Implementation Policies and Practices
Medical oncology employed multiple formal implementation policies and practices to support palliative care consultation, whereas gynecologic oncology employed one formal implementation policy; however, compared to medical oncology, gynecologic oncology was more apt to use informal implementation policies and practices. For example, several participants reported frequent spontaneous communication and feedback between gynecologic oncology and the palliative care service. Participants mentioned they were particularly incentivized to use the palliative care service because of its quickness to respond and strong presence in gynecologic oncology. In addition, in the absence of a formal training, most palliative care skills were learned on-the-job through informal interactions with the palliative care service. One resident stated,
It’s a constant dialogue. I don’t know if it’s truly feedback, but the nurse practitioner or the resident, whoever’s here, there’s almost always one of us kind of up here on the floor, whoever’s on the OR [operating room], and they [palliative care] come by and see our patients, and they sit in our workroom with us, and we talk about the patients, and they kind of tell us their thoughts, and they ask us clarifying questions.
Furthermore, champions in gynecologic oncology were also more emergent and informal as opposed to appointed. All interview participants identified at least one attending clinician whom they considered to be a champion for palliative care consults, with one participant identifying the fellows and residents as emergent champions because they “do a good job at remembering to call palliative care.” Several participants also discussed how the formal implementation policies and practices (written guideline) was developed by subspecialty residents in the service by adopting an informal bottom-up approach, which was in contrast to the formal top-down approach to implementation observed in medical oncology.
Despite multiple formal implementation policies and practices in medical oncology, only 5 of 12 interview participants (all attending clinicians) were aware of the implementation policies and practices. Moreover, these participants had only a vague understanding about what the policies and practices entailed. As one attending clinician commented, “So I don’t know what the automatic trigger is, but I know that a lot of our patients had palliative care consults and it was very useful.” Participants in medical oncology interviews also discussed the need for more formal implementation policies and practices, including feedback mechanisms, training, and specific clinical criteria for initiating palliative care consults. As one resident commented, “So I guess kind of the issue is palliative care kind of consults so they’ll come in and they’ll see a patient and they’ll give their recs. It’s so separate that there’s not really usually an opportunity for feedback in either direction.” In contrast, several interview participants in gynecologic oncology were aware of their single formal implementation policy, a written guideline describing the clinical criteria or initiating a consult and spoke about it in detail—identifying specific clinical criteria that would oftentimes trigger a consult, such as frequent admissions or presence of recurrent disease.
Medical oncology employed multiple formal implementation policies and practices, but most interview participants were unaware of the policies and practices, which contributed to a weak implementation climate. For example, few in medical oncology reported using palliative care consults was an expectation on the service. Similarly, medical oncology participants’ comments indicated palliative care consultation was not always strongly supported, mentioning many barriers including limited availability of palliative care resources and increasing complexity of care as possible disincentives to their use. Furthermore, consistent with the lack of awareness of the implementation policies and practices in medical oncology, participants’ clarity about when to use consults and whether they had the skills and tools to play their part in making referrals was also absent on this service.
In contrast, gynecologic oncology employed only one formal implementation policy, instead relying on multiple informal implementation policies and practices that contributed to broader clinician awareness and a strong implementation climate. For example, although referral is ultimately up to the individual clinician, gynecologic oncology participants generally reported consultation was expected. Likewise, participants’ comments indicated that consultation was supported in their work, citing few barriers or disincentives. Participants indicated clarity about when to use consults was strong and mentioned the formal implementation policy (written guideline) contributed to this clarity. Also in contrast to medical oncology, gynecologic oncology participants generally reported having the skills and tools to play their part in referring patients for consults, although some discussed needing more training and feedback from the palliative care service in this area.
Across both services, none reported receiving any specific recognition or rewards for palliative care consultation. Most participants mentioned this was not needed; better patient care was identified as the primary reward for consultation. However, almost all felt supported when it came to the logistics surrounding consultation (i.e., use of electronic health record system for referrals, paging process, talking on rounds). Many participants discussed how the electronic health record system made it easier to make palliative care consult referrals because the process was the same for all consult services in the hospital.
Both services exhibited a strong innovation-values fit for palliative care consultation. Across clinician roles, consultation was found to be highly valued and consistent with providing the best patient care possible. As indicated by one attending clinician, “in medical oncology, it’s a complex hospital. Our people are sick. You have multiple specialists…they’re all key. They’re [palliative care] as key to the team as the thoracic surgeon.” Each service had at least one attending state that every oncology inpatient should have a palliative care consult. Some students and residents spoke about the fit of palliative care consults with their values—the strong desire to learn and gain new skills—whereas attending clinicians spoke about the fit of palliative care consults with their commitment to educate residents. Clinicians in both services stated that palliative care consults were consistent with “keeping the flow open” and being “vested” in a team-based approach to care for inpatients admitted with complex medical needs. Given that one third of interview participants in each service reported receiving some palliative care training during their medical education, clinicians’ strong value for consults may have been fostered by this prior exposure.
Although interview participants from the palliative care service generally echoed the findings from medical and gynecologic oncology, several indicated that consults may not always be consistent with oncologists’ priority for chemotherapy treatment or timely discharge from the hospital.
Both services reported palliative care consults generally fit well with organizational tasks and workflow. Several themes may explain this finding. First, the main functions of the palliative care service are to address symptom management and facilitate goals of care discussions. Across both services, participants agreed consults added an extra layer of support for symptom management; however, in medical oncology the emphasis was primarily on managing pain, whereas in gynecologic oncology participants identified multiple symptoms that consults aided in managing. As stated by this attending clinician,
I think it’s usually many times symptom management, so if patients are having symptoms from their cancer, especially multiple symptoms from their cancer, there’s pain and nausea and maybe shortness of breath and the things that we know how to do as gynecologic oncologists don’t seem to maybe working the best, I think that’s really probably our number one reason why we call them is for symptom control and help with that.
Likewise, both services considered there to be a strong innovation-task fit if goals of care discussions were needed because clinicians face many competing demands while on-service and lack the time to have lengthier goals of care discussions with patients and their families. Participants mentioned that palliative care consults can help to offset this workload; however, our findings across the services suggest there may be a U-shaped relationship between patient volume and innovation-task fit for consults. Specifically, some participants mentioned high patient volume would promote consultation, whereas others commented they would be more likely to use consults when volume was low because there was “more time to think about individual people and some of their broader problems.” Of note, participants often referred to goals of care discussions as “end-of-life care” and indicated they were most compatible only if a patient was transitioning to hospice; however, this finding was more pronounced in medical oncology.
Second, both services reported attending clinicians’ preferred roles influenced how well consults fit in the service, particularly as it relates to goals of care discussions. For example, in gynecologic oncology some attending clinicians mentioned wanting to conduct goals of care discussions because they are “my patients.” This comment likely reflects that all clinicians on the service care for the same spectrum of cancer types. In contrast, because attending clinicians in medical oncology specialize in a variety of tumor types, they may be in a better position to discuss prognosis for one cancer type but less comfortable in discussing the outlook of patients with other cancer types represented on the service. Participants identified that patient and family preferences may also affect the fit of consults but that this could be addressed by improving the branding of the palliative care service.
Third, participants in gynecologic oncology reported consults were compatible with workflow if they were aware the patient was already receiving palliative care services in the outpatient setting. As one attending clinician stated, “I have a number of my patients that I have palliative care help take care of as an outpatient…so usually they will call the consult and say what is needed.” In contrast, interview participants in medical oncology were more apt to report a poor compatibility if they were unaware whether there was continuity of care with palliative care services in the outpatient setting. As one attending clinician expressed,
Unfortunately what we don’t have yet is a seamless process where the patients are getting these things done in the outpatient setting. And maybe they are, but I get this problem all the time, where is the documentation? It’s the weekend. I can’t reach the primary attending. I have to have these tough conversations now with these folks, so I did them.
We studied two initiatives to increase implementation of palliative care consults in inpatient oncology and found empirical support for the role of formal and informal implementation policies and practices as determinants of implementation effectiveness. Specifically, despite the medical oncology service’s use of multiple formal implementation policies and practices, most participants were unaware of the policies and practices, which contributed to a weak implementation climate. In contrast, the gynecologic oncology service employed only one formal implementation policy and instead relied on multiple informal implementation policies and practices, which contributed to broader clinician awareness and a strong implementation climate. Innovation-values fit and innovation-task fit (moderators of implementation climate and implementation effectiveness) were generally strong in both services.
According to the Klein and Sorra Organizational Theory of Innovation Implementation, we would expect consult uptake to be suboptimal in medical oncology; however, both services exhibited temporal increases. Despite medical oncology clinicians’ lack of awareness, there was a strong upward spike in consult uptake after the initiation of the formal implementation policies and practices in October 2015. Indeed, Figure 3 is illustrative of a significant increase previously reported in a study by the authors, which used a difference-in-differences analysis to compare uptake before and after palliative care consult implementation in the oncology services (DiMartino et al., 2017). This disparate finding is surprising and may be attributed to when implementation climate was assessed. Specifically, interviews were conducted several months after initiation of the formal implementation policies and practices in medical oncology and coincided with the declining uptake rates in this service observed at the end of the study (Figure 3). This decline may provide an indication that climate strength in medical oncology weakened over time. Accordingly, our findings from the interviews may not accurately reflect the climate strength that existed soon after the formal implementation policies and practices were initiated. Alternatively, we examined the potential for other initiatives occurring in the oncology services that may have impacted palliative care consult implementation. Participants in both oncology services and the palliative care service were asked if such initiatives had occurred in the past year, but there were no activities reported that would be expected to impact palliative care consult implementation.
These study findings ultimately point to a broader issue: Relying solely on organizationally sanctioned formal implementation policies and practices may not be effective in creating a strong and sustainable climate for implementation in busy, complex health care organizations such as the academic oncology services examined in this study (Sommerbakk, Haugen, Tjora, Kaasa, & Hjermstad, 2016). For example, training is a formal implementation policies and practices commonly used by health care organizations to promote innovation use, but residents often lack the time outside of their clinical responsibilities to attend skills trainings. In addition, new groups of residents rotate through the oncology services on a frequent (though predictable) schedule. Thus, unless training is mandatory and offered on a continuous and routine basis, exposure will be minimal and ultimately contribute to a weakened implementation climate over time.
From a practical standpoint, our findings support the idea that informal implementation policies and practices may compensate or substitute for formal implementation policies and practices under certain conditions. As we observed in the gynecologic oncology service, this may be more likely to occur in smaller health care organizations where there is greater proximity and opportunity for social interaction and information sharing (Klein, Conn, Smith, & Sorra, 2001). For example, one study found small primary care practices achieved effective implementation of the patient-centered medical home using informal care teams rather than more formal care coordination (Berry et al., 2013). Specifically, formal implementation policies and practices may influence implementation climate and subsequent effective implementation insofar as the targeted users of the innovation have the opportunity to develop a shared sense innovation use is expected, supported, and rewarded (Klein & Sorra, 1996). In gynecologic oncology, we found the use of informal implementation policies and practices may have played a critical role in creating that shared sense and a strong and sustainable implementation climate. For example, gynecologic oncology may have exhibited greater awareness of the written guideline because the strong presence of informal implementation policies and practices in the service continually reinforced its enactment. In particular, adopting an emergent bottom-up approach by involving clinicians in all roles in development of the guideline created a greater sense of ownership, which may have contributed to awareness and a more positive view of the guideline. In contrast, informal implementation policies and practices may be less likely to substitute for formal implementation policies and practices in larger organizations, such as medical oncology, where fragmented intradepartmental units have limited opportunity for social interaction (Klein, Conn, Smith, et al., 2001 ; Weiner, Belden, Bergmire, & Johnston, 2011). As we observed, medical oncology used multiple formal implementation policies and practices developed externally by the palliative care service. The absence of informal implementation policies and practices in combination with a top-down approach may have undermined clinicians’ awareness of the implementation policies and practices, which contributed to a weak shared sense that palliative care consultation was expected, supported, and rewarded. Future research should further investigate the role of formal and informal implementation policies and practices in shaping a strong and sustainable implementation climate, including the interplay between top-down versus bottom-up approaches and subsequent effective implementation of health care innovations.
Study Limitations and Conclusion
This study was conducted at a single academic medical center, which limits generalizability. However, case study research, which emphasizes depth over breadth, is appropriate for the purposes of theory refinement (Eisenhardt, 1989). Second, interview data were gathered after the initiation of the formal implementation policies and practices in both services. Therefore, we are unable to provide a longitudinal assessment of how the organizational context for palliative care consults may have changed over time or determine whether the sharp decline in palliative care consult uptake rates in medical oncology observed at the end of the study would persist or eventually rebound. Third, the medical oncology residents we interviewed described implementation climate at the time of the interview and may not be representative of residents who were rotating when the palliative care skills training was initiated. Had we interviewed residents soon after initiation of the training, we may have found different climate perceptions. Fourth, although development of quantitative measures of implementation climate are underway (Weiner et al., 2011), they have not been fully tested. Thus, we were unable to specify with precision how the services compared on this construct. Finally, there were contextual differences identified between the two services that may not be modifiable by administrators (e.g., service size). Understanding these differences could be helpful in guiding adaptation of the implementation policies and practices to accommodate varying contexts.
Despite these limitations, this study makes a novel contribution to the implementation science literature by offering preliminary evidence for the role of both formal and informal implementation policies and practices as determinants of implementation, suggesting refinements to the Klein and Sorra Organizational Theory of Innovation Implementation. There is precedent for elaborating on this theory (Birken, Lee, & Weiner, 2012 ; Helfrich et al., 2007). This study also adds to the small body of implementation research adapting the theory to include innovation-task fit to provide an indication of congruence of the innovation with the organization and is a critical determinant of implementation (Helfrich et al., 2007 ; Weiner et al., 2012). Future research examining whether our study findings are a function of other aspects of the theory, including readiness to change, management support, and/or resource availability within the service may lead to more robust results.
To date, the influence of formal policies and practices on health care innovation implementation has garnered more attention in the implementation science literature than informal policies and practices. However, by providing an in-depth exploration of the organizational determinants of palliative care consult implementation in inpatient oncology, our findings suggest informal policies and practices for promoting effective implementation should be encouraged in certain contexts, such as smaller health care organizations. The results from our study may help organizations to identify optimal strategies to improve effectiveness of health care innovation implementation and minimize gaps between evidence and practice.
The authors would also like to thank Kathryn Wessell and Kemi Doll, MD, for their assistance with this research.
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Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved
implementation policies and practices; innovation implementation; oncology; palliative care