Implementing Pediatric Asthma Pathways in Community Hospitals: A National Qualitative Study
BACKGROUND: Pathways can improve the quality of care and outcomes for children with asthma; however, we know little about how to successfully implement pathways across diverse hospital settings. Prior studies of pathways have focused on determining clinical effectiveness and the majority were conducted in children’s hospitals. These approaches have left crucial gaps in our understanding of how to successfully implement pathways in community hospitals, where most of the children with asthma are treated nationally.
OBJECTIVE: The aim of this study was to identify the key determinants of successful pediatric asthma pathway implementation in community hospitals.
METHODS: We conducted a qualitative study of healthcare providers that served as project leaders in a national collaborative to improve pediatric asthma care. Data were collected by recording semi-structured discussions between project leaders and external facilitators (EF) from December 2017 to April 2018. Using inductive thematic analysis, we identified the themes that describe the key determinants of pathway implementation.
RESULTS: Project leaders (n = 32) from 18 hospitals participated in this study. The key determinants of pathway implementation in community hospitals included (1) building an implementation infrastructure (eg, forming a team of local champions, modifying clinical workflows, delivering education/skills training), (2) engaging and motivating providers (eg, obtaining project buy-in, facilitating multidisciplinary collaboration, handling conflict), (3) addressing organizational and resource limitations (eg, support for electronic medical record integration), and (4) devising implementation solutions with EFs (eg, potential workflow modifications).
CONCLUSIONS: Our identification of the key determinants of pathway implementation may help guide pediatric quality improvement efforts in community hospitals. EFs may play an important role in successfully implementing pathways in community settings.
© 2020 Society of Hospital Medicine
Data Collection
We used the constructs described in the Consolidated Framework for Implementation Research (CFIR)27 and adapted those salient to pediatric asthma pathways to develop an interview guide that was used with all participants (Appendix 1). The CFIR offers an overarching typology to understand what works where and why across five major domains that influence implementation: intervention characteristics, inner setting (hospital), outer setting (economic, political, and social context of the hospital), characteristics of the individuals involved, and the process of implementation. Data were collected across these domains to inform our analysis of the key determinants of pediatric asthma pathway implementation in community hospitals.
Interviews were conducted by phone from December 2017 to April 2018 (first four months of pathway implementation). Interviews lasted 30-60 minutes and were recorded and transcribed verbatim. Transcripts were edited for accuracy using the audio recordings. As data collection occurred concurrently with analysis, the interview guide was iteratively revised to reflect new insights and patterns that emerged from our analysis. All sites were anonymized in the data analysis. New interviews were coded until thematic saturation was reached.
Analysis
We conducted an inductive thematic analysis using the CFIR as our conceptual framework.28,29 Four investigators (CM, MJ, ES, and SK) performed the initial open coding of the data. Investigators met twice during the open coding process to develop and then finalize a codebook of standard definitions for codes. This codebook facilitated coding consistency through the remainder of the analytic process. Two investigators (CM and MJ) then independently read and coded all data to ensure intercoder reliability. During this process, CM and MJ met every two weeks to compare coding consistency, resolve discrepancies, and discuss preliminary findings. When the coding was complete, all investigators met to explore and develop themes that encompassed related common codes.
The CFIR was used at two stages of the study: (1) developing the interview guide and (2) cross-checking for any potentially important codes that were missing/needed to be explored further. Thus, the investigators maintained an inductive approach grounded in the data. To assure study rigor, we employed investigator triangulation (use of multiple investigators and participants from multiple clinical roles) and reflexivity (ongoing critique and critical reflection of the individual biases of the investigators).30 Coding was performed using Dedoose (version 7.0.23; Los Angeles, California).
RESULTS
A total of 34 community hospitals completed the PIPA project, of which the project leaders of 25 hospitals connected with the facilitators and were approached to participate; 18 (72%) hospitals’ project leaders participated in the study. We analyzed 18 interviews conducted between facilitators and project leaders, which included a total of 32 project leaders (one to five leaders per interview). The hospitals represented were diverse in geographic location and size (range 4-50 pediatric beds per hospital), and the majority of sites (78%) supported the trainees (Table 1).
We identified four overarching themes that described the key determinants of pathway implementation in community hospitals. These themes are presented in order of their frequency of occurrence in the data. They included (1) building an implementation infrastructure, (2) engaging and motivating providers, (3) addressing organizational and resource limitations, and (4) devising implementation solutions with facilitators. Descriptions and exemplary quotations for each theme are provided in Table 2 and Appendix Figure 1.
