Contextual factors influencing the implementation of the obstetrics hemorrhage initiative in Florida

Abstract

Objective:

The purpose of this study was to explore the multilevel contextual factors that influenced the implementation of the Obstetric Hemorrhage Initiative (OHI) among hospitals in Florida.

Study Design:

A qualitative evaluation was conducted via in-depth interviews with multidisciplinary hospital staff (n=50) across 12 hospitals. Interviews were guided by the Consolidated Framework for Implementation Research and analyzed in Atlas.ti using rigorous qualitative analysis procedures.

Result:

Factors influencing OHI implementation were present across process (leadership engagement; engaging people; planning; reflecting), inner setting (for example, knowledge/beliefs; resources; communication; culture) and outer setting (for example, cosmopolitanism) levels. Moreover, factors interacted across levels and were not mutually exclusive. Leadership and staff buy-in emerged as important components influencing OHI implementation across disciplines.

Conclusion:

Key contextual factors found to influence OHI implementation experiences can be useful in informing future quality improvement interventions given the institutional and provider-level behavioral changes needed to account for evolving the best practices in perinatology.

Introduction

Obstetric hemorrhage is a leading cause of pregnancy-related death in the United States.¹ However, it is estimated that more than 90% of hemorrhage-related deaths could be prevented.² In Florida, the percentage of pregnancy-related hemorrhage deaths reviewed by the Pregnancy-Associated Mortality Review was 15.5% for years 1999 to 2012.³ Early identification and intervention through clinical care is the key to preventing these maternal deaths.⁴

In 2013, the Obstetric Hemorrhage Initiative (OHI) was launched in hospitals across the state of Florida, with the goal of decreasing maternal mortality and morbidity due to hemorrhage. Based on earlier contributions from the California Perinatal Quality Collaborative,⁵ the Florida Perinatal Quality Collaborative OHI Work Group assembled obstetric hemorrhage best practice protocols and tools into a project toolkit to assist hospitals in this quality improvement initiative.⁶ This intervention involved the translation and implementation of evidence-based practices to improve readiness, recognition, response and reporting on postpartum hemorrhages. Elements of the OHI included obstetric hemorrhage and massive transfusion protocols, antepartum risk assessments; active management of third stage labor; quantification of blood loss; construction of obstetric hemorrhage cart; availability of medications and equipment; interdisciplinary, team-building hemorrhage drills; and debriefings after obstetric hemorrhage events. The OHI Work Group aimed to share evidence-based information, promote methods of organizational change, involve hospital experts and share experiences among the participating hospitals.⁶

Continuous evaluation of the process, short-term and long-term outcomes is critical during the implementation of quality improvement efforts. In addition, evaluating the process of implementation not only allows for adjustments to be made mid-course, but also provides valuable learning opportunities for other interventions in similar settings.^{7, 8} As obstetric interventions continue to evolve with emerging evidence and best practices, the field should reflect and account for the barriers and facilitators to implementation in obstetric settings to maximize likelihood of success.

The Consolidated Framework for Implementation Research (CFIR) is a meta-framework that can assist during the development, implementation and evaluation of health interventions.⁹ This framework recognizes the contextual factors across multiple levels that can influence the implementation and ultimate success of an intervention. Specifically, this framework has 37 constructs within five domains: (1) intervention characteristics; (2) outer setting; (3) inner setting; (4) characteristics of individuals; and (5) process.⁹ For example, process, inner setting and outer setting factors can have a key role during the implementation process. Factors within the process domain include the planning process and engagement of stakeholders for implementation. Factors within the inner setting involve existing characteristics of the institution and personnel, such as culture, communication channels and readiness of implementation. Factors within the outer setting refer to the connectedness of an institution with others, external policies and disciplinary practices.⁹ The purpose of this study was to explore the contextual factors across the process, inner setting and outer setting domains that influenced the implementation experiences among diverse hospitals in Florida.

Materials and methods

A qualitative design was utilized to provide a rich, in-depth exploration of the contextual factors that influenced implementation experiences of the OHI. This quality improvement evaluation was submitted for review; however, the institutional review board determined its activities did not constitute research under the policy nor require institutional review board oversight.

Sampling and recruitment

Purposive sampling (a technique where participants are identified and selected on the basis of particular characteristics) was used to select approximately 10 sites among the first cohort of 31 hospitals that implemented the OHI in Florida based on the following characteristics: (1) geographic area as defined by the American Congress of Obstetricians and Gynecologists regions; (2) hospital size and number of deliveries per calendar year (small⩽1000, medium=1001 to 3000, large⩾3001); level of preparedness for OHI (self-reported as low, medium, high); and training hospital (yes, no). Snowball sampling (a technique where participants assist in identifying other key participants) was utilized where a designated person at the selected hospitals assisted in recruiting three to four additional diverse staff members. Given that this study aimed to explore experiences of key diverse staff involved in the early implementation of the OHI, these small convenience samples of participants per hospital are appropriate to elicit emerging experiences across the larger cohort of hospital sites.¹⁰

Data collection

The questions on a semi-structured interview guide were developed on the basis of three of the CFIR domains described above (process; inner setting; and outer setting). Salient constructs across these domains that were applicable to this intervention were identified on the basis of the feedback from a quantitative survey (five-item Likert scale; strongly agree to strongly disagree) that was administered to the Florida Perinatal Quality Collaborative OHI Work Group.

The data were collected during the early implementation phase of the OHI. At each hospital, in-depth interviews were conducted at dates and times convenient for the participants. In a few instances, small focus groups were conducted if deemed more feasible for hospital staff given scheduling constraints and employment demands. A brief participant profile sheet was also administered to collect basic demographic data to describe the sample. Each interview was audio-recorded and transcribed verbatim.

Data analysis

The deductive codes (based on the CFIR framework) and inductive codes were used applying the constant comparative method in Atlas.ti (Version 7).¹¹ Two members of the research team coded 14% of the transcripts and established a 0.83 kappa for inter-rater reliability (high agreement). The remaining transcripts were coded using this coding scheme. This paper reports on findings related to the following CFIR levels: (1) process (for example, leadership engagement; engaging people; planning; and reflecting/evaluating); (2) inner setting (for example, knowledge/beliefs; resources; communication; and culture); and (3) outer setting (for example, cosmopolitanism). Findings related to intervention characteristics are reported elsewhere. In addition, the interconnectedness of the outer setting, inner setting and process factors was assessed by identifying cross-coding of text for multiple themes.

Results

A total of 50 participants across 12 hospitals participated in this study. Most participants self-reported being female (91.7%) and white (85.4%). The participants had been in their discipline field for an average of 25 years (range 1 to 50) and were employed within their hospital for an average of 7 years (range 1 to 35). Diversity of roles was represented, although the majority of participants were nurse leaders/managers or staff nurses (see Table 1).

Table 1 Participant demographic data for OHI evaluation

Key factors that emerged across the three CFIR levels (process, inner setting and outer setting) during the participant interviews are described below. Table 2 presents a summary of these key findings with exemplary quotes providing rich context to these experiences.

Table 2 Key factors, emerging themes and illustrative quotes from OHI experiences per CFIR levels

Process factors

The process of implementing the OHI focused on four elements: (1) leadership engagement; (2) planning for implementation; (3) engaging people; and (4) reflecting and evaluating the progress.

Leadership engagement

Leadership engagement was discussed by all the participants, yet the degree of engagement varied by hospitals. Leadership at all levels—not only the traditional senior role was important and included persons in the following positions: vice presidents, administration, directors, physician champions, nurse managers, nurse educators and staff nurses. Hospitals also varied by how leaders were identified where some relied on traditional roles or previously identified leaders in departments, whereas others utilized newly motivated leaders for this initiative.

Planning for implementation

Planning for the implementation of OHI comprised several key steps. First, each hospital had to recognize the need for and importance of the OHI for the hospital; this required strong leadership and consensus building as described above. Hospitals differed in how this process evolved: some hospitals had leadership that urged the participation in the OHI; whereas others had a group of individuals advocating for their hospital’s participation in this state initiative. Regardless, all the hospitals had full support among higher administration to participate before initiating planning activities.

Owing to the differences in hospital sizes and networks, each hospital had to evaluate how the OHI could be implemented given existing policies, procedures and resources. Some hospitals already had protocols in place to address obstetric hemorrhage, which required either improving or updating these protocols to align with OHI specifications. In contrast, those hospitals without existing protocols were at a disadvantage and required additional time to form workgroups to develop obstetric hemorrhage policies and procedures. An additional consideration was needed for hospitals that were part of a larger network of hospitals. Within some networks, this was advantageous as activities could be divided among partners. On the other hand, some networks discussed how this created additional barriers where all the parties must provide approvals for items requiring standardization.

Establishing a team for implementation was also an important step within the planning process. This took on a variety of forms, such as assembling a task force, holding internal meetings or having external meetings with the Florida Perinatal Quality Collaborative (for example, kickoff, mid-course, remote or on-site technical assistance meetings). The team required participation from multidisciplinary stakeholders, which was integral for organizing the logistics of the initiative (for example, leading trainings; securing equipment), and serving as the driving force that assured the hospital progressed during implementation activities. At least one hospital team even elected to have their own internal ‘kickoff’ meeting to launch the initiative and to introduce staff to the upcoming practice changes within their hospital.

Engaging people

The participants discussed the importance of contributions from multidisciplinary staff during the implementation process at their hospital. These stakeholders included representation from different disciplines, such as anesthesiologists, obstetricians and nurses. At each hospital, a leader or champion was identified by participants, and included being the key person for either bringing the OHI to the hospital, giving the approval for the OHI at the hospital, coordinating day-to-day OHI activities and/or serving as a change agent or role model for other staff. However, the high-level leaders (administrators) were discussed as being essential for overall hospital staff buy-in.

In addition, multidisciplinary engagement was most evident during training events or simulation drills, which required the collaboration of diverse stakeholders across hospital departments. Strong leadership at the ground level was also needed in the planning, delivery and evaluation of these learning events. Yet, while leadership buy-in was an integral part of engaging other hospital staff, it was not always a sufficient step. Specifically, staff buy-in was identified as one of the major barriers to implementation and was often segmented to specific departments or staff roles, with private practice physicians identified as stakeholders who were most challenging to engage.

Reflecting and evaluating

Implementation of the OHI was an ongoing process, which required periodic reflection and evaluation. Debriefing with staff was the central mechanism for this to occur and included informal and formal discussions, debriefing forms after a hemorrhage event, staff presentations, multidisciplinary drills with feedback, standing meetings and education forums. In addition, some participants received direct feedback from leaders or supervisors.

Although most participants stated some involvement in critical reflection throughout the implementation process, others reported that they did not receive any feedback on the initiative. Sometimes this was attributed to the competing demands of the staffs’ work schedules, which made it difficult for members to re-convene after an event, or to staff resisting debriefing after a distressing hemorrhage event. Moreover, some participants indicated particular staff groups as being more resistant to reflection and evaluation, such as physicians who often leave after events to return to their office or clinic practices or for other unknown reasons. However, key components that facilitated the debriefing process were strong initiative champions or leadership, and staff solidarity that recognized the importance of debriefing.

Inner setting

The inner setting describes contextual issues related to communication, structure, organization and culture of the hospital that influence implementation experiences. These factors included (1) knowledge and beliefs, (2) resources, (3) communication and (4) culture.

Knowledge and beliefs

All the participants perceived the OHI as a positive initiative that was both needed and rooted in evidence-based practices. The participants had adequate knowledge of the intervention, but were most familiar with only those elements that they personally were involved. In addition, the value of this intervention was often overshadowed by participants experiencing challenges with buy-in and engagement from other staff members. This was often reflective of the difficulties inherent in changing practice behaviors among seasoned staff.

Resources

Although the OHI provided guidance on the implementation process, tangible resources were required for the initiative. Existing equipment, technology and protocols facilitated the implementation of intervention components, such as assembling a hemorrhage cart. However, there were types of equipment that needed to be purchased by hospitals for the OHI, which at times, served as a barrier to timeliness of implementation progress. In addition to tangible resources, the collaborative environment between departments (for example, information technology, labs, blood bank, maternity ward, management, education department) was invaluable that facilitated the utilization of existing resources and prompted multidisciplinary actions. On the other hand, staff turnover and competing hospital demands (for example, accreditation processes; physical construction projects) often limited the human and financial resources that could be dedicated towards OHI implementation.

Communication

Overall, most participants perceived communication channels at the hospitals as adequate for this initiative. However, there was diversity in the type of communication channels utilized, including active and passive methods. Active communication methods included scheduled meetings, debriefings after hemorrhage events, education meetings and e-mails. In contrast, passive communication also existed through flyers and announcements on bulletin boards. The communication style was responsive to the existing culture of the hospital and style preferences of leadership.

Culture

The workplace culture of the hospital was discussed as a factor that could either facilitate or inhibit the implementation success of the OHI. For the majority, the philosophy of embracing evidence-based practices, emphasizing patient-centered care and desire for quality healthcare contributed to implementation. Specific characteristics of the hospital, such as a being a teaching hospital, having a focus on maternal and child health or women’s health, and a core, dedicated group of staff also enabled the associated change processes. Furthermore, many participants reflected on past quality improvement experiences in shaping their current culture and acceptance of implementing new processes associated with the OHI.

In contrast, the participants discussed how the hospital’s culture hindered implementation either because they were not a teaching hospital and had less exposure to rapid changes in processes and practices, encountered resistance to change by physicians and/or because of buy-in initially occurring on a department basis. For example, buy-in from the nursing department was separate from buy-in from physicians, both of which occurred within these discipline-specific microcosms before multidisciplinary collaboration. Nonetheless, leadership within individual departments was critical to integrating new practices in the setting.

Outer setting

The outer setting describes the external contextual factors that influence implementation. For this study, the OHI Advisory Board identified the cosmopolitanism construct of the CFIR as a potential factor, or the degree to which a hospital is networked with other hospitals and organizations.

Cosmopolitanism

Because the OHI was implemented in 31 hospitals throughout the state of Florida, several participants indicated that they were in contact with other hospitals throughout the implementation process, mostly through the Florida Perinatal Quality Collaborative webinars and meetings. This allowed for sharing of experiences and information with each other to facilitate the implementation. Yet, linkage within a network also served as a barrier for some hospitals. For example, being part of a corporate network or hospital group required revisions to shared policies, procedures, computer systems or information technology systems. This often considerably slowed down the implementation process for many hospitals within larger networks.

Interconnectedness of factors

Although the CFIR identifies important constructs across different domains that have been found by established literature to greatly influence the implementation of initiatives, findings in this study highlighted the interconnectedness of factors across levels for the OHI. Within each of the examined levels, an association or reference to additional CFIR factors was discussed by participants. This demonstrates the elaborate and complex web of factors responsible for successful implementation in a hospital setting and highlights system characteristics such as reciprocal determinism (how implementation experiences are shaped by factors across other levels) and embededness (how each factor across system levels influences, and is influenced by, other factors). For example, the planning element within the process domain involved an assessment of existing resources at the institution and linkages to other institutions. This was also associated with the communication and leadership engagement (inner setting), cosmopolitanism (outer setting) and engaging people (process; see Figure 1).

Figure 1

Interconnectedness of key factors across CFIR levels. CFIR, Consolidated Framework for Implementation Research.

Most salient was the interconnection within in the inner setting level of each of these constructs influencing one another. Specifically, two factors emerged in the analysis as dominant and connected components to the OHI implementation—leadership and buy-in. The initial decision to begin the initiative at the hospital and the ongoing changes throughout the implementation process required leadership at different levels and buy-in from multiple stakeholders across hospital departments. Buy-in during the implementation process was also critical to engage the hospital staff needed from the different disciplines.

‘Well, going back to leadership again, it's not just getting their okay. If you don't get your leaders to buy in, your leaders aren’t gonna sell it to their nurses. So it kinda starts the same thing there. Unless you're gonna go in and have every nurse yourself buy in to it, you're not gonna be able to touch every single nurse yourself, you've gotta get your leadership to buy in. Because they are the leaders. So that's, I think, definitely very important, even though they may not be the ones directly educating every single time, but it's just as important to have your leadership buy in because then they'll try and sell it to the staff too.’

Moreover, hospital leadership and the overall culture of the hospital that values evidence-based practices and quality improvement processes facilitated buy-in at multiple levels for the initiative.

‘The nursing staff—Actually I've had great buy-in with the nursing staff. I think any time you bring it to our nurses and say, ‘This is one of the leading causes of morbidity and mortality in the State of Florida’, they go, ‘Okay what can we do to fix it?’ So I think my buy-in in my nursing staff is actually very good.’

Thus, this study demonstrated that these implementation factors are not mutually exclusive; rather, there is dependence among these factors with each other across levels of influence.

Discussion

This study evaluated the contextual factors that influenced the implementation experiences of the OHI across 12 diverse hospitals in Florida. Salient factors extended across the three levels of the CFIR framework, including process, inner setting and outer setting, and both facilitated and created barriers during implementation. Subsequently, this evaluation provided critical feedback on diverse hospitals’ and staffs’ experiences during the implementation of an obstetrics quality improvement intervention.

Although the evaluation elicited factors across these three levels through in-depth interviews, it was clear that these factors are not mutually exclusive. Rather, the factors were often dependent upon one another at different levels of influence. The ties between these multilevel factors are indicative of the complex implementation process required for successful incorporation of interventions in hospital settings. In particular, the actual process of implementation required assessing and evaluating assets and barriers already in place in inner and outer settings. Existing support—be that tangible, informational or social—facilitated the implementation process. This was especially necessary given the multidisciplinary nature required for this intervention. Established multidisciplinary relationships and the culture of quality improvement and patient-centered care within hospitals assisted in promoting communication, engagement and networking throughout departments. These types of skills for a multidisciplinary intervention are critical for complex, emergency conditions, such as obstetric hemorrhage.¹² Future quality improvement initiatives should consider the complex implementation process during the planning stage of the initiative, as well as establish multidisiplinary relationships for successful implementation.

Another vital factor that was continuously discussed by participants as influencing implementation of the OHI was buy-in. Although buy-in per se is not a CFIR construct, it was repeatedly discussed by participants as either a barrier or facilitator during implementation. Furthermore, buy-in interacted with other CFIR constructs. Specifically, it reflected the hospital’s culture (inner setting domain) and the ability of leadership to engage staff during the planning of the initiative (process domain). Moreover, buy-in was essential to engage departments and staff during implementation of the various OHI activities (for example, multidisciplinary drills). Buy-in has been found to be key in quality improvement programs, such as those occurring in NICU (neonatal intensive care unit) settings.^{13, 14} Thus, future quality improvement initiatives should seek buy-in from a range of stakeholders, including leadership, staff and patients.

An additional emerging theme in these data was the specific characteristics of each hospital that contributed to the implementation process. For example, participants from some hospitals reflected that implementation was facilitated by having a core group of staff that continuously collaborates together. This is similar to the finding to where teaching hospitals also reported positive environments for change, which may be attributed to the continuous training available within this environment. Future research should further compare and contrast key differences in implementation experiences across different hospital types (for example, size; teaching hospital). Additional advanced analyses, such as Qualitative Comparative Analysis, could be used to assist in identifying such casual implementation factors that produce effective implementation outcomes by accounting for within- and across-case (that is, hospital) analyses.¹⁵ Subsequently, with recognition of this emerging finding that implementation factors can vary on the basis of hospital types, interventions should consider conducting environmental scans of inner and outer settings of intervention sites to determine potential existing assets or needs that could impact the implementation process in advance.

While considering study findings, limitations must be noted. First, each hospital included in this evaluation was at a different stage within the implementation process of the OHI given the multiple activities associated with the initiative, which may reflect differences in barriers and facilitators at each hospital. Second, each participant self-reported their views regarding the implementation of the initiative at their hospital. Furthermore, because this evaluation was focused on a workplace program, social desirability bias may have influenced participants’ responses. Third, different types of stakeholders (for example, nurses, physicians, administration) were involved in the evaluation, and although this is a strength in providing a variety of perspectives, it also serves as a limitation in that different mixes of stakeholders were involved at each hospital, which may limit the transferability of results between hospitals. Fourth, there was a lack of diversity with regards to socio-demographics as the majority of participants were White and female. In addition, the majority of participants were nurses and thus findings could be skewed towards experiences and professions of that particular discipline. Last, this study only descriptively identified implementation factors to identify when a theme was common or rare among the participants and was not able to quantify emerging themes given the non-probability and convenience sampling. Thus, future research should further examine these implementation factors in larger sample sizes and reach thematic saturation to quantitatively report implementation factors. In addition, future research should administer a theory-driven quantitative implementation survey to assess and rank implementation barriers and assets and to examine the association of implementation factors by various hospital characteristics.

Overall, this evaluation revealed that factors across process, inner setting and outer setting levels were critical in shaping the participants’ experiences during implementation of the OHI among Florida hospitals. Moreover, leadership at different levels and buy-in from multidisciplinary stakeholders was essential during planning and execution of the various OHI components. The interconnectedness of these system-level factors illustrates the complexity of interventions implemented in perinatal settings. Future quality improvement initiatives should consider these complex factors that influence implementation of a hospital intervention, and plan to form and foster multidisciplinary teams and buy-in for the intervention. Given that perinatology is a dynamic field with evolving best practices that require both institutional- and provider-level behavior change, the key factors observed and lessons learned during the implementation of this OHI can be useful in informing other future quality-improvement interventions.