What impedes and what facilitates a quality improvement project for older hospitalized patients?

OBJECTIVE: To gain insight into which factors impede, and which facilitate, the implementation of a complex multi-component improvement initiative in hospitalized older patients. DESIGN: A qualitative study based on semi-structured interviews. The three dimensions of Pettigrew and Whipp's theoretical framework, namely, Process, Content and Context, were used to undertake a structured data analysis. SETTING: The study was conducted in 19 Dutch hospitals implementing the Frail Elderly Project. PARTICIPANTS: Sixty-five members of staff, including physicians, nurses and members of the policy team. INTERVENTION: The Frail Elderly Project, a Dutch quality improvement program, aims to decrease adverse events in frail older hospitalized people by implementing screening instruments and interventions targeting delirium, falls, malnutrition and physical impairment. MAIN OUTCOME MEASURES: The management of the process of implementation, participants' opinions of the program elements and contextual factors which influence the implementation. RESULTS: Barriers to implementation included two process factors (insufficient involvement of clinicians and lack of time), two content factors (having divergent objectives and concerns about recommended program elements) and two contextual factors (a lack of knowledge of delirium and minimal insight into the purposes and effects of the program). Facilitating factors included one process factor (leadership), one content factor (flexibility in choosing methods) and two contextual factors (the program's guidance and the use of digital patient records). CONCLUSION: We identified the barriers and the factors which facilitate implementing complex multi-component improvement programs concerning care for older patients. These barriers must be resolved in future improvement programs in order to ensure successful implementation.