Establishing a Learning Health System through the implementation of a health service wide Continuous Quality Improvement program: A qualitative evaluation

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Ellis, Robyn Clay-Williams, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4614057/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Continuous quality improvement (CQI) initiatives are commonly used to enhance patient safety and quality of care. A novel South Australian Local Health Network (SALHN) Continuous Improvement Program (CIP009) has integrated a top-down model of executive-directed change initiatives, with a bottom-up approach of clinician designed interventions to address an organisational-wide goal of improved patient flow. This study evaluated the strengths and challenges of CIP009 implementation from the perspective of participants and deliverers. Methods A qualitative study was conducted to evaluate the implementation of CIP009 and 12 associated quality improvement projects. Semi-structured interviews, document review, and observations were guided by the Consolidated Framework for Implementation Research (CFIR). Interviews, focus groups and observations were conducted with key stakeholders (executives, coaches and participants). Data were analysed inductively using thematic analysis, then deductively mapped against the five CFIR domains. Results Thirty-one participants were interviewed, two presentation days and six team meetings were observed, and 78 documents were reviewed. Seven key themes were identified highlighting key challenges and strengths of CIP009 implementation within the SALHN setting. These included four key strengths: the CIP framework and culture (the flexible framework, common language, training, and a culture of flattened hierarchy); the benefits of support from a dedicated, internal improvement Faculty (wrap around support from coaches); the advantages of an enthusiastic participant disposition and incentives (vested interests to enhance workflow and patient outcomes); and e ffective teams and team composition (teams comprised of senior clinician change agents). Three key challenges included: workforce and organisation-level challenges (individual workloads, workforce capacity, and data access); team cohesion, logistics and stakeholder engagement challenges (issues in the way teams worked together); and training and support shortcomings (the training course, and the top-down nature of CIP009). Conclusion This evaluation identified that CIP009 was considered an effective multifaceted CQI program. The strengths of CIP009 support a learning health system (a data driven model, utilising systematic frameworks, with commitment from leadership, and a culture of continuous learning). Further integration of implementation science principles may support the program to overcome the key challenges identified. Quality Improvement Continuous Quality Improvement implementation science strengths and challenges qualitative ambulance ramping patient flow Learning Health System Consolidated Framework for Implementation Research Thematic analysis Figures Figure 1 Figure 2 Introduction Continuous Quality Improvement (CQI) capacity and capability building are important and widely used methods( 1 – 4 ) to improve care pathways and service delivery in healthcare organisations( 5 , 6 ), and increase patient safety( 7 ). This is achieved by identifying, analysing and addressing quality issues and enhancing the efficiency of resource allocation( 3 , 5 , 8 ). It requires affective commitment from staff who identify a need for change as well as strong leadership support and active engagement( 9 ). Capacity building ensures there are enough staff trained in QI methods to implement projects, while capability building develops staff skills and confidence to implement QI projects( 10 ). The implementation of individual( 11 , 12 ) or organisation-wide projects( 13 – 17 ) are well documented in the literature. Examples include the Interprofessional QI program in the Netherlands, which facilitated interprofessional healthcare teams to design QI projects following online training and continuous support( 16 ); and the Safer Patients Initiatives in the U.K. which were whole-of-hospital, pre-prescribed (top-down) clinical improvements that were locally adapted( 15 , 17 ). There has been limited examination of the barriers and facilitators to effective implementation of sustainable QI training programs( 5 ), in particular cross disciplinary whole-of-hospital programs to improve quality of care through a combined top-down and bottom-up approach, warranting further investigation. The Continuous Improvement Program (CIP) has been run for 20 years by the Southern Adelaide Local Health District (SALHN), in South Australia. SALHN encompasses a tertiary teaching hospital, and a regional community hospital, as well as sub-acute, mental health and primary care services, with approximately 700 acute hospital beds( 5 ). Early iterations of the CIP were developed by the SALHN Department of Surgery and Perioperative Medicine in 2004( 5 ). CIP was adapted from frameworks( 18 – 22 ) including Lean methods and process redesign principals( 20 , 22 ), Model for Improvement methods[13], and key learnings from Intermountain Healthcare, Utah, USA( 5 , 18 , 19 ), to suit local needs( 5 , 23 , 24 ). CIP is led by an internal Continuous Improvement Unit (the Faculty) who support and mentor staff to enhance their QI skills and knowledge, and facilitate local CQI projects( 5 ). The CIP training is conducted with staff across the service and is designed to teach participants how to identify issues in the workplace, to problem solve and implement sustainable solutions by systematically using the SALHN 8-step continuous improvement framework( 5 ). Projects are designed and implemented by frontline healthcare workers at the interface of patient care, with the aim of achieving buy-in and adoption from healthcare staff. Project teams are trained and supported through continuous coaching from the Faculty to redesign processes, maximise capacity, enhance efficiency and reduce waste; all key strategies in overcapacity management( 25 ). Teams are supported to access data to measure baseline processes and monitor improvements, as well as provided with overt organisational permission and executive support for the interventions( 5 ). The most recent iteration of the program, CIP009 (2023/2024), is a novel CQI program which has been conducted using an innovative combined top-down and bottom-up approach. This integrates executive codesign of 12 CIP009 intervention topics aligned to hospital strategic priorities, with clinician design and implementation of 12 associated microsystem CQI projects. CIP009 has an overarching strategic macro-objective driving the projects to increase improvement capacity and capability and reduce ambulance ramping across SALHN hospitals. Emergency Department (ED) congestion and ambulance ramping is a persistent challenge, whereby patient flow from the ED across the hospital is impeded by various bottlenecks( 26 ), demand and bed capacity mismatches( 25 ), delaying the handover of patients from paramedics to ED clinicians( 26 ). Ramping has been shown to result in delayed triage and care, increased length of stay (LOS) and rates of admission, in addition to workforce burden and stress( 26 ). While ramping is related to increased demand for ED services and staff shortages across ED and ambulance services, challenges associated with hospital-wide patient flow also contribute to these issues by delaying patient transfer out of ED creating further delays for proceeding ED patients( 26 ). This qualitative evaluation study aimed to characterise the SALHN CIP009, a long-term improvement capacity and capability building training program, and examine the strengths and challenges of implementing 12 clinical micro-improvement projects. Methods Study design and setting: An exploratory, inductive and deductive pragmatic qualitative study design( 27 ) was used to evaluate CIP009. Interviews and focus groups were conducted with executives, coaches and participants. Participants were eligible if they had been involved in CIP009 as participants, coaches or in an executive capacity. Observations of presentations and training sessions, and project team meetings were conducted, and documents were reviewed to characterise the program. The study design, analysis and findings are reported in line with the Consolidated Criteria for Reporting Qualitative Studies (COREQ)( 28 ). Recruitment, Sampling strategy, data collection methods and data collection tools Indirect email and verbal recruitment of CIP009 project members, coaches, and executives was conducted by key contacts from the Faculty, circumventing recruitment by researchers. Participation was voluntary, and responses were treated confidentially with data de-identified. Interview recruitment continued along with iterative analysis, until data saturation was reached, and no new themes emerged( 29 ). Purposive sampling( 30 ) was used to ensure inclusion of participants from a range of health disciplines and with varying levels of experiences and participants self-selected by responding to recruitment invitations. Approximately 20–30 questions were asked in each individual and group interview. The semi-structured interview topic guide aimed to elucidate perceived strengths and challenges of the CIP009 (Appendix A). Questions were developed and reviewed by the research team and informed by the domains of the Consolidated Framework for Implementation Research (CFIR)( 31 ). All interviews and focus groups were audio-recorded, transcribed verbatim, and deidentified. Interviews were conducted by the first author (MB), an experienced qualitative researcher (PhD) who had no preexisting relationship with participants. Only the interviewer and interviewee(s) were present, and interviews were typically conducted on site in an office at a SALHN hospital, over the phone or by videoconference. Observations of CIP009 midpoint ‘report back’ and graduation sessions (where teams present their project progress and receive certification for completing the training course), and project team meetings were conducted in real-time or via video recording. All observations were conducted by MB, and field notes were taken. This enabled the researcher to develop a deeper understanding of the interactions between team members, as well as strengths and challenges to implementing the projects. Project team members were made up of CIP009 participants and core stakeholders. This ethnographic approach( 32 ) was used to observe team interactions and communication, how project work was planned and done. MB reviewed CIP009 documents to characterise the program. Data analysis Iterative and inductive thematic analysis( 33 ) was used to analyse the data from the interview and focus group transcripts, observations and field notes( 34 ). MB conducted the initial coding of transcripts, by reviewing the transcripts twice, then coding line by line to identify key codes and potential themes( 34 ), using the NVivo software v.14( 35 ). Once an initial coding framework was developed, MB recoded the data to verify the initial framework. Senior author (PH, professor) then reviewed the coding of a 10% sample of transcripts, after which themes and codes were discussed and refined through consensus decision making. Once the coding framework was finalised, MB recoded all the transcripts for a third time and finalised the key themes. Exemplar quotes were chosen to support the thematic framework, within which participants are identified by a code to maintain confidentiality. The document review informed the characterisation of the CIP009 program including mapping the milestones of the program, roles of clinicians and participants, and key strengths and challenges in line with the key themes identified. A deductive analysis of data was then conducted by MB to map the themes, subthemes and codes into the five CFIR domains( 31 ). The CFIR is a widely used framework for assessing implementation evaluation( 36 ) and was used to both inform the data collection, and to reassess the challenges and facilitators of the CIP009 implementation within SALHN. Data were triangulated to corroborate the findings across the three methods of data collection (observations, interviews and document review) and across participants from different roles and backgrounds (CIP faculty executives, coaches and project team members)( 37 ). Member checking was utilised through return of transcripts to interview participants to validate or amend the content before analysis began( 37 ). These techniques were used to enhance the reliability of the data analysis( 37 ). Results Between October 2023 and February 2024, participants, coaches and executives were interviewed face-to-face, over the phone or video conference by MB (n = 31) (Table 1 ). Each interview took on average 28 minutes. Three group interviews were conducted by MB using the same questions with: participants (n = 2, 20 minutes); coaches (n = 6, 80 minutes); and executives (n = 2, 18 minutes). Table 1 Interview Participant demographics Interview participant groups N CIP009 executives 6 CIP009 coaches 9 CIP009 participants 16 Participant clinical experience (Range 2–40 years)* 10 years or less 2 11–20 years 6 21 years or more 4 Participant Profession Nurse 5 Doctor 7 Allied Health Professional 4 *4 participants did not report their length of clinical experience Five CIP009 team meetings were observed, typically comprised of five team members and stakeholders plus a coach, each running for an hour on average, and one faculty meeting was observed, also an hour long. Teams typically discussed project progress, challenges, and made action plans for next steps. The midpoint presentations were observed (4.5 hours), as well as the graduation session (4.5 hours) and field notes were taken. Each team presented their progress at each of these sessions. CIP009 Faculty and team documents were reviewed (n = 78), such as: the training agenda, slides and notes, and recordings of guest lectures, midpoint and graduation presentation slides, recruitment and registration documents, support resources, team meeting agendas and minutes, project plans, project specific outlines of length of stay data, and draft protocols, training and presentation evaluation data. Analysis of these data enabled the characterisation of the program, along with the identification of key strengths and challenges associated with CIP009. Characterisation of the SALHN CIP009 program CIP background Since 2018, nine iterations of the CIP have been delivered, supporting over two hundred internal CQI projects over that timeframe. This has increased organisational awareness of the program, approaching a critical mass of staff having graduated from past CIPs, or with experience as CIP project stakeholders. The CIP is historically a 6-month CQI program delivered to staff which includes training sessions around the SALHN 8 step methodology( 5 ), and continuous support from CIP coaches and Faculty. Participants present project progress to their cohort at a midpoint presentation and at the graduation session (Table 2 ). CIP009 design In preparation for CIP009, 12 CIP project topics were selected and codesigned by hospital Division and CIP executives based on metrics such as high rates of admission, readmission, or length of stay. Project topics were designed to include at least two hospital Divisions involved in the patient care continuum, facilitating collaboration across the organisation. The CIP Faculty then conducted preliminary data analysis of the projects to gather baseline data and background information to justify and prepare each project for the 12 teams (Table 2 ). CIP009 recruitment CIP009 participants were typically nominated by their Heads of Units and Divisions and assigned to a CIP009 team. Project team members (doctors, nurses and allied health professionals) were multidisciplinary, with varying levels of seniority, from multiple divisions across SALHN. Each team was led by at least one CIP coach and some with an additional shadow coach in training. Team members were introduced to their coach by the Director of CIP and presented with the preliminary analysis and justification for the project topics (Table 2 ). CIP009 training and support CIP009 participants were provided with 3.5 days of training about CQI methodology and key objectives of CIP009 (Table 2 ). Participants were provided with resources to support the development of these skills. Sessions were delivered as seminars by the Faculty and senior executives, including shared experience of past CIP projects, and group workshops focused on practical cases. During and following the training sessions, teams initiated the CIP 8-step continuous improvement process, to identify, define and address their project issue. The most commonly reported data collection methods teams utilised included audits, electronic medical record analysis, observations and staff and patient surveys. The projects aimed to increase patient flow across micro-systems, with the intention of improving hospital-wide patient flow through the reduction in patient admission, readmission, length of stay and unwarranted clinical variation. The CIP009 teams were guided by improvement coaches, and the Faculty. Coaches played a project management role, accessing, conducting and supporting data analysis, providing expert CQI advice, and developing outputs such as presentations and protocols through face-to-face and virtual support. CIP009 teams met with their coaches regularly to discuss the project design and implementation plan. Coaches had a range of clinical backgrounds and CQI experience. All were graduates of a past CIP course and had shadowed another coach supporting a previous CIP team. Coaches received in-house training and mentoring, and regularly collaborated in Faculty brainstorming sessions to discuss CIP009 projects. In light of the complexity of projects, the Faculty and coaching support provided to CIP009 project teams was extended from a six-month program to over 18-months to enable teams to complete the SALHN 8 steps with wraparound support (Table 2 ). As a result, at the time of the evaluation, teams were still in the diagnostic and planning phases, and had not completed the SALHN 8 steps. Teams had typically refined the problem, conducted analysis including development of a cause-and-effect diagram, and identified outcomes to be measured. Table 2 Key CIP009 Project Milestones CIP009 Project Milestones: Preparation : • CIP009 projects (n = 12) were codesigned with clinical directors and SALHN division leadership Team Topic 1 Shorter Stays, Better Journeys: Improving back pain care 2 Alcohol presentations to ED 3 Preventing Delirium on 4D 4 Not just a failing heart 5 Standardising SALHN Mental Health Care Pathways for Clinical Presentations of Borderline Personality Disorder 6 Reducing short stay Undifferentiated abdominal pain admissions 7 Improving the patient flow processes at Southern Adelaide Palliative Care Services 8 Toe-Tal Improvement: Ramping Up Care for Patients with Diabetic Foot Infection 9 Future of Falls in Elderly at FMC 10 Bringing AIR (Acute Illnesses of the Respiratory Tract/System) in and out of Flinders Paediatrics 11 ED to Emergency Extended Care Unit Pathway 12 PV bleeding presentations to ED • CIP009 participants were nominated by division executives • Pre-training data analysis and project preparation conducted by coaches to justify projects to teams • Team introductions by director of CIP, preliminary analysis of projects discussed Commencement of CIP009 : • CIP training days (March 2023) including project team groupwork with coaches. Training day (hours) Topics Training day 1 (4.5h) Introduction to the ‘Towards Zero Ramping: Improving organisational capability through standardisation’ International Guest lectures-A Personal Journey in Acute Care Improvement Training day 2 (8.5h) Welcome from the Minister for Health and wellbeing Standardisation in clinical practice – reducing unnecessary variation Project pathways-Introduction of teams and project streams Continuous Improvement Principles Group Activity Continuous Improvement Program – 8 step Improvement Framework Diagnostic Tools ( 1 ) Breaking down the problem, focus on process mapping, tracking Work as imagined, work as done Allocation of small groups Part 1: draft milestones & stakeholders for process map (breakout rooms) Training day 3 (8.5h) Human Factors – The Influence on Healthcare Quality Measuring for Improvement Lessons learnt from protocol development over 20 years Small Group Work Part 2: further analysis of pathway and identify key steps/milestones (breakout rooms) Asking why Diagnostic Tools ( 2 ) Understand what to work on (tally sheets, brainstorming, Ishikawa, multi voting, Pareto charts) Consumer involvement- The value of having consumers on projects Small Group Work Part 3: discuss diagnostic plan (direct observations, plan mapping meeting, measure & mission statement) Training day 4 (7.5h) Data Clinician interface Ethics Approval Group Work – Part 3 continued: diagnostics: what will you do tomorrow? How to Publish Your Project Evidence: SALHN CI Sustainability Plan your Work, Work your Plan! Ready to Launch • Teams initiated the SALHN 8 step continuous improvement framework process Step Task 1 Define the Problem 2 Breakdown the Problem 3 Set a Target/Mission Statement 4 Root Cause Analysis 5 Improvement planning 6 Implementation 7 Evaluate/Assess Impact 8 Continuous Improvement • Continuous Support : CIP009 Project teams were provided with continuous support from coaches and Faculty (approximately 4 hours of support each week per team, via team meetings, data collection and analysis) • Stakeholder Engagement To further elucidate the root causes of selected problems, CIP009 participants recruited stakeholders to provide clinical insight and local knowledge to the problem-solving process through brainstorming and process mapping • Midpoint Report back session (June 2023) (4.5 hours) The project teams presented their progress at a midpoint report back session, and received feedback from the CIP009 teams, coaches, and Faculty. The hospital CEO and other SALHN executive attended these sessions and provided feedback to teams • Graduation Report back session (October 2023) (4.5 hours) The teams presented their progress to their CIP009 peers, coaches, Faculty and executive at their graduation ceremony, demonstrating their use of the 8 step CIP framework to design and implement a service improvement. Most teams had not completed the 8 steps by this point. They had refined the problem, conducted analysis including development of a cause-and-effect diagram, and identified outcomes to be measured • Planned ‘Where are you now?’ report back session (October 2024) The teams will present their progress and receive feedback from peers and executive. • Planned Sustainability following graduation (continuous support from the Faculty anticipated until project completion in June 2024) At intervention stage, teams report progress to executives and consumer adviser committees, for accountability and sustainability Thematic analysis of data identified seven key themes highlighting key challenges and strengths of CIP009 implementation within the SALHN setting: Four of the themes were focused on strengths of CIP009 implementation and captured concepts like: flattened hierarchy; wrap-around support from coaches; vested interests; and senior clinical change agents. Three themes were focused on key challenges of CIP009 implementation and included: individual workloads; issues in the way teams worked together; and training shortcomings (Fig. 1 ). Exemplar quotes (n = 36) from more than two thirds of interviewees are presented in Table 3 (22/31. 71%), including 21 quotes from CIP009 participants (n = 11/16, 69%), 8 quotes from coaches (n = 7/9, 71%) and 7 quotes from executives (n = 4/6, 67%). CIP009 Strengths Overwhelmingly, participants were positive about CIP009, and the improvements they had achieved in their teams. Four themes and subthemes were identified as strengths of CIP009 that facilitated the implementation of the projects (Fig. 1 ). Exemplar quotes are presented in Table 3 . Theme 1: CIP framework and culture embedded in the psyche of the SALHN organisation Key strengths of CIP009 included the flexible, adaptive, agile and transferable nature of the CIP methodology and the predetermined and clear nature of the projects. This enabled coaches to do preparation work identifying key literature and baseline data to present to teams and facilitated efficient problem definition and change implementation. The report back presentation sessions at midpoint and graduation were seen as an opportunity to learn from other teams and celebrate successes. Presentation deadlines held teams accountable, and the extended timeframe of CIP009 support facilitated progress of projects. Participants valued the protected time for training, away from clinical duties, to immerse themselves in the CQI topics (Quote 1). Many felt additional protected time would accelerate project progress. Achieving stakeholder buy-in and project engagement was considered essential to change, facilitated through coach support and networking. Participants valued the multidisciplinary and cross-divisional collaboration (particularly with ED), facilitated by CIP009, both in the composition of the teams, and engagement with stakeholders during brainstorming sessions and protocol development. This enabled teams to develop a clearer understanding of the patient journey end-to-end (Quote 2) and strengthen professional networks (Quote 3). Consumer involvement in projects was considered important but only utilised across some projects. SALHN was perceived to be moving towards critical mass regarding CIP training saturation, with awareness and engagement with CIP increasing exponentially (Quote 4). CIP has built a culture of inquiry over time, across SALHN, with continuous improvement ideas perceived to be embedded in the organisational psyche (Quote 5). The use of a standardised, adaptive and evidence-based framework to develop targeted improvements that is simple to follow and adapt to local problems, was valued. The SALHN CIP training builds improvement capacity and capability by teaching participants the skills to independently design and implement improvement projects. CIP009 however, had an outcome-focused strategic direction imposed upon the projects, with greater coaching support provided to facilitate and expedite progress of improvement projects. CIP009 was focused on organisational capacity building, efficiency and reducing waste, built on the foundation of organisation-wide CIP awareness and use of a common CQI language. This facilitated engagement with stakeholders who were already familiar with CIP (Quote 6). Participants valued the overarching hospital priority-aligned strategic approach used to address network-wide wicked problems (Quote 7) and the non-prescriptive combined top-down and bottom-up nature of CIP009. While executives nominated and codesigned the broad selection of CIP009 topics, clinicians at the patient interface valued their ownership over the design and implementation of the improvement projects (Quote 8). CIP has established avenues for ongoing accountability and sustainability of the improvement projects through regular reporting to committees and executives. However, few CIP participants commented on mechanisms for sustainability and accountability, possibly reflecting the early stages of the SALHN 8 step framework that they had reached. The CIP Faculty and program instilled a culture of flattened hierarchy, enabling participants to confidently engage with and discuss ideas across the team, enhancing collaboration. This was established through role modelling with coaches demonstrating humble enquiry and negotiation techniques as methods to constructively challenge current practices, and support change adoption (Quote 9). The CIP009 training sessions held off site were considered well-structured with interesting in-depth content. The theory and reference to the literature throughout the training content was generally well regarded, and participants felt the framework was applicable across disciplines. Many participants valued the lectures from the expert presenters (including international guests), the small group activities and the real-life examples of past CIP projects presented by alumni and coaches. These examples of learned experience, alongside the SALHN 8 step framework, were useful to shift mindsets around continuous improvement methodology (Quote 10). The team building benefits of the face-to-face sessions, and opportunities to network with other teams, coaches and participants, as well as provision of training resources were also valued. Theme 2: The benefits of support from a dedicated, internal improvement faculty Participants were complimentary about the large and experienced Faculty and leadership supporting the 12 CIP009 projects, and the breadth of knowledge coaches demonstrated (Quote 11). CIP Faculty executives played a key role as gatekeepers of coach workload to protect coach capacity to support CIP009 teams. The increased provision of coach support for CIP009, relative to past CIPs, resulted in a perceived higher standard of project outcomes. The continuous and resourced nature of Faculty CIP009 support was invaluable and seen to minimise the workload burden on CIP009 participants and ensure projects progressed. The internal nature of the Faculty meant the coaches could provide indispensable organisational knowledge-based advice (Quote 12). The Faculty also advocated for improvement changes that required policy escalation or changes to workflow and helped to navigate occasional challenging dynamics across divisions, as neutral stakeholders. Faculty staff who were embedded within executive teams and divisions, wielded influence to engage executives with change initiatives. High executive and leadership awareness, understanding and support of the CIP009 projects across SALHN was perceived to facilitate improvements, staff buy in, and minimise governance barriers. Participants also felt that executive attendance at the CIP009 training and presentation days increased recognition of and institutional support for their improvement initiatives. Similarly, ED leadership support of projects validated improvement programs and facilitated staff buy-in. Coaches and Faculty staff were considered to be a key strength of the CIP009 program demonstrating enthusiasm, commitment and belief in the value of each project (Quote 13). Coach support was respectful and encouraging, but not prescriptive (Quote 14). Coach clinical knowledge was another key strength perceived to facilitate project progress. Coaches aimed to provide a standardised approach to project support and facilitation, and the Faculty team promoted a culture of support and beneficence through their training, resources and coaching, which facilitated engagement with stakeholders. The extensive wrap-around support from coaches who were embedded in teams was considered a key strength of CIP009 (Quote 15). This included data sourcing and analysis, proactive project management, and output development such as protocols and preparation of presentations. This reduced the burden on participants (Quote 16) and freed up participant time to provide expert clinical advice on the improvement design and implementation. The coaches led the teams through the 8-step continuous improvement framework, providing structured guidance and feedback and preventing teams from jumping to solutions. The coaches who were embedded in Divisions were considered particularly helpful as they had pre-established relationships with staff, facilitating stakeholder engagement with the projects, as well as having greater clinical understanding of the project. Coaches were considered experts in improvement, with their process knowledge helpful to guide feasible intervention design and facilitate change. Coaches were also seen to have strong professional networks which were useful to progress interventions. Coaches coordinated regular meetings and communication between team members to maintain project momentum and hold team members accountable, without overburdening them. Team members valued these often-weekly meetings, particularly the flexible nature of the hybrid face-to-face and virtual meetings, and clear communication about expectations, task setting and virtual communication when they were unable to attend in real time. Theme 3: The advantages of an enthusiastic participant disposition and incentives Individual team members’ disposition was considered to have an impact on project progress, with an appetite for change, and respect and belief in CIP009 to achieve change being valuable characteristics. Participants, naturally, began the CIP009 course with varying skills and experience, but their capacity to be open to feedback and to show initiative was beneficial. The CIP009 process helped participants gain insight into the contributing factors of their project problem, which were often different to what they expected. Project progress was best supported by team members who managed their time to complete project tasks and meet with their teams regularly, by prioritising other work commitments. Past CIP participants had often become continuous improvement advocates themselves after graduating from CIP (Quote 17). There were various incentives identified to complete the CIP009 project including: a shared vision of beneficence and developing capability to improve patient support end-to-end; benefits to career progression; continuing professional development (CPD) points; easing workflow demands for staff; learning how to break down problems and design and implement effective feasible solutions; opportunities to network and collaborate with consultants to improve processes; gaining new perspectives on patient journeys from team members; supporting teammates; and opportunities for publication. Almost all participants reported a vested interest in the improvement being delivered effectively, with many projects being seen as impactful and meaningful to the team members. Theme 4: Effective teams and team composition Team cohesion and collaboration in the teams were important factors, ensuring that participants felt solutions to the identified problems were not imposed upon them, but generated together. The composition of team members was important, with value seen in having a balance between expertise from more senior medical staff, and members with capacity to do the work, with the later role predominantly falling to nursing and allied health-based team members (Quote 18). However, these staff often reported not having time to ‘do’ the work on top of their clinical workloads. The more senior participants were seen as change agents who facilitate change adoption, particularly through medical and surgical staff engagement. The multidisciplinary nature of teams was seen as a strength of CIP009. Familiarity with team members was also considered valuable, with pre-existing rapport facilitating smoother teamwork. Ensuring the team members were engaged and positive about the project was important, as was engaging the right stakeholders, particularly those from ED, to provide input and new perspectives. CIP009 Challenges This iteration of the CIP program had a focus on improving patient flow in comparison to past capability building CIPs. CIP is firmly embedded within SALHN culture, with CIP language common across SALHN, and leadership support facilitated through executive, and senior staff involvement in the CIP training and projects. Despite these factors, challenges persist. The thematic analysis identified three themes that represented challenges of CIP009 (Fig. 1 ). Exemplar quotes are presented in Table 3 . Theme 5 : Workforce and Organisation-level challenges of improvements Limited time and capacity to engage in the project was the most commonly reported organisational-level challenge for CIP009 teams. Competing priorities and clinical duties limited opportunities to meet and coproduce the work. Some felt that the timing of their improvement project implementation was impeded by other priorities that detracted from stakeholder engagement with the projects, such as accreditation. Participants talked about the importance of teams being ready, mature and capable for CIP009 and how if the team was in crisis-mode, from other stressors like workforce issues or seasonal demand, this was seen to detract from their ability to conduct improvement projects effectively (Quote 19). Workforce capacity and operational demand challenges included balancing annual leave, staff capacity with seasonal fluctuations in operational demand, and workforce shortages (Quote 20). Fitting the additional workload of CIP009 into daily workflow was challenging for many and created additional pressure. This was alleviated to some extent by the extensive wraparound support provided by coaches (Quote 21). Many participants noted that there was no sanctioned time to engage with the projects, other than the training days, mid-point and graduation sessions. They posited that additional protected time from clinical duties to immerse themselves in the project would facilitate the implementation of each improvement project (Quote 22). The timeframe of CIP009 (despite the extension) was perceived by many as too brief to progress through the SALHN 8 steps and achieve the types of improvements that had been designed, increasing pressure on participants (Quote 23). Another frequently discussed challenge was the poor access to electronic patient data and poor data quality (due to documentation variation) to support the improvement process. Access to data for both baseline problem analysis, and monitoring of change was a challenge noted by many participants, and led to project delays, frustration, and increased workload for the coaches (Quote 24). Delays to technological infrastructure (ICT) improvement changes, limited physical infrastructure such as bed capacity for improvement projects, governance approval processes delays, and medico legal barriers (which were reportedly time consuming to navigate), were all thought to impeded project progress (Quote 25). Theme 6: Team cohesion, logistics and stakeholder engagement challenges Team-based challenges were predominantly around logistics with team members and stakeholders located across divisions and locations making it challenging to schedule project meetings. This resulted in poor momentum for some teams. Participants felt that the composition of their core teams could have had greater representation from different Divisions, specifically ED, and General Medicine (Quote 26). Participants posited that greater involvement of diverse stakeholders, especially those previously CIP trained, would have enabled a greater understanding of the improvement projects, and enhanced adoption of the changes. Several participants and coaches discussed how challenging it was when there was unequal contribution, engagement and collaboration from team members. The composition of CIP009 teams was purposefully skewed toward more senior, executive, medical and surgical-specific staff who were perceived to be more time poor than their nursing and allied health counterparts. Utilisation of these individuals’ expertise and seniority meant that there was a greater reliance on coaches to provide the wrap around support (Quote 27). Some participants discussed poor team cohesion and a lack of consensus to be a challenge to overcome as they progressed, particularly when the team lacked clarity around the definition of the problem they were provided with. Project complexity, including complex patient cohorts, made problem definition challenging, impacting the design and implementation of feasible improvements. Similarly, not having a prior relationship with their team members meant some felt less accountable to their team (Quote 28). Careful team and coach alignment, as well as trust and rapport between teams and the Faculty were important to ensure participants felt confident they would be supported to succeed. Lack of engagement from stakeholders across the hospital (particularly surgical and medical-based clinicians and ED stakeholders) and resistance to change (Quote 29) were common challenges, which impacted the navigation, design and implementation of some improvement projects. Some participants reflected that it was difficult readjusting their thinking to the CIP009 framework to avoid jumping to solutions, and coaches noted that the expectation of participants to immediately generate solutions was challenging. Implementing projects and achieving behaviour change in a short timeframe was demanding, and depending on the project, required ongoing continuous support from coaches for an extended period of time to achieve desired outcomes. Implementation of projects was challenging, both in gaining stakeholder buy in and engagement and adoption of protocols, to achieve practice change and translation of evidence into practice. Several teams had not integrated consumer codesign into their improvement planning and design, and noted that this was an oversight, acknowledging the importance of consumer input as something that they would improve upon in future projects. Theme 7: CIP009 training and support shortcomings The length of the CIP009 3.5-day training sessions was perceived as too long for some staff to be away from clinical duties, with some staff feeling burdened if their roles were not backfilled (Quote 30). Some participants felt that lectures were too long, with some repetitive, redundant, superficial and disjointed content, and felt that the guest lectures were not given enough context to be relevant (Quote 31). Some team members were observed to not stay for the whole duration of the training days, supporting these concerns. Several participants felt that there was not enough group planning time with their team to progress their project, perhaps resulting in a missed opportunity to maximise momentum and enthusiasm from the training days (Quote 32). Similarly, some participants felt that they had limited team time with their coach during the training days, particularly when coaches were split across multiple teams, leaving some teams unsure how to proceed while waiting for their coach to return (Quote 33). Several participants noted that CIP009 projects were outcome focused rather than capability focused as past CIPs have been, with additional wrap around support from coaches meaning that the team members had fewer opportunities to practice the skills learnt in the CIP009 training course. Communication about expectations of participant commitment was another challenge identified. Some participants felt presentation fatigue after presenting project results across multiple forums (the midpoint session, graduation day and to executive committees), suggesting they could record their presentations to reduce time away from clinical duties. Participants also noted that the lack of notice around the commencement of the CIP009 program and training days created scheduling conflicts with clinical commitments, increasing staff burden. As a result of limited communication, some participants felt they were being enrolled in the program as a result of poor performance and had negative reactions to being nominated by Divisional Directors and Heads of Departments. That quickly dissipated once they understood the purpose of the program and why their role was integral to the improvement project. Some felt the prescriptive nature of this process reduced their internal motivation, while others felt that such external support for the projects was motivating (Quote 34). Many participants felt that the rapid design and top-down selection of project problems by executive, rather than by each team impacted their engagement with the project initially, and limited opportunities for codesign with project team members. This resulted in some topics being seen as less valuable or meaningful to solve compared to others (Quote 35). There was some scepticism noted about whether the CIP framework and 12 CIP009 projects would be able to impact patient flow and ramping in a significant way, with the sentiment that the CIP009 framework was useful for some projects, but not all (Quote 36). These participants highlighted that CIP was one of several methodologies being supported by the LHN working towards enhancing patient flow. In terms of sustainability, several participants discussed how they had not yet set plans in place for ongoing monitoring and adjustment of their projects. This may be reflective of the stage the teams were at, still focused on problem clarification, solution generation and implementation at the time of interviews. There was, however, concern that projects would drop off the radar once Faculty coaching support was reduced, and competing priorities took over participants’ workloads, particularly for projects viewed as person dependent. Table 3 Quotes representing the key strengths and challenges of CIP009 # Quote and participant number (p) Strengths Theme 1: CIP framework and culture embedded in the psyche of the SALHN organisation 1 “That’s a really valuable thing for a clinical leader to be taken out of the environments [so] that they can just really focus on that.” (p31, CIP009 participant) 2 “O ne of the key, kind of, crucial, it was the culture piece as well, to say ‘Actually this is what’s happening in my piece of the world. But what’s happening over there in yours?’ And that has been probably one of the biggest things when I’ve gone to a lot of the process mapping etcetera, it’s just the team seeing an alternate view or alternate perspective of how that patient is managed. ” (p6, executive) 3 “ Meeting other people and you get to know a different group of people in the hospital who we may never cross paths with. So, I think that relationship stuff’s great .” (p19, CIP009 participant) 4 “We’ve had nine other CIPs where we’ve trained a lot of other people, like, I think in terms of the trust and the interest and the knowledge of the general workforce in terms of even just participating in mapping sessions, I do think that’s been a critical factor to the success of this one, in the sense of, you know, people trusting the process.” (p20, CIP009 coach) 5 “Lots of other people have bought into [CIP] culture over the years, and I think, we’re seeing the end product of multiple decades of that.” (p2, CIP009 participant) 6 “Everybody then knows the common language and it’s transferable into that building that culture of, you know, change management.” (p12, CIP009 participant) 7 “[We used] the CIP as a strategic plan to be able to look at involving clinicians at the patient-clinician interface to systematically fix ambulance ramping because we know that ambulance ramping is a symptom of delays across the entire quantum of care.” (p6, executive) 8 “Everybody jumped on board because we all had a common purpose, so that was fine. But I think the real strength of it is that you can, you know, yes, you may well be given an area, but you can really delve down what’s most important and really focus on that.” (p19, CIP009 participant) 9 “[The CIP faculty are] very good at, I think, challenging the way that some of the ED people think, and actually in reshaping that. But also, I guess empowering them to say what’s wrong and involving them in the process of improving it. Umm. So yeah, we love the CIP.” (p22, executive) 10 “I think the fact that the facilitators were able to relate past stories or past examples where the process had worked, it was really good. So, we knew that even if we were early on in the process and it wasn't, and it wasn't really clear what direction we were heading, we knew that we have people who were experienced in this, had gotten results and the process had worked for them. That was a key motivator throughout.” (p2, CIP009 participant) Theme 2: The benefits of support from a dedicated, internal improvement faculty 11 “They're very experienced and they can see the wood for the trees, and I think that's really valuable.” (p23, executive) 12 “We have that capability that's in-house, we can network well with the process owners, and we can leverage that in a, in a very, very critical manner, comparative to other organisations. So, people who in in another situation, in comparison with other organisations, consultants would come from outside organisations like KPMG, EY, Deloitte, PwC. They would come, recommend and go, but they would not stay for the whole process. But I think we have from start to finish, end to end visibility, engagement.” (p16, CIP009 coach) 13 “We've got a lot riding on this, and the focus was patient flow and how we can actually make a difference with patient flow. And I think our reputations were on the line with this a little bit as well because we live and breathe this, and we I think every single one of us in this room 100% believes in the methodology. And we have a point to make now that this methodology can make a difference.” (p14, CIP009 coach). 14 “ [Coach] was really good. Like, it's really nice to have someone who's so keen to drive, sort of, everything, but also be so positive as well. Actually, I never felt like I was being told what to do. Like, [coach] wasn ’ t condescending or anything. Like, the whole, like, CIP team in general have been really supportive, which has been, umm, I think encourages you to want to do more, like, quality improvement projects and, like, it sort of helped us prioritise quality improvement in, in along with our clinical load as well, if that makes sense. So, I think yeah, that would be the strength, would be definitely the facilitator.” ( p21, CIP009 participant) 15 “I think the CIP team as a whole have been an amazing support for the ED this year, but they are very good at doing a wraparound support, I guess to take some of the smaller tasks away from us, you know, data collection. They’re very good at presenting the data analysis, and I think in trying to change the way that you think. I think as clinicians, we are good at jumping at problems and solutions very quickly. And I think, in slowing down that process, sometimes you really get the data you need to really understand the problem, which I think is really valuable.” (p22, executive) 16 “We know that our clinicians are doing this over and above their day jobs, yeah. And so, I think to actually have our support to know that the work could still progress without falling on their shoulders made a big, big difference.” (p5, CIP009 coach) Theme 3: The advantages of an enthusiastic participant disposition and incentives 17 “A lot then go on to really become fierce advocates and do continue to do things because it becomes, they adopt this, this, as their way of doing business. And that really does assist in reaching a tipping point within the organisation of enough people to really do things at scale… one of the greatest things to initiate cultural change is to align people on an improvement journey.” (p17, executive) Theme 4: Effective teams and team composition 18 “I think the strengths are the level of expertise of the people that are participating. The fact that it has support from the CEO here at [hospital], and you know high levels here at [hospital], it's definitely a priority that we're all interested in working towards, and people are very motivated to make change in that area. Especially people who have come on board from general medicine.” (p1, CIP009 participant) Theme 5: Workforce and Organisation-level challenges of improvements 19 “We've got, we've got a capability level that doesn't match what the CIP was trying to pull us to. [Our] NUM is absolutely stretched beyond capacity ... Does she have time to do this other extra thing? No. … So, if we set up our own CIP, we will set it at the level we need to set it at … we did feel a little bit like somehow this process was generating pressure and it was generating pressure in a way that wasn't always helpful.” (p29, CIP009 participant) 20 “So, I know there has been feedback in the past about, sort of, how slow some of these projects move. But I don't know how you could do that any differently in the environment that we're in. Yeah, because there’s such high staff turnover. People are on annual leave. People are on sick leave, like, it's just lots of moving parts.” (p30, CIP009 participant) Challenges 21 “I think it has been hampered by workloads. Yeah, absolutely have, and it's sort of, it's, if you've got a bunch of people who are completely overloaded and barely hanging on by their fingernails, and then they have to go and do this other stuff on top, it really does wear people's goodwill right down, yeah. And so, I think there were moments where we were really hanging on by fingernails. … It's yet another stressor: we had accreditation; we had training, like the medical accreditation as well. This CIP has added significantly to the distress of people in this department.” (p29, CIP009 participant) 22 “ I think it's been a significant workload, like around our clinical workload. It would have been nice to have some sanctioned time. We didn't get any sanctioned time. ” (p1, CIP009 participant) 23 “My personal view is that [6 months] is too, too quick to, you know, and we did spread it to what it ended up being [many more] months. And I, my personal view is that, you know, at least a nine-month course would actually give that time… But I think that, you know, six months, like, with sick leave and people's annual leave, and you know, so it ends up not there in six months if people take some leave in between.” (p9, CIP009 coach)) 24 “We got told that we would get given datasets for this. And we waited so long, and we were losing so much time that in the end, like, I found some, like, work arounds to actually pull it manually. And it probably, it took hours and hours of my time, but at least I had something that I could then give the team to say, ‘What do you think?’. I know that it could have been done a lot more efficiently.” (p14, CIP009 coach) 25 “That's the other challenge is when we come up with some interventions and it's anything to do with EMR. It's a statewide EMR system. So, we need to make sure that every other LHN providing the same service actually want to invest in that as well. So, we'll put an improvement ticket in, but it takes years for anything to happen. So, that's probably another challenge and a barrier to implementation” (p8, CIP009 coach) Theme 6: Team cohesion, logistics and stakeholder engagement challenges 26 “Initially in our, in our CIP, we did not have the emergency physicians. I mean, we are talking about [project topic] in emergency medicine and emergency department. And not having any representation from emergency was a bit hard. But even before we started the program, I approached the emergency medicine physicians who are keen to ma[ke] a patient journey through ED, quicker, easier, safer, providing them comprehensive assessment. So, the people who were keen, I already contacted them as well.” (p10, CIP009 participant) 27 “I think where we've lost capability build is we didn't have as many nurses, or we didn't have as many allied health, or other wrap around supports that would have been doing the course with them. But at the same time, I think what we did is we had a mindset change that this is the way we're going to approach problems within our units or Divisions. And this is also, ‘ I'm then gonna provide the authority to release some of my junior staff to do in future’ . So, I think, that was probably a good thing.” (p6, executive) 28 “I didn't know the team. Yeah, like, we were all strangers… When you don't have a personal relationship with someone in the team, you don't feel as accountable to them… If I'm working with my colleagues, they're my friends. Like, you don’t want to let them down… I think it was tricky trying to work with people that you've never worked with before.” (p30, CIP009 participant) 29 “But some of the barriers to that are, um, the teams that would be, um, overseeing those patients are quite resistant to change. They probably have quite a lot of change fatigue, and so when [our change initiative] was originally put through the senior consultants, they were like, ‘Absolutely not. No way’. So, there's potential that you may come up with an option for, you know, an alternative pathway and alternative location. But the barrier then may be, ‘No, we don't wanna change anything. Let's just leave it as it is’. So, it may be a very long-term solution that may take a lot of discussions and a lot of ongoing, and you know, mitigation strategies to say, ‘Oh, OK, the reason it would be a better option for patients is because we've engaged with consumers, and this is their feedback. This is a safety mechanism’.” (p7, CIP009 coach) Theme 7: CIP009 Training and support shortcomings 30 “W e had so many conflicting demands. And so, like, my phone was going constantly, you know, we had no cover. No one was covering our roles like so, taking three days off our normal jobs, it just meant that when we got back, we were swamped with so much work ” (p12, CIP009 participant) 31 “ I would say some of the material or lectures are redundant. And 3 1/2 days. Whether it's really that necessary to be that long is my main point and so personally, I mean, this is my opinion. I think it probably [could] be able to be condensed, the course into a maximum 1 1/2 days… even some of the lectures or guest lectures may not be all that necessary.” (p28, CIP009 participant) 32 “I think only a small amount of that time is dedicated to actually working on the actual problem. Like, you do little bits of it, but I wonder, if the teams, given they are actually together and the time’s already secured, would benefit from 1/2 day at the end or something to, um, really get the [project] kick started, going.” (p19, CIP009 participant). 33 “[I was] a bit unclear about what our task was. I probably would have wanted, maybe, more time with the coach. Because I know that the coaches had, like, multiple different teams. It would often be like set with the task and then you were sort of sitting down with strangers trying to complete a task you don't really understand. It would have been nice to have the coach there, sort of, driving that a little bit more so we had more of an understanding of what you're meant to be doing.” (p30, CIP009 participant) 34 “I rocked up at the course and I remember spending like the first two days, just being like, ‘What are these people talking about?... And there were lots of people, like I said, just thrown into it who didn't really want to do it…And I think the nature of the CIP009 was because we weren't a cohesive group that had come at it, like, chosen to, sort of, come at it together, I feel like that made it a lot harder. Like I've got colleagues who have done it before, and they've done it with their colleague with a really clear project in mind. So, you've got that, you've already got that buy-in. Like, they desperately want to be there, and they want to do it and they want to complete this project. That's why they signed up to it, whereas this was sort of thrust upon us a little bit more, so I feel like the coaches probably had to do more.” (p30, CIP009 participant) 35 “I must say, this year, because it was like, that focus on ramping and we got allocated our thing, it did, it wasn't the priority for me... I would have chosen a different priority.” (p29, CIP009 participant) 36 “I found, so that's why I think it was a little bit shallow, in that it was maybe asking for such a huge problem like ramping, you’ve gotta delve way deeper than the CIP course did…So, [CIP’s] really good for little problems, I think. Like, really good for some money saving, streamlining little problems that you would have on the wards or in outpatients or wherever.” (p24, CIP009 participant) The seven themes and subthemes representing determinants for CIP009 were deductively mapped against the five domains of the CFIR framework (Innovation, outer setting, inner setting, individual and implementation process)( 31 ) (Table 4 ). Mapping these strengths and challenges against the theoretical framework reinforced how each subtheme was aligned with the different levels of determinants most likely to influence the implementation of CIP009 and the 12 CQI interventions. A large proportion of key strengths and challenges were mapped to the inner setting domain of the intervention relating to teams and culture. Table 4 Strengths and challenges of CIP009 mapped against the CFIR domains ( 31 ). Themes Subthemes of Key strengths and challenges associated with CIP009 implementation Innovation domain Innovation Source, Evidence-Base, Relative Advantage, Adaptability, Trialability, Complexity, Design, Cost Theme 1 CIP framework and culture embedded in the psyche of the organisation • Strategic approach to capacity and capability building • Flexible and adaptive evidence-based program • Training strengths Theme 2 The benefits of support from a dedicated, internal improvement Faculty • An experienced internal faculty • Clinical directors and coaches embedded in divisions and within executive structures • Continuous wrap around support from knowledgeable and passionate coaches • Stable continuous support from an internal and well-resourced faculty Theme 7 Training and support shortcomings • Training shortcomings • Top-down and outcomes focus limiting codesign with staff • Scepticism related to complexity of issues Outer setting domain Critical Incidents, Local Attitudes, Local Conditions, Partnerships & Connections, Policies & Laws, Financing, External Pressure Theme 5 Workforce and organisation-level challenges of improvements • Infrastructural and ICT challenges (medicolegal and governance approvals) • Data access and quality • Workforce capacity Inner setting domain Structural Characteristics, Relational Connections, Communications, Culture, Tension for Change, Compatibility, Relative Priority, Incentive Systems, Mission Alignment, Available Resources, Access to Knowledge & Information Theme 1 CIP framework and culture embedded in the psyche of the organisation • Culture of flattened hierarchy • Accountability • Awareness of CIP and culture of enquiry Professional relationships, buy-in and engagement Theme 2 The benefits of support from a dedicated, internal improvement Faculty • Regular multimodal meetings with coaches and clear, respectful communication Theme 3 The advantages of an enthusiastic participant disposition and incentives • Shared vision of beneficence, and improving workflow and patient care end to end • Opportunities to collaborate across divisions and with consultants Theme 4 Effective teams and team composition • Team cohesion and collaboration • Multidisciplinary teams • Engagement with the right stakeholders • Senior team members as change agents • Balance of expertise and capacity to enact change Theme 6 Team cohesion, logistics and stakeholder engagement challenges • Team cohesion challenges • Team logistical challenges • Lack of stakeholder engagement and buy-in Theme 7 Training and support shortcomings • Communication issues Individual domain – roles and characteristics High-level and Mid-level leaders, Opinion Leaders, Implementation (Impl) Facilitators, Impl Leads, Impl Team Members, Other Impl Support, Innovation Deliverers, Innovation Recipients, Need, Capability, Opportunity, Motivation Theme 3 The advantages of an enthusiastic participant disposition and incentives • Participant disposition, belief in the program and skill level • Enthusiasm to learn how to break down problems • Capacity to rearrange priorities to complete tasks • Vested interests to improve care and workflow • Gaining new perspectives on patient journeys • Professional incentives like CPD points and career progression Theme 5 Workforce and organisation-level challenges of improvements • Clinician workloads, competing priorities and time Implementation process domain Teaming, Assessing Needs, Assessing Context, Planning, Tailoring Strategies, Engaging, Doing, Reflecting & Evaluating, Adapting Theme 7 Training and support shortcomings • Sustainability planning issues The key subthemes of the CIP009 were then collapsed into a more simplified structure of macro (hospital, outer setting), meso (teams, inner setting) and micro (individual) levels of the SALHN organisation, along with the key elements of the CIP009 program such as training and wraparound support from the Faculty. The fundamental elements of the CIP009 that were perceived to contribute to the implementation of CIP009 and its organisation-wide goal of improved patient flow and reduced ramping can be visualised in Fig. 2 . Discussion Overview of the CIP009 evaluation This evaluation of the SALHN CIP009, which encompassed interviews, observations and document review, has identified key factors impacting the perceived success of the CIP009 improvement program across seven themes: The first four themes related to key strengths of CIP009, and the final three themes related to challenges. The Learning Health System The key elements of CIP009 described in this evaluation together contribute to a culture of continuous improvement to enhance the delivery of patient care. A concept of a Learning Health System has been rapidly evolving in recent years and refers to a systems approach to support organisations to establish data-informed continuous learning processes to incorporate best practice into routine care( 36 , 38 , 39 ). The Institute of Medicine defined an LHS as one where “ science, informatics, patient-clinician partnerships, incentives, and culture are aligned to promote and enable continuous and real-time improvement in both the effectiveness and efficiency of care ”(40, p17). This evaluation identified that CIP009 is underpinned by elements essential to a sustainable Learning Health System (LHS)( 41 ). For example, key LHS elements that were found in this evaluation of the SALHN CIP009 include improvements to health and care processes that are delivered through data-driven research that inform changes to practice( 38 , 40 ). Similarly, continuous improvement cycles that utilise data and data infrastructure( 42 , 43 ) to inform practice change, followed by the implementation, assessment and amendments of the practice improvements( 38 , 44 ) were utilised by CIP009. Sustainable LHSs are grounded in systematic frameworks, have strong commitment from leadership to capture organisational priorities( 44 ) and align incentives( 42 ), are well resourced( 43 ), and establish a supportive culture of continuous learning( 42 – 44 ). LHSs must be supported by an engaged and skilled workforce( 43 ) with improvement capacity and capability( 44 ). An LHS can also enhance cross organisational collaboration by connecting siloed clinicians( 44 ) as well as consumers and the community who are actively involved in the processes of continuous improvement( 36 , 42 ). CIP009 has contributed to the development of these LHS elements within SALHN, with many of the themes from this evaluation reflected in the LHS literature. CIP009 has demonstrated the importance, and indeed the challenges, of access to quality routine service delivery data to inform the design of interventions at the patient-clinician interface (Theme 5)( 44 ). The longevity of the program has enabled CIP to evolve, establishing a systematic framework, CQI infrastructure, and a Faculty of knowledgeable personnel to provide continuous support and facilitate change (Theme 1)( 44 ). The novel combined top-down and bottom-up nature of CIP009 resulted in executive support for and investment in the program, while retaining participant design and ownership of the projects( 45 ), and motivation to sustain changes (Themes 1 and 2)( 46 ). Strong leadership support was perceived to contribute to the uptake and adoption of CIP009( 47 ). This support combined with the sustained resourcing for CIP009 has helped to build capability within the workforce (Theme 2)( 44 ), implement CQI interventions( 48 ), and enhance team accountability (Themes 1 and 2)( 25 ). CIP009 projects were also closely aligned with organisational priorities achieved through leadership codesign of CQI project topics to improve patient flow (Theme 1)( 49 ). CIP009 established a culture of inquiry and continuous learning( 44 , 50 ), with inhouse continuous wrap-around support( 48 ) to develop technical skills and CQI knowledge (Themes 1 and 2)( 16 ). The perceived cultural change at the organisational level (Theme 1) was achieved through increased awareness and engagement with the structured framework, language and methodology( 6 ), potentially mitigating loss of CIP knowledge from staff turnover( 45 ). CIP009 also focused on engagement and co-design of CQI interventions with key stakeholders (Theme 1). Stakeholder and leadership buy-in was facilitated through a combination of a flattened hierarchy and encouragement of equal participation by team members (Theme 1)( 51 , 52 ), and continuous support from coaches (Theme 2)( 53 , 54 ). The transformational leadership style( 55 ) used by coaches ensured momentum and coordination was maintained, and change mechanisms effectively communicated to persuade change adoption (Theme 2)( 48 ). Participant belief in the value of reducing unwarranted variation in practice and vested interests to improve care and workflow (Theme 3)( 56 ), multidisciplinary and interprofessional teams who provided insight into systems and processes( 16 ) and interdivisional collaboration (Theme 4)( 44 ) also contributed to staff buy-in. These elements are each fundamental to address the wicked problems that persist within the complex adaptive system that is healthcare( 57 ). The ongoing nature of CIP has meant that a large proportion of SALHN staff have graduated from CIP training, developing a community of CQI experts (Theme 1)( 16 ). CIP009 has endeavored to embed best practice into routine care( 25 ), and improve the value and efficiency of processes( 41 ) through data driven improvements( 44 ), contributing to the establishment of an LHS within SALHN. Quality Improvement and Implementation Science CIP009 teams faced implementation barriers such as overcoming resistance to change and achieving buy-in, in particular with the development and adoption of protocols to reduce unwarranted variation (Theme 6), both common barriers to guideline adherence( 58 , 59 ). This speaks to an aim to enhance translation of evidence into practice ( 59 ), the foundation of Implementation science( 60 ), while concurrently aiming to improve efficiency and effectiveness of processes and practice( 61 ). Implementation science elements that focus on the diffusion, dissemination, implementation, adoption and sustainability of the CQI interventions could be further integrated within the initial stages of the CIP project planning framework, to provide opportunity to identify, plan for and mitigate implementation challenges( 62 ). Implementation science highlights the importance of change efforts being grounded in principles of behaviour change( 61 ). Guidance from behaviour change models such as the Theoretical Domains Framework (TDF)( 63 ) during the CIP009 project planning phase, may increase the likelihood that interventions will achieve change( 63 ). To ensure changes are effectively embedded within organisational practice and sustained, long-term periodic feedback and evaluation of interventions should also be embedded within the early CQI project planning phase, to ensure the intervention remains applicable to the setting and sustainability is considered from the beginning of the project( 60 , 64 , 65 ). Further integration of implementation science and CQI theories and strategies would guide CIP participants on how to best support change adoption by considering local contexts and determinants (barriers and facilitators) of change, as outlined in the CFIR( 31 ) and Table 4 , and to discern whether their change initiatives have been maintained, sustained and improved over time( 60 ). In line with this, the nature of support from an internal CIP009 Faculty enabled coaches to provide contextually relevant guidance and project facilitation. Robust planning for implementation, sustainability and accountability, informed by an evidence based framework such as the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework( 66 ), the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM framework)( 67 ) or the Proctor Taxonomy of Implementation Outcomes( 68 ) would ensure the best opportunities for the implemented changes to continue( 36 ). The concept of sustainability is already incorporated within the SALHN CIP009 Continuous Improvement framework. However, the limited planning for, or application of sustainability processes reported by interviewees both reflects their early stage of progress within the SALHN 8-step framework but also indicates an opportunity for sustainability planning to be integrated at an earlier stage of CIP009. Quality improvement and implementation science differ methodologically, however there is potential for synergies that could enhance CIP patient care improvements. The bottom-up and top-down nature of this CQI program engages local stakeholders with strong leadership support and continuous measurement and adaptation to practice changes. This may be complemented by implementation science insights into mechanisms for contextually specific practice and behaviour change underpinned by theory and evidence. Systematic incorporation of implementation science frameworks may promote planning for both summative outcomes assessment as well as interim progress assessments to support adaptations and project sustainability( 36 ). Opportunities for Improvement Reflecting on the key perceived challenges of CIP009, overcoming limited clinician time to engage in CQI projects (Theme 5) is essential to establish an effective Learning Health System, and requires further organisational commitment to protect and resource clinician time for CQI involvement( 44 ). Multimodal and online modules of training may enhance the accessibility of CIP resources( 16 , 69 ). Similarly, CIP resources could be provided in an electronic format, within a repository of trusted and endorsed CQI education, support, and data analysis training resources, CIP case studies, online lectures to enable participants to refresh their understanding of concepts, and additional data analysis resources for those participants who want to extend their learning. A blended virtual and face-to-face model, along with greater protected time for training and implementation of the projects, may support those clinicians with competing clinical priorities (Themes 5 and 7)( 70 ). In saying this, it is worth noting that the face-to-face element of the training had perceived benefits of increased networking and collaboration with clinical members, and thus the provision of electronic training resources may introduce a trade-off of reduced engagement in the course. If, however, a blended model enables ongoing access to training resources, it is likely to facilitate further engagement in the program( 71 ). To increase the efficiency of training days and the amount of dedicated coach-team time (Theme 7), training days could be split into two parallel cohorts with practical workshops running concurrently to theory-based lectures. This would enable team time with coaches to be staggered; while one cohort listens to lectures, the other could engage in practical project planning activities with Faculty staff. Workforce and organisational challenges, such as limited data access and quality( 7 ) need to be addressed to achieve successful CQI implementation and an effective LHS( 36 ), specifically to enhance capacity to design locally appropriate data-informed improvement projects (Theme 5)( 44 ). Both increased and timely access to electronic medical record data and improved quality of data will contribute to the developing LHS supported by CIP009( 38 ). Future improvement projects will also be strengthened by increased consumer partnership and codesign of projects to improve healthcare service delivery( 72 ). These partnerships may be informed by the Building successful partnerships in healthcare QI: A capability development framework for service users, families, communities, and staff ( 72 ). The top-down nature of project topic selection resulted in variable responses from participants. Involving clinicians at an earlier stage of the topic selection process, through a brief survey, may ensure projects are clearly aligned with perceived need from both executive and clinician stakeholders. Limitations There may have been self-selection bias( 73 ) in recruitment, as those participants who chose to engage in an interview may not represent the cohort of CIP009 participants. Not all CIP009 teams were interviewed or observed, which reduces how generalisable the findings are across the 12 teams. Due to the complexity of the 12 CIP009 projects, and the corresponding extension of the program, teams were typically still in the early stages of the SALHN 8 step framework when data collection was conducted, meaning teams hadn’t fully implemented their projects nor assessed their impact. This evaluation therefore lacked data about the challenges and strengths experienced during the implementation stage of the individual quality improvement projects. Strengths of the study include the use of member checking, use of multiple coders, as well as triangulation of data across three cohorts, and across three methods of data collection (interviews, observations, and document review) to enhance the trustworthiness of the data( 74 ). Conclusion In conclusion, the 12 CIP009 clinical micro-system interventions together aimed to contribute to a common organisational goal of reduced ambulance ramping by increasing patient flow, and reducing admissions, readmissions, length of stay and unwarranted clinical variation. Protocolisation of practice change was a common tool used to enhance the delivery of evidence-based practice to patients. The continuous wrap around support, multidisciplinary collaboration, culture of enquiry and structured framework of CIP009, as well as the top-down support in combination with bottom-up intervention design, has resulted in a CQI training program that is perceived to effectively develop staff skills and facilitate progress of micro-system improvements to achieve macro-outcomes. Incorporation of implementation science principles within the continuous improvement framework may further support the implementation and sustainability of future CIP projects. Abbreviations COREQ: Consolidated Criteria for Reporting Qualitative Studies CFIR: Consolidated Framework for Implementation Research CPD: Continuing Professional Development CIP009: Continuous Improvement Program 009 The Faculty: Continuous Improvement Unit (CIU) CQI: Continuous Quality Improvement ED: Emergency Department EPIS: Exploration, Preparation, Implementation, Sustainment Framework HREC: Human Research Ethics Committee LHS: Learning Health System LNR: Low and Negligible Research LOS: Length of Stay SALHN: Southern Adelaide Local Health District TDF: Theoretical Domains Framework Declarations Ethics approval and consent to participate Human Research Ethics Committee (HREC) and governance approval for Low and Negligible Research (LNR) by the SALHN HREC (LNR Reference number: LNR/23/SAC/157.23; and Office for Research: OFR Number: 157.23) was obtained before research commenced. Participants provided written consent before participating in an interview or a meeting observation. Consent for publication Not applicable Availability of data and materials Interview transcripts are not publicly available to protect the confidentiality of study participants. However, data such as codes, and anonymised quotes may be available from the corresponding author (PH) upon reasonable request. Competing interests The authors declare that they have no competing interests Funding This evaluation project was funded by the Flinders Foundation. The interpretation of findings was independent to the funders. Authors' contributions MB, PH designed the study, while SH, LE and RCW reviewed and provided guidance regarding the study design. MB conducted all interviews, observations, and collected documents for review. MB analysed all data and conducted initial coding and thematic framework development. PH reviewed coding and analysed the final thematic framework. SH, LE and RCW provided feedback on the practical applicability of findings. All authors read and approved the final manuscript. Acknowledgements Not applicable References Dixon-Woods M, Martin GP. Does quality improvement improve quality? Future Hosp J. 2016;3(3):191. https://doi.org/10.7861/futurehosp.3-3-191 . Norton WE, McCannon CJ, Schall MW, Mittman BS. A stakeholder-driven agenda for advancing the science and practice of scale-up and spread in health. Implement Sci. 2012;7(1):1–6. https://doi.org/10.1186/1748-5908-7-118 . Hartviksen TA, Aspfors J, Uhrenfeldt L. Healthcare middle managers’ experiences of developing capacity and capability: a systematic review and meta-synthesis. BMC Health Serv Res. 2019;19(1):1–19. https://doi.org/10.1186/s12913-019-4345-1 . Hill JE, Stephani A-M, Sapple P, Clegg AJ. The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review. Implement Sci. 2020;15(1):1–14. Hibbert PD, Basedow M, Braithwaite J, Wiles LK, Clay-Williams R, Padbury R. How to sustainably build capacity in quality improvement within a healthcare organisation: a deep-dive, focused qualitative analysis. BMC Health Serv Res. 2021;21(1):1–13. https://doi.org/10.1186/s12913-021-06598-8 . Jones B, Vaux E, Olsson-Brown A. How to get started in quality improvement. BMJ. 2019;364:k5408. https://doi.org/10.1136/bmj.k5437 . Zoutman DE, Ford BD. Quality improvement in hospitals: barriers and facilitators. Int J Health Care Qual Assur. 2017;30(1):16–24. https://doi.org/10.1108/IJHCQA-12-2015-0144 . Mery G, Dobrow MJ, Baker GR, Im J, Brown A. Evaluating investment in quality improvement capacity building: a systematic review. BMJ Open. 2017;7(2):e012431. https://doi.org/10.1136/bmjopen-2016-012431 . Stelson P, Hille J, Eseonu C, Doolen T. What drives continuous improvement project success in healthcare? Int J Health Care Qual Assur. 2017;30(1):43–57. https://doi.org/10.1108/IJHCQA-03-2016-0035 . Sarff L, O'Brien R. Evidence-based quality improvement training programs: building staff capability and organizational capacity. J Nurs Care Qual. 2020;35(2):95–101. https://doi.org/10.1097/NCQ.0000000000000416 . O'Neill NE, Baker J, Ward R, Johnson C, Taggart L, Sholzberg M. The development of a quality improvement project to improve infection prevention and management in patients with asplenia or hyposplenia. BMJ Open Qual. 2020;9(3):e000770. https://doi.org/10.1136/bmjoq-2019-000770 . Louie JP, Alfano J, Nguyen-Tran T, Nguyen-Tran H, Shanley R, Holm T, et al. Reduction of paediatric head CT utilisation at a rural general hospital emergency department. BMJ Qual Saf. 2020;29(11):912–20. https://doi.org/10.1136/bmjqs-2019-010322 . Braithwaite J, Clay-Williams R, Taylor N, Ting HP, Winata T, Hogden E, et al. Deepening our Understanding of Quality in Australia (DUQuA): An overview of a nation-wide, multi-level analysis of relationships between quality management systems and patient factors in 32 hospitals. Int J Qual Health Care. 2020;32(Supplement1):8–21. https://doi.org/10.1093/intqhc/mzz103 . Wagner C, Groene O, Thompson CA, Dersarkissian M, Klazinga NS, Arah OA, et al. DUQuE quality management measures: associations between quality management at hospital and pathway levels. Int J Qual Health Care. 2014;26(suppl1):66–73. https://doi.org/10.1093/intqhc/mzu020 . Benning A, Ghaleb M, Suokas A, Dixon-Woods M, Dawson J, Barber N, et al. Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation. BMJ. 2011. 342https://doi.org/10.1136/bmj.d195 . Brugman IM, Visser A, Maaskant JM, Geerlings SE, Eskes AM. The Evaluation of an Interprofessional QI Program: A Qualitative Study. Int J Environ Res Public Health. 2022;19(16):10087. https://doi.org/10.3390/ijerph191610087 . Benning A, Dixon-Woods M, Nwulu U, Ghaleb M, Dawson J, Barber N, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ. 2011;342. https://doi.org/10.1136/bmj.d199 . Goitein L, James B. Standardized best practices and individual craft-based medicine: a conversation about quality. JAMA Intern Med. 2016;176(6):835–8. https://doi.org/10.1001/jamainternmed.2016.1641 . James BC, Savitz LA. How Intermountain trimmed health care costs through robust quality improvement efforts. Health Aff. 2011;30(6):1185–91. https://doi.org/10.1377/hlthaff.2011.0358 . Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The improvement guide: a practical approach to enhancing organizational performance. Wiley; 2009. Ben-Tovim DI. Process redesign for health care using lean thinking: a guide for improving patient flow and the quality and safety of care. CRC; 2017. Womack JP, Jones DT, Roos D. The machine that changed the world: The story of lean production–Toyota's secret weapon in the global car wars that is now revolutionizing world industry. Simon and Schuster; 2007. World Health Organization. Practical guidance for scaling up health service innovations: World Health Organization. 2009. https://iris.who.int/bitstream/handle/10665/44180/9789241598521_eng.pdf . Rogers Everett M. Diffusion of innovations. New York. 1995;12. Kreindler SA, Star N, Hastings S, Winters S, Johnson K, Mallinson S, et al. Working against gravity: the uphill task of overcapacity management. Health Serv Insights. 2020;13:1178632920929986. https://doi.org/10.1177/1178632920929 . Kingswell C, Shaban RZ, Crilly J. Concepts, antecedents and consequences of ambulance ramping in the emergency department: a scoping review. Australasian Emerg Nurs J. 2017;20(4):153–60. https://doi.org/10.1016/j.aenj.2017.07.002 . Ramanadhan S, Revette AC, Lee RM, Aveling EL. Pragmatic approaches to analyzing qualitative data for implementation science: an introduction. Implement Sci Commun. 2021;2:1–10. https://doi.org/10.1186/s43058-021-00174-1 . Booth A, Hannes K, Harden A, Noyes J, Harris J, Tong A. COREQ (consolidated criteria for reporting qualitative studies). 2014. In: Guidelines for reporting health research: a user's manual [Internet]. [214 – 26]. https://doi.org/10.1002/9781118715598.ch21 . Fusch PI, Ness LR. Are we there yet? Data saturation in qualitative research. Qualitative Rep. 2015;20(9):1408–16. http://www.nova.edu/ssss/QR/QR20/9/fusch1.pdf . Campbell S, Greenwood M, Prior S, Shearer T, Walkem K, Young S, et al. Purposive sampling: complex or simple? Research case examples. J Res Nurs. 2020;25(8):652–61. https://doi.org/10.1177/1744987120927 . Damschroder LJ, Reardon CM, Widerquist MAO, Lowery J. The updated Consolidated Framework for Implementation Research based on user feedback. Implement Sci. 2022;17(1):75. https://doi.org/10.1186/s13012-022-01245-0 . Strudwick RM. Ethnographic research in healthcare–patients and service users as participants. Disabil Rehabil. 2021;43(22):3271–5. https://doi.org/10.1080/09638288.2020.1741695 . Srivastava P, Hopwood N. A practical iterative framework for qualitative data analysis. Int J Qualitative Methods. 2009;8(1):76–84. https://doi.org/10.1177/1609406909008001 . Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. https://doi.org/10.1191/1478088706qp063oa . QSR International Pty Ltd. NVIVO version 14. Victoria. Australia: Qualitative Solutions and Research Pty Ltd; 2023. Ellis LA, Sarkies M, Churruca K, Dammery G, Meulenbroeks I, Smith CL, et al. The science of learning health systems: scoping review of empirical research. JMIR Med Inf. 2022;10(2):e34907. https://doi.org/10.2196/34907 . Morse JM. Critical analysis of strategies for determining rigor in qualitative inquiry. Qual Health Res. 2015;25(9):1212–22. https://doi.org/10.1177/10497323155885 . Enticott J, Johnson A, Teede H. Learning health systems using data to drive healthcare improvement and impact: a systematic review. BMC Health Serv Res. 2021;21:1–16. https://doi.org/10.1186/s12913-021-06215-8 . Pomare C, Mahmoud Z, Vedovi A, Ellis LA, Knaggs G, Smith CL, et al. Learning health systems: a review of key topic areas and bibliometric trends. Learn Health Syst. 2022;6(1):e10265. https://doi.org/10.1002/lrh2.10265 . Smith M, Saunders R, Stuckhardt L, McGinnis JM. Best care at lower cost: the path to continuously learning health care in America. Institute of Medicine CotLHCSiA. editor. Washington, DC: National Academies; 2013. Menear M, Blanchette M-A, Demers-Payette O, Roy D. A framework for value-creating learning health systems. Health Res Policy Syst. 2019;17:1–13. https://doi.org/10.1186/s12961-019-0477-3 . De Bruin J, Bos C, Struijs JN, Drewes HWT, Baan CA. Conceptualizing learning health systems: A mapping review. Learn Health Syst. 2023;7(1):e10311. https://doi.org/10.1002/lrh2.10311 . Easterling D, Perry AC, Woodside R, Patel T, Gesell SB. Clarifying the concept of a learning health system for healthcare delivery organizations: implications from a qualitative analysis of the scientific literature. Learn Health Syst. 2022;6(2):e10287. https://doi.org/10.1002/lrh2.10287 . Enticott J, Braaf S, Johnson A, Jones A, Teede HJ. Leaders’ perspectives on learning health systems: a qualitative study. BMC Health Serv Res. 2020;20:1–13. Long JC, Roberts N, Francis-Auton E, Sarkies MN, Nguyen HM, Westbrook JI, et al. Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability. BMC Health Serv Res. 2024;24(1):1–11. https://doi.org/10.1186/s12913-024-10721-w . Nilsen P, Seing I, Ericsson C, Birken SA, Schildmeijer K. Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and assistant nurses. BMC Health Serv Res. 2020;20:1–8. https://doi.org/10.1186/s12913-020-4999-8 . Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82(4):581–629. https://doi.org/10.1111/j.0887-378X.2004.00325.x . Wright D, Gabbay J, Le May A. Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies. BMJ Qual Saf. 2022;31(6):450–61. https://doi.org/10.1136/bmjqs-2021-013065 . Chang AM, Cohen DJ, Lin A, Augustine J, Handel DA, Howell E, et al. Hospital strategies for reducing emergency department crowding: a mixed-methods study. Ann Emerg Med. 2018;71(4):497–505. https://doi.org/10.1016/j.annemergmed.2017.07.022 . e4. Sutcliffe KM, Paine L, Pronovost PJ. Re-examining high reliability: actively organising for safety. BMJ Qual Saf. 2017;26(3):248–51. https://doi.org/10.1136/bmjqs-2015-004698 . Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature. BMJ Qual Saf. 2012;21(10):876–84. https://doi.org/10.1136/bmjqs-2011-000760 . Fitzsimons J. Quality and safety in the time of coronavirus: design better, learn faster. Int J Qual Health Care. 2021;33(1):mzaa051. https://doi.org/10.1093/intqhc/mzaa051 . Robert G, Morrow E, Maben J, Griffiths P, Callard L. The adoption, local implementation and assimilation into routine nursing practice of a national quality improvement programme: the Productive Ward in England. J Clin Nurs. 2011;20(7–8):1196–207. https://doi.org/10.1111/j.1365-2702.2010.03480.x . Sarkies M, Long JC, Pomare C, Wu W, Clay-Williams R, Nguyen HM, et al. Avoiding unnecessary hospitalisation for patients with chronic conditions: a systematic review of implementation determinants for hospital avoidance programmes. Implement Sci. 2020;15:1–17. https://doi.org/10.1186/s13012-020-01049-0 . Robbins B, Davidhizar R. Transformational leadership in health care today. Health Care Manag. 2020;39(3):117–21. https://doi.org/10.1097/HCM.0000000000000296 . Vaughn VM, Saint S, Krein SL, Forman JH, Meddings J, Ameling J, et al. Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies. BMJ Qual Saf. 2019;28(1):74–84. https://doi.org/10.1136/bmjqs-2017-007573 . Taylor N, Clay-Williams R, Hogden E, Braithwaite J, Groene O. High performing hospitals: a qualitative systematic review of associated factors and practical strategies for improvement. BMC Health Serv Res. 2015;15(1):1–22. https://doi.org/10.1186/s12913-015-0879-z . Bierbaum M, Rapport F, Arnolda G, Delaney GP, Liauw W, Olver I, et al. Clinical practice guideline adherence in oncology: a qualitative study of insights from clinicians in Australia. PLoS ONE. 2022;17(12):e0279116. https://doi.org/10.1371/journal.pone.0279116 . Bierbaum M, Rapport F, Arnolda G, Tran Y, Nic Giolla Easpaig B, Ludlow K, et al. Rates of adherence to cancer treatment guidelines in Australia and the factors associated with adherence: A systematic review. Asia-Pac J Clin Oncol. 2023;19(6):618–44. https://doi.org/10.1111/ajco.13948 . Braithwaite J, Marks D, Taylor N. Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature. Int J Qual Health Care. 2014;26(3):321–9. https://doi.org/10.1093/intqhc/mzu047 . Nilsen P, Thor J, Bender M, Leeman J, Andersson-Gäre B, Sevdalis N. Bridging the silos: a comparative analysis of implementation science and improvement science. Front Health Serv. 2022;1:817750. https://doi.org/10.3389/frhs.2021.817750 . Rapport F, Clay-Williams R, Churruca K, Shih P, Hogden A, Braithwaite J. The struggle of translating science into action: foundational concepts of implementation science. J Eval Clin Pract. 2018;24(1):117–26. https://doi.org/10.1111/jep.12741 . Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:1–17. https://doi.org/10.1186/1748-5908-7-37 . Rapport F, Smith J, Hutchinson K, Clay-Williams R, Churruca K, Bierbaum M, et al. Too much theory and not enough practice? The challenge of implementation science application in healthcare practice. J Eval Clin Pract. 2022;28(6):991–1002. https://doi.org/10.1111/jep.13600 . Silver SA, McQuillan R, Harel Z, Weizman AV, Thomas A, Nesrallah G, et al. How to sustain change and support continuous quality improvement. Clin J Am Soc Nephrol. 2016;11(5):916–24. https://doi.org/10.2215/CJN.11501015 . Moullin JC, Dickson KS, Stadnick NA, Rabin B, Aarons GA. Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Implement Sci. 2019;14(1):1. https://doi.org/10.1186/s13012-018-0842-6 . Glasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC, et al. RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review. Front Public Health. 2019;7:64. https://doi.org/10.3389/fpubh.2019.00064 . Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Mental Health Mental Health Serv Res. 2011;38:65–76. https://doi.org/10.1007/s10488-010-0319-7 . Alexander CC, Tschannen D, Hays D, Clouse M, Zellefrow C, Amer KS, et al. An integrative review of the barriers and facilitators to nurse engagement in quality improvement in the clinical practice setting. J Nurs Care Qual. 2022;37(1):94–100. https://doi.org/10.1097/NCQ.0000000000000562 . McKenna K, Gupta K, Kaiser L, Lopes T, Zarestky J. Blended learning: Balancing the best of both worlds for adult learners. Adult Learn. 2020;31(4):139–49. https://doi.org/10.1177/1045159519891997 . Alexander C, Tschannen D, Argetsinger D, Hakim H, Milner KA. A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders. J Nurs Adm Manag. 2022;30(3):694–701. Cox R, Kendall M, Molineux M, Miller E, Tanner B. Refining a capability development framework for building successful consumer and staff partnerships in healthcare quality improvement: A coproduced eDelphi study. Health Expect. 2022;25(4):1563–79. https://doi.org/10.1111/hex.13499 . Robinson OC. Sampling in interview-based qualitative research: A theoretical and practical guide. Qualitative Res Psychol. 2014;11(1):25–41. https://doi.org/10.1080/14780887.2013.801543 . Adler RH. Trustworthiness in qualitative research. J Hum Lactation. 2022;38(4):598–602. https://doi.org/10.1177/08903344221116 . Additional Declarations No competing interests reported. Supplementary Files AppendixA.Semistructuredinterviewtopicguide.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Ellis","email":"","orcid":"","institution":"Macquarie University","correspondingAuthor":false,"prefix":"","firstName":"Louise","middleName":"A.","lastName":"Ellis","suffix":""},{"id":326658060,"identity":"861a1a55-0703-4d7c-9fac-2f75d59b56fb","order_by":3,"name":"Robyn Clay-Williams","email":"","orcid":"","institution":"Macquarie University","correspondingAuthor":false,"prefix":"","firstName":"Robyn","middleName":"","lastName":"Clay-Williams","suffix":""},{"id":326658061,"identity":"d2688959-944a-4c09-b879-6febf8204efe","order_by":4,"name":"Peter Hibbert","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYBAC+wYwdYDHQAJEVzAwsIEF2HBrMTjAjKTlwBkStDCAtRxsg4nj03K8/+DjCoY7MubSzcc+f5x3OI+P//ADhg9lhxn4ZyRg90vPYWbDMwzPeCznHEuecXDb4WI2iTQDxhnnDjNI3MCuxUAimU2ygeEwj8GNHGMGoJbENgkGA2betsMMDLi0yD9m/wnRkv+Z4eAcoBb+4x+Y/wK1yOO0hZmNEWoLM8PBBqAWhhwDZkagFgNcWniSjSUbDA6D/GLMcOZYOtBhOQUHe86l8xieeYBdC/vBhx8bKg7bA0PsMUNFjXXi/P7jGx/8KLOWkzuO3RaoRjT+ASDmwaN+FIyCUTAKRgEBAAC8/2J/hcsqrQAAAABJRU5ErkJggg==","orcid":"","institution":"IIMPACT in Health, University of South Australia","correspondingAuthor":true,"prefix":"","firstName":"Peter","middleName":"","lastName":"Hibbert","suffix":""}],"badges":[],"createdAt":"2024-06-20 23:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4614057/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4614057/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60619922,"identity":"d9828e12-1881-4504-a041-c85fab6f8328","added_by":"auto","created_at":"2024-07-18 20:47:32","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1134088,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCIP009 thematic framework: Key strengths and challenges\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1CIP009thematicframework200624.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4614057/v1/0c6988001ccbdc7442de183a.jpg"},{"id":60619921,"identity":"2b2c82d7-6bf1-4772-a5b0-20c5c63a8cb2","added_by":"auto","created_at":"2024-07-18 20:47:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":403368,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKey attributes of the SALHN CIP009 program\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2KeyattributesofSALHNCIP009190624.png","url":"https://assets-eu.researchsquare.com/files/rs-4614057/v1/0c656fac9b7445859d2e660a.png"},{"id":65054149,"identity":"2935b175-e8ea-4c69-a16f-abdb4a2ae903","added_by":"auto","created_at":"2024-09-23 06:41:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2849542,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4614057/v1/10efdb07-64dc-4902-97fc-cfcbe3e3fe76.pdf"},{"id":60619920,"identity":"1eb77353-550f-48db-8233-8df3cdba7aa2","added_by":"auto","created_at":"2024-07-18 20:47:32","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18056,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.Semistructuredinterviewtopicguide.docx","url":"https://assets-eu.researchsquare.com/files/rs-4614057/v1/304ebeb631cbf21d595a9cee.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Establishing a Learning Health System through the implementation of a health service wide Continuous Quality Improvement program: A qualitative evaluation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eContinuous Quality Improvement (CQI) capacity and capability building are important and widely used methods(\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) to improve care pathways and service delivery in healthcare organisations(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), and increase patient safety(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This is achieved by identifying, analysing and addressing quality issues and enhancing the efficiency of resource allocation(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). It requires affective commitment from staff who identify a need for change as well as strong leadership support and active engagement(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Capacity building ensures there are enough staff trained in QI methods to implement projects, while capability building develops staff skills and confidence to implement QI projects(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe implementation of individual(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) or organisation-wide projects(\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) are well documented in the literature. Examples include the Interprofessional QI program in the Netherlands, which facilitated interprofessional healthcare teams to design QI projects following online training and continuous support(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e); and the Safer Patients Initiatives in the U.K. which were whole-of-hospital, pre-prescribed (top-down) clinical improvements that were locally adapted(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). There has been limited examination of the barriers and facilitators to effective implementation of sustainable QI training programs(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), in particular cross disciplinary whole-of-hospital programs to improve quality of care through a combined top-down and bottom-up approach, warranting further investigation.\u003c/p\u003e \u003cp\u003e The Continuous Improvement Program (CIP) has been run for 20 years by the Southern Adelaide Local Health District (SALHN), in South Australia. SALHN encompasses a tertiary teaching hospital, and a regional community hospital, as well as sub-acute, mental health and primary care services, with approximately 700 acute hospital beds(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Early iterations of the CIP were developed by the SALHN Department of Surgery and Perioperative Medicine in 2004(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). CIP was adapted from frameworks(\u003cspan additionalcitationids=\"CR19 CR20 CR21\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) including Lean methods and process redesign principals(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), Model for Improvement methods[13], and key learnings from Intermountain Healthcare, Utah, USA(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), to suit local needs(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCIP is led by an internal Continuous Improvement Unit (the Faculty) who support and mentor staff to enhance their QI skills and knowledge, and facilitate local CQI projects(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The CIP training is conducted with staff across the service and is designed to teach participants how to identify issues in the workplace, to problem solve and implement sustainable solutions by systematically using the SALHN 8-step continuous improvement framework(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Projects are designed and implemented by frontline healthcare workers at the interface of patient care, with the aim of achieving buy-in and adoption from healthcare staff. Project teams are trained and supported through continuous coaching from the Faculty to redesign processes, maximise capacity, enhance efficiency and reduce waste; all key strategies in overcapacity management(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Teams are supported to access data to measure baseline processes and monitor improvements, as well as provided with overt organisational permission and executive support for the interventions(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe most recent iteration of the program, CIP009 (2023/2024), is a novel CQI program which has been conducted using an innovative combined top-down and bottom-up approach. This integrates executive codesign of 12 CIP009 intervention topics aligned to hospital strategic priorities, with clinician design and implementation of 12 associated microsystem CQI projects. CIP009 has an overarching strategic macro-objective driving the projects to increase improvement capacity and capability and reduce ambulance ramping across SALHN hospitals. Emergency Department (ED) congestion and ambulance ramping is a persistent challenge, whereby patient flow from the ED across the hospital is impeded by various bottlenecks(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), demand and bed capacity mismatches(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), delaying the handover of patients from paramedics to ED clinicians(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Ramping has been shown to result in delayed triage and care, increased length of stay (LOS) and rates of admission, in addition to workforce burden and stress(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). While ramping is related to increased demand for ED services and staff shortages across ED and ambulance services, challenges associated with hospital-wide patient flow also contribute to these issues by delaying patient transfer out of ED creating further delays for proceeding ED patients(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This qualitative evaluation study aimed to characterise the SALHN CIP009, a long-term improvement capacity and capability building training program, and examine the strengths and challenges of implementing 12 clinical micro-improvement projects.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting:\u003c/h2\u003e \u003cp\u003eAn exploratory, inductive and deductive pragmatic qualitative study design(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) was used to evaluate CIP009. Interviews and focus groups were conducted with executives, coaches and participants. Participants were eligible if they had been involved in CIP009 as participants, coaches or in an executive capacity. Observations of presentations and training sessions, and project team meetings were conducted, and documents were reviewed to characterise the program. The study design, analysis and findings are reported in line with the Consolidated Criteria for Reporting Qualitative Studies (COREQ)(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment, Sampling strategy, data collection methods and data collection tools\u003c/h2\u003e \u003cp\u003e Indirect email and verbal recruitment of CIP009 project members, coaches, and executives was conducted by key contacts from the Faculty, circumventing recruitment by researchers. Participation was voluntary, and responses were treated confidentially with data de-identified. Interview recruitment continued along with iterative analysis, until data saturation was reached, and no new themes emerged(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePurposive sampling(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) was used to ensure inclusion of participants from a range of health disciplines and with varying levels of experiences and participants self-selected by responding to recruitment invitations. Approximately 20\u0026ndash;30 questions were asked in each individual and group interview. The semi-structured interview topic guide aimed to elucidate perceived strengths and challenges of the CIP009 (Appendix A). Questions were developed and reviewed by the research team and informed by the domains of the Consolidated Framework for Implementation Research (CFIR)(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). All interviews and focus groups were audio-recorded, transcribed verbatim, and deidentified. Interviews were conducted by the first author (MB), an experienced qualitative researcher (PhD) who had no preexisting relationship with participants. Only the interviewer and interviewee(s) were present, and interviews were typically conducted on site in an office at a SALHN hospital, over the phone or by videoconference.\u003c/p\u003e \u003cp\u003eObservations of CIP009 midpoint \u0026lsquo;report back\u0026rsquo; and graduation sessions (where teams present their project progress and receive certification for completing the training course), and project team meetings were conducted in real-time or via video recording. All observations were conducted by MB, and field notes were taken. This enabled the researcher to develop a deeper understanding of the interactions between team members, as well as strengths and challenges to implementing the projects. Project team members were made up of CIP009 participants and core stakeholders. This ethnographic approach(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) was used to observe team interactions and communication, how project work was planned and done. MB reviewed CIP009 documents to characterise the program.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eIterative and inductive thematic analysis(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) was used to analyse the data from the interview and focus group transcripts, observations and field notes(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). MB conducted the initial coding of transcripts, by reviewing the transcripts twice, then coding line by line to identify key codes and potential themes(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), using the NVivo software v.14(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Once an initial coding framework was developed, MB recoded the data to verify the initial framework. Senior author (PH, professor) then reviewed the coding of a 10% sample of transcripts, after which themes and codes were discussed and refined through consensus decision making. Once the coding framework was finalised, MB recoded all the transcripts for a third time and finalised the key themes. Exemplar quotes were chosen to support the thematic framework, within which participants are identified by a code to maintain confidentiality.\u003c/p\u003e \u003cp\u003eThe document review informed the characterisation of the CIP009 program including mapping the milestones of the program, roles of clinicians and participants, and key strengths and challenges in line with the key themes identified. A deductive analysis of data was then conducted by MB to map the themes, subthemes and codes into the five CFIR domains(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The CFIR is a widely used framework for assessing implementation evaluation(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) and was used to both inform the data collection, and to reassess the challenges and facilitators of the CIP009 implementation within SALHN.\u003c/p\u003e \u003cp\u003eData were triangulated to corroborate the findings across the three methods of data collection (observations, interviews and document review) and across participants from different roles and backgrounds (CIP faculty executives, coaches and project team members)(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Member checking was utilised through return of transcripts to interview participants to validate or amend the content before analysis began(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). These techniques were used to enhance the reliability of the data analysis(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween October 2023 and February 2024, participants, coaches and executives were interviewed face-to-face, over the phone or video conference by MB (n\u0026thinsp;=\u0026thinsp;31) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Each interview took on average 28 minutes. Three group interviews were conducted by MB using the same questions with: participants (n\u0026thinsp;=\u0026thinsp;2, 20 minutes); coaches (n\u0026thinsp;=\u0026thinsp;6, 80 minutes); and executives (n\u0026thinsp;=\u0026thinsp;2, 18 minutes).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterview Participant demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterview participant groups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCIP009 executives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCIP009 coaches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCIP009 participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant clinical experience\u003c/p\u003e \u003cp\u003e(Range 2\u0026ndash;40 years)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 years or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u0026ndash;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 years or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant Profession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAllied Health Professional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*4 participants did not report their length of clinical experience\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFive CIP009 team meetings were observed, typically comprised of five team members and stakeholders plus a coach, each running for an hour on average, and one faculty meeting was observed, also an hour long. Teams typically discussed project progress, challenges, and made action plans for next steps. The midpoint presentations were observed (4.5 hours), as well as the graduation session (4.5 hours) and field notes were taken. Each team presented their progress at each of these sessions. CIP009 Faculty and team documents were reviewed (n\u0026thinsp;=\u0026thinsp;78), such as: the training agenda, slides and notes, and recordings of guest lectures, midpoint and graduation presentation slides, recruitment and registration documents, support resources, team meeting agendas and minutes, project plans, project specific outlines of length of stay data, and draft protocols, training and presentation evaluation data. Analysis of these data enabled the characterisation of the program, along with the identification of key strengths and challenges associated with CIP009.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCharacterisation of the SALHN CIP009 program\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eCIP background\u003c/h2\u003e \u003cp\u003eSince 2018, nine iterations of the CIP have been delivered, supporting over two hundred internal CQI projects over that timeframe. This has increased organisational awareness of the program, approaching a critical mass of staff having graduated from past CIPs, or with experience as CIP project stakeholders. The CIP is historically a 6-month CQI program delivered to staff which includes training sessions around the SALHN 8 step methodology(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), and continuous support from CIP coaches and Faculty. Participants present project progress to their cohort at a midpoint presentation and at the graduation session (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCIP009 design\u003c/h2\u003e \u003cp\u003eIn preparation for CIP009, 12 CIP project topics were selected and codesigned by hospital Division and CIP executives based on metrics such as high rates of admission, readmission, or length of stay. Project topics were designed to include at least two hospital Divisions involved in the patient care continuum, facilitating collaboration across the organisation. The CIP Faculty then conducted preliminary data analysis of the projects to gather baseline data and background information to justify and prepare each project for the 12 teams (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eCIP009 recruitment\u003c/h2\u003e \u003cp\u003eCIP009 participants were typically nominated by their Heads of Units and Divisions and assigned to a CIP009 team. Project team members (doctors, nurses and allied health professionals) were multidisciplinary, with varying levels of seniority, from multiple divisions across SALHN. Each team was led by at least one CIP coach and some with an additional shadow coach in training. Team members were introduced to their coach by the Director of CIP and presented with the preliminary analysis and justification for the project topics (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCIP009 training and support\u003c/h2\u003e \u003cp\u003eCIP009 participants were provided with 3.5 days of training about CQI methodology and key objectives of CIP009 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Participants were provided with resources to support the development of these skills. Sessions were delivered as seminars by the Faculty and senior executives, including shared experience of past CIP projects, and group workshops focused on practical cases. During and following the training sessions, teams initiated the CIP 8-step continuous improvement process, to identify, define and address their project issue. The most commonly reported data collection methods teams utilised included audits, electronic medical record analysis, observations and staff and patient surveys. The projects aimed to increase patient flow across micro-systems, with the intention of improving hospital-wide patient flow through the reduction in patient admission, readmission, length of stay and unwarranted clinical variation.\u003c/p\u003e \u003cp\u003e The CIP009 teams were guided by improvement coaches, and the Faculty. Coaches played a project management role, accessing, conducting and supporting data analysis, providing expert CQI advice, and developing outputs such as presentations and protocols through face-to-face and virtual support. CIP009 teams met with their coaches regularly to discuss the project design and implementation plan. Coaches had a range of clinical backgrounds and CQI experience. All were graduates of a past CIP course and had shadowed another coach supporting a previous CIP team. Coaches received in-house training and mentoring, and regularly collaborated in Faculty brainstorming sessions to discuss CIP009 projects.\u003c/p\u003e \u003cp\u003eIn light of the complexity of projects, the Faculty and coaching support provided to CIP009 project teams was extended from a six-month program to over 18-months to enable teams to complete the SALHN 8 steps with wraparound support (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). As a result, at the time of the evaluation, teams were still in the diagnostic and planning phases, and had not completed the SALHN 8 steps. Teams had typically refined the problem, conducted analysis including development of a cause-and-effect diagram, and identified outcomes to be measured.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKey CIP009 Project Milestones\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eCIP009 Project Milestones:\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePreparation\u003c/em\u003e:\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cb\u003eCIP009 projects (n\u0026thinsp;=\u0026thinsp;12) were codesigned\u003c/b\u003e with clinical directors and SALHN division leadership\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTeam\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTopic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eShorter Stays, Better Journeys: Improving back pain care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlcohol presentations to ED\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePreventing Delirium on 4D\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot just a failing heart\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandardising SALHN Mental Health Care Pathways for Clinical Presentations of Borderline Personality Disorder\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReducing short stay Undifferentiated abdominal pain admissions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImproving the patient flow processes at Southern Adelaide Palliative Care Services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eToe-Tal Improvement: Ramping Up Care for Patients with Diabetic Foot Infection\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFuture of Falls in Elderly at FMC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBringing AIR (Acute Illnesses of the Respiratory Tract/System) in and out of Flinders Paediatrics\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eED to Emergency Extended Care Unit Pathway\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePV bleeding presentations to ED\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026bull; CIP009 participants were nominated by division executives\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026bull; Pre-training data analysis and project preparation conducted by coaches to justify projects to teams\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026bull; Team introductions by director of CIP, preliminary analysis of projects discussed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommencement of CIP009\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cb\u003eCIP training days\u003c/b\u003e (March 2023) including project team groupwork with coaches.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraining day (hours)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTopics\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraining day 1 (4.5h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntroduction to the \u0026lsquo;Towards Zero Ramping: Improving organisational capability through standardisation\u0026rsquo; International Guest lectures-A Personal Journey in Acute Care Improvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraining day 2 (8.5h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWelcome from the Minister for Health and wellbeing\u003c/p\u003e \u003cp\u003eStandardisation in clinical practice \u0026ndash; reducing unnecessary variation\u003c/p\u003e \u003cp\u003eProject pathways-Introduction of teams and project streams\u003c/p\u003e \u003cp\u003eContinuous Improvement Principles\u003c/p\u003e \u003cp\u003eGroup Activity\u003c/p\u003e \u003cp\u003eContinuous Improvement Program \u0026ndash; 8 step Improvement Framework\u003c/p\u003e \u003cp\u003eDiagnostic Tools (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Breaking down the problem, focus on process mapping, tracking\u003c/p\u003e \u003cp\u003eWork as imagined, work as done\u003c/p\u003e \u003cp\u003eAllocation of small groups Part 1: draft milestones \u0026amp; stakeholders for process map (breakout rooms)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraining day 3 (8.5h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHuman Factors \u0026ndash; The Influence on Healthcare Quality\u003c/p\u003e \u003cp\u003eMeasuring for Improvement\u003c/p\u003e \u003cp\u003eLessons learnt from protocol development over 20 years\u003c/p\u003e \u003cp\u003eSmall Group Work Part 2: further analysis of pathway and identify key steps/milestones (breakout rooms)\u003c/p\u003e \u003cp\u003eAsking why\u003c/p\u003e \u003cp\u003eDiagnostic Tools (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Understand what to work on (tally sheets, brainstorming, Ishikawa, multi voting, Pareto charts)\u003c/p\u003e \u003cp\u003eConsumer involvement- The value of having consumers on projects\u003c/p\u003e \u003cp\u003eSmall Group Work Part 3: discuss diagnostic plan (direct observations, plan mapping meeting, measure \u0026amp; mission statement)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraining day 4 (7.5h)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eData Clinician interface\u003c/p\u003e \u003cp\u003eEthics Approval\u003c/p\u003e \u003cp\u003eGroup Work \u0026ndash; Part 3 continued: diagnostics: what will you do tomorrow?\u003c/p\u003e \u003cp\u003eHow to Publish Your Project\u003c/p\u003e \u003cp\u003eEvidence: SALHN CI Sustainability\u003c/p\u003e \u003cp\u003ePlan your Work, Work your Plan!\u003c/p\u003e \u003cp\u003eReady to Launch\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026bull; Teams initiated the \u003cb\u003eSALHN 8 step continuous improvement framework\u003c/b\u003e process\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStep\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTask\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDefine the Problem\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBreakdown the Problem\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSet a Target/Mission Statement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRoot Cause Analysis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImprovement planning\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImplementation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEvaluate/Assess Impact\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eContinuous Improvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cb\u003eContinuous Support\u003c/b\u003e: CIP009 Project teams were provided with continuous support from coaches and Faculty (approximately 4 hours of support each week per team, via team meetings, data collection and analysis)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cb\u003eStakeholder Engagement\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo further elucidate the root causes of selected problems, CIP009 participants recruited stakeholders to provide clinical insight and local knowledge to the problem-solving process through brainstorming and process mapping\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cb\u003eMidpoint Report back session\u003c/b\u003e (June 2023) (4.5 hours)\u003c/p\u003e \u003cp\u003eThe project teams presented their progress at a midpoint report back session, and received feedback from the CIP009 teams, coaches, and Faculty. The hospital CEO and other SALHN executive attended these sessions and provided feedback to teams\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cb\u003eGraduation Report back session\u003c/b\u003e (October 2023) (4.5 hours)\u003c/p\u003e \u003cp\u003eThe teams presented their progress to their CIP009 peers, coaches, Faculty and executive at their graduation ceremony, demonstrating their use of the 8 step CIP framework to design and implement a service improvement. Most teams had not completed the 8 steps by this point. They had refined the problem, conducted analysis including development of a cause-and-effect diagram, and identified outcomes to be measured\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cb\u003ePlanned \u0026lsquo;Where are you now?\u0026rsquo; report back session (October 2024)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe teams will present their progress and receive feedback from peers and executive.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026bull; \u003cb\u003ePlanned Sustainability following graduation\u003c/b\u003e (continuous support from the Faculty anticipated until project completion in June 2024)\u003c/p\u003e \u003cp\u003eAt intervention stage, teams report progress to executives and consumer adviser committees, for accountability and sustainability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThematic analysis of data identified seven key themes highlighting key challenges and strengths of CIP009 implementation within the SALHN setting: Four of the themes were focused on strengths of CIP009 implementation and captured concepts like: flattened hierarchy; wrap-around support from coaches; vested interests; and senior clinical change agents. Three themes were focused on key challenges of CIP009 implementation and included: individual workloads; issues in the way teams worked together; and training shortcomings (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Exemplar quotes (n\u0026thinsp;=\u0026thinsp;36) from more than two thirds of interviewees are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e (22/31. 71%), including 21 quotes from CIP009 participants (n\u0026thinsp;=\u0026thinsp;11/16, 69%), 8 quotes from coaches (n\u0026thinsp;=\u0026thinsp;7/9, 71%) and 7 quotes from executives (n\u0026thinsp;=\u0026thinsp;4/6, 67%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eCIP009 Strengths\u003c/h2\u003e \u003cp\u003eOverwhelmingly, participants were positive about CIP009, and the improvements they had achieved in their teams. Four themes and subthemes were identified as strengths of CIP009 that facilitated the implementation of the projects (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Exemplar quotes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: CIP framework and culture embedded in the psyche of the SALHN organisation\u003c/h2\u003e \u003cp\u003eKey strengths of CIP009 included the flexible, adaptive, agile and transferable nature of the CIP methodology and the predetermined and clear nature of the projects. This enabled coaches to do preparation work identifying key literature and baseline data to present to teams and facilitated efficient problem definition and change implementation. The report back presentation sessions at midpoint and graduation were seen as an opportunity to learn from other teams and celebrate successes. Presentation deadlines held teams accountable, and the extended timeframe of CIP009 support facilitated progress of projects. Participants valued the protected time for training, away from clinical duties, to immerse themselves in the CQI topics (Quote 1). Many felt additional protected time would accelerate project progress.\u003c/p\u003e \u003cp\u003eAchieving stakeholder buy-in and project engagement was considered essential to change, facilitated through coach support and networking. Participants valued the multidisciplinary and cross-divisional collaboration (particularly with ED), facilitated by CIP009, both in the composition of the teams, and engagement with stakeholders during brainstorming sessions and protocol development. This enabled teams to develop a clearer understanding of the patient journey end-to-end (Quote 2) and strengthen professional networks (Quote 3). Consumer involvement in projects was considered important but only utilised across some projects.\u003c/p\u003e \u003cp\u003eSALHN was perceived to be moving towards critical mass regarding CIP training saturation, with awareness and engagement with CIP increasing exponentially (Quote 4). CIP has built a culture of inquiry over time, across SALHN, with continuous improvement ideas perceived to be embedded in the organisational psyche (Quote 5). The use of a standardised, adaptive and evidence-based framework to develop targeted improvements that is simple to follow and adapt to local problems, was valued.\u003c/p\u003e \u003cp\u003eThe SALHN CIP training builds improvement capacity and capability by teaching participants the skills to independently design and implement improvement projects. CIP009 however, had an outcome-focused strategic direction imposed upon the projects, with greater coaching support provided to facilitate and expedite progress of improvement projects. CIP009 was focused on organisational capacity building, efficiency and reducing waste, built on the foundation of organisation-wide CIP awareness and use of a common CQI language. This facilitated engagement with stakeholders who were already familiar with CIP (Quote 6). Participants valued the overarching hospital priority-aligned strategic approach used to address network-wide wicked problems (Quote 7) and the non-prescriptive combined top-down and bottom-up nature of CIP009. While executives nominated and codesigned the broad selection of CIP009 topics, clinicians at the patient interface valued their ownership over the design and implementation of the improvement projects (Quote 8).\u003c/p\u003e \u003cp\u003e CIP has established avenues for ongoing accountability and sustainability of the improvement projects through regular reporting to committees and executives. However, few CIP participants commented on mechanisms for sustainability and accountability, possibly reflecting the early stages of the SALHN 8 step framework that they had reached.\u003c/p\u003e \u003cp\u003e The CIP Faculty and program instilled a culture of flattened hierarchy, enabling participants to confidently engage with and discuss ideas across the team, enhancing collaboration. This was established through role modelling with coaches demonstrating humble enquiry and negotiation techniques as methods to constructively challenge current practices, and support change adoption (Quote 9).\u003c/p\u003e \u003cp\u003eThe CIP009 training sessions held off site were considered well-structured with interesting in-depth content. The theory and reference to the literature throughout the training content was generally well regarded, and participants felt the framework was applicable across disciplines. Many participants valued the lectures from the expert presenters (including international guests), the small group activities and the real-life examples of past CIP projects presented by alumni and coaches. These examples of learned experience, alongside the SALHN 8 step framework, were useful to shift mindsets around continuous improvement methodology (Quote 10). The team building benefits of the face-to-face sessions, and opportunities to network with other teams, coaches and participants, as well as provision of training resources were also valued.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: The benefits of support from a dedicated, internal improvement faculty\u003c/h2\u003e \u003cp\u003eParticipants were complimentary about the large and experienced Faculty and leadership supporting the 12 CIP009 projects, and the breadth of knowledge coaches demonstrated (Quote 11). CIP Faculty executives played a key role as gatekeepers of coach workload to protect coach capacity to support CIP009 teams. The increased provision of coach support for CIP009, relative to past CIPs, resulted in a perceived higher standard of project outcomes.\u003c/p\u003e \u003cp\u003eThe continuous and resourced nature of Faculty CIP009 support was invaluable and seen to minimise the workload burden on CIP009 participants and ensure projects progressed. The internal nature of the Faculty meant the coaches could provide indispensable organisational knowledge-based advice (Quote 12). The Faculty also advocated for improvement changes that required policy escalation or changes to workflow and helped to navigate occasional challenging dynamics across divisions, as neutral stakeholders.\u003c/p\u003e \u003cp\u003eFaculty staff who were embedded within executive teams and divisions, wielded influence to engage executives with change initiatives. High executive and leadership awareness, understanding and support of the CIP009 projects across SALHN was perceived to facilitate improvements, staff buy in, and minimise governance barriers. Participants also felt that executive attendance at the CIP009 training and presentation days increased recognition of and institutional support for their improvement initiatives. Similarly, ED leadership support of projects validated improvement programs and facilitated staff buy-in.\u003c/p\u003e \u003cp\u003eCoaches and Faculty staff were considered to be a key strength of the CIP009 program demonstrating enthusiasm, commitment and belief in the value of each project (Quote 13). Coach support was respectful and encouraging, but not prescriptive (Quote 14). Coach clinical knowledge was another key strength perceived to facilitate project progress. Coaches aimed to provide a standardised approach to project support and facilitation, and the Faculty team promoted a culture of support and beneficence through their training, resources and coaching, which facilitated engagement with stakeholders.\u003c/p\u003e \u003cp\u003eThe extensive wrap-around support from coaches who were embedded in teams was considered a key strength of CIP009 (Quote 15). This included data sourcing and analysis, proactive project management, and output development such as protocols and preparation of presentations. This reduced the burden on participants (Quote 16) and freed up participant time to provide expert clinical advice on the improvement design and implementation. The coaches led the teams through the 8-step continuous improvement framework, providing structured guidance and feedback and preventing teams from jumping to solutions. The coaches who were embedded in Divisions were considered particularly helpful as they had pre-established relationships with staff, facilitating stakeholder engagement with the projects, as well as having greater clinical understanding of the project. Coaches were considered experts in improvement, with their process knowledge helpful to guide feasible intervention design and facilitate change. Coaches were also seen to have strong professional networks which were useful to progress interventions.\u003c/p\u003e \u003cp\u003eCoaches coordinated regular meetings and communication between team members to maintain project momentum and hold team members accountable, without overburdening them. Team members valued these often-weekly meetings, particularly the flexible nature of the hybrid face-to-face and virtual meetings, and clear communication about expectations, task setting and virtual communication when they were unable to attend in real time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: The advantages of an enthusiastic participant disposition and incentives\u003c/h2\u003e \u003cp\u003eIndividual team members\u0026rsquo; disposition was considered to have an impact on project progress, with an appetite for change, and respect and belief in CIP009 to achieve change being valuable characteristics. Participants, naturally, began the CIP009 course with varying skills and experience, but their capacity to be open to feedback and to show initiative was beneficial. The CIP009 process helped participants gain insight into the contributing factors of their project problem, which were often different to what they expected. Project progress was best supported by team members who managed their time to complete project tasks and meet with their teams regularly, by prioritising other work commitments. Past CIP participants had often become continuous improvement advocates themselves after graduating from CIP (Quote 17).\u003c/p\u003e \u003cp\u003e There were various incentives identified to complete the CIP009 project including: a shared vision of beneficence and developing capability to improve patient support end-to-end; benefits to career progression; continuing professional development (CPD) points; easing workflow demands for staff; learning how to break down problems and design and implement effective feasible solutions; opportunities to network and collaborate with consultants to improve processes; gaining new perspectives on patient journeys from team members; supporting teammates; and opportunities for publication. Almost all participants reported a vested interest in the improvement being delivered effectively, with many projects being seen as impactful and meaningful to the team members.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Effective teams and team composition\u003c/h2\u003e \u003cp\u003eTeam cohesion and collaboration in the teams were important factors, ensuring that participants felt solutions to the identified problems were not imposed upon them, but generated together. The composition of team members was important, with value seen in having a balance between expertise from more senior medical staff, and members with capacity to \u003cem\u003edo\u003c/em\u003e the work, with the later role predominantly falling to nursing and allied health-based team members (Quote 18). However, these staff often reported not having time to \u0026lsquo;do\u0026rsquo; the work on top of their clinical workloads. The more senior participants were seen as change agents who facilitate change adoption, particularly through medical and surgical staff engagement. The multidisciplinary nature of teams was seen as a strength of CIP009. Familiarity with team members was also considered valuable, with pre-existing rapport facilitating smoother teamwork. Ensuring the team members were engaged and positive about the project was important, as was engaging the right stakeholders, particularly those from ED, to provide input and new perspectives.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCIP009 Challenges\u003c/h2\u003e \u003cp\u003eThis iteration of the CIP program had a focus on improving patient flow in comparison to past capability building CIPs. CIP is firmly embedded within SALHN culture, with CIP language common across SALHN, and leadership support facilitated through executive, and senior staff involvement in the CIP training and projects. Despite these factors, challenges persist. The thematic analysis identified three themes that represented challenges of CIP009 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Exemplar quotes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 5\u003c/b\u003e: \u003cb\u003eWorkforce and Organisation-level challenges of improvements\u003c/b\u003e\u003c/p\u003e \u003cp\u003eLimited time and capacity to engage in the project was the most commonly reported organisational-level challenge for CIP009 teams. Competing priorities and clinical duties limited opportunities to meet and coproduce the work. Some felt that the timing of their improvement project implementation was impeded by other priorities that detracted from stakeholder engagement with the projects, such as accreditation. Participants talked about the importance of teams being ready, mature and capable for CIP009 and how if the team was in crisis-mode, from other stressors like workforce issues or seasonal demand, this was seen to detract from their ability to conduct improvement projects effectively (Quote 19). Workforce capacity and operational demand challenges included balancing annual leave, staff capacity with seasonal fluctuations in operational demand, and workforce shortages (Quote 20). Fitting the additional workload of CIP009 into daily workflow was challenging for many and created additional pressure. This was alleviated to some extent by the extensive wraparound support provided by coaches (Quote 21). Many participants noted that there was no sanctioned time to engage with the projects, other than the training days, mid-point and graduation sessions. They posited that additional protected time from clinical duties to immerse themselves in the project would facilitate the implementation of each improvement project (Quote 22). The timeframe of CIP009 (despite the extension) was perceived by many as too brief to progress through the SALHN 8 steps and achieve the types of improvements that had been designed, increasing pressure on participants (Quote 23).\u003c/p\u003e \u003cp\u003eAnother frequently discussed challenge was the poor access to electronic patient data and poor data quality (due to documentation variation) to support the improvement process. Access to data for both baseline problem analysis, and monitoring of change was a challenge noted by many participants, and led to project delays, frustration, and increased workload for the coaches (Quote 24). Delays to technological infrastructure (ICT) improvement changes, limited physical infrastructure such as bed capacity for improvement projects, governance approval processes delays, and medico legal barriers (which were reportedly time consuming to navigate), were all thought to impeded project progress (Quote 25).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eTheme 6: Team cohesion, logistics and stakeholder engagement challenges\u003c/h2\u003e \u003cp\u003eTeam-based challenges were predominantly around logistics with team members and stakeholders located across divisions and locations making it challenging to schedule project meetings. This resulted in poor momentum for some teams. Participants felt that the composition of their core teams could have had greater representation from different Divisions, specifically ED, and General Medicine (Quote 26). Participants posited that greater involvement of diverse stakeholders, especially those previously CIP trained, would have enabled a greater understanding of the improvement projects, and enhanced adoption of the changes.\u003c/p\u003e \u003cp\u003e Several participants and coaches discussed how challenging it was when there was unequal contribution, engagement and collaboration from team members. The composition of CIP009 teams was purposefully skewed toward more senior, executive, medical and surgical-specific staff who were perceived to be more time poor than their nursing and allied health counterparts. Utilisation of these individuals\u0026rsquo; expertise and seniority meant that there was a greater reliance on coaches to provide the wrap around support (Quote 27).\u003c/p\u003e \u003cp\u003eSome participants discussed poor team cohesion and a lack of consensus to be a challenge to overcome as they progressed, particularly when the team lacked clarity around the definition of the problem they were provided with. Project complexity, including complex patient cohorts, made problem definition challenging, impacting the design and implementation of feasible improvements. Similarly, not having a prior relationship with their team members meant some felt less accountable to their team (Quote 28). Careful team and coach alignment, as well as trust and rapport between teams and the Faculty were important to ensure participants felt confident they would be supported to succeed.\u003c/p\u003e \u003cp\u003eLack of engagement from stakeholders across the hospital (particularly surgical and medical-based clinicians and ED stakeholders) and resistance to change (Quote 29) were common challenges, which impacted the navigation, design and implementation of some improvement projects. Some participants reflected that it was difficult readjusting their thinking to the CIP009 framework to avoid jumping to solutions, and coaches noted that the expectation of participants to immediately generate solutions was challenging. Implementing projects and achieving behaviour change in a short timeframe was demanding, and depending on the project, required ongoing continuous support from coaches for an extended period of time to achieve desired outcomes. Implementation of projects was challenging, both in gaining stakeholder buy in and engagement and adoption of protocols, to achieve practice change and translation of evidence into practice. Several teams had not integrated consumer codesign into their improvement planning and design, and noted that this was an oversight, acknowledging the importance of consumer input as something that they would improve upon in future projects.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eTheme 7: CIP009 training and support shortcomings\u003c/h2\u003e \u003cp\u003eThe length of the CIP009 3.5-day training sessions was perceived as too long for some staff to be away from clinical duties, with some staff feeling burdened if their roles were not backfilled (Quote 30). Some participants felt that lectures were too long, with some repetitive, redundant, superficial and disjointed content, and felt that the guest lectures were not given enough context to be relevant (Quote 31). Some team members were observed to not stay for the whole duration of the training days, supporting these concerns. Several participants felt that there was not enough group planning time with their team to progress their project, perhaps resulting in a missed opportunity to maximise momentum and enthusiasm from the training days (Quote 32). Similarly, some participants felt that they had limited \u003cem\u003eteam time\u003c/em\u003e with their coach during the training days, particularly when coaches were split across multiple teams, leaving some teams unsure how to proceed while waiting for their coach to return (Quote 33). Several participants noted that CIP009 projects were outcome focused rather than capability focused as past CIPs have been, with additional wrap around support from coaches meaning that the team members had fewer opportunities to practice the skills learnt in the CIP009 training course.\u003c/p\u003e \u003cp\u003e Communication about expectations of participant commitment was another challenge identified. Some participants felt presentation fatigue after presenting project results across multiple forums (the midpoint session, graduation day and to executive committees), suggesting they could record their presentations to reduce time away from clinical duties. Participants also noted that the lack of notice around the commencement of the CIP009 program and training days created scheduling conflicts with clinical commitments, increasing staff burden. As a result of limited communication, some participants felt they were being enrolled in the program as a result of poor performance and had negative reactions to being nominated by Divisional Directors and Heads of Departments. That quickly dissipated once they understood the purpose of the program and why their role was integral to the improvement project. Some felt the prescriptive nature of this process reduced their internal motivation, while others felt that such external support for the projects was motivating (Quote 34). Many participants felt that the rapid design and top-down selection of project problems by executive, rather than by each team impacted their engagement with the project initially, and limited opportunities for codesign with project team members. This resulted in some topics being seen as less valuable or meaningful to solve compared to others (Quote 35).\u003c/p\u003e \u003cp\u003eThere was some scepticism noted about whether the CIP framework and 12 CIP009 projects would be able to impact patient flow and ramping in a significant way, with the sentiment that the CIP009 framework was useful for some projects, but not all (Quote 36). These participants highlighted that CIP was one of several methodologies being supported by the LHN working towards enhancing patient flow.\u003c/p\u003e \u003cp\u003eIn terms of sustainability, several participants discussed how they had not yet set plans in place for ongoing monitoring and adjustment of their projects. This may be reflective of the stage the teams were at, still focused on problem clarification, solution generation and implementation at the time of interviews. There was, however, concern that projects would \u003cem\u003edrop off the radar\u003c/em\u003e once Faculty coaching support was reduced, and competing priorities took over participants\u0026rsquo; workloads, particularly for projects viewed as person dependent.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuotes representing the key strengths and challenges of CIP009\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e#\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eQuote\u003c/em\u003e and participant number (p)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"21\" rowspan=\"22\"\u003e \u003cp\u003e\u003cb\u003eStrengths\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTheme 1: CIP framework and culture embedded in the psyche of the SALHN organisation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;That\u0026rsquo;s a really valuable thing for a clinical leader to be taken out of the environments [so] that they can just really focus on that.\u0026rdquo; (p31, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;O\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ene of the key, kind of, crucial, it was the culture piece as well, to say \u0026lsquo;Actually this is what\u0026rsquo;s happening in my piece of the world. But what\u0026rsquo;s happening over there in yours?\u0026rsquo; And that has been probably one of the biggest things when I\u0026rsquo;ve gone to a lot of the process mapping etcetera, it\u0026rsquo;s just the team seeing an alternate view or alternate perspective of how that patient is managed.\u003c/span\u003e\u0026rdquo; (p6, executive)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eMeeting other people and you get to know a different group of people in the hospital who we may never cross paths with. So, I think that relationship stuff\u0026rsquo;s great\u003c/span\u003e.\u0026rdquo; (p19, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;We\u0026rsquo;ve had nine other CIPs where we\u0026rsquo;ve trained a lot of other people, like, I think in terms of the trust and the interest and the knowledge of the general workforce in terms of even just participating in mapping sessions, I do think that\u0026rsquo;s been a critical factor to the success of this one, in the sense of, you know, people trusting the process.\u0026rdquo; (p20, CIP009 coach)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Lots of other people have bought into [CIP] culture over the years, and I think, we\u0026rsquo;re seeing the end product of multiple decades of that.\u0026rdquo; (p2, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Everybody then knows the common language and it\u0026rsquo;s transferable into that building that culture of, you know, change management.\u0026rdquo; (p12, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;[We used] the CIP as a strategic plan to be able to look at involving clinicians at the patient-clinician interface to systematically fix ambulance ramping because we know that ambulance ramping is a symptom of delays across the entire quantum of care.\u0026rdquo; (p6, executive)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Everybody jumped on board because we all had a common purpose, so that was fine. But I think the real strength of it is that you can, you know, yes, you may well be given an area, but you can really delve down what\u0026rsquo;s most important and really focus on that.\u0026rdquo; (p19, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;[The CIP faculty are] very good at, I think, challenging the way that some of the ED people think, and actually in reshaping that. But also, I guess empowering them to say what\u0026rsquo;s wrong and involving them in the process of improving it. Umm. So yeah, we love the CIP.\u0026rdquo; (p22, executive)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I think the fact that the facilitators were able to relate past stories or past examples where the process had worked, it was really good. So, we knew that even if we were early on in the process and it wasn't, and it wasn't really clear what direction we were heading, we knew that we have people who were experienced in this, had gotten results and the process had worked for them. That was a key motivator throughout.\u0026rdquo; (p2, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTheme 2: The benefits of support from a dedicated, internal improvement faculty\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;They're very experienced and they can see the wood for the trees, and I think that's really valuable.\u0026rdquo; (p23, executive)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;We have that capability that's in-house, we can network well with the process owners, and we can leverage that in a, in a very, very critical manner, comparative to other organisations. So, people who in in another situation, in comparison with other organisations, consultants would come from outside organisations like KPMG, EY, Deloitte, PwC. They would come, recommend and go, but they would not stay for the whole process. But I think we have from start to finish, end to end visibility, engagement.\u0026rdquo; (p16, CIP009 coach)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;We've got a lot riding on this, and the focus was patient flow and how we can actually make a difference with patient flow. And I think our reputations were on the line with this a little bit as well because we live and breathe this, and we I think every single one of us in this room 100% believes in the methodology. And we have a point to make now that this methodology can make a difference.\u0026rdquo; (p14, CIP009 coach).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[Coach] was really good. Like, it's really nice to have someone who's so keen to drive, sort of, everything, but also be so positive as well. Actually, I never felt like I was being told what to do. Like, [coach] wasn\u003c/span\u003e\u003cem\u003e\u0026rsquo;\u003c/em\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003et condescending or anything. Like, the whole, like, CIP team in general have been really supportive, which has been, umm, I think encourages you to want to do more, like, quality improvement projects and, like, it sort of helped us prioritise quality improvement in, in along with our clinical load as well, if that makes sense. So, I think yeah, that would be the strength, would be definitely the facilitator.\u0026rdquo; (\u003c/span\u003ep21, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I think the CIP team as a whole have been an amazing support for the ED this year, but they are very good at doing a wraparound support, I guess to take some of the smaller tasks away from us, you know, data collection. They\u0026rsquo;re very good at presenting the data analysis, and I think in trying to change the way that you think. I think as clinicians, we are good at jumping at problems and solutions very quickly. And I think, in slowing down that process, sometimes you really get the data you need to really understand the problem, which I think is really valuable.\u0026rdquo; (p22, executive)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;We know that our clinicians are doing this over and above their day jobs, yeah. And so, I think to actually have our support to know that the work could still progress without falling on their shoulders made a big, big difference.\u0026rdquo; (p5, CIP009 coach)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTheme 3: The advantages of an enthusiastic participant disposition and incentives\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;A lot then go on to really become fierce advocates and do continue to do things because it becomes, they adopt this, this, as their way of doing business. And that really does assist in reaching a tipping point within the organisation of enough people to really do things at scale\u0026hellip; one of the greatest things to initiate cultural change is to align people on an improvement journey.\u0026rdquo; (p17, executive)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTheme 4: Effective teams and team composition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I think the strengths are the level of expertise of the people that are participating. The fact that it has support from the CEO here at [hospital], and you know high levels here at [hospital], it's definitely a priority that we're all interested in working towards, and people are very motivated to make change in that area. Especially people who have come on board from general medicine.\u0026rdquo; (p1, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTheme 5: Workforce and Organisation-level challenges of improvements\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;We've got, we've got a capability level that doesn't match what the CIP was trying to pull us to. [Our] NUM is absolutely stretched beyond capacity ... Does she have time to do this other extra thing? No. \u0026hellip; So, if we set up our own CIP, we will set it at the level we need to set it at \u0026hellip; we did feel a little bit like somehow this process was generating pressure and it was generating pressure in a way that wasn't always helpful.\u0026rdquo; (p29, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;So, I know there has been feedback in the past about, sort of, how slow some of these projects move. But I don't know how you could do that any differently in the environment that we're in. Yeah, because there\u0026rsquo;s such high staff turnover. People are on annual leave. People are on sick leave, like, it's just lots of moving parts.\u0026rdquo; (p30, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"17\" rowspan=\"18\"\u003e \u003cp\u003e\u003cb\u003eChallenges\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I think it has been hampered by workloads. Yeah, absolutely have, and it's sort of, it's, if you've got a bunch of people who are completely overloaded and barely hanging on by their fingernails, and then they have to go and do this other stuff on top, it really does wear people's goodwill right down, yeah. And so, I think there were moments where we were really hanging on by fingernails. \u0026hellip; It's yet another stressor: we had accreditation; we had training, like the medical accreditation as well. This CIP has added significantly to the distress of people in this department.\u0026rdquo; (p29, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eI think it's been a significant workload, like around our clinical workload. It would have been nice to have some sanctioned time. We didn't get any sanctioned time.\u003c/span\u003e\u0026rdquo; (p1, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;My personal view is that [6 months] is too, too quick to, you know, and we did spread it to what it ended up being [many more] months. And I, my personal view is that, you know, at least a nine-month course would actually give that time\u0026hellip; But I think that, you know, six months, like, with sick leave and people's annual leave, and you know, so it ends up not there in six months if people take some leave in between.\u0026rdquo; (p9, CIP009 coach))\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;We got told that we would get given datasets for this. And we waited so long, and we were losing so much time that in the end, like, I found some, like, work arounds to actually pull it manually. And it probably, it took hours and hours of my time, but at least I had something that I could then give the team to say, \u0026lsquo;What do you think?\u0026rsquo;. I know that it could have been done a lot more efficiently.\u0026rdquo; (p14, CIP009 coach)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;That's the other challenge is when we come up with some interventions and it's anything to do with EMR. It's a statewide EMR system. So, we need to make sure that every other LHN providing the same service actually want to invest in that as well. So, we'll put an improvement ticket in, but it takes years for anything to happen. So, that's probably another challenge and a barrier to implementation\u0026rdquo; (p8, CIP009 coach)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTheme 6: Team cohesion, logistics and stakeholder engagement challenges\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Initially in our, in our CIP, we did not have the emergency physicians. I mean, we are talking about [project topic] in emergency medicine and emergency department. And not having any representation from emergency was a bit hard. But even before we started the program, I approached the emergency medicine physicians who are keen to ma[ke] a patient journey through ED, quicker, easier, safer, providing them comprehensive assessment. So, the people who were keen, I already contacted them as well.\u0026rdquo; (p10, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I think where we've lost capability build is we didn't have as many nurses, or we didn't have as many allied health, or other wrap around supports that would have been doing the course with them. But at the same time, I think what we did is we had a mindset change that this is the way we're going to approach problems within our units or Divisions. And this is also, \u0026lsquo;\u003cem\u003eI'm then gonna provide the authority to release some of my junior staff to do in future\u0026rsquo;\u003c/em\u003e. So, I think, that was probably a good thing.\u0026rdquo; (p6, executive)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I didn't know the team. Yeah, like, we were all strangers\u0026hellip; When you don't have a personal relationship with someone in the team, you don't feel as accountable to them\u0026hellip; If I'm working with my colleagues, they're my friends. Like, you don\u0026rsquo;t want to let them down\u0026hellip; I think it was tricky trying to work with people that you've never worked with before.\u0026rdquo; (p30, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;But some of the barriers to that are, um, the teams that would be, um, overseeing those patients are quite resistant to change. They probably have quite a lot of change fatigue, and so when [our change initiative] was originally put through the senior consultants, they were like, \u0026lsquo;Absolutely not. No way\u0026rsquo;. So, there's potential that you may come up with an option for, you know, an alternative pathway and alternative location. But the barrier then may be, \u0026lsquo;No, we don't wanna change anything. Let's just leave it as it is\u0026rsquo;. So, it may be a very long-term solution that may take a lot of discussions and a lot of ongoing, and you know, mitigation strategies to say, \u0026lsquo;Oh, OK, the reason it would be a better option for patients is because we've engaged with consumers, and this is their feedback. This is a safety mechanism\u0026rsquo;.\u0026rdquo; (p7, CIP009 coach)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTheme 7: CIP009 Training and support shortcomings\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;W\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ee had so many conflicting demands. And so, like, my phone was going constantly, you know, we had no cover. No one was covering our roles like so, taking three days off our normal jobs, it just meant that when we got back, we were swamped with so much work\u003c/span\u003e\u0026rdquo; (p12, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eI would say some of the material or lectures are redundant. And 3 1/2 days. Whether it's really that necessary to be that long is my main point and so personally, I mean, this is my opinion. I think it probably [could] be able to be condensed, the course into a maximum 1 1/2 days\u0026hellip; even some of the lectures or guest lectures may not be all that necessary.\u0026rdquo;\u003c/span\u003e (p28, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I think only a small amount of that time is dedicated to actually working on the actual problem. Like, you do little bits of it, but I wonder, if the teams, given they are actually together and the time\u0026rsquo;s already secured, would benefit from 1/2 day at the end or something to, um, really get the [project] kick started, going.\u0026rdquo; (p19, CIP009 participant).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;[I was] a bit unclear about what our task was. I probably would have wanted, maybe, more time with the coach. Because I know that the coaches had, like, multiple different teams. It would often be like set with the task and then you were sort of sitting down with strangers trying to complete a task you don't really understand. It would have been nice to have the coach there, sort of, driving that a little bit more so we had more of an understanding of what you're meant to be doing.\u0026rdquo; (p30, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I rocked up at the course and I remember spending like the first two days, just being like, \u0026lsquo;What are these people talking about?... And there were lots of people, like I said, just thrown into it who didn't really want to do it\u0026hellip;And I think the nature of the CIP009 was because we weren't a cohesive group that had come at it, like, chosen to, sort of, come at it together, I feel like that made it a lot harder. Like I've got colleagues who have done it before, and they've done it with their colleague with a really clear project in mind. So, you've got that, you've already got that buy-in. Like, they desperately want to be there, and they want to do it and they want to complete this project. That's why they signed up to it, whereas this was sort of thrust upon us a little bit more, so I feel like the coaches probably had to do more.\u0026rdquo; (p30, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I must say, this year, because it was like, that focus on ramping and we got allocated our thing, it did, it wasn't the priority for me... I would have chosen a different priority.\u0026rdquo; (p29, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;I found, so that's why I think it was a little bit shallow, in that it was maybe asking for such a huge problem like ramping, you\u0026rsquo;ve gotta delve way deeper than the CIP course did\u0026hellip;So, [CIP\u0026rsquo;s] really good for little problems, I think. Like, really good for some money saving, streamlining little problems that you would have on the wards or in outpatients or wherever.\u0026rdquo; (p24, CIP009 participant)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe seven themes and subthemes representing determinants for CIP009 were deductively mapped against the five domains of the CFIR framework (Innovation, outer setting, inner setting, individual and implementation process)(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Mapping these strengths and challenges against the theoretical framework reinforced how each subtheme was aligned with the different levels of determinants most likely to influence the implementation of CIP009 and the 12 CQI interventions. A large proportion of key strengths and challenges were mapped to the inner setting domain of the intervention relating to teams and culture.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStrengths and challenges of CIP009 mapped against the CFIR domains (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubthemes of Key strengths and challenges associated with CIP009 implementation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInnovation domain\u003c/b\u003e \u003cem\u003eInnovation Source, Evidence-Base, Relative Advantage, Adaptability, Trialability, Complexity, Design, Cost\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 1\u003c/b\u003e CIP framework and culture embedded in the psyche of the organisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Strategic approach to capacity and capability building\u003c/p\u003e \u003cp\u003e\u0026bull; Flexible and adaptive evidence-based program\u003c/p\u003e \u003cp\u003e\u0026bull; Training strengths\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 2\u003c/b\u003e The benefits of support from a dedicated, internal improvement Faculty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; An experienced internal faculty\u003c/p\u003e \u003cp\u003e\u0026bull; Clinical directors and coaches embedded in divisions and within executive structures\u003c/p\u003e \u003cp\u003e\u0026bull; Continuous wrap around support from knowledgeable and passionate coaches\u003c/p\u003e \u003cp\u003e\u0026bull; Stable continuous support from an internal and well-resourced faculty\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 7\u003c/b\u003e Training and support shortcomings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Training shortcomings\u003c/p\u003e \u003cp\u003e\u0026bull; Top-down and outcomes focus limiting codesign with staff\u003c/p\u003e \u003cp\u003e\u0026bull; Scepticism related to complexity of issues\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOuter setting domain\u003c/b\u003e \u003cem\u003eCritical Incidents, Local Attitudes, Local Conditions, Partnerships \u0026amp; Connections, Policies \u0026amp; Laws, Financing, External Pressure\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 5\u003c/b\u003e Workforce and organisation-level challenges of improvements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Infrastructural and ICT challenges (medicolegal and governance approvals)\u003c/p\u003e \u003cp\u003e\u0026bull; Data access and quality\u003c/p\u003e \u003cp\u003e\u0026bull; Workforce capacity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInner setting domain\u003c/b\u003e \u003cem\u003eStructural Characteristics, Relational Connections, Communications, Culture, Tension for Change, Compatibility, Relative Priority, Incentive Systems, Mission Alignment, Available Resources, Access to Knowledge \u0026amp; Information\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 1\u003c/b\u003e CIP framework and culture embedded in the psyche of the organisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Culture of flattened hierarchy\u003c/p\u003e \u003cp\u003e\u0026bull; Accountability\u003c/p\u003e \u003cp\u003e\u0026bull; Awareness of CIP and culture of enquiry\u003c/p\u003e \u003cp\u003eProfessional relationships, buy-in and engagement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 2\u003c/b\u003e The benefits of support from a dedicated, internal improvement Faculty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Regular multimodal meetings with coaches and clear, respectful communication\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 3\u003c/b\u003e The advantages of an enthusiastic participant disposition and incentives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Shared vision of beneficence, and improving workflow and patient care end to end\u003c/p\u003e \u003cp\u003e\u0026bull; Opportunities to collaborate across divisions and with consultants\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 4\u003c/b\u003e Effective teams and team composition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Team cohesion and collaboration\u003c/p\u003e \u003cp\u003e\u0026bull; Multidisciplinary teams\u003c/p\u003e \u003cp\u003e\u0026bull; Engagement with the right stakeholders\u003c/p\u003e \u003cp\u003e\u0026bull; Senior team members as change agents\u003c/p\u003e \u003cp\u003e\u0026bull; Balance of expertise and capacity to enact change\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 6\u003c/b\u003e Team cohesion, logistics and stakeholder engagement challenges\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Team cohesion challenges\u003c/p\u003e \u003cp\u003e\u0026bull; Team logistical challenges\u003c/p\u003e \u003cp\u003e\u0026bull; Lack of stakeholder engagement and buy-in\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 7\u003c/b\u003e Training and support shortcomings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Communication issues\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIndividual domain\u003c/b\u003e \u003cb\u003e\u0026ndash;\u003c/b\u003e \u003cem\u003eroles and characteristics High-level and Mid-level leaders, Opinion Leaders, Implementation (Impl) Facilitators, Impl Leads, Impl Team Members, Other Impl Support, Innovation Deliverers, Innovation Recipients, Need, Capability, Opportunity, Motivation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 3\u003c/b\u003e The advantages of an enthusiastic participant disposition and incentives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Participant disposition, belief in the program and skill level\u003c/p\u003e \u003cp\u003e\u0026bull; Enthusiasm to learn how to break down problems\u003c/p\u003e \u003cp\u003e\u0026bull; Capacity to rearrange priorities to complete tasks\u003c/p\u003e \u003cp\u003e\u0026bull; Vested interests to improve care and workflow\u003c/p\u003e \u003cp\u003e\u0026bull; Gaining new perspectives on patient journeys\u003c/p\u003e \u003cp\u003e\u0026bull; Professional incentives like CPD points and career progression\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 5\u003c/b\u003e Workforce and organisation-level challenges of improvements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Clinician workloads, competing priorities and time\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImplementation process domain\u003c/b\u003e \u003cem\u003eTeaming, Assessing Needs, Assessing Context, Planning, Tailoring Strategies, Engaging, Doing, Reflecting \u0026amp; Evaluating, Adapting\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 7\u003c/b\u003e Training and support shortcomings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Sustainability planning issues\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe key subthemes of the CIP009 were then collapsed into a more simplified structure of macro (hospital, outer setting), meso (teams, inner setting) and micro (individual) levels of the SALHN organisation, along with the key elements of the CIP009 program such as training and wraparound support from the Faculty. The fundamental elements of the CIP009 that were perceived to contribute to the implementation of CIP009 and its organisation-wide goal of improved patient flow and reduced ramping can be visualised in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eOverview of the CIP009 evaluation\u003c/h2\u003e \u003cp\u003eThis evaluation of the SALHN CIP009, which encompassed interviews, observations and document review, has identified key factors impacting the perceived success of the CIP009 improvement program across seven themes: The first four themes related to key strengths of CIP009, and the final three themes related to challenges.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eThe Learning Health System\u003c/h2\u003e \u003cp\u003eThe key elements of CIP009 described in this evaluation together contribute to a culture of continuous improvement to enhance the delivery of patient care. A concept of a \u003cem\u003eLearning Health System\u003c/em\u003e has been rapidly evolving in recent years and refers to a systems approach to support organisations to establish data-informed continuous learning processes to incorporate best practice into routine care(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). The Institute of Medicine defined an LHS as one where \u0026ldquo;\u003cem\u003escience, informatics, patient-clinician partnerships, incentives, and culture are aligned to promote and enable continuous and real-time improvement in both the effectiveness and efficiency of care\u003c/em\u003e\u0026rdquo;(40, p17).\u003c/p\u003e \u003cp\u003eThis evaluation identified that CIP009 is underpinned by elements essential to a sustainable Learning Health System (LHS)(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). For example, key LHS elements that were found in this evaluation of the SALHN CIP009 include improvements to health and care processes that are delivered through data-driven research that inform changes to practice(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Similarly, continuous improvement cycles that utilise data and data infrastructure(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) to inform practice change, followed by the implementation, assessment and amendments of the practice improvements(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) were utilised by CIP009. Sustainable LHSs are grounded in systematic frameworks, have strong commitment from leadership to capture organisational priorities(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) and align incentives(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), are well resourced(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), and establish a supportive culture of continuous learning(\u003cspan additionalcitationids=\"CR43\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). LHSs must be supported by an engaged and skilled workforce(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) with improvement capacity and capability(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). An LHS can also enhance cross organisational collaboration by connecting siloed clinicians(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) as well as consumers and the community who are actively involved in the processes of continuous improvement(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCIP009 has contributed to the development of these LHS elements within SALHN, with many of the themes from this evaluation reflected in the LHS literature. CIP009 has demonstrated the importance, and indeed the challenges, of access to quality routine service delivery data to inform the design of interventions at the patient-clinician interface (Theme 5)(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). The longevity of the program has enabled CIP to evolve, establishing a systematic framework, CQI infrastructure, and a Faculty of knowledgeable personnel to provide continuous support and facilitate change (Theme 1)(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe novel combined top-down and bottom-up nature of CIP009 resulted in executive support for and investment in the program, while retaining participant design and ownership of the projects(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), and motivation to sustain changes (Themes 1 and 2)(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Strong leadership support was perceived to contribute to the uptake and adoption of CIP009(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). This support combined with the sustained resourcing for CIP009 has helped to build capability within the workforce (Theme 2)(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), implement CQI interventions(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e), and enhance team accountability (Themes 1 and 2)(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). CIP009 projects were also closely aligned with organisational priorities achieved through leadership codesign of CQI project topics to improve patient flow (Theme 1)(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). CIP009 established a culture of inquiry and continuous learning(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), with inhouse continuous wrap-around support(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) to develop technical skills and CQI knowledge (Themes 1 and 2)(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The perceived cultural change at the organisational level (Theme 1) was achieved through increased awareness and engagement with the structured framework, language and methodology(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), potentially mitigating loss of CIP knowledge from staff turnover(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCIP009 also focused on engagement and co-design of CQI interventions with key stakeholders (Theme 1). Stakeholder and leadership buy-in was facilitated through a combination of a flattened hierarchy and encouragement of equal participation by team members (Theme 1)(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e), and continuous support from coaches (Theme 2)(\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). The transformational leadership style(\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e) used by coaches ensured momentum and coordination was maintained, and change mechanisms effectively communicated to persuade change adoption (Theme 2)(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Participant belief in the value of reducing unwarranted variation in practice and vested interests to improve care and workflow (Theme 3)(\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e), multidisciplinary and interprofessional teams who provided insight into systems and processes(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) and interdivisional collaboration (Theme 4)(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) also contributed to staff buy-in. These elements are each fundamental to address the wicked problems that persist within the complex adaptive system that is healthcare(\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). The ongoing nature of CIP has meant that a large proportion of SALHN staff have graduated from CIP training, developing a community of CQI experts (Theme 1)(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). CIP009 has endeavored to embed best practice into routine care(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), and improve the value and efficiency of processes(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) through data driven improvements(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), contributing to the establishment of an LHS within SALHN.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eQuality Improvement and Implementation Science\u003c/h2\u003e \u003cp\u003eCIP009 teams faced implementation barriers such as overcoming resistance to change and achieving buy-in, in particular with the development and adoption of protocols to reduce unwarranted variation (Theme 6), both common barriers to guideline adherence(\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). This speaks to an aim to enhance translation of evidence into practice (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e), the foundation of Implementation science(\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e), while concurrently aiming to improve efficiency and effectiveness of processes and practice(\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). Implementation science elements that focus on the diffusion, dissemination, implementation, adoption and sustainability of the CQI interventions could be further integrated within the initial stages of the CIP project planning framework, to provide opportunity to identify, plan for and mitigate implementation challenges(\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImplementation science highlights the importance of change efforts being grounded in principles of behaviour change(\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). Guidance from behaviour change models such as the Theoretical Domains Framework (TDF)(\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e) during the CIP009 project planning phase, may increase the likelihood that interventions will achieve change(\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). To ensure changes are effectively embedded within organisational practice and sustained, long-term periodic feedback and evaluation of interventions should also be embedded within the early CQI project planning phase, to ensure the intervention remains applicable to the setting and sustainability is considered from the beginning of the project(\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurther integration of implementation science and CQI theories and strategies would guide CIP participants on how to best support change adoption by considering local contexts and determinants (barriers and facilitators) of change, as outlined in the CFIR(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) and Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, and to discern whether their change initiatives have been maintained, sustained and improved over time(\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). In line with this, the nature of support from an internal CIP009 Faculty enabled coaches to provide contextually relevant guidance and project facilitation.\u003c/p\u003e \u003cp\u003eRobust planning for implementation, sustainability and accountability, informed by an evidence based framework such as the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework(\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e), the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM framework)(\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e) or the Proctor Taxonomy of Implementation Outcomes(\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e) would ensure the best opportunities for the implemented changes to continue(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). The concept of sustainability is already incorporated within the SALHN CIP009 Continuous Improvement framework. However, the limited planning for, or application of sustainability processes reported by interviewees both reflects their early stage of progress within the SALHN 8-step framework but also indicates an opportunity for sustainability planning to be integrated at an earlier stage of CIP009. Quality improvement and implementation science differ methodologically, however there is potential for synergies that could enhance CIP patient care improvements. The bottom-up and top-down nature of this CQI program engages local stakeholders with strong leadership support and continuous measurement and adaptation to practice changes. This may be complemented by implementation science insights into mechanisms for contextually specific practice and behaviour change underpinned by theory and evidence. Systematic incorporation of implementation science frameworks may promote planning for both summative outcomes assessment as well as interim progress assessments to support adaptations and project sustainability(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eOpportunities for Improvement\u003c/h2\u003e \u003cp\u003eReflecting on the key perceived challenges of CIP009, overcoming limited clinician time to engage in CQI projects (Theme 5) is essential to establish an effective Learning Health System, and requires further organisational commitment to protect and resource clinician time for CQI involvement(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Multimodal and online modules of training may enhance the accessibility of CIP resources(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e). Similarly, CIP resources could be provided in an electronic format, within a repository of trusted and endorsed CQI education, support, and data analysis training resources, CIP case studies, online lectures to enable participants to refresh their understanding of concepts, and additional data analysis resources for those participants who want to extend their learning. A blended virtual and face-to-face model, along with greater protected time for training and implementation of the projects, may support those clinicians with competing clinical priorities (Themes 5 and 7)(\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e). In saying this, it is worth noting that the face-to-face element of the training had perceived benefits of increased networking and collaboration with clinical members, and thus the provision of electronic training resources may introduce a trade-off of reduced engagement in the course. If, however, a blended model enables ongoing access to training resources, it is likely to facilitate further engagement in the program(\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e). To increase the efficiency of training days and the amount of dedicated coach-team time (Theme 7), training days could be split into two parallel cohorts with practical workshops running concurrently to theory-based lectures. This would enable team time with coaches to be staggered; while one cohort listens to lectures, the other could engage in practical project planning activities with Faculty staff.\u003c/p\u003e \u003cp\u003eWorkforce and organisational challenges, such as limited data access and quality(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) need to be addressed to achieve successful CQI implementation and an effective LHS(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), specifically to enhance capacity to design locally appropriate data-informed improvement projects (Theme 5)(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Both increased and timely access to electronic medical record data and improved quality of data will contribute to the developing LHS supported by CIP009(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Future improvement projects will also be strengthened by increased consumer partnership and codesign of projects to improve healthcare service delivery(\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e). These partnerships may be informed by the \u003cem\u003eBuilding successful partnerships in healthcare QI: A capability development framework for service users, families, communities, and staff\u003c/em\u003e(\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e). The top-down nature of project topic selection resulted in variable responses from participants. Involving clinicians at an earlier stage of the topic selection process, through a brief survey, may ensure projects are clearly aligned with perceived need from both executive and clinician stakeholders.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThere may have been self-selection bias(\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e) in recruitment, as those participants who chose to engage in an interview may not represent the cohort of CIP009 participants. Not all CIP009 teams were interviewed or observed, which reduces how generalisable the findings are across the 12 teams. Due to the complexity of the 12 CIP009 projects, and the corresponding extension of the program, teams were typically still in the early stages of the SALHN 8 step framework when data collection was conducted, meaning teams hadn\u0026rsquo;t fully implemented their projects nor assessed their impact. This evaluation therefore lacked data about the challenges and strengths experienced during the implementation stage of the individual quality improvement projects. Strengths of the study include the use of member checking, use of multiple coders, as well as triangulation of data across three cohorts, and across three methods of data collection (interviews, observations, and document review) to enhance the trustworthiness of the data(\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the 12 CIP009 clinical micro-system interventions together aimed to contribute to a common organisational goal of reduced ambulance ramping by increasing patient flow, and reducing admissions, readmissions, length of stay and unwarranted clinical variation. Protocolisation of practice change was a common tool used to enhance the delivery of evidence-based practice to patients. The continuous wrap around support, multidisciplinary collaboration, culture of enquiry and structured framework of CIP009, as well as the top-down support in combination with bottom-up intervention design, has resulted in a CQI training program that is perceived to effectively develop staff skills and facilitate progress of micro-system improvements to achieve macro-outcomes. Incorporation of implementation science principles within the continuous improvement framework may further support the implementation and sustainability of future CIP projects.\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eCOREQ: Consolidated Criteria for Reporting Qualitative Studies\u003c/li\u003e\n \u003cli\u003eCFIR: Consolidated Framework for Implementation Research\u003c/li\u003e\n \u003cli\u003eCPD: Continuing Professional Development\u003c/li\u003e\n \u003cli\u003eCIP009: Continuous Improvement Program 009\u003c/li\u003e\n \u003cli\u003eThe Faculty: Continuous Improvement Unit (CIU)\u003c/li\u003e\n \u003cli\u003eCQI: Continuous Quality Improvement\u003c/li\u003e\n \u003cli\u003eED: Emergency Department\u003c/li\u003e\n \u003cli\u003eEPIS: Exploration, Preparation, Implementation, Sustainment Framework\u003c/li\u003e\n \u003cli\u003eHREC: Human Research Ethics Committee\u003c/li\u003e\n \u003cli\u003eLHS: Learning Health System\u003c/li\u003e\n \u003cli\u003eLNR: Low and Negligible Research\u003c/li\u003e\n \u003cli\u003eLOS: Length of Stay\u003c/li\u003e\n \u003cli\u003eSALHN: Southern Adelaide Local Health District\u003c/li\u003e\n \u003cli\u003eTDF: Theoretical Domains Framework\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHuman Research Ethics Committee (HREC) and governance approval for Low and Negligible Research (LNR) by the SALHN HREC (LNR Reference number: LNR/23/SAC/157.23; and Office for Research: OFR Number: 157.23) was obtained before research commenced. Participants provided written consent before participating in an interview or a meeting observation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterview transcripts are not publicly available to protect the confidentiality of study participants. However, data such as codes, and anonymised quotes may be available from the corresponding author (PH) upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis evaluation project was funded by the Flinders Foundation. The interpretation of findings was independent to the funders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMB, PH designed the study, while SH, LE and RCW reviewed and provided guidance regarding the study design. MB conducted all interviews, observations, and collected documents for review. MB analysed all data and conducted initial coding and thematic framework development. PH reviewed coding and analysed the final thematic framework. SH, LE and RCW provided feedback on the practical applicability of findings. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDixon-Woods M, Martin GP. Does quality improvement improve quality? Future Hosp J. 2016;3(3):191. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7861/futurehosp.3-3-191\u003c/span\u003e\u003cspan address=\"10.7861/futurehosp.3-3-191\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorton WE, McCannon CJ, Schall MW, Mittman BS. A stakeholder-driven agenda for advancing the science and practice of scale-up and spread in health. Implement Sci. 2012;7(1):1\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1748-5908-7-118\u003c/span\u003e\u003cspan address=\"10.1186/1748-5908-7-118\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHartviksen TA, Aspfors J, Uhrenfeldt L. Healthcare middle managers\u0026rsquo; experiences of developing capacity and capability: a systematic review and meta-synthesis. BMC Health Serv Res. 2019;19(1):1\u0026ndash;19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-019-4345-1\u003c/span\u003e\u003cspan address=\"10.1186/s12913-019-4345-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHill JE, Stephani A-M, Sapple P, Clegg AJ. The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review. Implement Sci. 2020;15(1):1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHibbert PD, Basedow M, Braithwaite J, Wiles LK, Clay-Williams R, Padbury R. How to sustainably build capacity in quality improvement within a healthcare organisation: a deep-dive, focused qualitative analysis. BMC Health Serv Res. 2021;21(1):1\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-021-06598-8\u003c/span\u003e\u003cspan address=\"10.1186/s12913-021-06598-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones B, Vaux E, Olsson-Brown A. How to get started in quality improvement. BMJ. 2019;364:k5408. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmj.k5437\u003c/span\u003e\u003cspan address=\"10.1136/bmj.k5437\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZoutman DE, Ford BD. Quality improvement in hospitals: barriers and facilitators. Int J Health Care Qual Assur. 2017;30(1):16\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1108/IJHCQA-12-2015-0144\u003c/span\u003e\u003cspan address=\"10.1108/IJHCQA-12-2015-0144\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMery G, Dobrow MJ, Baker GR, Im J, Brown A. Evaluating investment in quality improvement capacity building: a systematic review. BMJ Open. 2017;7(2):e012431. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjopen-2016-012431\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2016-012431\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStelson P, Hille J, Eseonu C, Doolen T. What drives continuous improvement project success in healthcare? Int J Health Care Qual Assur. 2017;30(1):43\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1108/IJHCQA-03-2016-0035\u003c/span\u003e\u003cspan address=\"10.1108/IJHCQA-03-2016-0035\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarff L, O'Brien R. Evidence-based quality improvement training programs: building staff capability and organizational capacity. J Nurs Care Qual. 2020;35(2):95\u0026ndash;101. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/NCQ.0000000000000416\u003c/span\u003e\u003cspan address=\"10.1097/NCQ.0000000000000416\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Neill NE, Baker J, Ward R, Johnson C, Taggart L, Sholzberg M. The development of a quality improvement project to improve infection prevention and management in patients with asplenia or hyposplenia. BMJ Open Qual. 2020;9(3):e000770. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjoq-2019-000770\u003c/span\u003e\u003cspan address=\"10.1136/bmjoq-2019-000770\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLouie JP, Alfano J, Nguyen-Tran T, Nguyen-Tran H, Shanley R, Holm T, et al. Reduction of paediatric head CT utilisation at a rural general hospital emergency department. BMJ Qual Saf. 2020;29(11):912\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjqs-2019-010322\u003c/span\u003e\u003cspan address=\"10.1136/bmjqs-2019-010322\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraithwaite J, Clay-Williams R, Taylor N, Ting HP, Winata T, Hogden E, et al. Deepening our Understanding of Quality in Australia (DUQuA): An overview of a nation-wide, multi-level analysis of relationships between quality management systems and patient factors in 32 hospitals. Int J Qual Health Care. 2020;32(Supplement1):8\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/intqhc/mzz103\u003c/span\u003e\u003cspan address=\"10.1093/intqhc/mzz103\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWagner C, Groene O, Thompson CA, Dersarkissian M, Klazinga NS, Arah OA, et al. DUQuE quality management measures: associations between quality management at hospital and pathway levels. Int J Qual Health Care. 2014;26(suppl1):66\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/intqhc/mzu020\u003c/span\u003e\u003cspan address=\"10.1093/intqhc/mzu020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenning A, Ghaleb M, Suokas A, Dixon-Woods M, Dawson J, Barber N, et al. Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation. BMJ. 2011. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e342https://doi.org/10.1136/bmj.d195\u003c/span\u003e\u003cspan address=\"34210.1136/bmj.d195\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrugman IM, Visser A, Maaskant JM, Geerlings SE, Eskes AM. The Evaluation of an Interprofessional QI Program: A Qualitative Study. Int J Environ Res Public Health. 2022;19(16):10087. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijerph191610087\u003c/span\u003e\u003cspan address=\"10.3390/ijerph191610087\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenning A, Dixon-Woods M, Nwulu U, Ghaleb M, Dawson J, Barber N, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ. 2011;342. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmj.d199\u003c/span\u003e\u003cspan address=\"10.1136/bmj.d199\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoitein L, James B. Standardized best practices and individual craft-based medicine: a conversation about quality. JAMA Intern Med. 2016;176(6):835\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jamainternmed.2016.1641\u003c/span\u003e\u003cspan address=\"10.1001/jamainternmed.2016.1641\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJames BC, Savitz LA. How Intermountain trimmed health care costs through robust quality improvement efforts. Health Aff. 2011;30(6):1185\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1377/hlthaff.2011.0358\u003c/span\u003e\u003cspan address=\"10.1377/hlthaff.2011.0358\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLangley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The improvement guide: a practical approach to enhancing organizational performance. Wiley; 2009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBen-Tovim DI. Process redesign for health care using lean thinking: a guide for improving patient flow and the quality and safety of care. CRC; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWomack JP, Jones DT, Roos D. The machine that changed the world: The story of lean production\u0026ndash;Toyota's secret weapon in the global car wars that is now revolutionizing world industry. Simon and Schuster; 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Practical guidance for scaling up health service innovations: World Health Organization. 2009. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/bitstream/handle/10665/44180/9789241598521_eng.pdf\u003c/span\u003e\u003cspan address=\"https://iris.who.int/bitstream/handle/10665/44180/9789241598521_eng.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRogers Everett M. Diffusion of innovations. New York. 1995;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKreindler SA, Star N, Hastings S, Winters S, Johnson K, Mallinson S, et al. Working against gravity: the uphill task of overcapacity management. Health Serv Insights. 2020;13:1178632920929986. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1178632920929\u003c/span\u003e\u003cspan address=\"10.1177/1178632920929\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKingswell C, Shaban RZ, Crilly J. Concepts, antecedents and consequences of ambulance ramping in the emergency department: a scoping review. Australasian Emerg Nurs J. 2017;20(4):153\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.aenj.2017.07.002\u003c/span\u003e\u003cspan address=\"10.1016/j.aenj.2017.07.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamanadhan S, Revette AC, Lee RM, Aveling EL. Pragmatic approaches to analyzing qualitative data for implementation science: an introduction. Implement Sci Commun. 2021;2:1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s43058-021-00174-1\u003c/span\u003e\u003cspan address=\"10.1186/s43058-021-00174-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBooth A, Hannes K, Harden A, Noyes J, Harris J, Tong A. COREQ (consolidated criteria for reporting qualitative studies). 2014. In: Guidelines for reporting health research: a user's manual [Internet]. [214\u0026thinsp;\u0026ndash;\u0026thinsp;26]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/9781118715598.ch21\u003c/span\u003e\u003cspan address=\"10.1002/9781118715598.ch21\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFusch PI, Ness LR. Are we there yet? Data saturation in qualitative research. Qualitative Rep. 2015;20(9):1408\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.nova.edu/ssss/QR/QR20/9/fusch1.pdf\u003c/span\u003e\u003cspan address=\"http://www.nova.edu/ssss/QR/QR20/9/fusch1.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampbell S, Greenwood M, Prior S, Shearer T, Walkem K, Young S, et al. Purposive sampling: complex or simple? Research case examples. J Res Nurs. 2020;25(8):652\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1744987120927\u003c/span\u003e\u003cspan address=\"10.1177/1744987120927\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDamschroder LJ, Reardon CM, Widerquist MAO, Lowery J. The updated Consolidated Framework for Implementation Research based on user feedback. Implement Sci. 2022;17(1):75. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13012-022-01245-0\u003c/span\u003e\u003cspan address=\"10.1186/s13012-022-01245-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrudwick RM. Ethnographic research in healthcare\u0026ndash;patients and service users as participants. Disabil Rehabil. 2021;43(22):3271\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/09638288.2020.1741695\u003c/span\u003e\u003cspan address=\"10.1080/09638288.2020.1741695\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSrivastava P, Hopwood N. A practical iterative framework for qualitative data analysis. Int J Qualitative Methods. 2009;8(1):76\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1609406909008001\u003c/span\u003e\u003cspan address=\"10.1177/1609406909008001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1191/1478088706qp063oa\u003c/span\u003e\u003cspan address=\"10.1191/1478088706qp063oa\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQSR International Pty Ltd. NVIVO version 14. Victoria. Australia: Qualitative Solutions and Research Pty Ltd; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEllis LA, Sarkies M, Churruca K, Dammery G, Meulenbroeks I, Smith CL, et al. The science of learning health systems: scoping review of empirical research. JMIR Med Inf. 2022;10(2):e34907. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2196/34907\u003c/span\u003e\u003cspan address=\"10.2196/34907\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorse JM. Critical analysis of strategies for determining rigor in qualitative inquiry. Qual Health Res. 2015;25(9):1212\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/10497323155885\u003c/span\u003e\u003cspan address=\"10.1177/10497323155885\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnticott J, Johnson A, Teede H. Learning health systems using data to drive healthcare improvement and impact: a systematic review. BMC Health Serv Res. 2021;21:1\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-021-06215-8\u003c/span\u003e\u003cspan address=\"10.1186/s12913-021-06215-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePomare C, Mahmoud Z, Vedovi A, Ellis LA, Knaggs G, Smith CL, et al. Learning health systems: a review of key topic areas and bibliometric trends. Learn Health Syst. 2022;6(1):e10265. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/lrh2.10265\u003c/span\u003e\u003cspan address=\"10.1002/lrh2.10265\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith M, Saunders R, Stuckhardt L, McGinnis JM. Best care at lower cost: the path to continuously learning health care in America. Institute of Medicine CotLHCSiA. editor. Washington, DC: National Academies; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMenear M, Blanchette M-A, Demers-Payette O, Roy D. A framework for value-creating learning health systems. Health Res Policy Syst. 2019;17:1\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12961-019-0477-3\u003c/span\u003e\u003cspan address=\"10.1186/s12961-019-0477-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Bruin J, Bos C, Struijs JN, Drewes HWT, Baan CA. Conceptualizing learning health systems: A mapping review. Learn Health Syst. 2023;7(1):e10311. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/lrh2.10311\u003c/span\u003e\u003cspan address=\"10.1002/lrh2.10311\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEasterling D, Perry AC, Woodside R, Patel T, Gesell SB. Clarifying the concept of a learning health system for healthcare delivery organizations: implications from a qualitative analysis of the scientific literature. Learn Health Syst. 2022;6(2):e10287. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/lrh2.10287\u003c/span\u003e\u003cspan address=\"10.1002/lrh2.10287\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnticott J, Braaf S, Johnson A, Jones A, Teede HJ. Leaders\u0026rsquo; perspectives on learning health systems: a qualitative study. BMC Health Serv Res. 2020;20:1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLong JC, Roberts N, Francis-Auton E, Sarkies MN, Nguyen HM, Westbrook JI, et al. Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability. BMC Health Serv Res. 2024;24(1):1\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-024-10721-w\u003c/span\u003e\u003cspan address=\"10.1186/s12913-024-10721-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNilsen P, Seing I, Ericsson C, Birken SA, Schildmeijer K. Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and assistant nurses. BMC Health Serv Res. 2020;20:1\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-020-4999-8\u003c/span\u003e\u003cspan address=\"10.1186/s12913-020-4999-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82(4):581\u0026ndash;629. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.0887-378X.2004.00325.x\u003c/span\u003e\u003cspan address=\"10.1111/j.0887-378X.2004.00325.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWright D, Gabbay J, Le May A. Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies. BMJ Qual Saf. 2022;31(6):450\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjqs-2021-013065\u003c/span\u003e\u003cspan address=\"10.1136/bmjqs-2021-013065\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang AM, Cohen DJ, Lin A, Augustine J, Handel DA, Howell E, et al. Hospital strategies for reducing emergency department crowding: a mixed-methods study. Ann Emerg Med. 2018;71(4):497\u0026ndash;505. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.annemergmed.2017.07.022\u003c/span\u003e\u003cspan address=\"10.1016/j.annemergmed.2017.07.022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. e4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSutcliffe KM, Paine L, Pronovost PJ. Re-examining high reliability: actively organising for safety. BMJ Qual Saf. 2017;26(3):248\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjqs-2015-004698\u003c/span\u003e\u003cspan address=\"10.1136/bmjqs-2015-004698\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature. BMJ Qual Saf. 2012;21(10):876\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjqs-2011-000760\u003c/span\u003e\u003cspan address=\"10.1136/bmjqs-2011-000760\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFitzsimons J. Quality and safety in the time of coronavirus: design better, learn faster. Int J Qual Health Care. 2021;33(1):mzaa051. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/intqhc/mzaa051\u003c/span\u003e\u003cspan address=\"10.1093/intqhc/mzaa051\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobert G, Morrow E, Maben J, Griffiths P, Callard L. The adoption, local implementation and assimilation into routine nursing practice of a national quality improvement programme: the Productive Ward in England. J Clin Nurs. 2011;20(7\u0026ndash;8):1196\u0026ndash;207. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1365-2702.2010.03480.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1365-2702.2010.03480.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarkies M, Long JC, Pomare C, Wu W, Clay-Williams R, Nguyen HM, et al. Avoiding unnecessary hospitalisation for patients with chronic conditions: a systematic review of implementation determinants for hospital avoidance programmes. Implement Sci. 2020;15:1\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13012-020-01049-0\u003c/span\u003e\u003cspan address=\"10.1186/s13012-020-01049-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobbins B, Davidhizar R. Transformational leadership in health care today. Health Care Manag. 2020;39(3):117\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/HCM.0000000000000296\u003c/span\u003e\u003cspan address=\"10.1097/HCM.0000000000000296\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaughn VM, Saint S, Krein SL, Forman JH, Meddings J, Ameling J, et al. Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies. BMJ Qual Saf. 2019;28(1):74\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjqs-2017-007573\u003c/span\u003e\u003cspan address=\"10.1136/bmjqs-2017-007573\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor N, Clay-Williams R, Hogden E, Braithwaite J, Groene O. High performing hospitals: a qualitative systematic review of associated factors and practical strategies for improvement. BMC Health Serv Res. 2015;15(1):1\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-015-0879-z\u003c/span\u003e\u003cspan address=\"10.1186/s12913-015-0879-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBierbaum M, Rapport F, Arnolda G, Delaney GP, Liauw W, Olver I, et al. Clinical practice guideline adherence in oncology: a qualitative study of insights from clinicians in Australia. PLoS ONE. 2022;17(12):e0279116. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0279116\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0279116\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBierbaum M, Rapport F, Arnolda G, Tran Y, Nic Giolla Easpaig B, Ludlow K, et al. Rates of adherence to cancer treatment guidelines in Australia and the factors associated with adherence: A systematic review. Asia-Pac J Clin Oncol. 2023;19(6):618\u0026ndash;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ajco.13948\u003c/span\u003e\u003cspan address=\"10.1111/ajco.13948\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraithwaite J, Marks D, Taylor N. Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature. Int J Qual Health Care. 2014;26(3):321\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/intqhc/mzu047\u003c/span\u003e\u003cspan address=\"10.1093/intqhc/mzu047\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNilsen P, Thor J, Bender M, Leeman J, Andersson-G\u0026auml;re B, Sevdalis N. Bridging the silos: a comparative analysis of implementation science and improvement science. Front Health Serv. 2022;1:817750. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/frhs.2021.817750\u003c/span\u003e\u003cspan address=\"10.3389/frhs.2021.817750\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRapport F, Clay-Williams R, Churruca K, Shih P, Hogden A, Braithwaite J. The struggle of translating science into action: foundational concepts of implementation science. J Eval Clin Pract. 2018;24(1):117\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jep.12741\u003c/span\u003e\u003cspan address=\"10.1111/jep.12741\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCane J, O\u0026rsquo;Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:1\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1748-5908-7-37\u003c/span\u003e\u003cspan address=\"10.1186/1748-5908-7-37\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRapport F, Smith J, Hutchinson K, Clay-Williams R, Churruca K, Bierbaum M, et al. Too much theory and not enough practice? The challenge of implementation science application in healthcare practice. J Eval Clin Pract. 2022;28(6):991\u0026ndash;1002. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jep.13600\u003c/span\u003e\u003cspan address=\"10.1111/jep.13600\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilver SA, McQuillan R, Harel Z, Weizman AV, Thomas A, Nesrallah G, et al. How to sustain change and support continuous quality improvement. Clin J Am Soc Nephrol. 2016;11(5):916\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2215/CJN.11501015\u003c/span\u003e\u003cspan address=\"10.2215/CJN.11501015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoullin JC, Dickson KS, Stadnick NA, Rabin B, Aarons GA. Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Implement Sci. 2019;14(1):1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13012-018-0842-6\u003c/span\u003e\u003cspan address=\"10.1186/s13012-018-0842-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC, et al. RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review. Front Public Health. 2019;7:64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpubh.2019.00064\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2019.00064\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Mental Health Mental Health Serv Res. 2011;38:65\u0026ndash;76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10488-010-0319-7\u003c/span\u003e\u003cspan address=\"10.1007/s10488-010-0319-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlexander CC, Tschannen D, Hays D, Clouse M, Zellefrow C, Amer KS, et al. An integrative review of the barriers and facilitators to nurse engagement in quality improvement in the clinical practice setting. J Nurs Care Qual. 2022;37(1):94\u0026ndash;100. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/NCQ.0000000000000562\u003c/span\u003e\u003cspan address=\"10.1097/NCQ.0000000000000562\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKenna K, Gupta K, Kaiser L, Lopes T, Zarestky J. Blended learning: Balancing the best of both worlds for adult learners. Adult Learn. 2020;31(4):139\u0026ndash;49. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1045159519891997\u003c/span\u003e\u003cspan address=\"10.1177/1045159519891997\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlexander C, Tschannen D, Argetsinger D, Hakim H, Milner KA. A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders. J Nurs Adm Manag. 2022;30(3):694\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCox R, Kendall M, Molineux M, Miller E, Tanner B. Refining a capability development framework for building successful consumer and staff partnerships in healthcare quality improvement: A coproduced eDelphi study. Health Expect. 2022;25(4):1563\u0026ndash;79. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/hex.13499\u003c/span\u003e\u003cspan address=\"10.1111/hex.13499\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobinson OC. Sampling in interview-based qualitative research: A theoretical and practical guide. Qualitative Res Psychol. 2014;11(1):25\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/14780887.2013.801543\u003c/span\u003e\u003cspan address=\"10.1080/14780887.2013.801543\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdler RH. Trustworthiness in qualitative research. J Hum Lactation. 2022;38(4):598\u0026ndash;602. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/08903344221116\u003c/span\u003e\u003cspan address=\"10.1177/08903344221116\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Quality Improvement, Continuous Quality Improvement, implementation science, strengths and challenges, qualitative, ambulance ramping, patient flow, Learning Health System, Consolidated Framework for Implementation Research, Thematic analysis","lastPublishedDoi":"10.21203/rs.3.rs-4614057/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4614057/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction\u003c/p\u003e\n\u003cp\u003eContinuous quality improvement (CQI) initiatives are commonly used to enhance patient safety and quality of care. A novel South Australian Local Health Network (SALHN) Continuous Improvement Program (CIP009) has integrated a top-down model of executive-directed change initiatives, with a bottom-up approach of clinician designed interventions to address an organisational-wide goal of improved patient flow. This study evaluated the strengths and challenges of CIP009 implementation from the perspective of participants and deliverers.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eA qualitative study was conducted to evaluate the implementation of CIP009 and 12 associated quality improvement projects. Semi-structured interviews, document review, and observations were guided by the Consolidated Framework for Implementation Research (CFIR). Interviews, focus groups and observations were conducted with key stakeholders (executives, coaches and participants). Data were analysed inductively using thematic analysis, then deductively mapped against the five CFIR domains.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eThirty-one participants were interviewed, two presentation days and six team meetings were observed, and 78 documents were reviewed.\u003csub\u003e \u003c/sub\u003eSeven key themes were identified highlighting key challenges and strengths of CIP009 implementation within the SALHN setting. These included four key strengths:\u003cem\u003e the CIP framework and culture \u003c/em\u003e(the flexible framework, common language, training, and a culture of flattened hierarchy); \u003cem\u003ethe benefits of support from a dedicated, internal improvement Faculty\u003c/em\u003e (wrap around support from coaches); \u003cem\u003ethe advantages of an enthusiastic participant disposition and incentives \u003c/em\u003e(vested interests to enhance workflow and patient outcomes); and e\u003cem\u003effective teams and team composition\u003c/em\u003e\u003cem\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/em\u003e(teams comprised of senior clinician change agents). Three key challenges included: \u003cem\u003eworkforce and organisation-level challenges \u003c/em\u003e(individual workloads, workforce capacity, and data access); \u003cem\u003eteam cohesion, logistics and stakeholder engagement challenges \u003c/em\u003e(issues in the way teams worked together); and \u003cem\u003etraining and support shortcomings\u003c/em\u003e (the training course, and the top-down nature of CIP009).\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eThis evaluation identified that CIP009 was considered an effective multifaceted CQI program. The strengths of CIP009 support a learning health system (a data driven model, utilising systematic frameworks, with commitment from leadership, and a culture of continuous learning). Further integration of implementation science principles may support the program to overcome the key challenges identified.\u003c/p\u003e","manuscriptTitle":"Establishing a Learning Health System through the implementation of a health service wide Continuous Quality Improvement program: A qualitative evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:47:27","doi":"10.21203/rs.3.rs-4614057/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"050b9bec-43bb-4d26-999e-c20d25987813","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-23T06:33:23+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-18 20:47:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4614057","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4614057","identity":"rs-4614057","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}