Table 5.

The development and implementation of a GDM dietitian-led model of care using the i-PARIHS framework

	Innovation	Recipients	Context	Facilitation activities
Development Phase
Overview	Starting point: • Minimum schedule of dietetic appointments (Queensland Clinical Guideline for GDM) • Goal to increase women’s access to dietetic support and reduce pharmacotherapy requirements. Organisational fit: • Task duplication identified • Low and high-risk models of care (diet-controlled vs pharmacotherapy + diet) • Models of care: Low risk as dietitian-led, high risk as diabetes educator and physician led • Increased surveillance for low-risk GDM patients (due to third dietetic appointment) • Timing of appointments and changes to ongoing monitoring of all women with GDM. Supporting material: • Escalation of care flow chart for dietitians • Low and High-risk model of care summary flowcharts • Updated patient information • Pre-implementation checklists	Recipients (Staff): • Diabetes team members: Dietitians, Diabetes Educators, Nursing Unit Manager, Clinical Nurse Consultant, Director of Endocrinology, Obstetric Physicians, Administration Officers. • Working party: Clinical Nurse Consultant (opinion leader/ authority), Dietitians (champions/ opinion leader), Nursing Unit Manager (authority), Diabetes Educators (champions)	Local: • Increasing GDM diagnosis requiring efficient model of care • Task duplication within the team • Leadership change Organisational: • Change to organisational structure. • Period of transition (opening of new hospital). External Health Systems: • State-wide publication of Clinical Guideline for GDM (2015)	Problem identification: • Clinical guideline recommendation for MNT not met Acquiring/appraising evidence: • Literature review [7, 8, 22, 32, 33] • Prior research (Surveys) [12, 23] • Service mapping Consensus building: • Stakeholder mapping and engagement • Team meetings • Goal setting • Local context assessment: • Diagnosis using i-PARIHS guidance • Model of care development meetings • Working party contributions
Barriers	• Staff resourcing • Education/knowledge • Managing schedule of appointments	• Some resistance to change (minor) • Competing interdisciplinary priorities • Differences of opinion • Perceived workload pressures • Motivation and engagement	Local: • Historical resistance to change • Team culture Organisational: • Period of high organisational change and transition	Project management: • Increase to dietitian FTE/ clinic days • Appointment template changes • Working party meetings • Newsletters/ email updates Improvement methods: • Professional development sessions • Team meetings Conflict management and resolution: • Leadership involvement • One-on-one meetings Team building • Team meetings • Acknowledging key contributions
Enablers	• Strong evidence-base • State-wide guidelines • Well-established team • Dedicated researcher	• Leadership support • Local opinion leaders/ champions • Minimal disruption to usual workflow • Individuals and team able to implement change • Low staff turnover	Local: • Team autonomy • Leadership support Organisational: • Executive support • Alignment with organisational and research priorities External Health System: • State-wide mandate	Team building: • Acknowledging enablers • Feedback
Implementation Phase
Intervention/ change in practice	• New schedule of dietetic appointments and reduction of diabetes educator appointments • Dissemination of supporting materials	• Increase to dietetic staffing time for GDM • Procedures and policies to inform local system changes	• Procedures and policies to inform local system changes • Informed stakeholders and executive of change to model of care	Communication and feedback: • Fortnightly meetings • Newsletters/ email updates Conflict management and resolution: • One-on-one meetings • Leadership involvement
Evaluation Phase
Successes	• Adherence to schedule of dietetic appointments (29% vs 88%)	• NoMAD survey: familiar, understanding of purpose, support for the model of care, change in negative perceptions	Local: • Dietitian-led model of care adopted as standard practice
Confounders	• Appointment timing deviated from original Academy of Nutrition and Dietetics Nutrition Practice Guidelines • Initial education as group rather than individual • Fidelity: patient satisfaction survey not implemented • Sustainability: FFQ data collection not completed at second review	• Lack of perceived value for understanding patient satisfaction and FFQ • Significant differences in baseline characteristics between pre-and-post intervention groups (early diagnosis, family history of diabetes mellitus, previous diagnosis of GDM)	Local: • Increased surveillance of women with GDM to the end of their pregnancy	Communication and feedback: • Newsletters/ email updates • Post-implementation presentation to team members

GDM Gestational diabetes mellitus; FFQ Food frequency questionnaire