Table 5.
Champions’ effectiveness in increasing patient, provider and system/facility’s innovation use
| Subcategory (# of studies) | First author, year | Study design | Champion operationalization | Outcome extracted from included study | Statistical analysis/approach | Test statistic (measure of magnitude) | p-value | |||
|---|---|---|---|---|---|---|---|---|---|---|
| Conceptual innovation use (knowledge/enlightenment) | ||||||||||
|
Provider (n = 4) Conclusion: Across four studies, there are mixed findings with respect to use of champions and improvement in providers’ conceptual innovation use | ||||||||||
|
Implementation of new technology or equipment (n = 4) |
One study two reports: |
Cross-sectional study |
Existence of a champion of hip protectors (single item scored on a 5-point Likert scale) |
Overall commitment to hip protectors | Bayesian Model Averaging logistic model | Logistic regression coefficient (95% CI) = 0.24 (0.17–0.31) | < .05 | |||
| Kabukye, 2020 [61] | Cross-sectional study | Presence of an effective champion (3-item survey scale by Paré et al.[68] | Organizational readiness in a low-resource setting | Structural equation model using a partial least square method | Path coefficient = 0.15 | .0299 | ||||
| Paré, 2011 [68] | Cross-sectional study |
Presence of an effective champion (3-item survey scale) |
Organizational readiness in a large teaching hospital | Structural equation model using a partial least squares method | Path coefficient = 0.23 | < .05 | ||||
| Organizational readiness in implementing a mobile computing system for home care | Path coefficient = 0.05 | > .05 | ||||||||
| One study, two reports: Weiler, 2012, 2013 [77, 78] | Interrupted time series | Endorsed by champions (three items rated at a 6-point Likert scale based on Mullins et al. [98] | Intention to use transfer boards 2 months post-introduction of transfer boards | Stepwise logistic regression |
Partial R2a = 0.036 C(p) = − .041 F = 16.25 |
< .0001 | ||||
| Structural equation model using a maximum likelihood method | Path coefficients (95 CI) = 0.27 (− .0156–.5556) | > 0.05a | ||||||||
|
System/Facility (n = 1) Conclusion: There is a study suggesting that the use of champions is related to system/facility’s conceptual innovation use | ||||||||||
|
Implementation of best practices related to vaccination processes (n = 1) |
Tierney, 2003 [75] | Mixed study (generic qualitative and cross-sectional) | Presence of a champion lead (“Yes/No” survey item) | Pediatrician practices’ likelihood or intent to adopt reminder and recall system in their practice in a year | Multivariable linear regression | Test statistic not reported | < .03 | |||
| Pediatrician practices’ likelihood or intent to adopt immunization coverage rates assessments in their practice in a year | Test statistic not reported | .002 | ||||||||
| Instrumental Innovation Use (adherence in using the innovation (evidence-based practice or technology)) | ||||||||||
|
Patient (n = 1) Conclusion: There is a study suggesting that the use of champions is related to improving patients’ instrumental innovation use | ||||||||||
|
Implementation of Kangaroo-Mother Care (n = 1) |
Soni,2016 [73] | Interrupted time series |
Absence of champions (two champion were present from January 5, 2010–July 31, 2011; transition period from August 1, 2011, to July 31, 2012; champion was absent from August 1, 2012, to October 7, 2014) |
Initiation rate of skin to skin by mothers of neonatal intensive care unit (NICU) patients | Competing-risks regression model and observation-weighted linear polynomial test | Subhazard rate ratios (SHR)c (95 CI) = 0.62 (0.47 − 0.82) | < .001b | |||
| Overall use of skin to skin by mothers of NICU patients | Multivariate logistic regression and observation-weighted linear polynomial test | OR (95 CI) = 0.49 (0.34–0.70) | .004b | |||||||
| Average duration of skin to skin provided by mothers of NICU patients | Multivariate linear regression and observation-weighted linear polynomial test | β (95 CI) = − 1.47 (− 2.07 to − 0.86) | < .001b | |||||||
| Initiation rate of breastfeeding by mothers of NICU patients | Competing-risks regression model and observation-weighted linear polynomial test | SHR (95 CI) = 0.88 (0.68–1.14) | .30b | |||||||
| Overall use of “breastfeeding” by mothers of NICU patients | Multivariate logistic regression and observation-weighted linear polynomial test | OR (95 CI) = 0.89 (0.55–1.44) | 0.61b | |||||||
|
Provider (n = 17) Conclusion: Across 17 studies, there are mixed findings with respect to use of champions and improvement in providers’ instrumental innovation use | ||||||||||
|
Implementation of best practices for smoking cessation (n = 3) |
Bentz, 2007 [52] | Cluster randomised trial | Presence of a champion (“Yes/No” item determined through structured interviews with clinic managers or lead nurses) | Monthly rates of documented clients connected by health care providers to the Oregon Tobacco Quitline | Generalized estimating equations | OR (95 CI) = 3.44 (2.35–5.03) | < .05 | |||
| Papadakis, 2014 [67] | Cross-sectional study |
Presence of physician champion (“Yes/No” survey item) |
Frequency of evidence-based smoking cessation treatments delivered by health care providers | Multivariable logistic regression | OR (95 CI) = 2.0 (1.1–3.6) | < .01 | ||||
| Strasser, 2003 [74] | Cross-sectional study | Presence of a designated champion (single item rated on a 6-point Likert scale) | Extent that health care providers apply smoking cessation guideline to help parents of cystic fibrosis patients quit smoking | Multivariable logistic regression |
β (SE) = − .7570 (0.2110) OR (95 CI) = 0.469 (0.310–0.709) |
0.0003 | ||||
|
Implementation of best practices related to vaccination processes (n = 3) |
Albert, 2012 [47] | Cross-sectional study |
Presence of an immunization champion on site (“Yes/No” survey item) |
Consistent use of standard orders for influenza vaccines only by non-physician staff | Multivariable logistic regression | OR (95% CI) = 1.12 (0.72–1.76) | > .05 | |||
| Consistent use of standard orders for both influenza vaccine and PPV by non-physician staff | OR (95% CI) = 1.67 (1.01–4.54) | .046 | ||||||||
| Granade, 2020 [58] | Cross-sectional study |
Presence of immunization champions (“Yes/No” survey item) |
Primary care clinicians’ adherence to adult vaccination standards | Multivariable logistic regression | APR (95% CI) = 1.40 (1.26–1.54) | < .05 | ||||
| Pharmacist’s adherence to adult vaccination standards | APR (95% CI) = 1.20 (0.96–1.49) | > .05 | ||||||||
| Slaunwhite, 2009 [72] | Case–control study | 23 champions randomly allocated to 23 hospital units versus 23 matched units with no champion | Difference in overall health care providers vaccination rates between champion and non champion units | t -test |
t (22) = 2.86 (11% higher vaccination rate in champion units) |
< .03 | ||||
| Percentage change in health care provider vaccination rates from previous year in champion units |
t (21) = 4.38 (increase from 44 to 54%) |
< .001 | ||||||||
| Implementation of new technology/equipment (n = 2) | Alidina, 2018 [48] | Cross-sectional study | Presence of an implementation champion for cognitive aids (selected as an important facilitator from a list of facilitators) | Regular use of operating cognitive aids during applicable clinical events | Chi square | Test statistic not reported | 0.8968 | |||
| Absence of an implementation champion for cognitive aids (selected as important barrier from a list of barriers) | Regular use of operating cognitive aids during applicable clinical events | Multivariable logistic regression | OR (95% CI) = 0.44 (0.23–0.84) | .0126 | ||||||
| Shea, 2016 [70] | Cross-sectional study | Presence of nurse champions (“Yes/No” survey item) | Percentage of providers in a clinic demonstrating Stage 1 meaningful use of electronic health records | Multivariable logistic regression | OR (95 CI) = 0.99 (0.60–1.65) | .983 | ||||
| Implementation of best practices related to pain management in neonatal intensive care units (n = 2) | Anand, 2017 [49] | Prospective cohort study |
Presence of a nursed champion (“Yes/No” survey item) |
Number of continuous pain assessments performed and documented by nurses per day for 1 month in neonatal intensive care units | Generalized estimating equations | OR (95 CI) = 2.54 (1.27–5.11) | 0.009 | |||
| Lago, 2013 [66] | Cross-sectional study | Presence of a local champion (single item asking whether a physician champion, a nurse champion, both types of champions, or no champion was present) | Routine use (> 90% of the time) of non-pharmacological and pharmacological pain management interventions during invasive procedures in neonatal intensive care units | Stepwise logistic regression |
Six out of 11 interventions: (1) Heel prick: OR (95 CI) = 2.78 (1.2–6.43) (2) Venipuncture: OR (95 CI) = 2.59 (1.13–5.96) (3) PICC insertion: OR (95 CI) = 3.33 (1.38–8.02) (4) Tracheal intubation: OR (95 CI) = 2.68 (1.17–6.16) (5) Mechanical ventilation: OR (95 CI) = 3.74 (1.5–9.32) (6) Chest tube insertion: OR (95 CI) = 3.26 (1.31–8.1) |
< 0.05 | ||||
|
Five out of 11 interventions: (1) Tracheal Aspiration: OR (95 CI) = 1.96 (0.82–4.66) (2) Nasal CPAP: OR (95 CI) = 1.98 (0.87–4.53) (3) Lumbar puncture: OR (95 CI) = 1.99 (0.86–4.59) (4) ROP screening: OR (95 CI) = 2.35 (0.96–5.8) (5) Postoperative pain: OR (95 CI) = 1.58 (0.56–4.43) |
> 0.05 | |||||||||
|
Implementation of best practices related to prevention, identification and management of infections (n = 2) |
Campbell, 2008 [54] | Non-controlled before and after study | Appointment of six nurses (two for each shift) champions for 4 weeks | Intensive care unit nurses’ compliance with sepsis-screening protocols | Chi square | χ2 = 30.86 | < .001 | |||
| Physician’s initiation of sepsis protocol for patients with severe sepsis | χ2 = 0.563 | .453 | ||||||||
| Zavalkoff, 2015 [80] | Interrupted time series | Appointment of a single physician champion to lead projects decreasing catheter associated urinary tract infections | Urinary catheter-use ratio in a pediatric intensive care | Binomial regression (PROC GENMOD, binomial distribution, canonical link) | OR (95% CI) = 0.83 (0.77–0.90) | < .05 | ||||
|
Generic implementation of best research evidence (n = 2) |
Kenny, 2005 [62] | Cross-sectional study |
Presence of a champion (“Yes/No” survey item) |
Nurses’ direct (instrumental) research use | Pearson’s correlation coefficient | r = .250 | .001 | |||
| Goff, 2019 [57] | Cross-sectional study |
Presence of a designated quality champion (“Yes/No” survey item) |
Average clinical quality scores (adherence of providers to best practices in prescribing treatments for diseases (e.g. asthma, diabetes) | ANOVA | Test statistics not reported (Mean difference = 0.2 favouring presence of a champion) | .03 | ||||
|
Implementation of diabetes guideline (n = 1) |
Ward, 2004 [76] |
Cross-sectional study |
Presence of champion (single item rated on a 5-point Likert scale) |
Provider process measures relative to guideline-based diabetes management | Multivariable predictor generalized estimating equation | β (SE) = 1.24 (0.51) | .02 | |||
|
Implementation of best practices related to medications prescribed during or after an acute myocardial infarction (n = 1) |
Ellerbeck, 2006 [55] | Cross-sectional study |
Presence of a physician champion (“Yes/No” survey item) |
Aspirin use at admission | Generalized estimating equations | OR (95% CI) = 1.31 (0.87–2.01) | > .05 | |||
| Aspirin use at discharge | OR (95% CI) = 1.17 (0.69–2.02) | > .05 | ||||||||
| Beta-blockers use at admission | OR (95% CI) = 1.45 (0.91–2.31) | > .05 | ||||||||
| Beta-blockers use at discharge | OR (95% CI) = 4.14 (1.66–11.66) | < .05 | ||||||||
| Implementation of the findings of a phase III, multicentre randomized control trial (BMT CTN 0201) [88] study (n = 1) | Khera, 2018 [63] | Cross-sectional study |
Engagement of local champions (single item scored on a 5-point Likert scale) |
Physician reported personal change in preferred unrelated donor graft source for patients with hematologic malignancies from peripheral blood source to bone marrow | Multivariable logistic regression | OR (95 CI) = 1.91 (0.87–4.19) | .11 | |||
| Physician reported transplant centre change in preferred unrelated donor graft source for patients with hematologic malignancies from peripheral blood source to bone marrow | OR (95 CI) = 3.18 (1.29–7.85) | .01 | ||||||||
|
System/Facility (n = 7) Conclusion: Across seven studies, the use of champions was reported to be related to increase in system/facility instrumental innovation use | ||||||||||
|
Implementation of technology /equipment (n = 3) |
Ash, 1997 [50] | Cross-sectional study | Champion scale formulated from existing measures (unknown number of items and lack of detail on items reported (rated on a 5-point Likert scale) | Infusion of electronic mail | Multivariable linear regression | β = 0.09 | .52 | |||
| Diffusion of electronic mail | β = 0.34 | .01 | ||||||||
| Hsia, 2019 [59] | Cross-sectional study | Presence of leadership's e-health championing behaviour (6-item survey scale) | Extent of hospital medical services and work processes are performed by health care providers using E-health technologies | Structural equation model using a partial least square method | Path Coefficient = 0.280 | < .05 | ||||
| Sharkey, 2013 [39] | Non-controlled before and after study | Presence of an internal champion (“Yes/No” question in facilitator reports) | Facility-wide implementation of at least two process improvements focused on using health information technology as a medium for clinical decision support to prevent pressure ulcers in nursing homes (labelled as “Level 2 outcome” by authors) | Nonparametric Spearman correlation | ρ = 0.65 | .013 | ||||
| Facility-wide implementation of three or more process improvements focused on using health information technology as a medium for clinical decision support to prevent pressure ulcers in nursing homes (labelled as “Level 3 outcome” by authors) | ρ = 0.75 | 0.002 | ||||||||
| Implementation of a depression care programs (n = 2) | Chang, 2012 [40] | Cross-sectional study | Presence of clinical champion (“Yes/No” survey item) | Collocation model implemented | Multivariable logistic regression models | OR (95 CI) = 2.36 (1.14–4.88) | < .05 | |||
| TIDES model implemented | Bivariate regression analysis | OR (95 CI) = 0.59 (0.20–1.78) | > .05 | |||||||
| BHL model implemented | OR (95 CI) = 0.65 (0.14–2.98) | > .05 | ||||||||
| No depression care improvement model implemented | OR (95 CI) = 0.63 (0.31–1.29) | > .05 | ||||||||
| Whitebird, 2014 [41] | Mixed study (Generic qualitative and prospective cohort) |
Presence of a strong primary care provider champion (“Yes/No” extracted from quality improvement narrative reports) |
Average monthly activation rate (patients entering the program per number of full-time health care provider) | Pearson’s correlation coefficient | r (95 CI) = 0.60 (0.10–0.86) | < .05 | ||||
|
Implementation of patient-reported outcomes collection program (n = 1) |
Sisodia, 2020 [71] | Retrospective cohort study |
Presence of a clinician champion (“Yes/No” survey item) |
Patient-reported outcomes (PRO) collection rate per clinic in the most recent 6 months | Multivariable linear regression | Collection rate change (95 CI) = 11.2 (2.5–20.0) | .01 | |||
| PRO successful collection rate (50% or greater) in a 6-month period | Multivariable logistic regression | OR (95 CI) = 3.36 (1.06–10.61) | .04 | |||||||
|
Implementation of best practices related to vaccination processes (n = 1) |
Tierney, 2003 [75] | Mixed study (generic qualitative and cross-sectional) | Presence of a champion lead (“Yes/No” survey item) | Pediatrician practices’ current use of reminder and recall systems | Multivariable logistic regression | OR (95% CI) = 1.85 (1.08–3.18) | < .05 | |||
| Public health clinic’s current use reminder and recall systems | Multivariable logistic regression | OR (95% CI) = 3.01 (1.34–6.73) | < .05 | |||||||
| Pediatrician practices’ current use of immunization coverage rates assessments | OR (95% CI) = 1.38 (0.89–2.13) | < .05 | ||||||||
| Public health clinic’s current use of immunization coverage rates assessments | OR (95% CI) = Not reported | > .05 | ||||||||
aThe authors reported a path coefficient that they stated is significant at a p-value of 0.1. Manual calculation of the 95% CI was done by JES to determine significance of both ergonomic advantage and intention to use at a p-value of .05
bThese p-values were denoted as p(trend) by authors because an observation-weighted linear polynomial test was conducted to determine trends for differences in estimates across all the different models
cSubhazard rate ratios were calculated separately using separate competing risk regression models to consider discharge against medical advice prior to initiation of breast feeding and skin to skin
dIn bivariate testing, both physician and nurse champions were significantly correlated with continuous pain assessments; the physician champion variable was not included in the multivariate testing because it was highly correlated with the nurse champion variable
APR adjusted prevalence ratio; CI confidence interval; OR odds ratio; SE standard error; SHR subhazard rate ratios