National clinical programmes in the Republic of Ireland: a qualitative study of acute hospitals

Abstract

Background

The national clinical programmes (NCPs) were established in 2010 to achieve three objectives, namely: improve quality, access and cost effectiveness. Limited research exists on their implementation in the Republic of Ireland (ROI). This qualitative study identified key stakeholders’ perceptions on (a) implementation thus far, and (b) conditions perceived necessary for implementation in acute hospitals.

Aims

The overall aim of this research was to undertake an in-depth study to explore from the perspectives of key stakeholders, their perceptions on implementation of the national clinical programmes, thus far, in relation to three overarching objectives (to improve quality, access, cost effectiveness) and what are the conditions necessary for their implementation in the Republic of Ireland's acute hospitals.

Methods

Twenty participants were interviewed using face-to-face audio-recorded semi-structured interviews. Transcribed data were coded and analysed, and a number of themes emerged from the dataset relating to the study aims.

Results

Implementation was perceived as being inconsistent. Outcomes were identified as: best practice guidelines, models of care, protocols, pathways; education & training; new services; improved discharges; improved patient outcomes; reduced length of stay; timely access; reduced waiting lists; cost effectiveness and other intangible outcomes. Sixteen conditions, under four themes, were perceived necessary for implementation, namely: Governance – structure, audit & monitoring, senior management support, accountability, and clear objectives and expectations; Communication – visible face-to-face engagement, internal awareness, and external awareness; Leadership – programme level, national level, hospital level, and professional level; Resources – budget, staff, information technology, training, skills, and competency.

Conclusions

This study adds to the existing limited body of knowledge on implementation of the NCPs in the acute hospitals in the ROI while contributing to the wider international literature in this area. The study provides hitherto unreported knowledge on the conditions that are perceived necessary for implementation. Novel in the ROI context is the perceived necessity to condense the number of NCPs, placing greater emphasis on (a) the need to structurally integrate the NCPs across the continuum of care, and (b) the importance of communication through visible face-to-face engagement. This study concludes that significant progress has been made by the NCPs towards meeting the objectives, albeit to varying degrees. There is a strong perception that the NCPs should remain, and that addressing the conditions perceived necessary for implementation in the areas of governance, communications, leadership and resources by both top-down senior health officials and bottom-up front-line hospital staff would significantly enhance the ability of the NCPs to meet objectives and implementation. It provides the ROI health services with valuable information to inform future reform, strategic planning and NCP implementation.

Introduction

The Health Services Executive (HSE) Ireland in 2010 established the national clinical programmes in collaboration with the Irish postgraduate medical training bodies. They were established to improve and standardise patient care throughout the organisation by bringing together clinical disciplines and enabling them to share innovative solutions to deliver greater benefits to users of the HSE Services. Programmes such as the national clinical programmes are in existence in other countries, and in Australia, the United Kingdom, the United States of America and Scotland are known as clinical networks. In broad terms, clinical networks and national clinical programmes provide a structure for connecting professionals across institutions and geographical areas to implement innovations in healthcare delivery, planning and performance. Some authors argue that clinical networks are an important strategy for increasing evidence-based practice and improving models of care, and suggest that clinical networks provide bottom-up views on the best way to tackle complex healthcare problems and can facilitate or champion changes in practice at the clinical interface (Goodwin et al., 2004; Stewart et al., 2006). Similar to clinical networks in other countries, each national clinical programme in the Republic of Ireland (ROI) has a structured programme management approach which is led by a Medical Clinical Lead at Consultant level, is assigned a dedicated Programme Manager, and has the input of a multidisciplinary team, that is, Nurses/Midwives, Health and Social Care Professionals.

Studies from a number of other countries have shown that while there is some empirical evidence of positive impact on processes of care (Greene et al., 2009; Ray-Coquard et al., 2005; Touati et al., 2006), there remains uncertainty around what specific conditions are required to assist clinical networks (clinical programmes) to more fully achieve their aspirant outcomes (Braithwaite and Westbrook, 2009). A review of the literature revealed a gap in relation to the national clinical programmes in a ROI context. This presented an opportunity for empirical research with the specific aims (research questions) of (a) to investigate, from the perspective of key stakeholders, their perceptions on implementation thus far of the national clinical programmes in the acute hospitals, with a specific emphasis on the following three overarching objectives: to improve the quality of care the HSE delivers to all users of its services; to improve access to services; to improve cost effectiveness; and (b) to investigate key stakeholder perceptions on the conditions necessary for their implementation within the ROI acute hospitals.

Addressing these questions was very timely within the ROI healthcare context, given the widespread interest in the implementation of the national clinical programmes from both a policy and operational practice perspective. In addition, as there is currently limited research in the ROI on the perceptions of those connected with national clinical programmes or their operation, and even less so in the acute hospitals, this study adds to the body of national and international knowledge and is of significance to this field of research.

Method

Research design

To answer the research questions a qualitative research design was selected to obtain participant perceptions. The rationale is that qualitative research approaches are naturalistic to the extent that the research takes place in real-world settings; ‘if you want to know how people understand their world and their life, why not talk with them’ (Kvale, 1996: 105). In addition, qualitative research methods are particularly relevant for studying the perceptions of a specific social or cultural group, as they are concerned with the perspectives and experiences of the social world that are both unique and common to the particular persons under study (Bryman, 2004). Therefore, qualitative methods were expected in this study to identify patterns of shared perspectives among key healthcare stakeholders about the national clinical programmes, and would also allow for exploration of unique experiences within this group.

Participants

A purposeful maximum variation sampling approach was used to select participants from each of four identified groups who are directly involved in the national clinical programmes as a participating clinician/programme manager/nurse/health & social care professional, or alternatively, involved directly or indirectly at a hospital, policy or strategic level. This sampling method aims to ‘select study units that represent a wide range of variation in dimensions of interest and to select information rich cases whose study will illuminate the questions under study’ (Miles and Huberman, 1994: 27; Patton, 1990: 169). Additional details of the four key stakeholder groups are provided below:

• Clinical Programme, i.e. Clinical Medical Consultant Lead and Programme Manager.

• Other Clinical Programme Participants representation, namely nurses, health and social care professionals.

• Senior Acute Hospital Managers; senior managers at hospital level. This includes individuals with the title of Chief Executive Officer (CEO), Deputy CEO, Chief Operations Officer, and General Manager.

• Senior Health Policy Executives/HSE Management; individuals with nationwide strategic senior management roles in health policy and planning concerning acute hospitals and the national clinical programmes.

Those identified in the Clinical Programme and Other Clinical Programme Participant Groups categories had to have been associated with the national clinical programmes for a minimum of 2 years in order to capture detailed informed perspectives from those with experience of working in, or establishing, a national clinical programme. In addition, those interviewed were not from the same national clinical programme, and a cross-section of national clinical programmes reflecting the service-user cohort from children to adults in the acute hospitals was interviewed. Those in the Senior Policy Executive roles and Senior Acute Hospital Management had to have held such posts for at least 2 years since the formation of the national clinical programmes in order to capture informed perspectives from these key stakeholder groups. In addition, the latter were not from the same hospital and had a wide ROI geographic spread. In addition, eligible individuals were those 18 years of age or over and able to give written informed consent.

Participants were recruited by asking the central office administrator of the Clinical Strategy and Programmes Division, HSE, to identify those who met eligibility criteria. Once selected, participants were sent a letter explaining the research purpose, advising of anonymity and asking if they were agreeable to participate. All individuals contacted consented to participate. An initial number of a minimum of five key individuals from each of the four groups was selected to ensure that a range of authentic views were captured. The numbers were intended to be representative, not exhaustive. The final number of 20 participants interviewed was reached by saturation of themes, in that additional interviews would not have added any significant additional material to what had already been gathered. Those participants from the Clinical Programme and Other Clinical Programme Groups were associated with 11 of the 19 national clinical programmes established within the acute hospitals division, while both Senior Acute Hospital Managers/Senior Health Policy Executives Groups had knowledge of all 19 at the time the research was conducted.

Data collection

The principal research instrument was individual face-to-face, in-depth, semi-structured audio-recorded interviews aided by an interview guide; these were held at a location of the participant’s choice and carried out between July 2015 and May 2016. Interviews lasted from 30 to 60 minutes. Participants were asked their perceptions on the implementation, thus far, of the national clinical programmes in the acute hospitals, with a specific emphasis on the three overarching clinical programme objectives – to improve the quality of care the HSE delivers to all users of its services, to improve access to services, and to improve cost effectiveness – and their perceptions regarding the conditions necessary for the implementation of the national clinical programmes within the ROI acute hospitals. Participants were asked to give their general views rather than to focus on any specific national clinical programme in the acute hospitals division.

Although in-depth semi-structured interviews were the primary method of data collection, this study also reviewed relevant published ROI documents at that time to clarify or substantiate participants’ statements (Glaser and Strauss, 1967) and to provide ‘thick description of the case’ (Esterberg, 2002: 87; Merriam, 2002: 5). The following list of published documents was reviewed:

• National Stroke Audit (McElwaine et al., 2015).

• Heart Attack Care in Ireland, report of the national clinical programme for Acute Coronary Syndrome (ACS) on standardising treatment of patients with STEMI in 2014 (Irish Heart Foundation Ireland, 2016).

• Over 20,000 patients removed from Orthopaedic and Rheumatology waiting lists thanks to the National Clinical Programmes (Royal College Physicians, Ireland, 2014).

• The Productive Operating Theatre (Royal College Surgeons, Ireland, n.d.).

• New heart attack treatment saves 30 lives a year (Cullen, 2016: 14).

• Early Warning Scores: A Sign of Deterioration in Patients and Systems (Fox and Elliott, 2015).

Validity and reliability

To safeguard reliability the approach was pilot tested initially with one of each of the four stakeholder groups. Validity was strengthened by the use of descriptive and interpretive approaches (Maxwell, 1992), operationalised in this study by recording of interviews, verbatim transcription and use of the words of the participants (descriptive validity). Interpretive validity was achieved by the generation of themes from the primary data based on participants’ individual and collective perspectives. Field and Morse (1985: 120) recommend the use of ‘low inference descriptors to reduce the threat to internal reliability’. This translates to using descriptions that reflect the participants’ accounts, for example direct verbatim quotes. This is an important technique that was used in this research to limit bias, informing the approach to coding of the verbatim accounts of the interviews and for presenting the findings. An inter-rater reliability exercise was also conducted with one study participant, asking them to carefully read through their interview transcript along with a draft of the themes and sub themes devised independently by the author. Triangulation is espoused by many authors as a strategy to address validity issues. This involves cross-checking information and conclusions. It can ‘strengthen a study by combining methods’ (Patton, 2002: 247). This study incorporated a combination of (a) data triangulation – a review of the issues involved using a number of different published data sources such as literature, HSE/postgraduate medical colleges/national clinical programme published documents of relevance, interview transcript triangulation within and between participants; (b) method triangulation – a review of the issues involved using a number of different published data sources such as literature, HSE/postgraduate medical colleges/national clinical programme published documents of relevance, interview transcript triangulation within and between participants: and (c) theory triangulation – theories and perspectives from research into implementation and national clinical programmes/clinical networks were incorporated into the analysis of data.

Data analysis

Interviews were anonymised using pseudonyms and transcribed verbatim to produce transcripts of narrative text for thematic analysis. The factors of interest to this research, namely perceptions of implementation and conditions required for implementation, provided a framework for the initial categorisation of text. Themes and sub themes were identified by examining regularities, convergences and divergences in the data. Analysis of themes arising from the transcript content was undertaken manually by the author for this study, assisted by The Framework Method (Ritchie and Lewis, 2003) to structure the findings. The Framework Method provides clear steps to follow and produces highly structured outputs of summarised data. The specific roadmap followed includes transcription, familiarisation with the data set, coding, developing an analytical framework, applying the analytical framework, charting the data and interpreting the data.

The principal steps in the data analysis included the following:

Step 1, transcription: the author reviewed audio tapes from interviews and transferred into Word document transcripts. The first nine transcripts were completed by the author and the remaining 11 transcripts were completed by a reputable transcription service (because of time constraints) and further proofed/validated against the audio tapes, again by the author, to ensure transcription accuracy.

Step 2, familiarisation: the author reflected on the overall meaning to gain a general sense of the information and ideas that the participants conveyed. This involved intensive reading and reflection and the use of pencilled annotations in the margins to record ideas on possible codes. It took a number of iterations of this process, over a number of transcriptions, before a final approach to the coding was arrived at.

Step 3, coding: the author began detailed analysis with the coding process, and organised the material into segments by taking the text data and segmenting sentences into themes/sub themes. The author then labelled those themes with terms based on the actual language from the participants.

Step 4, developing an analytical framework: the author used the coding process to generate the themes/sub themes for analysis. This process also involved a member check with a participant to validate the final number of themes and sub themes, which led to condensing to a small number of themes.

Step 5, applying the analytical framework: the author wove the emergent themes into narrative passages, so that the findings emerged logically from the participants’ responses.

Step 6, charting the data and interpreting the data: during the author’s own interpretation process, her experience as a healthcare professional informed her understanding of the participants’ stories. Creswell (2007) recognises that a researcher’s own background plays just as important a part of the meaning-making process as a researcher’s fidelity to a theoretical lens. In order to convey the participants’ perceptions of their experiences accurately, the author focused specifically on what they were saying, the conclusions they drew, and their intentions for future practice. The themes that emerged from this study came directly from the author’s awareness of the healthy tension between her own biases and the participants’ own meaning-making processes.

Results

Overall perceptions of implementation of the national clinical programmes

Generally, the participants across all of the four groups interviewed perceived implementation of the national clinical programmes in the acute hospitals as being inconsistent. Table 1 provides a representative selection of comments obtained from each level of participant.

Table 1.

Sample comments on perceptions of implementation of the national clinical programmes.

Level	Participant comments
Senior Acute Hospital Manager	‘The concept was quite good, the implementation has been more patchy’.
Senior Policy Executive	‘So with regard to implementation, it’s sporadic, some more successful than others’.
Clinical Lead	‘I think it has been very patchy’.
Health & Social Care Professional	‘From an implementation point of view, I have to say it’s kind of been a bit fragmented, it’s certainly not been consistent’.

All of the participants in each of the four groups agreed substantively that the clinical programmes had achieved implementation, but only to varying degrees, and despite the inconsistency of implementation they were unanimous in agreeing, unprompted by the author, that the health system is better for having the clinical programmes in place since their inception. This is summarised by a senior policy executive who stated:

I think without the programmes we would have had a worse result throughout austerity than we had. I think they drove an efficiency and a productivity that had they not gained would have seen the health system in a much more difficult space.

Perceptions on how the national clinical programmes are meeting the objective to improve quality

All of the participants across all groups referred to the production and implementation of evidence-based best practice models of care, guidelines and pathways as being an important quality improvement outcome of the clinical programmes. Table 2 provides a representative selection of comments obtained from each level of participants.

Table 2.

Sample comments on perceptions of the national clinical programmes improving quality.

Level	Participant comments
Senior Policy Executive	‘I think there is no doubt over the past five to seven years the involvement of clinicians at national level in designing models of care, change and reform and at a local level as well, has improved quality hugely’.
Senior Acute Hospital Manager	‘So to tie the access and quality together you have people who are recovering from stroke faster because they are getting the treatment’.
Nurse	‘The thrombolysis policy has been standardised across the country and now there are identified centres where this treatment can be given to patients quite soon, and because they get this treatment early it reduces the rehabilitation time and improves their overall quality of life’.
Clinical Lead	‘So, stroke, every hospital in Ireland has a stroke unit so the access is superb, quality has gone up miles’.

Perceptions on how the national clinical programmes are meeting the objective of improving access

Within the ROI’s healthcare setting, the indicators often used to assess improving access are length of stay, waiting list numbers and activity/throughput numbers. Table 3 provides a representative selection of comments obtained from each level of participant.

Table 3.

Sample comments on perceptions of the national clinical programmes improving access.

Level	Participant comments
Senior Policy Executive	‘The introduction of AMUs has had an effect on length of stay’.
Senior Acute Hospital Manager	‘I was able to say that last year we saved 200,000 in bed days by using the surgical care programme’.
Clinical Lead	‘We have hard data to support that access has improved because we are treating 15–20% more patients now than in 2010, we are doing it more cheaply and with fewer beds’.
Programme Manager	‘One of the theatres which was only utilised 35% of the time and the utilisation of that theatre then went up to 85%’ and ‘virtual fracture clinics which will reduce the numbers at fracture clinics by 38% which improved ED wait times’.

Perceptions on how the programmes are meeting the objective of improving cost effectiveness

Reduced length of stay

An area quickly identified by all interviewees related to reduced length of stay and associated cost savings, with a nurse participant noting, ‘with regard to cost then, the average cost of stay for medical patients was reduced from 8.5 days to 6.9 days’. One of the senior hospital managers observed, ‘from a cost point of view we have saved an awful lot of money in my view on bed days used, and we have reduced our average length of stay in the country’. This was supported by a separate senior hospital manager who quantified the savings thus, ‘I was able to say that last year we saved 200,000 in bed days by using the surgical clinical programme and average length stay in days’.

Reduced waste

The findings from the interviews across all participant groups show a limited number of examples where the clinical programmes are meeting the objective of improving cost effectiveness. One of the clinical programme managers gave an example of the paediatric diabetes clinical programme:

One of our initiatives was around paediatric diabetes and one of the specific initiatives in that project was in insulin pump procurement, and we managed to save 1.55 million euro over a number of years through pump procurement which meant we were able to reinvest the money in additional staffing, so we saved money, we improved access in that we put staff into regions that previously wouldn’t have had sufficient nursing or dieticians.

This element of cost effectiveness was not always clear cut among the participants, and they struggled to recount concrete examples and figures. Indeed, a number of participants voiced that implementation of the clinical programme could increase the cost, as summarised by a clinical lead citing the example of developing stroke units in every acute hospital: ‘cost has definitely gone up, so it costs more to look after these patients but quality costs’. A senior policy executive observed: ‘and cost, we can’t answer that question in many cases because we don’t have the data to back it up’.

This lack of data makes it difficult to categorise the level of progress towards implementation for this specific objective, although some progress has been made by the clinical programmes in improving cost effectiveness.

Perceptions on conditions necessary for implementation of the national clinical programmes within the acute hospitals

Four meta themes of significance emerged from the data as:

1. governance;

2. communication;

3. leadership; and

4. resources.

Within the four meta themes, a number of sub themes were identified for each based on data familiarisation as the most common conditions identified by participants (Table 4).

Table 4.

Perceived conditions necessary for implementation of the national clinical programmes in the acute hospitals.

Meta theme	Sub themes
Governance	• Approach to implementation (structure)
	• Audit & monitoring
	• Senior management support
	• Accountability
	• Clear objectives and expectations
Communication	• Visible face-to-face engagement
	• Greater internal awareness
	• Greater external awareness
Leadership	• Programme level
	• National level
	• Hospital level
	• Professional level
Resources	• Budget
	• Staff
	• Training (including skills and competency)
	• Information technology (IT)

Findings are presented under the specific sub theme, with those reported most frequently by all participants appearing in descending order.

Governance

Structure of approach to implementation

The need for integration of the clinical programmes both within themselves (grouping programmes together) and across secondary/primary care boundaries (horizontal continuum of care) was a dominant common theme across all four participant groups. Table 5 provides a representative selection of comments obtained from each level of participants on their perception of what structure of approach is required for clinical programme implementation.

Table 5.

Sample comments on perceptions of required structure of approach.

Level	Participant comments
Senior Policy Executive	‘lack of integration and too many programmes with lack of integration amongst the programmes’.
Senior Acute Hospital Manager	‘going forth the programme should be configured across health boundaries and acute and primary care or geographical networks and also to pull the programmes back into a smaller number of strands. I think there was a realisation that the programmes were getting too unreal, and competing for the same infinite resources which affects speed of implementation’.
Health & Social Care Professional	‘Integration, if we can get the system working better in an integrated way, what we are saying is that the integrated programmes span each of the five operational divisions and we need to look at the patient from beginning to end’.
Clinical Lead	‘I think what we got to do is slim them down and support them more’.

Although no particular suggestions were offered by the participants as to how the national clinical programmes should be condensed and prioritised, they did all state support for the current HSE strategy to integrate clinical programmes and structure the implementation approach across all five HSE operational divisions including prevention, primary and secondary care in an integrated way.

Audit and monitoring

All the participants in this study articulated in one way or another the need to be able to demonstrate (using hard evidence) to the different levels (corporate to front line) the status of the national clinical programmes, their impacts, outcomes and benefits. Audit and monitoring was seen as the vehicle to achieve this, and was embraced within the interviews in a positive way, in that it would be useful to promote the work of the programme and additionally a mechanism to present business cases for resources. Participant groups each placed different emphasis on the need for audit and monitoring. Senior hospital managers spoke of the requirement for the clinical programme to ask them (hospitals) to account for implementation progress of the national clinical programmes and what has been the outcome of any resource investment by the national clinical programmes into a particular site. A clinical lead spoke of the need for hospitals themselves to record against a set of metrics and show their performance and have it available on their website. A senior policy executive spoke to the need for an assurance mechanism surrounding funding of models of care and that they actually do what the models says they will do. A nurse participant noted the issue of designated individuals taking ownership of their specific areas:

I do think that if you are not in a position to keep an eye on implementation, that if it’s left to other people, other people are not going to do it because they don’t really see it as their area, so I think that there has to be support there all the time for someone at a senior level to encourage and monitor the implementation.

Senior management support

Senior management support was seen as a key condition to support effective implementation of the national clinical programmes across all four groups of participants. This plays itself out in different ways in this research, as identified by one of the clinical programme managers who focused on dedicated time allocation for programmes from the top down, ‘senior management within the HSE giving time to or allocating time to implementation’, and also highlighting the bottom-up requirements:

I am talking the whole way down, at every level, because I would like to see that in a hospital group that there would be someone who would be responsible for the implementation of clinical programmes.

Accountability

Accountability did not emerge as a particularly strong theme and was only highlighted by those in the clinical programme groups. In particular, the need to have clearly identified named accountable personnel at hospital level for implementation was emphasised.

Clear objectives and expectations

A key emerging theme from the clinical programme participant group, and in particular the clinical programme managers, was seeking greater role and function clarification from the top down, expressed by a clinical programme manager as:

… need to know what our role is, what the remit of the clinical programme is, and I just don’t feel that is clear.

Communication

Communication was raised in this study by some participants, and in particular the clinical programme managers spoke to the need for greater internal and external communication both between the programmes themselves, the clinical strategy & programmes division, and the wider public healthcare system.

Leadership

All participants across all the four groups described leadership at the different levels and clinical professional leadership as a common key condition necessary for implementation of the national clinical programmes within the acute hospitals. The different groups placed emphasis of leadership being exercised outside of themselves; for example, the clinical programmes placed the emphasis on managers, and the senior policy executives placed emphasis on the clinical and professional leadership requirements. However, all four stakeholder groups perceived clinical leadership at the clinical programme level, and in particular the clinical lead was a key enabler for implementation, with a hospital manager stating:

I think the positives around the clinical care programmes is the very fact that they are clinically driven, the clinical leadership is key and they are respected by the consultant body, so when they come into the hospital setting to meetings, you couldn’t really argue with their expertise and the data that they were presenting.

Resources

Resources include budget, IT, staff, and training resources which were also highlighted in the context of staff skills and competency. The need for adequate budget and IT was highlighted by all participants; the clinical programme managers and senior policy executives additionally emphasised the need for staff training.

Discussion

This primary research identified the perceptions of a number of key healthcare stakeholders from within the national clinical programmes, senior hospital management, nurses, health and social care professionals and senior national policy executives regarding (a) the implementation, thus far, of the national clinical programmes in the ROI acute hospitals, with a specific emphasis on the three overarching objectives: (i) to improve the quality of care the HSE delivers to all users of its services, (ii) to improve access to services, and (iii) to improve cost effectiveness, and (b) perceptions regarding the conditions necessary for implementation of the national clinical programmes within the acute hospitals.

Generally, there were no major significant differences of opinion between the four stakeholder groups, even if some glossed over or mentioned in passing certain areas and others placed greater emphasis on certain elements.

There was a broad consensus among all participants on a number of areas: (a) implementation thus far was perceived as inconsistent; (b) the national clinical programmes have made improvements in quality, access and cost, albeit with the latter proving more difficult for some participants to cite examples. Outcomes were identified as:- best practice guidelines, models of care, protocols, pathways; education and training; new services; improved discharges; improved patient outcomes; reduced length of stay; timely access; reduced waiting lists; cost effectiveness and the benefits of other intangible outcomes such as clinical leadership. The findings from this study on positive outcomes from implementation of the national clinical programmes concur with some of the literature in this area (Concannon et al., 2013; Cunningham et al., 2012; Currie et al., 2010; Ferlie et al., 2010; Gaston and Rice, 2003; Goodwin et al., 2004; Guthrie et al., 2010; Haines et al., 2011; Laliberte et al., 2005; Lega and Sartirana, 2011; O’Reilly et al., 2015; Ray-Coquard et al., 2002; Sheaff et al., 2011; Tolson et al., 2007); (c) structurally, the number of clinical programmes should be condensed and prioritised in an aligned fashion across the continuum of care from secondary to primary care and out of the perceived longitudinal ‘silos’ of a particular division to span the five operational HSE divisions. Although no particular suggestions were offered by the participants as to how the national clinical programmes should be condensed and prioritised, they did all state support for the current HSE strategy to integrate clinical programmes and structure the implementation approach across all five HSE operational divisions including prevention, primary and secondary care in an integrated way. Similar findings were reported in the literature from other countries on clinical networks in that they had ‘developed in vertical silos and not integrated across the continuum of care and that this had negatively impacted on the implementation of network initiatives’ (McInnes et al., 2012: 5); (d) communication, and specifically visible face-to-face engagement, was a crucial factor for implementation of the national clinical programmes. Consistent with the clinical network literature in this area (McInnes et al., 2012, 2015), visible engagement in this study translated into the age-old concept of national clinical programmes having direct personal contact with front-line staff, and people liking to see people was very evident among all the participants as something that was stated as a necessary requirement. Some participants referred to staff in the system suffering from change fatigue, and perceived that direct contact with clinical programme personnel could reinvigorate staff and assist with overcoming this while progressing implementation. The visible engagement of the programmes with the hospital sites was also cited as a means of influencing clinical staff and gaining ‘buy in’ through the leadership and expertise of the programme clinical lead. It was further elaborated on as a key enabler and facilitator for building networks and relationships across hospital groups and clinicians, including in some instances communication structures with General Practitioners; (e) one particular intangible implementation outcome (Figure 1) of the national clinical programmes emerged with greater emphasis early on in the interviews by the majority of participants. The interviewees all noted the centrality of leadership in both advocating for clinical programme implementation and ensuring that they remain actively on the agenda of resourcers. This has been recognised in the review of the literature in the area (Cunningham et al., 2012; Currie et al., 2010; Fixsen et al., 2005; Guthrie et al., 2010; Haines et al., 2012; Hamilton et al., 2005; Johnston, 2014; Lega and Sartirana, 2011; McInnes et al., 2012; Rycroft-Malone, 2004; Wandersman et al., 2008). While there were convergences of views to some degree, it is noteworthy also that different participant groups further emphasised leadership requirements at different levels. Similar to other studies on clinical networks (Cunningham et al., 2012; Guthrie et al., 2010; Haines et al., 2011, 2012; McInnes et al., 2012, 2015), all four stakeholder groups perceived that clinical leadership at the clinical programme level, and in particular the clinical lead, was a key enabler for implementation, with some (Hamilton et al., 2005: 10) noting ‘the drive and energy of a lead clinician was vital to the success of a managed clinical network’. This study’s findings present a strongly positive assessment of the significant leadership associated with implementation, and in particular the clinical lead. In the examples of national clinical programme initiatives perceived to have been successfully implemented, the interviewees attributed the success in large part to good strong leadership: (f) Resources – the need for funding (budget) was reported by all participant groups, in order to fund the models of care, develop services and recruit and release the staff required to implement the national clinical programmes. The clinical programme managers and the senior policy executives additionally emphasised the requirement for staff training in project/programme management, quality improvement methodology and implementation skills. All the participants emphasised the need for better IT systems, albeit for slightly different reasons including data collection, auditing and increasing efficiency; (g) overall, and consistent with similar findings in the clinical network literature (McInnes et al., 2012), all the participants in this study articulated in one way or another the need to be able to demonstrate (using hard evidence) to the different levels (corporate to front line) the status of the national clinical programmes, their impacts, outcomes and benefits. Audit and monitoring was seen as the vehicle to achieve this, and was embraced within the interviews in a positive way, in that it would be useful to promote the work of the programme and additionally a mechanism to present business cases for resources.

Figure 1.

Perceived outcomes and conditions necessary for implementation of the national clinical programmes in the acute hospitals, Republic of Ireland.

In addition, the clinical programme groups, and specifically the clinical programme managers and allied health and social care professionals, emphasised the need for (a) accountability – in particular, the need to have clearly identified named accountable personnel at hospital level for implementation was emphasised. It did not emerge as a particularly strong theme and was only highlighted by those in the clinical programme groups; (b) clarity around objectives and expectations of the national clinical programmes in relation to their function with specific reference to operational implementation, and the need to address the perceived current disconnection between the strategy design element of the programmes and the operational implementation within the acute hospitals division. As with other studies in this area (Cunningham et al., 2012), the clinical programme managers expressed frustration at a disconnection between national clinical programme-designed initiatives (e.g. models of care) and their operational implementation in the acute division. They referred to conflicting messages as to their role in operational implementation, being advised from a national programme perspective that their role was design only, and at other times expected by the acute hospitals division to be involved in implementation, resulting in a disconnection between design and operational implementation. Programme managers perceived a lack of clarity on what they were mandated to do, asking the question who is responsible for implementation. Their own view was that they should be involved in both, in order to optimise clinical programme implementation. Similar findings are reported within the clinical network implementation literature among the ‘network group at not being mandated to implement network initiatives’ (McInnes et al., 2012). Participants in this study spoke of the need for clearer links between programme design and operational implementation to assist planning and execution. Participants welcomed the new role of the National Clinical Advisor Group Lead (NCAGL) as a positive conduit for achieving this; (c) greater internal and external communication by the clinical programme personnel at all levels. This was emphasised by the clinical programme managers and expressed in the need for more (i) meetings within and between programme personnel themselves and with divisional team, (ii) communication with front-line hospital staff, greater visible face-to-face communication between the programmes and the hospitals in order to create greater awareness of programme work, and (iii) communicating with HSE staff in general and the public, highlighting/advertising programme successes and ongoing projects positively impacting on quality, access and cost; (d) senior management support from national and hospital management. Those in the senior policy group spoke to the need for bottom-up senior hospital managers and clinicians owning and adapting national clinical programme policy to their demographic while maintaining the national standard set. Interestingly, although senior management support is a top-down variable within the policy implementation literature, the top-down officials (senior policy executives) in this study recognise and advocate for what the bottom-up scholars (Barrett and Fudge, 1981; Berman, 1980; Lipsky, 1980) describe as local discretion and adaptation of a central plan, thereby acknowledging that ‘implementation is an interactive process’ (Hill and Hupe, 2009: 45); (e) the clinical programme managers and the senior policy executives expressed the perceived requirement for staff skills and competency and in particular in project/programme management and implementation skills for those involved at all levels with implementation of the national clinical programmes. Similarly, within the policy implementation literature scholars cite ‘staff skills and training as crucial variables for implementation’ (McInnes et al., 2012: 6).

The senior policy group emphasised the importance of clinical and professional leadership and staff skills and competency. The Hospital Manager Group emphasised the importance of clinical and professional leadership.

Findings from this study are mostly consistent with the literature, although in the ROI acute hospitals context there are nuances in that participants did not emphasise the following conditions as a necessary requirement for implementation: public support, incentives, compromise, managing ambiguity and conflict, detailed work plans, focus on the individual/people aspect of implementation (behaviour/commitment/willingness/motivation), coordination, characteristics of the intervention, and context/environment. However, the latter was alluded to and glossed over, with the majority of participants briefly referring to the possible negative effect that the economic downturn and staff moratorium has had on implementation of the clinical programmes over the last six years.

In particular, two conditions emerged with greater emphasis from this study. These were implementation approach (structures) and communication, with the particular focus of the latter on visible face-to-face engagement.

All participants, unprompted, articulated that the HSE is better for having the national clinical programmes in place and wanted to see them continue as the service design strategy; this was summed up by a senior policy executive: ‘they’ve added value, they can add more’. This view is consistent with the literature where some (Goodwin et al., 2004) argue that clinical networks are an important healthcare strategy for increasing evidence-based practice and improving models of care. It is also suggested that clinical networks can facilitate or champion changes in practice at the clinical interface (Goodwin et al., 2004; Stewart et al., 2006). Similarly, other authors concluded that ‘these disease-related networks present a practical approach to the difficult issue of clinician engagement in state-level implementation of best practice for improving patient care and outcomes’ (Cunningham et al., 2012).

Conclusions

This study adds to the existing limited body of knowledge on implementation of the national clinical programmes in the acute hospitals in the ROI while also contributing to the wider international literature in this area. It provides hitherto unreported knowledge on the conditions that are perceived necessary (Figure 1) by key senior healthcare stakeholders (at different levels) for their implementation in the ROI acute hospitals. Novel in the ROI context is the perceived necessity to condense and prioritise the number of national clinical programmes while additionally placing greater emphasis on (a) the need to structurally integrate the national clinical programmes across the continuum of care, and (b) the importance of communication through visible face-to-face engagement. Based on the findings from this study, it seems reasonable to conclude that significant progress (Figure 1) has been made towards implementation and meeting the national clinical programmes objectives, albeit to varying inconsistent degrees.

There is a strong perception that the national clinical programmes should remain, and that addressing the conditions perceived necessary for implementation in the areas of governance, communications, leadership and resources by both top-down senior health officials and bottom-up front-line hospital staff would significantly enhance the ability of the national clinical programmes to meet objectives and implementation. It provides the ROI health services with valuable information to inform future reform, strategic planning and national clinical programme implementation.

Limitations

The author has been the single researcher on this study, which led to constraints on time and resources that may have impacted on the amount and type of data collected. An additional limitation to the study proved to be the data collection process. Since information obtained during the interview largely depended on the interviewee and what he or she was willing to share with this author, the nature of their information was limited to his or her own perspective and lived experiences in addition to any bias or political elements to answers given. However, this study’s triangulation with ROI published data helped to assist with verifying findings, and helped to support the accuracy of the themes developed from the interview transcripts. A number of the participants were known in a professional working capacity to the author (as someone who works closely with the national clinical programmes), therefore interview responses (and the delivery of interview questions) may have been more strongly influenced by social desirability bias and confirmation bias than if the author (researcher) was completely independent. However, the interviews were confidential and anonymised. In conducting this study through purposeful sampling in the acute hospitals only, this research has therefore possibly limited the scope for the generalisability of the findings to other areas and other instances of implementation.

Key points for policy, practice and/or research

• Significant progress has been made by the NCPs in the Republic of Ireland, towards meeting their objectives, albeit to varying degrees as reported in the outcomes identified, that is, best practice guidelines, models of care, protocols, pathways; education and training; new services; improved discharges; improved patient outcomes; reduced length of stay; timely access; reduced waiting lists; cost effectiveness and other intangible outcomes, especially the crucial impact clinical leadership has made to implementation.

• There is a strong perception that the national clinical programmes should remain, and that continuing to address the conditions perceived necessary for implementation in the areas of governance, communications, leadership and resources by both top-down senior health officials and bottom-up front-line hospital staff would significantly enhance the ability of the national clinical programmes to meet objectives and implementation.

• Future policy should incorporate reviewing the number of national clinical programmes with a view to prioritising and strengthening the development and implementation of a more integrated approach across the continuum of care from secondary (acute hospitals) to primary care.

• Continue to build leadership capability at all levels as a key driver and enabler for implementation. Promote and nurture clinicians in leadership roles working alongside managers as key influences for implementation within the acute hospitals.

• Continue to promote, facilitate and strengthen communication in particular through visible face-to-face engagement of programme personnel, with hospitals as a key means of progressing implementation.

• Due to resource and time constraints upon the author, this qualitative research is limited to perceptions, hence there is scope to build upon this study’s findings for future specific rigorous evaluation research of each of the national clinical programmes in the ROI utilising mixed methods with the aim of providing empirical evidence that the particular national clinical programme objectives were successfully achieved (quantitative would be especially appropriate for measuring cost effectiveness), and secondly to quantify the key conditions that contributed to successful implementation of that programme.

Biography

Geraldine Shaw, RGN, PhD, MA, BA, is Nursing and Midwifery Service Director of the National Office of Nursing & Midwifery Services Director (ONMSD), Office of the Chief Clinical Officer, Health Service Executive (HSE), Republic of Ireland. She strategically leads and manages the ONMSD to ensure the provision of professional nursing and midwifery guidance and expertise at a corporate and service level to develop the capacity and capability of nursing and midwifery professions to maximise their contribution to safe patient centred care. She actively contributes to the ongoing development of nursing & midwifery and its integration into new forms of healthcare delivery as informed by policy. Geraldine is an experienced leader and innovator in challenging and busy environments incorporating both acute hospital operational and strategic at Directorate / Hospital / Group / Executive Board / and Corporate level. Analysing and planning for the improvement of patient services is her passion with a track record of delivering innovations as a Director of Nursing & Midwifery in Acute Hospital settings and more recently in a National strategic capacity. She has first-hand knowledge and experience of healthcare systems in both Ireland and the United Kingdom (UK).

Declaration of conflicting interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval and consent to participate

This research was conducted in compliance with the University College Dublin (UCD) code of good practice in research, requiring the author to observe ethical principles in interacting with individuals and reporting data. An application was made to and granted by the UCD Human Research Ethics Committee for exemption from full ethical review. The author provided a letter of written approval from the National Director of Clinical Strategy and Programmes Division, Health Services Executive (HSE) to access participants. All participants gave written informed consent.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Geraldine Shaw https://orcid.org/0000-0003-0156-5292