Frontline Implementation Research Articles

Implementation of NCCARE360, a Digital Statewide Closed-Loop Referral Platform to Improve Health and Social Care Coordination: Evidence from the North Carolina COVID-19 Support Services Program.

Efforts to improve population health by being responsive to patients' social and economic conditions will benefit from care models and technologies that assess and address unmet social needs. In 2019, NCCARE360 launched in North Carolina as the first state-wide digital care coordination network to "close the loop" on referrals between community-based organizations (CBOs), health service providers, and social service agencies. The platform creates a shared network for sending and receiving electronic referrals and track client outcomes. As a case study, we compare NCCARE360 resolution rates for community resource referrals originating from a large integrated health system primarily in Durham County from September 1, 2020, through February 28, 2021. In the first year, COVID-19 Support Ser-vices Program (COVID-SSP) funding was available to reimburse associated CBOs for providing food assistance and case management services. We compared this with the same period the following year after funds had been exhausted. We present frontline implementation experiences and highlight opportunities, challenges, and recommendations for NCCARE360 implementation. Multi-level considerations for individual end users, organizations adopting the platform, and policymakers are presented. Addi-tionally, we find that when COVID-SSP funding was available, more referrals were placed (3,220 cases) and referrals were more likely to be resolved (88% resolution rate) when compared to the same time frame when funds were no longer available (860 cases; 30% resolution rate). These results underscore the importance of reimbursement mechanisms and funding. The examination of referral rates is observational and may not generalize to other contexts. The shift to value-based care is an opportunity to embrace structural solutions to health and social care fragmentation. There is also an opportunity to realize the potential of NCCARE360 and efforts like it to contain costs and improve health outcomes and equity.

Infection prevention and control for COVID-19 response in the Rohingya refugee camps in Bangladesh: an intra-action review

BackgroundInfection Prevention and Control (IPC) is critical in controlling the COVID-19 pandemic and is one of the pillars of the WHO COVID-19 Strategic Preparedness and Response Plan 2020. We conducted an Intra-Action Review (IAR) of IPC response efforts to the COVID-19 pandemic in Cox's Bazar, Bangladesh, to identify best practices, challenges, and recommendations for improvement of the current and future responses.MethodsWe conducted two meetings with 54 participants purposively selected from different organizations and agencies involved in the frontline implementation of IPC in Cox's Bazar district, Bangladesh. We used the IPC trigger questions from the WHO country COVID-19 IAR: trigger question database to guide the discussions. Meeting notes and transcripts were then analyzed manually using content analysis, and results were presented in text and quotes.ResultsBest practices included: assessments, a response plan, a working group, trainings, early case identification and isolation, hand hygiene in Health Facilities (HFs), monitoring and feedback, general masking in HFs, supportive supervision, design, infrastructure and environmental controls in Severe Acute Respiratory Infection Isolation and Treatment Centers (SARI ITCs) and HFs and waste management. Challenges included: frequent breakdown of incinerators, limited PPE supply, inconsistent adherence to IPC, lack of availability of uniforms for health workers, in particular cultural and gender appropriate uniforms and Personal Protective Equipment (PPE). Recommendations from the IAR were: (1) to promote the institutionalization of IPC, programs in HFs (2) establishment of IPC monitoring mechanisms in all HCFs, (3) strengthening IPC education and training in health care facilities, and (4) strengthen public health and social measures in communities.ConclusionEstablishing IPC programmes that include monitoring and continuous training are critical in promoting consistent and adaptive IPC practices. Response to a pandemic crisis combined with concurrent emergencies, such as protracted displacement of populations with many diverse actors, can only be successful with highly coordinated planning, leadership, resource mobilization, and close supervision.

Real-World Outcomes and Adverse Events of Elderly Patients with Ph-Negative Acute Lymphoblastic Leukemia Treated with a Pediatric-Inspired Protocol

Poor outcomes in elderly patients with Acute Lymphoblastic Leukemia (ALL) result from the disease's adverse biology and poor tolerance to chemotherapy, leading to dose reductions, treatment delays, and high rates of early death and treatment-related mortality. Some reports indicate that pediatric-inspired chemotherapy protocols can be safely and efficiently used in older adults, resulting in improved median overall survival (mOS) ranging from 17 to 40 months. Despite such reports, front-line implementation of pediatric-inspired approaches to elderly patients with ALL remains a topic of discussion. Our goal is to estimate OS and define adverse events (AEs) in patients with ALL, aged > 60 years, and treated with a pediatric-inspired protocol. Methods All newly diagnosed patients aged > 60 years with Ph-negative ALL who received induction chemotherapy with a modified, asparaginase-intense, pediatric-inspired regimen between January 2002 and January 2022 were included. The treatment regimen consisted of induction, central nervous system prophylaxis, 7 cycles of intensification, and 24 cycles of maintenance. During these 20 years, we switched from native to pegylated E.coli asparaginase. Standard descriptive statistics were used to summarize patients’ demographics and outcomes of interest. 95% confidence intervals were provided where possible. Fisher's exact test was used to assess the impact of categorical covariates of interest on induction mortality. Using Fine-Gray methods, the Multivariable Cox proportional hazards regression model was used to determine the joint effect of potential factors for outcomes. P<0.05 was considered significant. Results A total of 76 patients were included. Patient and disease characteristics are presented in table 1. The median dose of Peg-asparaginase and L- asparaginase were 935 iu/m2 (477-1,111 iu/m2) and 5,944 iu/m2 (4,388-15,000 iu/m2) respectively. AEs rates found were severe pancreatitis 3.9%, thrombosis at any time during treatment 43.2%, hypofibrinogenemia <1g/L 30.6%, CTCAE grade IV transaminases, and total bilirubin 35.2%, and 17.3% respectively. The induction mortality rate was 12% (N=9) and the complete remission rate after induction (CR1) was achieved at 79% (n=60). Allogeneic hematopoietic stem cell transplantation in CR1 was carried out for 9.2% (N=7). The median follow-up among survivors was 49.7 months (range: 9-155) and the mOS was 35.1 months (95%CI: >19.3) (figure 1). OS rate at 1 and 4 years was 73.6% (95%CI: 62 - 82) and 42.2% (95%CI: 29.3 - 54.6) respectively, with a cumulative incidence of relapse from the date of diagnosis at 12 months of 12% (95% CI: 5.8 - 20). Leukemia-free survival rate at 4 years was 42.4% (95% IC 30 - 53). For the patients with early mortality, 5 patients had L-asparaginase, 3 patients had no asparaginase, and one Peg-asparaginase (11.11%). In contrast, in the no early mortality group, 46 (68.6%) patients received L-asparaginase, 2 (2.9%) patients had no asparaginase, and 19 (28.3%) patients received Peg-asparaginase (p=0.011). In univariate analysis, variables significantly associated with worse OS were: older age [<70 years old (n=46) median OS 70.8 months (95%CI >31.1) vs >70 years old (n=30)14.4 months (95%CI 9.2-54.2) (p=0.016)], higher WBC count [<11x10e9/L (n=54) median OS was 70 months (95%CI 27-NA), while in those with WBC >11x10e9/L (n=22) was 17.2 months (95%IC 6-31) (p= 0.004)], and no asparaginase given [OS at 12 months was: 85% (95%CI 60.4 -94.9) in patients treated with Peg-asparaginase; 72.4% (95%CI 57.9-82.6) in patients treated with L-asparaginase, and 40% (95%CI 5.2-75.3) in patients that did not receive asparaginase (p=0.0021). In multivariable analysis, younger age and lower WBC remained independent significant prognostic factors for increased OS [Patients <70 years old HR 2.67 (95% CI[1.38 - 5.17], p=0.0034) and patients with WBC <11x10e9/L HR 2.5 (95% CI [1.30- 4.82], p= 0.007)]. Conclusions The use of a pediatric-inspired chemotherapy protocol is shown to be effective and well tolerated in patients with Ph-negative ALL aged >60 years. Although AE rates were not negligible, outcomes were excellent and, early mortality improved over prior reports (Marc Poch Martell et al, BJH 2013, early mortality 20%). Further research will be needed to understand how the outcomes could be improved further using newer targeted treatments. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Creating conditions for effective knowledge brokering: a qualitative case study

BackgroundProcess improvement in healthcare is informed by knowledge from the private sector. Skilled individuals may aid the adoption of this knowledge by frontline care delivery workers through knowledge brokering. However, the effectiveness of those who broker knowledge is limited when the context they work within proves unreceptive to their efforts. We therefore need greater insight into the contextual conditions that support individuals to broker process improvement knowledge to the frontline of care delivery, and how policy makers and organizations might generate such conditions.MethodsOur research took place in a healthcare system within an Australian State. We undertook a qualitative, embedded single case study over the four year period of a process improvement intervention encompassing 57 semi-structured interviews (with knowledge brokers, policy makers, and executive sponsors), 12 focus groups, and 137 h of observation, which included the frontline implementation of actual process improvement initiatives, where knowledge brokering took place.ResultsWe identified four phases of the process improvement intervention that moved towards a more mature collaboration within which knowledge brokering by improvement advisors began to emerge as effective. In the first phase knowledge brokering was not established. In the second phase, whilst knowledge brokering had been initiated, the knowledge being brokered lacked legitimacy amongst frontline practitioners, resulting in resistance. Only in the fourth and final phase of the intervention did the collective experience of policy makers result in reflections on how they might engender a more receptive context for knowledge brokering.ConclusionWe highlight a number of suggested actions that policy makers might consider, if they wish to engender contextual conditions that support knowledge brokering. Policy makers might consider: ensuring they respect local context and experience, by pulling good ideas upward, rather than imposing foreign knowledge from on high; facilitating the lateral diffusion of knowledge by building cultural linkages between people and organizations; strengthening collaboration, not competition, so that trans-organisational flow of ideas might be encouraged; being friend, not foe, to healthcare organizations on their knowledge integration journey. In sum, we suggest that top-down approaches to facilitating the diffusion and adoption of new ideas ought to be reconsidered.

Correction to: An Expert Consensus Process to Distill Tier 1 PBIS into Core Practice Elements Essential to Frontline Implementation

Correction to: An Expert Consensus Process to Distill Tier 1 PBIS into Core Practice Elements Essential to Frontline Implementation

Frontline leadership for implementing clinical guidelines in Norwegian mental health services: a qualitative study

PurposeThe purpose of this study was to explore and interpret how frontline leaders define, experience and rationalise their approaches to the successful implementation of clinical guidelines in mental health care.Design/methodology/approachEmploying an interpretative phenomenological design, the authors conducted and analysed individual interviews of frontline leaders at 14 psychiatric clinics involved in a national study of implementing evidence-based clinical guidelines in mental health.FindingsThe authors found a broad spectrum of attitudes and attributes, as well as a wide repertoire of strategies for frontline implementation leadership. Three main approaches were revealed, comprising “Curious and welcoming”, “Integrity and setting standards” and “Caring and collegial”.Research limitations/implicationsThe study present what experienced frontline leaders emphasise to enable implementation of guidelines, not empirical pieces of evidences for what they in fact do or if these actions lead to implementation. The generalisability to other settings is unknown. Another sample profile, context or organisational level may have impacted the result. The concreteness of the frontline leaders’ considerations, approaches and actions gives important knowledge about frontline leaders leadership across traditional leadership theories.Originality/valueExisting leadership theories describe different leadership styles, while this study reveals the need for a wide range of approaches to balance the many needs and demands. The complexity of leadership approaches this study found is in line with implementation theories; thus, the present study incorporates implementation science into the leadership literature.

Searching for “the usual suspects”: The role of discretion and target group constructions in the frontline of policy implementation

AbstractThis study investigates the implementation of preventive policy targeting children. Based on longitudinal survey data we analyze how frontline workers assign meaning to core concepts of the policy and categorize the children and in this light how their exercise of discretion affects policy implementation. Many studies problematize the effects of limiting the discretion in the frontline. We identify a case where the policy is highly ambiguous, the definitions of target groups, core concepts, or central goals are vague, and the general steering of the frontline is not characterized by a lack of discretion but a lack of organizational boundaries to shape the discretion. This expands not only the policymaking role of the frontline but also becomes a barrier to developing a stronger preventive effort. The findings give nuanced insight into how organizational boundaries affect the discretion and target group construction in the frontline during frontline implementation of welfare policies.

An Expert Consensus Process to Distill Tier 1 PBIS into Core Practice Elements Essential to Frontline Implementation

An Expert Consensus Process to Distill Tier 1 PBIS into Core Practice Elements Essential to Frontline Implementation

Helping Babies Breathe Global Development Alliance and the Power of Partnerships.

The Helping Babies Breathe Global Development Alliance (GDA) was a public-private partnership created simultaneously with the launch of the educational program Helping Babies Breathe to accelerate dissemination and implementation of neonatal resuscitation in low- and middle-income countries with the goal of reducing the global burden of neonatal mortality and morbidity related to birth asphyxia. Representatives from 6 organizations in the GDA highlight the recognized needs that motivated their participation and how they built on one another's strengths in resuscitation science and education, advocacy, frontline implementation, health system strengthening, and implementation research to achieve common goals. Contributions of time, talent, and financial resources from the community, government, and private corporations and foundations powered an initiative that transformed the landscape for neonatal resuscitation in low- and middle-income countries. The organizations describe the power of partnerships, the challenges they faced, and how each organization was shaped by the collaboration. Although great progress was achieved, lessons learned through the GDA and additional efforts must still be applied to the remaining challenges of prevention, widespread implementation, improvement in the quality of care, and sustainable integration of neonatal resuscitation and essential newborn care into the fabric of health care systems.

Neoliberalism, accounting, and the transformation of subjectivities in social work: A study on the implementation of personal budgets

AbstractThis study examines, through the case of Personal Budgets in England, the role of accounting in transforming the subjectivities of social workers through a Foucauldian lens. The findings show how accounting can reshape the subjectivities of social workers serving as intermediaries responsible for the frontline implementation of neoliberal reforms. It does so through an empirical demonstration on how accounting harnesses an individual's autonomy and responsibility to nurture “productive” relationships between citizens and the state. Furthermore, the findings also highlight the vulnerability of social workers’ subjectivities from the installation of an accounting infrastructure with multiple capabilities. This study contributes to a more nuanced understanding of how neoliberal policies transform subjectivities in social work and adds to the literature on accounting's biopolitical role in the reconstitution of such subjectivities. It also addresses the relative neglect of studies examining the role of accounting in neoliberal transformations of social work that, despite its significance for an ageing society and its attendant consequences for public finances, receives far less attention than healthcare reforms.

Neoliberalism, Accounting and the Transformation of Subjectivities in Social Work: A Study on the Implementation of Personal Budgets

This study examines, through the case of Personal Budgets in England, the role of accounting in transforming the subjectivities of social workers through a Foucauldian lens. The findings show how accounting can reshape the subjectivities of social workers serving as intermediaries responsible for the frontline implementation of neoliberal reforms. It does so through an empirical demonstration on how accounting harnesses an individual’s autonomy and responsibility to nurture ‘productive’ relationships between citizens and the state. Furthermore, the findings also highlight the vulnerability of social workers’ subjectivities from the installation of an accounting infrastructure with multiple capabilities. This study contributes to a more nuanced understanding of how neoliberal policies transforms subjectivities in social work and adds to the literature on accounting’s biopolitical role in the reconstitution of such subjectivities. It also addresses the relative neglect of studies examining the role of accounting in neoliberal transformations of social work which, despite its significance for an ageing society and its attendant consequences for public finances, receives far less attention than healthcare reforms.

Frontline implementation of welfare conditionality in Norway: A maternalistic practice

AbstractWelfare conditionality is both ambitious and ambiguous for the frontline workers who put policy into practice. Since January 2017, the Norwegian frontline service should require social assistance benefit recipients under the age of 30 to participate in some sort of work‐related activation, so‐called mandatory activation. Drawing on qualitative interviews with frontline workers at local offices in the Norwegian Public Welfare Service (NAV), we investigate how the requirement is implemented in a context of a professionalised social welfare service. Mandatory activation is arguably a paternalistic measure. Drawing on Bernardo Zacka's concept of moral dispositions and Laura Specker Sullivan's concepts of maternalism, our findings indicate that at the frontline, mandatory activation policies are implemented by maternalistic decision making, emphasising the interpersonal relation between trained caseworkers and clients. The caseworkers use their discretionary powers in the implementation of conditionality and sanctions by emphasising care and support as embedded in the strict rules.

Institutionalizing quality within national health systems: key ingredients for success.

Quality improvement initiatives can be fragmented and short-term, leading to missed opportunities to improve quality in a systemic and sustainable manner. An overarching national policy or strategy on quality, informed by frontline implementation, can provide direction for quality initiatives across all levels of the health system. This can strengthen service delivery along with strong leadership, resources, and infrastructure as essential building blocks for the health system. This article draws on the proceedings of an ISQua conference exploring factors for institutionalizing quality of care within national systems. Active learning, inclusive of peer-to-peer learning and exchange, mentoring and coaching, emerged as a critical success factor to creating a culture of quality. When coupled by reinforcing elements like strong partnerships and coordination across multiple levels, engagement at all health system levels and strong political commitment, this culture can be cascaded to all levels requiring policy, leadership, and the capabilities for delivering quality healthcare.

Editorial Note

Editorial Note

The impact of middle manager affective commitment on perceived improvement program implementation success.

Recent literature suggests that middle manager affective commitment (emotional attachment, identification, and involvement) to an improvement program may influence implementation success. However, less is known about the interplay between middle manager affective commitment and frontline worker commitment, another important driver of implementation success. We contribute to this research by surveying middle managers who directly manage frontline workers on nursing units. We assess how middle manager affective commitment is related to their perceptions of implementation success and whether their perceptions of frontline worker support mediate this relationship. We also test whether a set of organizational support factors foster middle manager affective commitment. We adapt survey measures of manager affective commitment to our research context of hospitals. We surveyed 67 nurse managers from 19 U.S. hospitals. We use hierarchical linear regression to assess relationships among middle manager affective commitment to their units' falls reduction program and their perceptions of three constructs related to the program: frontline worker support, organizational support, and implementation success. Middle manager affective commitment to their unit's falls reduction program is positively associated with their perception of implementation success. This relationship is mediated by their perception of frontline worker support for the falls program. Moreover, middle managers' affective commitment to their unit's falls program mediates the relationship between perceived organizational support for the program and perceived implementation success. We, through this research, offer an important contribution by providing empirical support of factors that may influence successful implementation of an improvement program: middle manager affective commitment, frontline worker support, and organizational support for an improvement program. Increasing levels of middle manager affective commitment to an improvement program could strengthen program implementation success by facilitating frontline worker support for the program. Furthermore, providing the organizational support items in our survey construct may bolster middle manager affective commitment.

Person-centred care in a digital hospital: observations and perspectives from a specialist rehabilitation setting

Objective This study investigated use of electronic medical records (eMRs) in a spinal cord injury rehabilitation unit and the implications for person-centred care. Methods This exploratory mixed-methods study conducted 17.5hours of observations of practitioner-patient encounters, 50 patient-experience surveys and 10 focus groups with 53 practitioners. Descriptive statistics and qualitative analysis were integrated into key themes. Results Practitioners in this specialised setting were reconciling the emergent challenges of eMR in practice with the advantages of improved accessibility and documentation legibility. eMR increased task complexity and information retrieval, particularly for nurses. Some documentation was an uneasy fit with the specialised setting, disrupting informal communications and aspects of person-centred care. Conclusions Technological change closely aligned with frontline practice brought expected and unexpected challenges that may resolve over time. Practitioners' persistence and adaptability demonstrated their commitment to person-centred care in the digital environment. The impact of this less visible work of professional discretion seemed to vary, primarily by discipline-specific roles, with nurses experiencing the greatest pressure. What is known about this topic? Integrated electronic medical records (eMRs) bring benefits but challenge person-centred care. What does this paper add? These first insights regarding frontline implementation of eMR in spinal injury rehabilitation suggest nursing challenges when seeking to fit specialised work into the generic eMR. However, most patients reported receiving person-centred care. What are the implications for practitioners? Commitment to person-centred care appears to strengthen practitioners' perseverance with the eMR implementation challenges.

What happened at the front lines of US welfare reform? Exploring the experiences of front-line implementers

This article aims to explore the story of the front-line implementation of US welfare reform through analyzing the experiences of front-line workers with a grounded theory approach. There were deep concerns about the working poor and unelaborated programs for economic independence, which were attributable to the legislation’s thrust to work-first and a skill mismatch, without taking the quality of jobs into account. Welfare roll reduction resulted in taking a generous approach to welfare clients on the front lines. Although discretion resulted in the operation of more local initiatives on the front lines, it was not a substantial response to the demands of the real lives of clients. This article argues that the quality and sustainability of work is critical, prior to an emphasis on work-first. Front-line implementation must shift to increasing employers’ willingness to create incentives for skill-building and to giving clients some motivation to work. Points for practitioners A gap between policymaking and nonlinear policy implementation on the front lines is inevitable as local demands vary. Particularly, perspectives of front-line implementers are useful in reflecting various local demands and adjusting the different interests of clients in the process of refining welfare reform in lieu of federal policymakers. Although the discretion of front-line implementers is critical, less attention has been paid to how they put welfare reform into practice and what they learned. Qualitative exploration of such issues thus provides field-based evidence to improve its implementation to help the clients, which has rarely been examined in the literature.

Social and Task Interdependencies in the Street-Level Implementation of Innovation

Organizations often adopt, though do not always successfully implement, innovations that require widespread frontline participation to realize their full benefits. To better understand the mechanisms that support or inhibit the implementation of such innovations, we apply constructs from organizational learning theory to the case of implementing innovation in schools, and operationalize those constructs in a computational, agent-based model. Model analysis reveals how the misalignment between an organization’s social network and the task structure of its target innovation can impede frontline implementation, even when the individuals inside the organization have the skill and willingness to implement the innovation’s constituent activities. We find that individual-level improvement before the decision to adopt the innovation can exacerbate this problem by reducing the utilization of tasks needed to support future implementation. We also translate our insights into specific propositions about how the work required by the target innovation and an organization’s social network relate to the level of frontline implementation in organizations.

The role of program, people, process, policy and place (5Ps) in the implementation of a positive youth development program

There is scant literature about identifying factors contributing to the success of the implementation of programs to help understand the interrelationships among multiple facets of implementation. In this paper, a front-line implementer reviewed the execution practice of Project P.A.T.H.S. (Positive Adolescent Training through Holistic Social Programmes) in her former school in terms of program, people, process, policy and place (5Ps). By examining the factors contributing to the success of the implementation, the authors intend to fill the gap between the research and the practical school-based front-line implementation. Although the program implementation process was examined in researchers' "expert" perspective, it would be helpful if more research employed front-line workers as collaborators and participants in the implementation process to understand what actually happen in the program implementation process.

It’s What Happens on the Front Lines of Civic Education Policy that Matters: Reflections on a Natural Experiment on Youth Turnout in Ontario

In the last decade there has developed a new level of coordination among those working in the fields of citizenship education and political participation. The paper puts this link to an empirical test, using a natural experiment of youth turnout in the 2004 and 2006 federal election to investigate what, if any, effect can be found of Ontario’s introduction of a compulsory Grade 10 Civics course in 2000. We find that changing the curriculum in itself does not appear to have the desired results, concluding that, in practice, any lasting effect of civic education upon youth political participation rests on the effectiveness of front-line implementation.