Mind the gap: analysis of two pilot projects of a home telehealth service for persons with complex conditions in a Swedish hospital.

BACKGROUND: Developing and implementing home telehealth (HTH) services for patients with chronic conditions is a challenge. HTH services provide continuous and integrated care to patients, but very often pilot projects face non-adoption and abandonment issues. Change processes in healthcare are often complex and require learning to adapt to non-linear and unpredictable events. Complexity science can thus provide a complementary view to the predominant Quality Improvement (QI) approach in healthcare. In this study of two pilot projects in a Swedish hospital, we explore how a theory-driven approach can be used (a) to support the development of a self-monitoring HTH service in hospital care and (b) to evaluate staff and patients' experiences from early adoption. METHODS: To plan and evaluate the service for the recipients (i.e., patients and healthcare providers), we used the Plan-Do-Study-Act (PDSA) tool in combination with two complexity-informed frameworks: the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework, and the joint Complexity Assessment Tool (CAT). The theory-informed development process led to two pilot projects of an HTH service for patients with heart failure and COVID-19. We collected data from multiple sources (project documents, a survey on readiness for change among staff, and semi-structured interviews with patients and staff) and analyzed the data using descriptive statistics and qualitative content analysis with a deductive approach. RESULTS: Patients and staff perceived the services as valuable as they enabled rapid feedback, and improved communication and collaboration between patients and healthcare providers. Yet, despite the extensive development efforts, there was a perceived gap between how individuals valued the service and the capacity of adopters, the organization, and the wider system to effectively integrate these services into routine care. CONCLUSIONS: The combined use of PDSA, NASSS, and CAT can support the development and evaluation of HTH services that are perceived as valuable by individual patients and staff. For successful adoption, the value for individuals must be supported by organizational efforts to learn how to integrate new routines and tasks into clinical practice and daily life, and how to coordinate multiple providers within and outside the hospital walls.

Evaluation of iLead, a generic implementation leadership intervention: mixed-method preintervention-postintervention design.

OBJECTIVES: The present study aimed to evaluate the iLead intervention and to investigate whether or not transfer of training can be supported by contextualising the intervention (recruiting all managers from one branch of the organisation while focusing on one implementation case, as well as training senior management). DESIGN: A pre-evaluation-postevaluation design was applied using mixed methods with process and effect surveys and interviews to measure the effects on three levels. SETTING: Healthcare managers from Stockholm's regional healthcare organisation were invited to the training. PARTICIPANTS: 52 managers participated in the iLead intervention. Group 1 consisted of 21 managers from different organisations and with different implementation cases. Group 2, representing the contextualised group, consisted of 31 managers from the same organisation, working on the same implementation case, where senior management also received training. INTERVENTION: iLead is an intervention where healthcare managers are trained in implementation leadership based on the full-range leadership model. PRIMARY OUTCOME MEASURES: Reactions, knowledge and implementation leadership are measured. RESULTS: Quantitative and qualitative analyses indicate that iLead was perceived to be of high quality and capable of increasing participants' knowledge. Mixed effects were found regarding changes in behaviours. The contextualisation did not have a boosting effect on behaviour change. Hence, group 2 did not increase its active implementation leadership in comparison with group 1. CONCLUSIONS: iLead introduces a new approach to how implementation leadership can be trained when knowledge of effective leadership for implementations is combined with findings on the importance of environmental factors for the transfer of training. Even though managers reported general positive effects, transfer was not facilitated through the contextualisation of the intervention. There is a need to further develop approaches to help participants subsequently apply the learnt skills in their work environment.

Building implementation capacity (BIC): a longitudinal mixed methods evaluation of a team intervention.

BACKGROUND: Managers and professionals in health and social care are required to implement evidence-based methods. Despite this, they generally lack training in implementation. In clinical settings, implementation is often a team effort, so it calls for team training. The aim of this study was to evaluate the effects of the Building Implementation Capacity (BIC) intervention that targets teams of professionals, including their managers. METHODS: A non-randomized design was used, with two intervention cases (each consisting of two groups). The longitudinal, mixed-methods evaluation included pre-post and workshop-evaluation questionnaires, and interviews following Kirkpatrick's four-level evaluation framework. The intervention was delivered in five workshops, using a systematic implementation method with exercises and practical working materials. To improve transfer of training, the teams' managers were included. Practical experiences were combined with theoretical knowledge, social interactions, reflections, and peer support. RESULTS: Overall, the participants were satisfied with the intervention (first level), and all groups increased their self-rated implementation knowledge (second level). The qualitative results indicated that most participants applied what they had learned by enacting new implementation behaviors (third level). However, they only partially applied the implementation method, as they did not use the planned systematic approach. A few changes in organizational results occurred (fourth level). CONCLUSIONS: The intervention had positive effects with regard to the first two levels of the evaluation model; that is, the participants were satisfied with the intervention and improved their knowledge and skills. Some positive changes also occurred on the third level (behaviors) and fourth level (organizational results), but these were not as clear as the results for the first two levels. This highlights the fact that further optimization is needed to improve transfer of training when building teams' implementation capacity. In addition to considering the design of such interventions, the organizational context and the participants' characteristics may also need to be considered to maximize the chances that the learned skills will be successfully transferred to behaviors.

How do iLead? Validation of a scale measuring active and passive implementation leadership in Swedish healthcare.

OBJECTIVES: This study aims to describe the creation of a scale-the iLead scale-through adaptations of existing domain-specific scales that measure active and passive implementation leadership, and to describe the psychometric properties of this scale. METHODS: Data collected from a leadership intervention were used in this validation study. Respondents were 336 healthcare professionals (90% female and 10% male; mean age 47 years) whose first-line and second-line managers participated in the intervention. The data were collected in the Stockholm regional healthcare organisation that offer primary, psychiatric, rehabilitation and acute hospital care, among other areas. The items for measuring implementation leadership were based on existent research and the full-range leadership model. Confirmatory factor analysis was performed to evaluate the dimensionality of the scale, followed by tests for reliability and convergent, discriminant and criterion-related validity using correlations and multilevel regression analyses. RESULTS: The final scale consists of 16 items clustered into four subscales representing active implementation leadership, and one scale signifying passive implementation leadership. Findings showed that the hypothesised model had an acceptable model fit (χ2(99)=382.864**, Comparative Fit Index=0.935, Tucker-Lewis Index=0.911, root mean square error of approximation=0.059). The internal consistency and convergent, discriminant and criterion-related validity were all satisfactory. CONCLUSIONS: The iLead scale is a valid measure of implementation leadership and is a tool for understanding how active and passive leader behaviours influence an implementation process. This brief scale may be particularly valuable to apply in training focusing on facilitating implementation, and in evaluating leader training. Moreover, the scale can be useful in evaluating various leader behaviours associated with implementation success or failure.

iLead-a transformational leadership intervention to train healthcare managers' implementation leadership.

BACKGROUND: Leadership is a key feature in implementation efforts, which is highlighted in most implementation frameworks. However, in studying leadership and implementation, only few studies rely on established leadership theory, which makes it difficult to draw conclusions regarding what kinds of leadership managers should perform and under what circumstances. In industrial and organizational psychology, transformational leadership and contingent reward have been identified as effective leadership styles for facilitating change processes, and these styles map well onto the behaviors identified in implementation research. However, it has been questioned whether these general leadership styles are sufficient to foster specific results; it has therefore been suggested that the leadership should be specific to the domain of interest, e.g., implementation. To this end, an intervention specifically involving leadership, which we call implementation leadership, is developed and tested in this project. The aim of the intervention is to increase healthcare managers' generic implementation leadership skills, which they can use for any implementation efforts in the future. METHODS/DESIGN: The intervention is conducted in healthcare in Stockholm County, Sweden, where first- and second-line managers were invited to participate. Two intervention groups are included, including 52 managers. Intervention group 1 consists of individual managers, and group 2 of managers from one division. A control group of 39 managers is additionally included. The intervention consists of five half-day workshops aiming at increasing the managers' implementation leadership, which is the primary outcome of this intervention. The intervention will be evaluated through a mixed-methods approach. A pre- and post-design applying questionnaires at three time points (pre-, directly after the intervention, and 6 months post-intervention) will be used, in addition to process evaluation questionnaires related to each workshop. In addition, interviews will be conducted over time to evaluate the intervention. DISCUSSION: The proposed intervention represents a novel contribution to the implementation literature, being the first to focus on strengthening healthcare managers' generic skills in implementation leadership.