improvement collaborative model to help teams to implement a laparotomy care bundle.…”

Scaling up perioperative medicine for older people undergoing surgery (POPS) services; use of a logic model approach

“…To meet these challenges, broad stakeholder buy-in, organisational readiness and efficient use of scarce resources (funding and workforce) are necessary. [12][13][14] Ensuring fidelity refers to the delivery of interventions as designed and intended and applies particularly to complex multicomponent interventions such as the POPS service. Addressing these translational challenges is necessary to establish effective, efficient and equitable services for older surgical patients across the UK.…”