Implementation strategies of a national standard for comprehensive care in acute care hospitals: An interview study

Abstract

Objective

This study aimed to explore the strategies used by acute care hospitals in implementing a national standard for comprehensive care.

Methods

A qualitative descriptive study was conducted with 28 care professionals (20 nurses, two doctors, and six allied health professionals) recruited from a broad range of Australian acute care hospitals. Data were collected using semi-structured interviews from March to August 2023. The interviews were audio-recorded, transcribed, and thematically analyzed.

Results

Strategies for implementing the Comprehensive Care Standard (CCS) vary, even within a health service organization. We identified strategies hospitals used regarding the implementation team and plan, communication, education and training, documentation system, patient care plan, networking, incentives and pressure, feedback, and reflecting and evaluating.

Conclusions

This interview study sheds light on the various strategies adopted by hospitals in implementing the CCS, providing a practical foundation to inform implementation efforts both within Australia and internationally.

What is known?

• •Comprehensive care has been shown to improve the provision of high-quality care. Several countries (Australia, Norway, and the UK) have developed a national standard for comprehensive care.
• •Comprehensive care is a broad concept, and implementing a standard for it presents significant challenges.
• •How a national standard for comprehensive care is implemented in real-world hospital settings remains underexplored.

What is new?

• •This study identified strategies in acute hospitals used to implement the Comprehensive Care Standard across ten areas.
• •Hospitals adopted diverse implementation strategies, some proving effective while others revealed real-world gaps.
• •Although hospitals vary in resources, many identified strategies are adaptable and can inform implementation efforts.

1. Introduction

Gaps in patient safety and quality are often recognized as failures to provide adequate care or to achieve desired outcomes for patients with multiple care needs [1]. Comprehensive care has been developed to address the various needs of patients. According to the Australian Commission on Safety and Quality in Health Care (ACSQHC), comprehensive care is defined as “the coordinated delivery of total health care required or requested by a patient” (p.44) [2]. It focuses on the person’s needs and preferences, values shared decision-making with patient, family, and/or carers, and stresses collaboration among multidisciplinary team members [1,2]. Comprehensive care has been shown to improve the provision of high-quality care, including increased patient satisfaction, shared decision-making, and goal alignment, as well as reduced lengths of stay, acute care readmission, and cost of care [3,4]. Some countries (Australia, Norway, and the UK) have developed a standard for comprehensive care [1].

In 2017, the ACSQHC released the Comprehensive Care Standard (CCS), part of the National Safety and Quality Health Service (NSQHS) Standards, to ensure that patients receive comprehensive care [2]. The NSQHS standards are mandatory for all Australian hospitals, with accreditation against these standards commencing in 2019 and being reassessed every three years [5]. The accreditation assessment of the CCS is based on four criteria and 36 actions that comprise the CCS [2]. The ACSQHC has provided guidelines and resources to support CCS implementation in health service organizations [6], but organizations can use different strategies tailored to their settings [7]. Previous studies have shown that the CCS improves various aspects of patient care and health outcomes, including interdisciplinary collaboration, shared decision-making, continuity of care, patient quality of life and satisfaction, and reduced hospital readmissions [1,8,9].

Comprehensive care is a broad concept, and implementing a standard for it has proven challenging [10]. Two years after the CCS came into effect, 15 % of the assessed health service organizations did not meet all CCS requirements, with 12 % receiving recommendations to meet some actions, indicating implementation challenges and underperformance [11]. Various barriers have impeded the implementation of a standard for comprehensive care, including staff shortage, lack of skilled staff, and high staff turnover; poorly integrated documentation system; limited staff availability, capability, and motivation; lack of resources; and inadequate education and training [8,9].

A literature review revealed that despite a national standard for comprehensive care’s existence for many years, literature on its implementation is scarce, with outcome evaluation relatively common but process evaluation rare [1]. Previous literature has discussed theoretical frameworks and guidance documents for implementing the CCS; however, little is known about how a national standard for comprehensive care has been implemented in the real world [1]. For example, it is poorly understood who has led the implementation within hospitals, what roles care professionals have played, and how the implementation process has unfolded in practice.

This study aimed to identify the various strategies used in Australian acute care hospitals to implement the CCS. Most of the hospitals in Australia are acute care hospitals, which provide healthcare services to patients for short periods of severe or urgent conditions and are distinct from long-term care hospitals [3]. The dynamic and fast-paced nature of acute care hospital settings requires a tailored approach to integrate comprehensive care practices successfully. Insights from this study are valuable for Australian hospitals seeking to enhance the CCS implementation, as well as hospitals in other countries considering the implementation of a standard for CCS.

This study is part of a larger project exploring the implementation strategies, challenges, facilitators, and impacts of the national standard for comprehensive care across acute care hospitals in Australia [12]. The findings reported here focus specifically on implementation strategies used within acute care hospitals.

2. Methods

2.1. Study design

As Sandelowski [13] outlined, a qualitative descriptive method was employed. This design offers a direct description and comprehensive summary of the phenomenon under investigation, using participants’ language and staying closely connected to the data [14,15]. The Consolidated Criteria for Reporting Qualitative Studies was followed, as shown in Appendix A.

2.2. Study participants

Recruitment of eligible participants utilized a purpose and convenience sampling approach through emails to healthcare organizations (Agency for Clinical Innovation, Australian Medical Association, Queensland Health, Health Translation Queensland, Alfred Health), clinical networks (Queensland Statewide Clinical Networks, New South Wales Statewide Clinical Networks), and social media (Facebook, X, LinkedIn, Instagram). This was supplemented using a snowballing approach, with those interviewed identifying further participants.

The inclusion criteria were care professionals who reported their usual place of employment as Australian acute care hospitals, had at least three months of work experience in their current organization, had some familiarity with the CCS (self-identified), were willing to participate in an online interview, and were willing to give informed consent. Participants who did not meet the above criteria were excluded. The term “care professional” is a broad term that covers a wide range of professions, including doctors, nurses, and allied health professionals (e.g., physiotherapists, pharmacists, psychologists, occupational therapists, dietitians, etc). The broad inclusion strategy was chosen to reflect the multidisciplinary nature of CCS implementation and ensure a wide range of perspectives.

2.3. Data collection

The study was conducted online from March to August 2023. Based on participants’ preferences, interviews were conducted online via platforms such as Microsoft Teams, Zoom, or over the phone. Each interview was scheduled for an hour and followed a semi-structured interview guide (Appendix B). We continued conducting interviews until data saturation in both codes and meaning was achieved. No new themes or insights emerged after three consecutive interviews, and data saturation was confirmed through team discussions. The research team collaboratively developed the guide, drawing from the Consolidated Framework for Implementation Research (CFIR), the CCS implementation guide, and preliminary findings of a survey study on the CCS [8].

The CFIR [16] comprises 48 constructs across five domains (intervention characteristics, outer setting, inner setting, characteristics of individuals, and process) [16]. It provides a comprehensive lens to explore various implementation aspects, enabling a structured data collection and analysis approach. The CFIR is deeply rooted in a comprehensive review of implementation literature and has been universally utilized in health services research [17,18].

The pool of questions was initially derived from the CFIR developer’s interview questions database, as CFIR provides a comprehensive structure for examining the implementation of an innovation [19]. The research team assessed each question’s relevance to the CCS implementation through voting and reached a consensus on selected questions. The draft guide was refined by incorporating insights from the CCS implementation guide and findings from our preceding survey study to ensure contextual relevance. To address the breadth of CFIR constructs, diverse questions were grouped into sets under key topics, such as the implementation team and communication strategy. This process led to the final version of the interview guide (Appendix B). The average interview length was 52 min (SD = 5 min). Four participants opted in to review their transcripts, and none of them asked for corrections.

2.4. Data analysis

The interviews were audio recorded, transcribed verbatim by professional companies, GoTranscript and DAAT, and analyzed using NVIvo 12 software. Data were analyzed thematically based on key topics in the interview guide (Appendix C). More specifically, a thematic framework was used, including six steps: 1) read the interview transcripts and become familiar with participants’ responses on the implementation approach; 2) generate initial codes on the recurring topics on the implementation approach; 3) search for common themes on the codes; 4) review the data associated with each theme; 5) define themes, and 6) write up the results of themed data [20]. B. Xiong kept field notes and performed the initial qualitative analyses, and P. Prudon reviewed and validated the analysis. Consensus discussions were held to resolve disagreements. C. Stirling, D. Bailey, and M. Martin-Khan provided guidance and support for data analysis. All authors assisted with reviewing and refining coded themes.

2.5. Research team and reflexivity

The interview was conducted by a research assistant (P. Prudon), holding a bachelor’s degree (Honours) in psychology, along with a PhD candidate (B. Xiong) with a bachelor’s degree in nursing, a master’s degree in health sciences, and experience in qualitative research. P. Prudon led all the interviews, with support from B. Xiong through Microsoft Teams or Zoom chat. B. Xiong and P. Prudon underwent training sessions in interview techniques and the interview guide. A formal relationship was not established with most participants (except one being their colleague and the other being a personal contact of B. Xiong). Both interviewers expressed a shared interest in the CCS, with B. Xiong concurrently pursuing her PhD on this project. The interviewers disclosed no explicit biases.

2.6. Community and public involvement

From inception, we partnered with members of the evaluating Quality of Care (eQC) Patient and Carer Advisory Board [21], seeking their input and feedback on the protocol, analysis, and results by regularly presenting and discussing the research at board meetings.

2.7. Ethical considerations

All participants verbally confirmed informed consent before interviews began. Participants were allowed to skip questions or end the interview at any time. The study was approved by the University of Queensland ethics committee (No. 2022/HE001036; 06/30/2022).

3. Results

3.1. Characteristics of the participants

The sample included 28 interviewees (20 nurses, two doctors, and six allied health professionals) working in public hospitals from five Australian states. These hospitals varied in both size and location, including remote/rural (10.7 %), regional (46.4 %), and metropolitan (42.9 %) settings and ranged from small (<100 beds, 17.9 %) to medium (100–499 beds, 14.3 %) and large (≥500 beds, 67.9 %) facilities. Most participants were female (82.1 %), and the majority were nurses (71.4 %), followed by allied health professionals (21.4 %) and doctors (7.1 %). A significant 67.9 % had leadership roles (67.9 %), and nearly half (46.4 %) had over 20 years of work experience. Further demographic details are provided in Appendix D.

3.2. Themes of implementation strategies

Findings revealed that hospitals adopted diverse strategies to implement the CCS, some proving effective, while others highlighted real-world gaps. Final themes are summarised below, with relevant data from the interview transcriptions provided to support each theme.

3.2.1. Implementation team

Various implementation team structures were identified. Some mentioned a formal CCS committee, with several subcommittees (e.g., Falls, Pressure Injury, End-of-life Committee) or working groups under it. The CCS committee often comprises a multidisciplinary group of stakeholders, including executive board members, chairs of previous smaller clinical committees, nursing staff, allied health professionals, medical representatives, a patient safety officer, consumer representatives, and community members. As stated by a participant:

“We’ve got nursing staff, we’ve got dietitians, we’ve got the medical representative, and execs have been on there [CCS committee], as well as one of our patient safety officers. We don’t have a routine consumer representative on the committee, but they’ve been invited to various policy reviews and things.” (F03, doctor)

In some cases, a formal CCS committee was not mentioned, but information was provided about the implementation leadership structure. Some hospitals had an overarching leadership hierarchy at the highest level, responsible for clinical governance. The levels down included a nursing director responsible for overseeing standards and quality leads designated for each standard, with multiple leads for larger standards like the CCS. Some hospitals had a quality and safety board and a director of quality and safety who led a quality and safety office. As stated by a participant:

“The director of quality and safety would control what comes out of our office, like how we portray it or talk about it. Then at a higher level than that, you’d have the quality and safety board … they would be the highest level.” (F018, nurse)

Some hospitals had a quality and safety unit responsible for all standards, with service transformation project officers implementing changes.

Within a unit, nursing unit managers (NUMs) led in some cases, while in others, it was clinical nurse consultants (CNCs) and clinical facilitators. Clinical nurse specialists (CNS) or Clinical Nurses (CN) served as standard champions within each ward. They selected a group of registered nurses (RNs) and enrolled nurses (ENs) to drive initiatives related to their specific standards. As stated by a participant:

“Each ward has its standard champion; a CN would be the standard champion, under them in their group for Standard 5 would have some RNs, potentially some ENs.” (F018, nurse)

When there were too many levels in the structure, there tended to be inconsistencies or modifications as directives were passed down to lower levels. As one participant stated:

“It doesn’t come directly from the top straight to the people implementing the care … There are a few steps in between, which allows things to change.” (F22, nurse)

Conversely, when there were too few levels, the responsibility and tasks from the top-level management fell directly onto the shoulders of on-the-ground staff without intermediary support or guidance.

Individuals at upper levels were thought to have both the power and availability necessary to drive decision-making processes. In contrast, those at lower levels often lacked authority and may have faced constraints on their availability. However, by collaborating with CNCs and NUMs, issues could be escalated effectively, enabling discussions with upper-level stakeholders to address concerns and facilitate decision-making.

“They [champions] don’t have the full power to change what they want to change, but by liaising with CNCs and the NUMs, they can escalate issues and then discuss with the upper level … It’s like teamwork from different levels.” (M05, nurse)

The deliverers of the CCS included professionals from all disciplines, predominantly nursing staff. However, greater engagement and clarity were needed regarding the roles of other professions, particularly allied health professionals:

“The pathways for escalating, pursuing standards best practice, as it states, I’ve found that unclear at times in my role.” (M02, allied health professional)

3.2.2. Implementation plan

Some mentioned that an implementation plan for the CCS was in place and developed following a gap analysis against the standard. The action plan was adjusted at the individual ward level, tracked and measured progress, and reports were made regularly. As one participant stated:

“As part of that gap analysis, we identified what we were missing and then what we needed to create. Those included policies, guidelines, procedures, etc. Within each of the facets of comprehensive care, a similar thing was done, has been tracked, is on the risk register, and is followed up by the executive.” (F16, allied health professional)

Often, there was an implementation plan, but it was not specific to the CCS. For example, one participant stated:

“We have our overarching documents in terms of strategic plans, clinical plans, health equity plans, and I guess it’s built into all of those strategic documents and the implementation plans that come from that.” (F16, allied health professional)

However, for the majority, the implementation plan lacked visibility, and there was no update on progress or implementation. The role of the plan was not strategic, and it was not used as a goal tracking, road map, or progress monitor. As one participant stated:

“I haven’t heard of any official plan about how we would implement the standard into our ward. It’s a general impetus to be professional, do well, do right by the patients, but nothing shall we say that’s specific … no coordinated plan.” (F17, nurse)

Participants stressed the necessity of a visible implementation plan with structured goals and a tracking system, supported by regular updates and reporting mechanisms, to ensure accountability, transparency, progress tracking, and identifying areas requiring additional support or adjustments. As one participant stated:

“I think there are very clearly structured goals for our allied health department. I think just having a goal tracking system where we’ve collected and collated information on where we’re not meeting the standards optimally or if there are areas for improvement …” (M02, allied health professional)

3.2.3. Communication strategies

Various communication channels were utilized to disseminate information about the CCS (Appendix E), such as emails, meetings, bulletin boards, and posters. Targeting message boards or posters towards staff or consumers depended on the ward's specific practices. Participants highlighted the use of various communication channels.

“As effective as it can be with people within the hospital being busy and having their attention pulled in multiple directions.” (F16, allied health professional)

Some hospitals relied heavily on key personnel like the nursing director, NUMs, or allied health managers to disseminate information about the CCS. There were critiques regarding passive communication methods (e.g., massive emails), which were perceived as less effective. As one participant noted:

“If they’re not interested, then we probably miss them.” (F18, nurse)

This highlighted a need for more direct and engaging methods of communication to ensure effective dissemination of information and engagement across all levels of the organization.

Some hospitals used special programs like Senior Nurse Day, held quarterly, to discuss the CCS. Some engaged staff in the CCS by organizing activities, such as throwing a standard over the 12 days of Christmas, to convey the message. As stated by one participant:

“Our quality and safety people have 12 days of Christmas every year, so they come round, and they throw a standard out over those 12 days of Christmas to try and get the message across in a fun way.” (F08, nurse)

To raise awareness about patient safety topics within the CCS, months were dedicated to specific issues, with each month having a focus, e.g., April No Falls. Additionally, team members took turns presenting small topics within the CCS during the staff forum, which was held fortnightly or monthly.

3.2.4. Education and training

Hospitals employed various strategies for education, training, and information dissemination, utilizing both traditional and modern methods, as summarised in Appendix F. Education plans, along with action plans, offered comprehensive education before the CCS implementation. For example,

“There was an education plan put in place … that was implemented through the whole hospital … On go-live day, there were champions around who were on the ward helping staff, and quite often, that’s there for a good couple of weeks during the implementation phase.” (F06, nurse)

Mandatory training kept staff up-to-date on essential protocols and procedures. For example, orientation training for new hires and recent graduates built foundational competency, while continuous training facilitated by nurse educators, clinical facilitators, and CNCs supported ongoing learning and development. Some hospitals also utilized My Health Learning and events like World Patient Safety Day to promote awareness and continuous learning. Bedside education, complemented by CCS-specific training, was tailored to staff needs. CCS-specific training included ACSQHC webinars on the criteria of comprehensive care planning and its significance, and instructions on how to document the CCS, implement recommendations, and collect data. Undergraduate education was also an important avenue for junior nurses; as one participant stated:

“When I was in university, we got exposed to the CCS. … we had to read all of the ACSQHC thing.” (F17, nurse)

At the governance level, there were processes and spreadsheets to ensure division-wide awareness, and regular fact sheets highlighting different standards, often with a quiz to reinforce the standard's importance. Paid education days were provided to encourage staff engagement.

Several gaps in current education and training were identified. Firstly, new staff lacked introductory guidance on implementing the CCS in specific settings. Secondly, training broke down the CCS into isolated components, focusing solely on clinical skills rather than addressing it as a holistic framework. Thirdly, relying solely on individuals to seek information and placing the burden of learning solely on them proved ineffective. For instance, one participant noted:

“You can dig for your information, which is probably the expectation, rather than receiving strict in-service training.” (F09, nurse)

Participants believed that while self-directed online learning may be suitable for younger staff, it fell short for others. Moreover, some hospitals relied on one individual to acquire and disseminate knowledge to the entire workforce. Often, resources were overly text-heavy, demanding significant time to comprehend, maintain, and update. Additionally, dedicated learning time was not allocated, available resources remained underutilized, and there was a lack of updates to these resources.

Participants suggested developing an overall checklist or basic principles applicable across all departments while allowing for individualization. Explaining the rationale behind actions, rather than just giving instructions, could improve understanding and motivation. They also proposed utilizing hypothetical scenarios and case studies to provide staff with practical examples of applying the CCS in their daily work, fostering awareness of the CCS. As stated by a participant:

“With care planning and risk assessment, we would all love to see an example of a single view, multidisciplinary effort, preventive care plan, … We all interpret the wording in our own way. … It’d be nice to look at a good case study.” (F018, nurse)

Additionally, coordinated and consistent education was key to avoiding duplication and ensuring all staff were adequately prepared. Multidisciplinary education formats could also promote collaboration and a holistic approach to patient care. As summarised by a participant,

“Higher education may have opportunities for us … There are opportunities for education and learning that align with the clinical care standards … I find with CCS, …more multidisciplinary education and delivery in a multidisciplinary format is required … there are opportunities around consistent education, so we’re avoiding duplication of effort.” (M01, nurse)

3.2.5. Documentation system

Hospitals used paper-based, electronic, or hybrid combination systems with limitations. The paper-based system was criticized as labor-intensive and prone to losing documents. As stated by a participant:

“We have an entirely paper-based documentation system at my hospital, so it is quite labor-intensive to complete documentation on every single patient.” (F07, nurse)

Electronic Medical Records (EMRs) supported communication and information sharing. Tools like Medtask, the Viewer, and the Patient Flow Manager improved access to patient data. Other benefits included a traffic light dashboard linked with referral systems, incident management monitoring systems (RiskMan), and the Measurement, Analysis, and Reporting System (MARS). Mobile apps allowed consumers to track appointments, review test results, and communicate with care professionals. However, EMRs were not always integrated, and system incompatibility across hospitals hindered communication. As stated by a participant:

“In an ideal world, if you’d be using the same system … at the moment, we’ve got this difficulty where one doesn’t talk to the other, and it’s going to be a pickup and drop system that IT is still, two years later trying to work out how and what they’re going to do about that.” (F09, nurse)

Using different referral systems (e.g., Hospital-Based Corporate Information System (HBCIS), Smart Referrals) added challenges in care coordination. Limited access to records also hindered multidisciplinary collaboration, as systems restricted some functions to administrative staff. Moreover, some tasks merely involved box-ticking exercises, and staff focused on clearing flags for not ticking the box rather than reflecting actual care.

In hybrid systems, some hospitals used paper-based care plans alongside digital documentation, with test results recorded electronically or paper documents being scanned into the system:

“We’re using some paper forms, but they all get scanned … When the patient comes back, …You just go on their health record, and you will see all our previous assessments and the forms.” (M05, nurse)

The integrated Electronic Medical Records (ieMRs), which addressed many EMR limitations, were generally viewed more favorably. They featured different pathways directed intelligently, editable and accessible information, and dashboards with outcome measures. AMR also improved communication across departments (e.g., medical, nursing, and laboratory departments) and included alerts to flag patient issues or high-risk cases:

“The ieMR is quite smart, and I like the ieMR because anyone can input into that care plan.” (F11, nurse)

3.2.6. Patient care plan

Various patient care plans were identified, including non-standardized or unofficial ones. Some hospitals featured standardized basic or general plans, like admission to discharge planners, alongside specialized or individualized care plan pathways:

“From my understanding, it’s semi-standardised, and then depending on what the nurses tick, it branches off into other things. Everyone would have the same bit filled out, but some people would have a lot more, and others wouldn’t have much.” (F06, nurse)

Templates were tailored to patient groups (e.g., pediatric care) and care settings (e.g., admission, discharge). Multiple care plans were universally utilized, covering pain management, pressure injury prevention, and fall risk management. However, participants noted a lack of clear guidance on which plans to use and when to document. Additionally, several participants mentioned a sub-acute care plan, often implemented weekly.

The care plan was frequently utilized to convey information or trigger referrals during bedside or shift-to-shift handovers and case conferences, which helped streamline communication and prevent duplication of efforts. As one participant stated:

“It’s a trigger for referrals … nutritional deficits for a dietitian and slow learning speed for a speech pathologist … It intends to function where multidisciplinary team members can flag concerns for our medical team to review and vice versa; the medical team can document their goals for the admission and critical actions.” (M02, allied health professional)

Care plans were routinely transferred during internal ward moves and included discharge planning and education. Some participants mentioned that patients and/or their GPs received a copy of the discharge plan or summary. However, not all care plans were automatically transferred to the next care destination.

Patient and carer involvement in care planning was common, often occurring during bedside handovers and case conferences. As one participant noted:

“Most patients in the hospital, though, are discussed at a multidisciplinary meeting, and sometimes for some units, that’s every day for our quick turnover units … That meeting really is driven by our medical staff from their ward rounds three or four times a week. They talk to the families; they talk to the patients.” (F08, nurse)

In most cases, hospitals exhibited a significant drive to inquire and document patient goals of care within the care plan, utilizing these goals to measure outcomes and assess whether goals were met. As one participant noted:

“Patient care plans are being used to increase patient-driven goals and outcome reporting. So that’s the intention that’s starting to happen, but it’s a slow process.” (F12, nurse)

Several gaps were identified, including difficulties in easily capturing plan updates. Participants expressed a need for a designated section within the plan to document daily progress or updates. Some highlighted the need for improved written communication among multidisciplinary teams.

“There is room on this comprehensive care plan for written communication between teams, but that doesn’t really happen.” (F07, nurse)

A dedicated care coordinator to oversee care plans and patient outcomes was often lacking. Instead, responsibility usually fell to the primary nurse on each shift or occasionally to a doctor, specialist, or GP. While some hospitals employed Patient Flow Managers or Continuity Care Coordinators, their focus was mainly on onward transfers and discharge planning rather than comprehensive care coordination. Participants also questioned the feasibility of paper-based care plans in modern healthcare facilities and raised concerns regarding poor information transfer among hospitals utilizing different templates.

3.2.7. Networking

A wide array of network channels was identified as effective conduits for exchanging information and fostering collaboration. Internally, communication was facilitated through channels like crosstalk between departments, fostering intra-organizational dialogue and coordination.

“Departments are reaching out to other departments for support and help with looking into the way their systems are working and helping by guiding them to provide them with some advice and support around how they can improve their guidelines or pathways for different client groups.” (F10, nurse)

Hospitals also networked with other healthcare institutions to share best practices, resources, and experiences. Partnerships with community services supported integrated and holistic care provision beyond hospital walls. Collaborative research with universities also advanced knowledge and promoted interdisciplinary collaboration.

At a broader level, participation in organization-wide and statewide committees or working groups allowed for collective efforts in addressing healthcare challenges.

“We see that when we have our state-wide collaboratives, and all of those that lead the standard across the state collaborate and talk about their experiences from accreditation …” (F12, nurse)

Moreover, engagement with regulatory bodies such as the Commission and the oversight of statewide coordinators ensured alignment with standards and guidelines.

“What we have found very helpful and useful at the state-wide level, in our state-wide working group and also our inter-jurisdictional level, is having the participation of members from the Commission for that standard actually part of these working groups to hear our challenges, to help us understand what the actual intent behind this standard is.” (F12, nurse)

Constant benchmarking and information-sharing among these networks further enhanced collective learning and continuous improvement across healthcare.

A few gaps in networking and collaborative efforts were identified. Participants emphasized the insular nature of tertiary hospitals, which tended to address issues internally. The example provided by a participant:

“If home visiting is an issue, they create a home visiting program, but they forget that there’s a home visiting program already established [in the community].” (F10, nurse)

Some participants mentioned that their hospital only became aware of the CCS through collaboration with other hospitals, indicating a disconnect from broader healthcare networks. Participants highlighted the need for improved networking and collaboration to leverage existing resources and collective expertise better.

3.2.8. Incentive and pressure

At the individual level, drivers included intrinsic factors such as self-motivation, the pursuit of quality improvement, and responses to clinical incidents. While positive feedback on individual efforts could be motivational, there was a noticeable lack of team motivation. As one participant stated,

“I’ve been nursing for 25 years, so obviously, I’m happy to put things into place that I think will benefit my patients. That’s just who I am. But as a team, I don’t feel that incentive is there.” (F01, nurse)

It was recognized that fostering a sense of team motivation may require improvement. Some participants noted the pressure from patients and higher authorities, who expected high-quality care and outcomes, with limited resources. Others noticed competitive pressure among heads of departments, driven by the need to excel in their respective areas.

At the organization level, the CCS alone did not serve as the primary motivator; rather, accreditation from the ACSQHC stood as the foremost driving force behind compliance.

“[Accreditation] is the biggest driver, no doubt. … It’s when they have to do something because the standards say so, and they don’t see that it will improve patient care; it’s when it’s very difficult to get it over the line.” (F18, nurse)

While competitive pressure was limited within hospitals, it was more evident at the statewide committee level, where hospitals aimed to outperform others. This sometimes led to shortcuts or oversimplifications in care delivery to boost compliance rates. A focus on superficial metrics, such as compliance percentages, risked overshadowing quality and individualized care. As one participant stated,

“[HOSPITAL A]’s compliance was 100 % because the CNC and the NUM would just sit on a computer and activate those care plans … for my area, it took a lot of time because I had to go with the patient, with the nurse every single day … our compliance …. was hovering about 60 %, but it was quality. … when it was time to present at [Hospital B] … all we saw basically was the 100 % … two weeks later after … they decided that they’d go with [HOSPITAL A] … Regardless of the level of risk, every patient gets the same care plan … So, then we had to roll with that.” (F11, nurse)

3.2.9. Feedback

Several methods of seeking consumer feedback were identified and categorized into formal and unofficial strategies. Formal methods include surveys, the use of Patient Reported Experience Measures (PREMs), and Patient Reported Outcome Measures (PROMs), which are statewide tools often automatically sent out via SMS (text message) with a link at the end for each patient admission. Additionally, feedback or suggestion boxes, feedback brochures placed in wards, the use of the ‘Have Your Say Form’ (mentioned at orientation), phone calls, monthly patient meetings (where all patients in the ward are invited), and social media platforms like Facebook were all employed to gather formal feedback. These feedback mechanisms were then typically reviewed monthly or quarterly. Unofficial methods included verbal face-to-face feedback and presenting thank-you gifts or cards from patients.

Some helpful tips were also identified. Refined PREMS versions specific to patient groups were more effective, as a generic survey tended to yield less engagement.

“The work we’ve done within CCS, particularly, is where we can individualize and tailor the patient-reported experience measure, the evaluation, to a specific cohort of patients. So, for example, for a chronic wound or stoma, we’ve assigned a specific tool for that group … We have refined a generic patient-reported experience measure.” (M01, nurse)

Introducing a QR code at the end of an intervention was proven to be a more timely and targeted feedback method. However, some believed a discharge survey was more effective than an in-hospital post-message, as it allowed patients to reflect on their entire experience.

Participants also mentioned staff feedback mechanisms, such as annual professional development plans or performance reviews with the director, though these focused more on individual performance than the CCS. Peer review processes like the LIKE system also served as feedback but were “primarily used by nurses complimenting each other” (F017, nurse).

These systems focused on the nursing staff's views and lacked comprehensive feedback on CCS implementation. While some informal conversations occurred, there was limited feedback on progress or outcome. Participants expressed interest in a structured staff survey to explore this further.

“I think it was just sitting down with the nurses and saying what they thought, what went right, what didn’t go right, what could be improved. There would have been conversations; I would expect, possibly surveys asking the staff.” (F06, nurse)

3.2.10. Reflecting and evaluating

Several participants noted strong executive-level commitment to data collection and closing the feedback loop. Audits were conducted through multiple methods, including chart/documentation reviews, clinician and patient interviews, incident systems like RiskMan, the MARS system, and integrating PREMs and PROMs.

“By way of monthly, weekly cycle audits, which is a weekly reminder based on this system [MARS] … once the staff put it in, we get a dashboard which tells us a unit level compliance.” (M04, nurse)

Participants emphasized the importance of regular evaluations, such as weekly reviews, to identify contributing factors like staffing and inform improvements. As stated by a participant,

“If you’re doing it every week or twice a week or whatever, this week was bad because we had bad staffing. And all the patients have commented about; they’ve had their call bells not answered half an hour or whatever, whereas the following week, they haven’t had that complaint, because we had excellent staffing … if there are associated factors like staffing or whatever.” (F01, nurse)

Many participants highlighted the importance of sharing learning points with clinicians, such as presenting audit results during focus months or designated service times. A senior participant explained,

“We find that by doing that, people tend to have this perspective that it is real, how they care for is real. It’s not just a tick-tock to get rid of that red.” (F11, nurse)

Junior staff also valued feedback:

“We want to see the benefits, and we want to hear about why this particular training that we’re doing, not that it just aligns with that standard.” (M02, allied health professional)

Participants noted that audit feedback sometimes led to specific organizational changes. However, some frequently observed with frustration that data was collected but not effectively utilized or disseminated:

“We’re collecting the data, but not doing anything with that data. Not taking that next step of mitigating that risk and formulating a care plan.” (F05, nurse)

4. Discussion

This interview study reveals the diverse strategies adopted by, or even within, hospitals in implementing the CCS. While some strategies prove effective, others expose real-world gaps. Our findings confirm the challenges inherent in policy implementation, even when written guidelines outlining goals, methods, and monitoring frameworks are provided [22].

Successful implementation of organization-wide initiatives requires a well-structured and effective implementation team [23]. A formal CCS committee comprising multidisciplinary members was reported as effective in many hospitals. The committee should represent all levels of the organization [24], with members selected based on roles rather than individuals to reduce disruption from turnover and address diverse workforce needs [25]. Commitment from all staff is necessary, so the roles of all professions should be clearly defined. An overly hierarchical or flat team structure or one-way communication can hinder effectiveness. Upper-level leadership guides strategy and allocates resources [26], middle managers (e.g., NUMs and allied NUMs) link leadership and frontline staff, and consulting frontline staff helps identify barriers and improve decision-making.

The implementation challenge is exacerbated by the absence of written guidance and clear action plans [22]. Although most hospitals have an implementation plan, awareness of its systematic or scientific use is often limited. Applying implementation science principles can enhance its effectiveness. For instance, employing a visible implementation plan with specific, measurable, attainable, relevant, and timely (SMART) goals [27], along with a robust goal-tracking system [28], benchmarks, timelines, and planned measures [29,30], can optimize its value. Establishing regular updates and reporting mechanisms enables hospitals to effectively coordinate and track progress, thereby identifying areas needing support or adjustments. A systematic approach ensures efficient implementation that is aligned with the implementation goals and objectives.

Selecting an appropriate communication channel is essential as it can impact message comprehension and interpretation time. Email is widely used in Australian hospitals but is less effective than face-to-face or virtual communication, which convey nuances like voice inflections and body language [31,32]. However, written communication provides the flexibility of self-paced absorption, which is beneficial for complex information. Our findings highlighted the value of utilizing multiple communication channels to reach individuals in various ways [33]. This aligns with prior research stressing the importance of adequate communication channels in project success [31,34]. Maintaining multiple communication channels requires time and effort, necessitating a designated communication officer or shared responsibility among team members. Special events or programs can also make communication more engaging or entertaining.

Education and training are crucial when implementing new policies, especially when organizations need to adopt new strategies or modify existing practices [7]. Properly training staff in required skills within the policy context is necessary for effective execution [22]. This training is a time investment, and providing paid training time can be beneficial. Tailoring education plans to accommodate the diverse needs of professionals with varying experiences is also advantageous [7]. Continuous training is essential as standards evolve, introducing new advisories or updated versions [35]. Practical experience also serves as a valuable educational source. Furthermore, university programs can integrate national standards and essential skills, such as effective communication and multidisciplinary teamwork, into curricula to ensure professionals are equipped to implement and adhere to national standards.

Developing a comprehensive care plan is a frontline clinical task and a management-level requirement under the CCS [2]. Given hospitals’ diverse patient populations, a one-size-fits-all plan is challenging. Our research showed benefits in combining a standardized overarching plan with specialized care plan pathways, though clearer guidance on using these pathways is needed. In Australia, the role of a designated care coordinator is not clearly defined [1], with shift nurses typically assuming this responsibility. However, the rotation of nurses may disrupt care continuity. In contrast, Norway has legislated care coordinators for individual care plans [1], ensuring consistent and coordinated care. There are opportunities to learn from Norway and explore ways to enhance care coordination within Australian healthcare systems. Our findings also highlight the demand for the ieMR that embeds care-plan documentation into workflows and allows input from all team members, including patients [36]. Such a system can help optimize patient care by providing a unified platform for recording and accessing essential information throughout the continuum of care.

The CCS promotes coordinated care delivery and requires collaboration among multiple providers [7]. Establishing internal and external networks is crucial, particularly when care providers come from diverse settings [37]. Continuous benchmarking and information-sharing among these networks support collective learning and improvement initiatives across the healthcare system [38]. Small, remote hospitals may face challenges in accessing information or engagement channels, necessitating effective communication of opportunities from state health or hospital and health services (HHS). Large tertiary hospitals should also actively pursue collaboration with external entities, fostering an open approach to network engagement.

As an NSQHS standard, accreditation is the primary source of pressure or incentive. Funding mechanisms require accreditation and may impose sanctions for non-compliance, including regulatory oversight, loss of licenses, and/or funding withdrawal [1]. Positive reinforcement and rewards are recommended to motivate staff to achieve and maintain high performance. Research suggests rewards are more effective than penalties for motivation, which can be counterproductive for underresourced staff [39]. Individual motivation also influences CCS implementation, which is consistent with previous research indicating that many staff members consider standards adherence to be a professional duty [39]. Informal rewards, like friendly competition and peer influence, also drive performance improvement [40]. While competitive pressure could drive motivation, it must be directed toward patient care quality and align with the standards’ intent.

Reflection and evaluation are crucial for improving policy implementation by assessing progress toward desired outcomes. Monitoring or audit systems can enhance evaluation by providing systematic and structured strategies for data collection and analysis [41]. Using various evaluation methods helps address the limitations of any single approach. Feedback from both deliverers and recipients offers valuable perspectives and insights [42]. Sharing their evaluation results fosters transparency, accountability, and continuous improvement. Research highlights the significance of feedback in project success, enabling all parties to review progress, provide suggestions, and make corrections through formal feedback channels or review meetings [34].

4.1. Strengths and limitations of this study

The diversity and rich experiences of the study participants enhance the depth and breadth of the study’s findings. Moreover, the study distinguishes itself by using CFIR to capture a comprehensive understanding of the implementation of national standards.

This study also has some limitations. Recruiting participants via organizational correspondence and social media might have introduced a bias towards those with a specific interest in the CCS, potentially excluding care professionals with differing views. However, their inclusion was essential for obtaining in-depth insights. Another limitation is the limited participation of doctors, with only two taking part. Their absence may be due to busy schedules or a perceived view of CCS as a nursing-focused standard. Although the CFIR framework was used to inform the development of the interview guide, the real-world implementation experiences did not align neatly with its structure. Therefore, results were presented thematically to reflect the data better. We acknowledge this as a limitation regarding direct alignment with the CFIR framework, though its constructs still informed theme development.

4.2. Recommendations for further research

Limited research exists on the real-world implementation of national standards for comprehensive care. Future research should utilize an implementation framework to investigate factors impacting CCS implementation comprehensively. Additionally, using hospital data in future research could evaluate the outcomes of various implementation strategies. Other interesting research topics would be studying the development of a template for a comprehensive care plan and the role of a care coordinator to enhance comprehensive care.

4.3. Implications for policy and practice

At the institutional level, hospitals can consider adopting the strategies identified in this study, such as establishing a well-structured implementation team, developing a clear implementation plan, and promoting interdisciplinary collaboration to address challenges in CCS implementation. These strategies complement existing literature and provide practical guidance that can be tailored to diverse hospital contexts.

Globally, the findings add to the growing body of comprehensive care research by offering real-world strategies adaptable to other healthcare systems. Countries or hospitals aiming to implement or improve comprehensive care can use these insights as a reference point. For instance, the importance of establishing a dedicated implementation team, engaging staff early in the planning process, and integrating documentation systems are lessons that can inform policy and practice across diverse settings. While healthcare systems differ, these findings support cross-context learning and adaptation for internationally successful implementation of comprehensive care.

5. Conclusions

This interview study sheds light on the various strategies adopted by hospitals in implementing the CCS. While hospitals may differ in their resources and challenges, many strategies identified, such as establishing an implementation team, conducting gap analyses, and engaging in careful planning, can be adapted to fit diverse contexts. Further steps may include resource allocation, integrating documentation systems, education and training, and piloting patient care plan templates. Additionally, communicating in various ways, seeking feedback, reflecting on outcomes, and evaluating progress can be valuable strategies to drive improvement. Introducing some degree of pressure or incentives and seeking out or establishing networks can also contribute to successful implementation. These findings offer a foundation of practical strategies that can inform implementation efforts both within Australia and internationally.

CRediT authorship contribution statement

Beibei Xiong: Conceptualization, Methodology, Investigation, Formal analysis, Data curation, Writing – original draft, Writing – review & editing, Project administration. Christine Stirling: Conceptualization, Methodology, Writing – review & editing, Supervision. Daniel X. Bailey: Conceptualization, Methodology, Writing – review & editing, Supervision. Paul Prudon: Investigation, Formal analysis, Writing – review & editing. Melinda Martin-Khan: Conceptualization, Methodology, Resources, Writing – review & editing, Supervision, Funding acquisition.

Data availability statement

The datasets generated and/or analyzed during the current study are not publicly available due to privacy or ethical restrictions but are available from the corresponding author on reasonable request.

Funding

Beibei Xiong is supported by an Australian Government Research Training Program Scholarship. This work is part of the project “Improving quality of care for people with dementia in the acute care setting (eQC)” which is funded by the National Health and Medical Research Council of the Australian Government (No. APP1140459). The research was designed, implemented, and analyzed independently, with no involvement from the funding organization.

Declaration of competing interest

The authors have declared no conflict of interest.

Appendices. Supplementary data

The following are the Supplementary data to this article: