Implementing Systematic Assessment of Physical Function in Hospitalised Medical Patients: Description and Evaluation Guided By the Quality Implementation Framework

ABSTRACT

Rationale

Although older adults comprise 16%–22% of the population, they account for up to 75% of hospital admissions and nearly half of related costs. Frailty, multimorbidity and reduced physical function are common, requiring assessment and follow‐up. Systematic assessment of physical function using the Cumulated Ambulation Score (CAS), 30‐second sit‐to‐stand test (30s‐STS), and handgrip strength (HGS) has shown predictive value for outcomes such as length of hospital stay, complications, readmission and survival in hospitalised older patients. This underscores the importance of early intervention in rehabilitation. The successful integration of evidence‐based practices necessitates the use of an evidence‐based implementation model, such as the Quality Implementation Framework (QIF), which clearly outlines what to address and which actions to take to secure the quality of the implementation process and patient outcomes in the clinical setting.

Aims and Objectives

This study aims to describe and evaluate the implementation process of systematic assessment of physical function in hospitalised medical patients using QIF.

Method

A prospective implementation study, incorporating both quantitative and qualitative methods, was conducted at two medical wards in a Danish hospital. QIF was employed to guide the implementation and the evaluation of the systematic assessment.

Results

Implementation of the systematic assessment showed that early stakeholder engagement and leadership support ensured ownership and staff buy‐in. A structured implementation plan clarified roles and accountability. Process evaluation revealed high penetration and acceptability, with improved fidelity over time. Workflow challenges remained, and adoption into daily practice among therapists was limited due to time constraints and documentation burden. Expansion to new departments demonstrated scalability.

Conclusion

A structured QIF‐based approach to implementing systematic assessments in hospitalised medical patients proved feasible, acceptable, and potentially scalable. Stakeholder engagement, management support and strengthened cross‐sector collaboration were key to success. Sustainability depends on workflow integration, timely data‐driven feedback and continued training.

1. Introduction

Though older adults comprise around 16%–22% of the population worldwide, they are disproportionately likely to be hospitalised [1, 2, 3, 4]. Thus, worldwide, 40%–75% of patients admitted to a hospital are 65 years or older and incur nearly half of all hospital costs [5, 6, 7, 8]. Frailty is very common among older patients, and they present with multimorbidity and polypharmacy, as well as physical and cognitive challenges [9, 10]. The complex health condition of these older patients requires thorough assessment and follow‐up to ensure appropriate care and rehabilitation [11]. However, signs of frailty and reduced physical function might also be present in younger adults admitted to acute hospitals, but knowledge about this is limited [12]. Therefore, identifying and promoting factors to mitigate the decline towards frailty and dependency is considered important in all hospitalised adult patients to potentially reduce healthcare costs and improve quality of life [12].

In that view, three tests, the Cumulated Ambulation Score (CAS), the 30‐second sit‐to‐stand test (30s‐STS), and handgrip strength (HGS), have been suggested for systematic assessment of physical function (now termed “systematic assessment”) in different patient populations and across healthcare sectors [13]. These tests include sex and age‐decade reference values for Danish adults from 18 to 80+ years old and using a traffic light system for normal (green), reduced (yellow) and strongly reduced (red) physical function [13]. The systematic assessment has proven to be a strong predictor of outcomes such as length of hospital stay, complications, readmission and survival in hospitalised older patients but also for longer‐term outcomes for community‐dwelling individuals such as mortality [12, 14].

However, there is very limited literature on the implementation of CAS, 30s‐STS, and HGS across clinical settings, representing a clear knowledge gap [15]. This study addresses this gap by describing and evaluating the implementation process of systematic assessment, including all three tests, in hospitalised medical patients as a part of routine clinical practice. This is important because systematic assessment can support early identification of patients who may benefit from rehabilitation interventions.

The implementation of new evidence‐based practice in busy clinical settings can be challenging [16, 17], and successful implementation requires effective strategies, including recognition of potential individual and organisational barriers [18, 19]. The Quality Implementation Framework (QIF), an evidence‐based action‐oriented model, provides a structured set of steps and phases that have proven effective in clinical settings when implementing new practices [20]. Employing QIF ensures that the implementation adheres to a systematic approach by addressing key challenges and ensuring that each phase contributes to the overall success [20].

This study aims to describe and evaluate the implementation process of systematic assessment of physical function in hospitalised medical patients using QIF.

2. Methods

2.1. Design

A prospective implementation study incorporating both quantitative and qualitative methods. The QIF was employed to guide the implementation and the evaluation of the systematic assessment [20, 21]. The 14 critical steps in QIF are divided into four implementation phases (Figure 1). Ten of the 14 steps focus on preparation and adaptations to the implementation context and the establishment of a structure for implementation (Phases 1 and 2), serving as a prerequisite for high‐quality implementation [20]. QIF is a dynamic model, and some of the steps are consistent in all phases [20].

Figure 1.

Dynamic interplay among the four phases and 14 critical steps of the Quality Implementation Framework. Reproduced with permission from Abraham Wandersman.

This study was reported following the Standards for Reporting Implementation Studies (StaRI) [22].

2.2. Context

This study was conducted between February 2023 and September 2024 at two medical inpatient wards at the Medical Diagnostic Centre, Silkeborg Regional Hospital, Central Denmark Region, serving a catchment area of ~101.500 residents. In 2023, there were ~500 admissions to the two medical inpatient wards and a notable proportion of patients (46%) presented with heart or lung conditions. Rehabilitation in Denmark involves collaboration between hospitals, municipal healthcare centres, and nursing homes, with hospitals being responsible for in‐hospital assessments of functioning and the formulation of rehabilitation plans. The municipal healthcare centres and nursing homes are responsible for general rehabilitation in the primary care sector. All these healthcare services are funded through national taxation, ensuring equal access for all citizens.

2.3. The Target Population for the Intervention

The intervention targeted all patients 18 years and older admitted to one of the two medical inpatient wards who were referred to physio‐ or occupational therapy during admission. Patients with severe cognitive impairment or receiving end‐of‐life were excluded.

The implementation followed a consecutive, practice‐based approach rather than formal sampling. All eligible patients admitted during the study period were considered part of the target population. Based on electronic medical record data, 1799 were referred to physiotherapy and/or occupational therapists, 1531 patients met the eligibility criteria during the implementation period, of whom 1273 (83%) were assessed using the systematic assessment. This information was used to evaluate penetration of the intervention.

2.4. Target Sites and Staff for the Implementation Strategy

All physiotherapists and occupational therapists, including students, in total 17, affiliated with the two medical inpatient wards. In addition, we engaged physiotherapists and occupational therapists at the municipal healthcare centre and the nursing homes to examine the impact of the systematic assessment on the patient's pathway following discharge.

2.5. Intervention Description

The systematic assessment was implemented at one of the major acute hospitals in Denmark in 2022 [23], and other hospitals have followed this initiative, including the study hospital of this work. The systematic assessment included three tests: CAS, 30s‐STS, and HGS [13]. The tests were conducted at specific time points (Table 1), and the test results were entered into the patient's Electronic Medical Record. If required, a rehabilitation plan was developed and forwarded to municipal healthcare centres and nursing homes upon discharge.

Table 1.

Time points for systematic assessment of physical function.

Test	Time
	*At admission	Initial assessment	Initial assessment or as early as possible thereafter	At the end of therapy/discharge
The Cumulated Ambulation Score (CAS)	√	√		√
30‐second sit‐to‐stand (30s‐STS)		√		√
Handgrip strength (HGS)			√

^*Habitual basic mobility level before the admission [13].

2.6. Implementation Strategy Description

Phase 1 involved participatory consultation between project coordinators, the research department, and the clinical lead. The key elements included conducting a need and resource assessment, determining the organisation's readiness for change, and obtaining specific engagement from key stakeholders, especially the clinical lead and the physiotherapists and occupational therapists. This involved multiple meetings and training sessions. Table 2 shows the stakeholders and how they were involved in the implementation process. Phase 2 focused on developing an implementation plan, including determining how to evaluate the implementation process. Technical assistance ensured that documentation in Electronic Medical Records was straightforward and user‐friendly. Phase 3 consisted of a process evaluation, and a continuous feedback structure was provided to relevant stakeholders. Phase 4 emphasised continuous adjustment and customisation to sustain and improve implementation over time.

Table 2.

Stakeholders and their involvement in the implementation of the systematic assessment of physical function.

Stakeholder	Participants	Involvement
Steering group	One clinical lead at the physio‐ and occupational therapy, two project coordinators (one physiotherapist and one occupational therapist), and one researcher (physiotherapist). Ad hoc: two ambassadors (one physiotherapist and one occupational therapist) and one Electronic Medical Record Specialist (physiotherapist).	Planned the implementation process. Monitored implementation progress and ensured that milestones were met, provided strategic oversight and facilitated problem‐solving when barriers emerged.
Project coordinators	One physiotherapist, MSc. and one occupational therapist, MHH, each with expertise in quantitative and qualitative methods and knowledge of implementation theory.	Ensured adherence to schedules and milestones. Supported the ambassadors and planned steering group meetings.
Researcher	One physiotherapist, PhD.	Ensured systematics and spared with the project coordinators about methodological considerations.
Management/leadership	The clinical directors (nurse and doctor).	Gave support and necessary financial allocation.
Ambassadors	One physiotherapist and one occupational therapist with an interest in systematic assessment.	Ensured logistical preparations and provided consistent reminders for daily use of the systematic assessment. Participated in data collection and processing.
Data experts	One Electronic Medical Record Specialist (physiotherapist).	Adapted the Electronic Medical Record to integrate the results from the systematic assessment and trained the physiotherapist and occupational therapists in how to document the assessment.
	Business intelligence data expert (Data warehouse with all data from Electronic Medical Records).	Used Business Intelligence data to visualise data for process evaluation regarding penetration.
Physiotherapists and occupational therapists (Target sites for the implementation strategy)	The clinical lead at the physio‐ and occupational therapy and the employed physiotherapist and occupational therapist.	Gave a clear signal of management support and ensured time and resources.
Cross‐sectoral partners	Physiotherapists and occupational therapists from municipal healthcare centres and nursing homes.	Was informed about implementation and engaged in dialogue about the dissemination and inclusion of the test results cross‐sectoral. Was invited to participate in a motivational video meeting with experienced therapists and an external specialist.
Interdisciplinary health professionals	Nurses and medical doctors working in the two medical inpatient wards.	Were informed about the implementation and where to find the test results in the Electronic Medical Records, and what they could use the results for.
External specialists	Clinical Professor, PhD (physiotherapist) from Bispebjerg Hospital, Copenhagen, with extensive experience in implementing systematic assessment.	Motivated physiotherapists and occupational therapists to implement and explain the rationale behind the three tests. Engaged in discussions with the project coordinators regarding the implementation process.
	Anthropologist with expertise in implementation and Quality Implementation Framework in particular.	Supported project coordinators in using the Quality Implementation Framework.
Patients (Target population for the intervention)	Patients above 18 years admitted to the two medical inpatient wards.	Accepted to receive the systematic assessment during hospitalisation.

2.7. Evaluation

We evaluated the extent to which the 14 steps outlined in the QIF framework were implemented, including a process evaluation in Phase 3, where we applied Proctor and colleagues taxonomy of implementation outcomes (Table 3) [24, 25]. Additionally, a separate logbook was used to continuously describe actions, facilitators and barriers throughout the entire implementation period.

Table 3.

Implementation outcomes as described by Proctor et al. [24, 25].

Outcome	Definition
Penetration	The integration or saturation of an intervention within a service setting and its subsystem.
Fidelity	The degree to which an intervention was implemented as prescribed or intended.
Acceptability	Stakeholders' perception that an implementation target is agreeable, palatable, or satisfactory.
Adoption	The intent, initial decision, or action to employ an implementation target.

To assess penetration, we used data from the Electronic Medical Record to evaluate whether 80% of the eligible population was assessed with the systematic assessment. A cut‐off of 80% was chosen based on what was considered realistic.

To assess fidelity, two audits in the Electronic Medical Record were conducted to evaluate whether systematic assessments were conducted as prescribed, documented in the Electronic Medical Record, and incorporated into rehabilitation plans.

To assess acceptability, we explored the patient's response to and interaction with receiving the systematic assessment by conducting individual interviews with nine patients, facilitated by a research assistant, the same day they were tested with the initial systematic assessment. A purposive sampling strategy [26] was used to recruit patients with direct experience of systematic assessment, ensuring the inclusion of information aligned with the study aim, and to include both men and women. Patients who had language difficulties, reduced alertness, delirium, or dementia were excluded.

Further, two group interviews were conducted. One group interview with three doctors (one senior physician, one junior physician, and one geriatrician) from the medical inpatient wards, facilitated by a research assistant, and one group interview with three health professionals from a municipal healthcare centre (one physiotherapist) and a nursing home (one physiotherapist and one occupational therapist), facilitated by HNK.

Semi‐structured interview guides were employed in individual interviews and group interviews, drawing inspiration from the key functions of process evaluation [24, 25]. All interviews were recorded and transcribed verbatim.

To assess adoption, an anonymised questionnaire survey developed by Bispebjerg Hospital originally describing and implementing systematic assessment was conducted approximately 5 months after implementation started [27]. The local survey gauged physiotherapists and occupational therapists (n = 12).

2.8. Methods of Analysis

Methodological triangulation was applied. Quantitative and qualitative data were analysed separately and integrated at the interpretation stage to examine convergence and divergence across data sources and stakeholders, strengthening the overall evaluation of the implementation process. Quantitative data was described with numbers and proportions.

Qualitative data was analysed using thematic analysis to identify themes following six phases: familiarisation with the data, coding, searching for themes, reviewing themes, defining and naming themes, and writing up [28, 29]. Thematic analysis is useful to examine different perspectives and to highlight differences and similarities, as well as generate unanticipated insights [28]. An inductive approach was used for the initial coding, allowing for openness to unexpected themes. To increase validity and accuracy in data interpretation, two researchers (HNK and research assistant) independently received and assessed the data and collaboratively reassessed the final interpretations during the data condensation process [30]. NVivo11 was used to facilitate data analysis.

Credibility was enhanced through independent coding by two researchers followed by iterative discussions to reach consensus on themes. Dependability was supported by systematic documentation of analytic decisions. Reflexive dialogue was maintained throughout the analytic process to consider potential influences of the researchers' professional roles and involvement in the implementation context.

2.8.1. Ethics

In accordance with the guidelines of the Danish Data Protection Agency, the hospital management at Regional Hospital Central Jutland granted permission for data collection from the Electronic Medical Record (Journal number: 243985). According to Danish legislation and the Act on Biomedical Research Ethics Committee System in Denmark, research using questionnaires or register‐based research without human biological material does not require approval from the ethics committee (§14 Section 2).

The study adhered to the ethical principles outlined in the Helsinki Declaration [31]. Written informed consent was obtained from all patients and health professionals prior to participation in the interviews. Participation was voluntary, and participants were free to withdraw from the study at any time without consequences. Sensitive personal information was stored securely in MidtX (a secure regional digital platform) in accordance with relevant guidelines.

3. Results

The four QIF phase's structure the main results presented below.

3.1. Phase 1: Initial Consideration Regarding the Host Setting

Early engagement efforts included stakeholder meetings, training sessions, and pilot testing, which ensured alignment with clinical routines. The implementation ambassadors and support from the clinical lead facilitated local ownership. Initial feedback from physiotherapists and occupational therapists highlighted both facilitators, such as support from the clinical lead and barriers, such as time constraints and documentation complexity. Table 4 summarises the key actions taken during this phase and the related results.

Table 4.

Actions and results of Phase 1 using the Quality Implementation Framework.

Steps	Actions	Results
1. Conducting a needs and resources assessment	Some of the nine physiotherapists and occupational therapists, along with the two project coordinators, took action to address the compelling need in clinical practice for an objective assessment to evaluate physical functioning. The assessment was intended to facilitate measurement standardisation, enhance interdisciplinary communication, and provide cross‐sectoral insights.	We looked for information about the implementation of systematic assessment at Bispebjerg Hospital and contacted them to hear about their experiences.
	A need to collect group‐level and individual data was identified, e.g. to support readmission tracking and facilitate collaboration with municipal healthcare centres or nursing homes.	Data from the systematic assessment was used for readmissions and communicated to municipal health centres or nursing homes in rehabilitation plans.
	The steering group sought to determine whether data could effectively guide targeted interventions and identify patients in need of rehabilitation.	Data from systematic assessments were used as part of the overall assessment of physical functioning and, thus, the patient's need for rehabilitation. There is still room for further work on how data can inform rehabilitation interventions.
2. Conducting a fit assessment	The project coordinators assessed the feasibility of adapting systematic assessment to align with the hospital's vision, ensuring that it supported fast, efficient, high‐quality patient pathways and effective implementation of existing knowledge.	The implementation of systematic assessment was found to support the hospital's vision seamlessly.
3. Conducting a capacity/readiness assessment	The project coordinators searched and read literature on systematic assessment of physical functioning.	Two relevant articles were identified, read and discussed in order to provide physiotherapists and occupational therapists with evidence supporting the implementation of the systematic assessment. This led to comprehensive discussions among physiotherapists and occupational therapists.
	Two ambassadors were chosen based on their interest and commitment to systematic assessment.	The two ambassadors actively facilitated daily implementation by applying their in‐depth knowledge of the systematic assessment tests and ensuring the availability of practical measures, such as correct chair height, hand dynamometer, and reference values.
	The project coordinators scheduled meetings with the clinical lead to discuss and ensure management support.	Support from the clinical lead ensured a constant focus on daily implementation and financial allocation, e.g. for the hand dynamometers.
4. Possibility for adaption	A start‐up period of four months was decided by the steering group.	The start‐up period allowed physiotherapists and occupational therapists to practice the systematic assessment, make necessary adjustments, and develop a stronger sense of co‐ownership.
	A feedback area was established in the office where facilitators and barriers could be communicated via post‐it notes.	Provided physiotherapists and occupational therapists with a visible area for continuous feedback, fostering co‐ownership and continuous adjustments.
	The project coordinators planned monthly meetings to address implementation barriers.	The meetings fostered ongoing dialogue. E.g. the post‐it notes from the feedback area were discussed, initiating early dialogue about specific patient groups, including those with severe cognitive impairment or receiving end‐of‐life care.
5. Obtaining explicit buy‐in from critical stakeholders and fostering a supportive community/organisation	The clinical lead was present daily.	The presence of the clinical lead supported the prioritisation of the systematic assessment in a busy daily clinical practice.
	The project coordinators liaised with the research department.	Led to sparring on implementation framework and data collection to support data‐driven feedback during the implementation.
	The ambassadors planned three practical training sessions of systematic assessment for all the physiotherapists and occupational therapists.	This ensured that physiotherapists and occupational therapists felt confident about how to perform the systematic assessment and buy‐in.
	The project coordinators planned online meetings for the physiotherapist and occupational therapist with experienced therapists and a professor from Bispebjerg Hospital. Physiotherapists and occupational therapists from municipal healthcare centres and nursing homes were also invited.	Strengthened motivation and engagement and increased knowledge of the rationale behind systemic assessment among physiotherapists and occupational therapists at the hospital. Provided knowledge to cross‐sectoral partners about the systematic assessment and the implementation process at the hospital.
	The project coordinators planned weekly meetings with the ambassadors, and if needed, the clinical lead was invited.	The ambassadors felt they had someone to spare with, and any issues or ambiguities were resolved immediately.
	The project coordinators planned ongoing information in the weekly newsletter, e.g., regarding number of executed systematic assessments.	We did not manage to include updates in the weekly newsletters. Instead, it was presented verbally ad hoc in the morning by the ambassadors, and otherwise, it was presented at regular meetings. This helped sustain focus and maintain momentum in the implementation.
6. Building general/organisational capacity	The project coordinators, along with the Electronic Medical Record specialist, the Business Intelligence data expert, and the two ambassadors, planned to utilise Business Intelligence data to provide ongoing visual data‐driven feedback on the number of systematic assessments executed.	The Electronic Medical Record setup was continuously refined to optimise documentation, ensuring it was intuitive, easily accessible, and clinically useful. Additionally, the data cycle was secured to enable data extraction and feedback, allowing ambassadors to relay insights to clinical practice and support ongoing adjustments. Visualising data took longer than expected and became available in the spring of 2024, which meant it did not become an active part of the implementation.
7. Staff recruitment/maintenance	The clinical lead determined that recruiting physiotherapists and occupational therapists was unnecessary, as enough were already employed to ensure the implementation of the systematic assessment.	No one was recruited.
	The ambassadors were tasked with focusing on practising and performing the systematic assessment in a busy workday.	They ensured that the implementation became feasible in daily clinical practice by serving as a link between the steering group and the therapists conducting the systematic assessments. Ensured continuous focus on implementation.
8. Effective pre‐innovation staff training	The ambassadors ensured ongoing training, skills maintenance and education sessions.	Ensured consistency and quality of execution. Continuous introduction to students and new staff was ensured.

3.2. Phase 2: Creating a Structure for Implementation

The structured approach established clear organisational responsibilities and ensured a smooth transition from planning to practice.

A structured implementation plan with clear milestones was developed by the two project coordinators (supporting information). The key components of the implementation plan were training schedules, documentation processes, and feedback loops. The steering group monitored progress and supported the physiotherapists and occupational therapists, particularly the ambassadors, in the implementation actions taken to put the systematic assessments into clinical practice. Table 5 summarises the key actions taken during this phase and the related results.

Table 5.

Actions and results of Phase 2 using the Quality Implementation Framework.

	Actions	Results
9. Creating implementation teams	Establishment of the steering group, see Table 2.	Strict adherence to the implementation plan and monitoring of the planned activities was ensured.
10. Developing an implementation‐plan	The project coordinators created a combined timetable and implementation‐ plan (supporting information).	This ensured agreement about the schedule to follow, which was continuously addressed at the regular meetings.
	The project coordinators and the ambassadors developed a logbook with the following headings: data, problem/awareness and action.	It provided continuous information about the process and feedback, allowing for quick adjustments.

3.3. Phase 3: Ongoing Structure once Implementation Begins

We established a continuous support structure to ensure the long‐term sustainability of systematic assessments by providing structured support and streamlining workflows. Table 6 summarises the key actions and the related results during this phase.

Table 6.

Actions and results of Phase 3 using Quality Implementation Framework.

	Actions	Results
11. Technical assistance/coaching/supervision	Based on the feedback collected from post‐it notes, the project coordinators, the clinical lead and the ambassadors planned content and topics for future training sessions and meetings.	Meeting and training sessions were held once a month, respectively, and had content that made sense to the physiotherapists and occupational therapists as it was based on their feedback.
	Time was allocated for physiotherapists and occupational therapists to supervise each other in conducting a physical assessment. They teamed up with each other to practise the systematic assessment and discuss the scoring of the different tests.	Increased their competencies and capabilities to perform the tests and focussed on what uncertainties there were in performing the tests.
	The Electronic Medical Records were configured for easy access to documentation.	Standardised phrases were created to streamline the conclusion of the assessments.
12. Process evaluation	Process evaluation was planned, and outcomes were selected.	Penetration: The systematic assessments were conducted in ≥ 80% of eligible patients in most months during the study period (Figure 2). Periods below this threshold occurred and were primarily observed during holiday periods, likely reflecting reduced staffing and clinical capacity.
		Fidelity: Seven months after implementation, systematic assessments were completed in 80% of eligible patients, increasing to 90% after 17 months. Documentation of test results in the Electronic Medical Record improved from 50% to 78%, and integration into rehabilitation plans rose from 40% to 90%, highlighting enhanced adherence over time.
		Acceptability: Interviews showed high acceptability among patients, interdisciplinary health professionals and cross‐sectional partners (Table 7).
		Adoption: Four months after the implementation had started, 75% of the physiotherapists and occupational therapists felt confident in performing and documenting systematic assessments, but time constraints remained a challenge. 59% reported that conducting systematic assessments had become an automatic part of their workflow, and 67% agreed that they performed systematic assessments even when they had another urgent task.
13. Supportive feedback mechanism	Data from process evaluation was planned communicated to management, ambassadors and physiotherapists and occupational therapists.	During regular meetings, the physiotherapist and occupational therapist received feedback from the process evaluation.

Through ongoing training, peer supervision, structured process evaluation, and feedback loops, the physiotherapists and occupational therapists received the necessary support to maintain high implementation fidelity. In addition to the findings in Tables 6 and 7 presents further details on patient and health professional experiences, while Figure 2 illustrates the penetration of systematic assessments during the study period.

Table 7.

Acceptability experienced by patients and health professionals at hospital and from the municipal healthcare centre and nursing home.

Theme	Results
Individual interviews with patients admitted to one of the two medical wards (n = 9)
“Sense of security”	Patients were generally satisfied with performing the systematic assessment. They felt well‐informed and safe when tested with systematic assessment. “I think it has been great. I really think I have been well informed about how and why. I have been pleased with that” (P1). “And he stood over here to help me to make sure that if I had a fear of falling, he would take me. So, I think that was excellent” (P3).
“A sense of meaningfulness”	The nine informants appreciated the systematic assessments. They felt the experience gave them a clearer understanding of their physical capabilities and how these related to their everyday routines, enabling them to better plan and manage life after discharge. “It feels like a real privilege to have this kind of test done. It gives me concrete insight into what my body is actually capable of. Normally, no one tests me like this. At home, I stick to certain rhythms and habits, but coming here and being tested shows me whether what I am doing actually works. It is a kind of validation and that means a lot to me” (P7). “Well, I think it is exciting for myself ‐ what can I do and what can I do when I do not have you” (P3).
Group interview with three doctors from the two medical inpatient wards (n = 3)
“Use of test results in practice”	Doctors focused on physiotherapists’ and occupational therapists’ conclusions rather than the individual results of the systematic assessment in the Electronic Medical Record, using these conclusions to evaluate discharge feasibility and prioritise readmission prevention. “So, the thing about concluding whether it is 50, 30 or 15 or whether it is 1, 3 or 5, that number does not tell me much, but it is more the conclusion. Short and to the point” (I1).
“Strengthening interdisciplinary collaboration”	The doctors believed systematic assessments could enhance interdisciplinary collaboration, but they emphasised the need for a shared language, particularly in areas like Activities of Daily Living. “It could provide a nice common language that could be useful and be more precise when talking about the patients, and maybe sometimes make some things shorter” (I2).
“Continuity as part of a good implementation”	The doctors were satisfied with the initial information about the systematic assessments but saw a need for ongoing updates and information. They suggested a mid‐project up‐date and recommend teaching the three tests to new medical students. “Maybe you could have made some kind of presentation like ‘now we have been going on for 0.5 years, and we have been there and there’, because otherwise, I do not think people are so aware that it is something that's going on” (I2).
Group interview with health professionals from municipal healthcare centres and nursing homes (n = 3)
“Systematic testing as an educational tool”	The initiative rapidly expanded to the municipality, and the informants characterised the systematic assessment as a highly effective educational tool, valuable for guiding patients in their exercise focus and for demonstrating progress or lack thereof when comparing hospital test results with a new systematic assessment conducted in the municipal healthcare centre and nursing home. “It is a useful pedagogical tool for engaging citizens, this is where we really need to focus our efforts. At the same time, measuring handgrip and overall strength can also indicate whether sarcopenia might be an issue” (I1). “Even though she was cognitively ill and poorly, she could see that I am at 7. The normal is there and there. It is impaired” (I1).
“Useful in cross‐sector collaboration.”	The informants described systematic assessments as crucial for cross‐sector communication and saw it as a better opportunity to compare results in the rehabilitation plan upon hospital discharge and in the final status report at the end of municipal rehabilitation. “And also, when we discharge a patient and write the final report to the hospital, it is beneficial to include their results. So, you have something to compare with if you see them again. Just like we use the information you send us to track progress, that way, we can both see whether there has been any development from start to finish” (Informant 2).
“Adaptations for people with severe disabilities”	The three tests were performed in the municipal healthcare centres and nursing homes, but adaptations to the three tests were made at the nursing home, especially for citizens with the poorest functional, e.g., cognitive abilities. A modified 30s‐STS, using an armrest, was used for these citizens. Informants agreed that the three tests alone were insufficient; a detailed prose description was crucial for conveying the functional abilities of the most vulnerable citizens to nursing staff after hospital discharge. “We really appreciate your prose descriptions, as they are valuable when communicating with nursing staff. The prose is critical because it highlights cognitive aspects, professional assessments, and functional abilities related to ADL. In that sense, the prose adds significant value (Informant 3).

Figure 2.

Penetration: Proportion of patients assessed with systematic assessment in the study period.

3.4. Phase 4: Improving Future Applications

Several key learnings emerged that can improve future implementation initiatives in similar clinical settings. The most important elements were early stakeholder engagement and strong support from the clinical lead. The use of an implementation framework helped maintain focus on facilitators and barriers throughout the implementation process. In addition, continuous feedback from users and data played a central role in refining and improving the implementation. A noteworthy observation was the initiative's expansion beyond its initial scope, as physiotherapists and occupational therapists across the hospital adopted its underlying principles. For example, systematic assessment was integrated into the pulmonary rehabilitation program, the cardiac rehabilitation team procedures, and fall risk assessments within the Geriatrics Clinic, underscoring the initiative's relevance and practical utility on a broader scale.

4. Discussion

This study describes and evaluates the implementation process of a systematic assessment of physical function in hospitalised medical patients using QIF.

In Phase 1 structured stakeholder engagement and leadership endorsement enhanced organisational readiness and contextual fit. While local ambassadors strengthened professional commitment, early concerns regarding time and documentation highlighted potential sustainability challenges. In Phase 2, a structured implementation plan clarified roles and responsibilities, which likely supported fidelity and facilitated adoption despite workflow pressures. In Phase 3, fidelity improved over time, although adoption remained limited. Workflow challenges and concerns about time constraints and documentation burden were observed, likely reflecting competing clinical priorities, the need to integrate assessments into established routines, and differences in familiarity with the systematic assessment. In Phase 4, the approach was extended to outpatients, indicating potential feasibility across settings, although sustainability continued to depend on support from clinical leadership and periodic training. A key strength of this study was the use of the QIF, which provided a structured framework for planning, executing, and evaluating the process. Compared to other frameworks like Consolidated Framework for Implementation Research (CFIR) and Context and Implementation of Complex Interventions (CICI), QIF's emphasis on pre‐implementation planning, resource allocation, and iterative feedback made it particularly suitable in our context [32, 33]. In contrast to other implementation studies, this study achieved an 80% penetration relatively early, suggesting that the use of the structured framework, stakeholder buy‐in and strong clinical lead were crucial facilitators [34, 35]. A further strength was the incorporation of both quantitative and qualitative data, which provided a nuanced understanding of facilitators and barriers to implementation. Patient interviews provided important insights into the acceptability of systematic assessments, which added a layer of patient‐centred evaluation. A final strength was that interviews with health professionals from the hospital, municipal healthcare centre, and nursing home provided valuable perspectives on the patient pathway. Their experiences suggest that the implementation of the systematic assessments supported cross‐sector communication and alignment within the current setting, indicating potential relevance and applicability beyond a single institution. Although these findings suggest potential relevance beyond a single institution, the single‐site design and limited adoption mean they should be interpreted cautiously. Cross‐sector collaboration and integration into routine documentation systems may enhance sustainability and clinical relevance, but further research is needed to confirm this.

A limitation of the study was the delayed integration of data‐driven feedback mechanisms. Data‐driven feedback has been shown to enhance decision‐making, increase efficiency, and support continuous improvement, although its impact varies depending on context and delivery methods [36]. Furthermore, real‐time feedback can improve clinician engagement by providing relevant and actionable insights, fostering better communication, and enabling rapid adaptation to site‐specific challenges [37, 38]. In our study, the delayed integration of data‐driven feedback likely stemmed from technical and workflow constraints, which may have limited early clinical engagement and slow adoption. This highlights the importance of aligning feedback mechanisms with routine clinical practice from the outset. Previous studies have emphasised the importance of structured implementation strategies in clinical practice, and applicability of QIF across different contexts [39, 40, 41]. A study using QIF to implement Family Systems Nursing Conversations in Swedish home health care found that nurses emphasised the significance of early and structured education, ongoing support, and active leadership involvement as critical components for successful implementation [42]. However, barriers in their setting included fluctuating feasibility and adoption rates, mainly due to contextual challenges in municipal home care [42]. In contrast, our setting benefited from more substantial structural alignment between hospital and municipal sectors, and the intervention was perceived as better integrated into existing workflows, which may explain the higher adoption and fidelity observed in our study. Another study implementing the Professional Nurse Advocate role in a United Kingdom acute and community hospital setting, also guided by the QIF [43]. They emphasised the value of a steering group and a clearly defined implementation framework, supporting a structured approach [43]. Overall, these studies support the applicability of QIF across different clinical contexts [42, 43].

Studies indicate that implementation barriers, particularly those related to time constraints, workflow integration, lack of management support, and staff buy‐in, are common in healthcare settings [15, 16, 44]. In contrast to a study that implemented hand grip strength assessments among older adults in a medical inpatient ward and faced challenges with staff engagement and clinical lead support, we did not encounter significant barriers [15]. This likely reflects our structured approach and early engagement of key stakeholders, including the physiotherapists and occupational therapists who conducted the systematic assessment, and the supportive context in which the systematic assessments were conducted.

Our findings are further supported by a systematic review, which identified key barriers to implementation in physiotherapy and occupational therapy settings, including limited time, lack of resources, and resistance to change [16]. Notably, the review highlighted strong organisational support as a central facilitator for successful adoption. This element was present in our implementation and may explain the relatively high penetration achieved early in the process. The central components of the present study are stakeholder engagement and clear implementation plans, which other studies have also highlighted as essential for successful implementation (39, 40). Proctor et al. emphasised the importance of clear and well‐defined implementation strategies, outlining that comprehensive planning, including explicit operational definitions of intervention components, specification of stakeholder roles, and detailed procedural guidance, is crucial to overcome barriers and ensure fidelity and sustainability [45]. These insights align with our structured approach, which combines stakeholder engagement with a systematic and articulated implementation plan, and provide context for why fidelity improved despite ongoing workflow and adoption challenges.

5. Conclusion and Implications

This study demonstrates that implementing systematic assessments in hospitalised medical patients is feasible, acceptable, and potentially scalable when guided by a structured framework such as QIF. Using QIF as an implementation guide was a key to achieving a well‐planned and successful implementation. To the best of our knowledge, no other studies have used QIF as an evaluation tool, which has resulted in a structured reporting that we recommend others can be inspired by.

Our findings highlight the importance of management support, workflow integration, ongoing training, and timely data‐driven feedback as key enablers of sustainable implementation. The approach offers a replicable model for implementing evidence into clinical practice.

The systematic use of evidence‐based tests like CAS, 30s‐STS, and HGS can enhance the early identification of rehabilitation needs, improve discharge planning, and support targeted interventions for older adults. This has the potential to improve the quality of care, inform policy, and guide resource allocation in hospitals.

Future efforts should focus on refining and scaling systematic assessments across different hospital settings and cross‐sector to understand context‐specific barriers and facilitators better. Based on the results of this study, we recommend the use of QIF as a guiding framework for implementation and as a structured approach to evaluation.

Conflicts of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Supporting information

Supporting File.

Kristensen H. N., Bloch‐Nielsen J. R., Kristensen M. T., Høgh H., Hannibal L., and Schmidt A. M., “Implementing systematic assessment of physical function in hospitalised medical patients: Description and evaluation guided by the Quality Implementation Framework,” Journal of Evaluation in Clinical Practice 32 (2026): e70447. 10.1111/jep.70447.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.