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Barriers and Facilitators to Implementing a Change Initiative in Long-Term Care Using the INTERACT® Quality Improvement Program

Tappen, Ruth M. EdD, RN, FAAN; Wolf, David G. PhD, FACHCA, CNHA, CALA, CAS; Rahemi, Zahra PhD, MSN, RN; Engstrom, Gabriella PhD, RN; Rojido, Carolina MD, MHA; Shutes, Jill M. MSN, GNP-BC; Ouslander, Joseph G. MD

doi: 10.1097/HCM.0000000000000168

Implementation of major organizational change initiatives presents a challenge for long-term care leadership. Implementation of the INTERACT® (Interventions to Reduce Acute Care Transfers) quality improvement program, designed to improve the management of acute changes in condition and reduce unnecessary emergency department visits and hospitalizations of nursing home residents, serves as an example to illustrate the facilitators and barriers to major change in long-term care. As part of a larger study of the impact of INTERACT® on rates of emergency department visits and hospitalizations, staff of 71 nursing homes were called monthly to follow-up on their progress and discuss successful facilitating strategies and any challenges and barriers they encountered during the yearlong implementation period. Themes related to barriers and facilitators were identified. Six major barriers to implementation were identified: the magnitude and complexity of the change (35%), instability of facility leadership (27%), competing demands (40%), stakeholder resistance (49%), scarce resources (86%), and technical problems (31%). Six facilitating strategies were also reported: organization-wide involvement (68%), leadership support (41%), use of administrative authority (14%), adequate training (66%), persistence and oversight on the part of the champion (73%), and unfolding positive results (14%). Successful introduction of a complex change such as the INTERACT® quality improvement program in a long-term care facility requires attention to the facilitators and barriers identified in this report from those at the frontline.

Author Affiliations: Christine E. Lynn College of Nursing (Dr Tappen and Ms Rahemi), and Charles E. Schmidt College of Medicine (Drs Engstrom, Rojido, and Ouslander, and Ms Shutes), Florida Atlantic University, Boca Raton; Health Services Administration, School of Professional and Career Education, Barry University (Dr Wolf), Miami Shores, Florida; and School of Nursing and Midwifery, Kashan University of Medical Sciences and Health Services (Ms Rahemi), Kashan, Isfahan, Iran.

Joseph Ouslander has ownership interest in INTERACT® Training, Education and Management Strategies, LLC (I TEAM). Jill Shutes receives honoraria for training conducted on behalf of I TEAM. For the remaining authors, none were declared.

Correspondence: Ruth M. Tappen, EdD, RN, FAAN, Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Rd, Bldg NU-84, Room 307, Boca Raton, FL 33431 (

This project was funded by NIH/NINR Grant #5R01NR01236-04. The principal investigators were J.G.O. and R.M.T. The study received approval from the Florida Atlantic University Institutional Review Board.

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