Overton, Charlotte
(2020)
A comparative case study of the implementation of standardised tools in healthcare: the active role everyday technologies play in quality improvement.
PhD thesis, University of Nottingham.
Abstract
The implementation of evidence-based medicine frequently hinges on the introduction of technologies and tools within established social practices, and so often requires behavioural or cultural change at the clinical frontline. This research explored the implementation of an evidence-based intervention, in the form of a standardised tool, in the English National Health Service (NHS). In this context, local implementation of an evidence-based intervention is under the influence of external forces such as: NHS targets and financial incentives; the political landscape; and the public and media.
Care bundles are evidence-based standardised tools that have become a widely used solution for a range of patient safety and quality issues. However, the evidence on their use is mixed. Complex sociological factors influence the success of their implementation, sustainment and spread. Initiation of a care bundle relies on assessment of a patient and the recognition that the specified ‘bundle criteria’ are met. This research explored the implementation of sepsis screening tools and the Sepsis Six care bundle. Sepsis screening tools are used to stratify the severity of sepsis in order to identify if administration of the Sepsis Six care bundle is indicated. The Sepsis Six care bundle is a bundle of six interventions that are all to be instituted within an hour of recognition of severe sepsis. Sepsis screening tools and the Sepsis Six are underpinned by evidence-based medicine and in the English NHS implementation has been incentivised through a financial target. Sepsis has also been the focus of political and media attention, with several high-profile cases of failures of care.
The field of implementation science seeks to create knowledge of implementation processes and develop an understanding of the uptake in routine practice of research findings and other evidence-based practices, in order to promote their systematic application. Implementation science models, frameworks and theories have been developed to explain and predict aspects of implementation. In addition, the field of Science and Technology Studies (STS) offers a useful theoretical perspective to contribute towards implementation science by exploring the implementation of care bundles. By applying this perspective, care bundles are viewed as everyday technologies that play an active part in healthcare as opposed to being inactive, inanimate objects in the form of paper-based or computer-based tools.
Concepts from STS, specifically from Actor-Network Theory (ANT) and technology-in-practice, were applied in this research to study systematically and critically how and why external drivers and evidence-based interventions were interpreted, implemented and used in clinical practice. Using a conceptual framework based on ANT and technology-in-practice allowed a move away from the idea that technology impacts upon healthcare workers as an external force, and allows for technical interventions to be considered as active actors that affect implementation strategies.
A qualitative methodology, specifically ethnography, underpinned the research design and the theoretical foundations of this research. The ethnographic methodology allowed for the lived experiences of the actors involved to be accounted for in this exploration of the external drivers, the implementation of the care bundle and its use in clinical practice. The research design was a multi-site case study. This enabled a close and in-depth investigation and comparison within and across the case sites of the contemporary real-life phenomenon of care bundle implementation.
Two hundred hours of observation across the Emergency Department (ED), acute inpatient settings and relevant meetings were undertaken. Forty-seven semi-structured interviews were also undertaken with: executive board members; corporate nurses; doctors and nurses in management roles; and frontline doctors, nurses and support staff. Policy documents and internal documents were also collected. An inductive research strategy was used and the data were examined using thematic analysis to identify key themes. These themes were then viewed through the lens of a framework constructed from concepts from Actor-Network Theory and technology-in-practice.
This research had two main aims: firstly, to ascertain how secondary-care organisations interpret and implement external drivers associated with care bundles; and secondly, to ascertain how care bundles are used in clinical practice. Analysis found that two actor-networks were simultaneously translated for the external guidelines to be interpreted and implemented, one at a corporate level and the other in clinical practice. The way that organisations mobilised around the external pressures and guidelines, their orientation towards improvement, and how external pressures were balanced against the intended purpose of these tools in clinical practice influenced the design of the local implementation strategies. In clinical practice, the characteristics of the clinical setting, experience of healthcare workers and their interpretation of the tools’ scripts influenced their implementation and use in clinical practice. As such, different perspectives on the care bundle were not always aligned.
The two actor-networks could be connected by embedded governance reporting structures (from the executive board to the clinical frontline) and by quality improvement methods. This facilitated understanding of the influence of context on implementation, in addition to the use of quantifiable measures of compliance. By drawing on ANT and technology-in-practice, this research provides valuable insights for implementation science by demonstrating empirically that care bundles do not just slip into the social world of secondary care in the NHS.
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