TABLE 3.

Challenges and facilitators in implementation of Geriatric Emergency Department Accreditation (GEDA) care processes using the Consolidated Framework for Implementation Research (CFIR) 2.0.

Construct	Definition from CFIR 2.0	Role in accreditation
Innovation
Design	The innovation is well designed and packaged, including how it is assembled, bundled, and presented.	EDs had difficulty interpreting the Geriatric ED Guidelines and GEDA website and translating outlined care processes into clinical practice. Participants leveraged leadership contacts from EDs that already achieved accreditation (peer support) to answer questions about implementation and feasibility of specific care processes.
		ED geriatric champions developed presentations and training materials to effectively describe selected care processes to ED operational leadership and frontline staff.
Complexity	The innovation is complicated, which may be reflected by its scope and/or the nature and number of connections and steps.	These are complex, often multi‐step care processes with multiple ED staff members involved. Geriatric ED champions made decisions about which improvements were most feasible to implement based on their complexity: whether existing processes could be modified, what resources/staff/staff training would be needed, and how/whether workflows for each process could be easily optimized.
Outer setting
Local attitudes	Sociocultural values (e.g., shared responsibility in helping recipients) and beliefs (e.g., convictions about the worthiness of recipients) encourage the outer setting to support implementation and/or delivery of the innovation.	Institutional and hospital system leadership shared a sense of responsibility to improve care for older adults.
Local conditions	Economic, environmental, political, and/or technological conditions enable the outer setting to support implementation and/or delivery of the innovation.	Health system‐wide initiatives such as pursuing age‐friendly hospital status or geriatric accreditation of multiple health system EDs help promote implementation.
Financing	Funding from external entities (eg, grants and reimbursement) is available to implement and/or deliver the innovation	Grants, philanthropic, and/or dedicated health system‐level funding earmarked for geriatric ED accreditation were crucial in facilitating implementation of care processes and meeting other requirements for accreditation such as employing dedicated geriatric‐trained staff or purchasing equipment/supplies.
External pressure	External pressures drive implementation and/or delivery of the innovation.	Market pressures to create a reputation as the best local ED for geriatric care helped drive EDs to pursue accreditation.
		Top‐down pressure from a larger health system drove individual EDs to adopt care improvements.
Inner setting
Structural characteristics: Work infrastructure	Organization of tasks and responsibilities within and between individuals and teams, and general staffing levels, support functional performance of the inner setting.	EDs involved frontline staff to establish how new care processes could best fit into existing workflows and team structures or determine if new workflows needed to be developed.
		Adequate staffing is necessary to avoid overburdening frontline staff with additional tasks.
Structural characteristics: IT infrastructure	Technological systems for tele‐communication, electronic documentation, and data storage, management, reporting, and analysis support functional performance of the inner setting.	EHR integration was crucial to support new care processes, automate follow‐up or direct users to management protocols for positive screenings, and to track quality metrics associated with geriatric care processes.
		Integrating care processes into the EHR de novo often took months to years.
		If EHR tools for specific care processes existed in other care settings within a hospital or other hospitals within a health system, adopting them into the ED could occur relatively rapidly.
Available resources	Resources are available to implement and deliver the innovation.	Multiple types of resources are required for geriatric ED accreditation including staffing, equipment, and supplies. Some care processes require availability of specialized consults (physical therapy, occupational therapy, pharmacy, and case management).
Access to knowledge and information	Guidance and/or training is accessible to implement and deliver the innovation.	The complexity of some geriatric care processes requires specific instructions/education to properly perform them.
		Attrition of ED staff, burnout, and turnover negatively impacted maintenance of geriatric care processes. Continual education was needed to promote uptake of care processes in new staff members while assuring quality and fidelity of implementation.
Individuals
Midlevel leaders	Individuals with a moderate level of authority, including leaders supervised by a high‐level leader and who supervise others.	Accreditation was facilitated when ED leadership outside of the local geriatrics champions/accreditation team recognized and responded to needs for additional resource allocation, modified workflows, team reorganization to support geriatric care processes.
Implementation leads	Individuals who lead efforts to implement the innovation.	Geriatric champions were crucial in planning, driving change, educating and incentivizing frontline staff, and monitoring and evaluating progress and achievements.
Implementation deliverers	Individuals who are directly or indirectly delivering the innovation.	Establishing buy‐in and providing education about the potential benefits of geriatric care processes to frontline staff helped improve motivations to assume new or added work responsibilities.
		Involving frontline staff in decisions about how to implement specific care processes helped promote their uptake.
Implementation process
Engaging	Attract and encourage participation in implementation and/or the innovation.	Participation and engagement of frontline ED staff in selecting and planning how to implement processes helped with adherence to screening protocols and departmental policy changes.
		Providing frontline staff with feedback about and patient impacts from their performance helped promote uptake of geriatric care processes.
Reflecting and evaluating	Collect and discuss quantitative and qualitative information about the success of implementation.	The EHR automated tracking adherence to geriatric care processes and specifically for screenings.
		Tracking processes and providing local leadership and frontline staff with feedback about their performance helped demonstrate implementation success and drive local departmental‐level buy‐in.

Abbreviations: ED, emergency department; EHR, electronic health record.