Collective implementation in primary and specialised health care – a multimethod study on four different health service domains.

In today's Norwegian health service, many patients are offered treatment based on yesterday's recommendations. Every year, more than 600 patients are seriously injured or die as a result of errors or deficiencies in Norwegian hospitals. The main challenge for the health service now and in the future is insufficient ability and efficiency in making use of updated knowledge and making it part of «usual practice», often through packages of measures. Implement-it is a research study that examines the strategies and factors for successful use of new knowledge in the health service, developing a program and testing how it increases the health service's ability to include new knowledge in existing practice. In a systematic literature review, we found 159 scientific studies on clincal bundles for the correct use of antibiotics, medication reconciliation and rapid response systems for deteriorating patients, describing both implementation measures and factors that influenced implementation. The majority of these were inspired by knowledge of quality improvement methodology and some studies were inspired by scientifically based implementation knowledge. The studies showed to a small extent how packages of measures. The studies showed little of how knowledge about the various factors identified was used to select effective and correct implementation measures. Preliminary results from our own studies also show that during ongoing implementation, it is possible to measure the extent to which effective implementation takes place with a simple survey instrument. Studies are performed to identify such associations in the implementation of similar packages of measures in Norwegian hospitals and for antibiotic stewardship, also outside hospitals. Implement-it is a research collaboration between primary health care, hospitals, universities and patient representatives, managed by Helse Bergen and Helse Fonna Health Trusts in Norway. We aim to learn together with and from health care providers across nursing homes, homebased care, medical services in primary health care and hospitals to implement defined patient safety intervention bundles such as the appropriate use of antibiotics, accuracy of medication lists and detection and handling detoriating patients. We do also study the implementation of Choosing Wisely in radiology examinations ordered in primary health care. Our aim is to improve knowledge on efficient implementation and improve health services' competence on how to integrate new evidence-based practices into everyday clinical practice. By this, we expect to contribute to a faster and wider spread of updated clinical practices and thereby improve the probability of survival, improved prognosis and quality of life.

A vast majority of patients do not receive updated, recommended care in every respect. Especially, care interventions that should be implemented collectively across care units and organisational levels, and in cooperation with patients, are often not provided sufficiently. Results of implementation efforts vary by degree of compliance to the guidelines, penetration and sustainability. These insufficiencies imply limited return of the investments made by health services, and hinder provision of high quality health care. This problem is general across fields of medicine and health service levels, but the vast majority of implementation knowledge is developed in the context of hospital units. We need more knowledge on cooperative implementation, i.e. collective implementation efforts across cooperating partners. The purpose of this research is to contribute to the faster up-take of recommended clinical practices across organisational boundaries into everyday work. The objectives are to investigate and describe how implementation of patient safety intervention-bundles in primary and secondary health care settings can be improved. We will study the successful implementation of antibiotics usage guidelines, and investigate if implementation of the national guidelines for detecting deteriorating patients, ensuring medication list coherence and patient involvement in planning of mental health care improve when learning from successful implementation of antibiotics usage guidelines. This proposal introduces a research cooperation between primary care services, specialised health care services, patient representatives and universities. It is a collaboration between existing national clinical research networks, research networks on patient safety and implementation science, patient involvement panels, and clinical practices in both primary and secondary care. This project will establish an evidence based program for efficient implemetation in health care.