Table 3 Framework analysis for the NPT subconstructs with supportive data
NPT mechanisms and subconstructs | Framework analysis | Illustrative quotes and observations |
|---|---|---|
Coherence “Sense-making work as individuals and collective” | ||
Differentiation | Most CP able to differentiate PROMa from normal work Terminology (ICHOM, VBHC, PROM) made it abstract Helped by previous experiences, kick-off session, e-learning | PTM1, OCN 3, HM/PL(OCN2): [preparing kick-off session, PL of OCN2 attends PTM to help] “I would present the practical aspect of discussing PROM answers, along an example case. Otherwise, it remains quite abstract with the ICHOM circle and value-based healthcare” |
Communal specification | Shared vision amongst kick-off and QI session participants: goal is patient centered care and collaboration for better outcomes Varied per OCN if staff had aligned project goals and whether their goal was clear to CP in clinic Easier in OCN with a more mature organization structure | PTM18, OCN1, report: [after doubts in previous meeting] “Looking back, participation of X (the hospital) and X (a midwifery practice) in this project has surely been discussed and decided upon in the OCN. They would start with the PROM and evaluate whether it’s feasible to move up with the whole OCN and would report that to the OCN” |
Individual specification | Most CP comprehended individual tasks, supported by the protocol, IT training and key participants PROM often interpreted as research: both CP and patients | PTM18, OCN1, observation: “She (CM), and the other project team members, have always interpreted the PROM as research and informed patients that way too. […] Now, she informs her patients clearer that PROM completion is for their own care and, thereby, in their own good. She states that she gets more responses and has to ‘go after it’ less. That is also really motivating for themselves (CM + her colleague)” |
Internalization | Most CP constructed potential value of PROM at start Helped further by e-learning, kick-off session and previous experiences Not all CP aware of ownership to use group-level PROM for QI | QI1, OCN3, mentimeter: [after introduction video: what attracts you in the video?] (Attending CP) “Honest answers, ability to raise issues, more fulfilment of work, elaboration of a person, customized care, patient at the center, being seen, prepared for situation, personal attention” |
Cognitive participation “Relational work to build and sustain a community of practice around the intervention” | ||
Initiation Mean survey scoreb: 3.82 | Project leader and team members initiated with training and support. These key-participants felt facilitated by one-year implementation period (felt as ‘try out’) and by the action research project providing materials, support and earlier regions experiences Still, for some CP, it felt the PROM appeared without explanation Towards end: key-participants stopped motivating their peers, feeling they asked too much effort whilst IT issues were unresolved | Kick-off, OCN2, observation: PL takes charge in the presentation, including general information and vision why the project is carried out. […] The project team members are clearly the early adopters/key-participants, also clear for the other CP attending this kick-off session. The project team members have completed the e-learning and the IT training already {before this kick-off session)” |
Enrolment Mean survey score: 3.84 | Most CP open to working with PROM, some wanted to await results Sceptic/hesitant about technology, time investment, patient burden Helped by education/training, but continuous attention and support in practice more important regarding low training attendance Impaired by little real-life contact (COVID-19 pandemic) Harder in larger organizations with distant leadership | Kick-off, OCN2, observation: [question attitude towards PROM]: Most CP answer positive, few neutral, no negative. CPs answering positive share they have a better understanding of what is expected from them. They praise the project team for their good preparations and hard work. CP answered neutral because of worries about IT, workload, and uncertainty about the exact time investment” |
Legitimation Mean survey score: 3.48 | Most midwives and obstetricians considered PROM a legitimate part of their role (except T5). Others felt not in need of PROM to discuss the topics these PROM address: felt as check/registration burden CP without active involvement invited to QI sessions (i.e., obstetric nurses, preventive youth care, non-participating CM) had to attend before understanding their valid contribution | Interview, OCN1, CM: “It somewhat has been brought, in my experience, like “well this is really the tool to provide personal care”. […] In my opinion, I already provide very personal care and all freedom for women to feel the opportunity to raise their personal items. […] And yes, then we [CP] get the next check off list on our plates” |
Activation Mean survey score: 3.69 | Over time, IT issues for both CP and their patients created resistance.—Most CP stopped working with PROM because too much effort and time (mainly IT, see feasibility) for little gain (low PROM exposure) Key-participants and OCN boards continued to support the potential of PROM for VBHC and looked for alternatives to embed them | Focus group, OCN2, multiple CP: "(CM3) yes but the question… the content of the project: that was something we fully supported. Well, I’ll speak for myself, I fully supported that. Only how the IT system… that was where it got stuck on for me. (CM2) well, for everybody here (OB) also for our patients” |
Collective action “Operational work to enact a set of practices” | ||
Interactional workability Mean survey score: 2.91 | Protocol and experiences form earlier regions helped. Still, hard to integrate PROM in clinical routine (IT issues, time) Different experiences of CP how long the PROM took to discuss, but existing workload was already high, with little time to learn new skills CP needed more exposure to build routine. Yet local project teams hesitant with expansion because of time investment and IT struggles | Evaluation report, OCN2, CM: “However, the usability [of the IT system] causes irritation, both in midwives as well as patients. Our patients complain about leaving personal data, the barrier to log-in and recurrent reminders even if they already completed the PROM. For midwives, integrating PROM in their consultations remained difficult, having to log-in to an external system is a barrier” |
Relational integration Mean survey score: 3.71 | ROM were mostly an individual task in clinic, highest workload CM Group-level PROM results led to conversations about improvement opportunities in the OCN, motivating CPs’ implementation efforts and contributing positively to working culture and pleasure Trust in the innovation was negatively affected by bad functioning IT system, privacy questions and PROM content or timing | PTM18, OCN1, report: “She (HM) also states that she feels all negative emotions about the use of the IT system also affect CP’s receptivity for the idea of value-base care” Evaluation report, OCN2, HM/PL: "A hindering factor for CP was the uncertainty whether questionnaires were sent out. Sometimes they would not be sent out at all, and it wasn’t clear to the CP whether this was due to the IT system or a problem in patient’s registration” |
Skill set workability Mean survey score: 3.41 | Most CP felt skilled to use PROM in clinic and for QI. CP negative on self-efficacy, CP needed more time, administrative staff, open answer options to the PROM, and better IT and data-analysis Allocating administrative tasks was difficult because of the external IT system (e.g., manual tasks: enter delivery date, invite patients) | PTM8, OCN1, PL: “After birth, date of delivery has to be entered in the IT system directly to send out the postpartum questionnaires on time. The project team suggests allocating this task to the secretary. They should be contacted to discuss their possibilities” |
Contextual integration Mean survey score: 3.44 | CP felt PROM need to be integrated in their EHRs, but also easy to share across organizations, but at this point impossible Resources (for project leader, IT, data analysis), external incentives (policy guidelines) and accreditation for learning were helpful Resources and leadership support varied, dependent on collaboration (and reimbursement) structure of OCNs and size of individual practices | Evaluation report, OCN3, CM: “Working in a system accessible across practices is nice! It is a pity we have to log-in to an external system first, and that this system isn’t connected to you own EHR. That would make it way easier to use as it [external system] costs a lot of extra time” PTM16, OCN2, OB: “This [decision to stop at end of project] represents two points very clearly: the need for one EHR and the fact that we have had many startup problems in this project” |
Reflexive monitoring “Appraisal work to assess and understand the ways that the innovation affects them and others” | ||
Systemization | Response rates and practice experiences with input from colleagues (directly and from survey), discussed in project team and QI sessions Some CP discussed (negative) experiences amongst each other, without sharing with the project leaders Some CP indicated they did not receive feedback on project results or adaptations and felt unheard in their struggle to integrate in workflow Each team planned an evaluation report to their OCN at 12 months | PTM7, OCN2, report: (PL) “The project team questions whether we generate enough patients with the current selection in patient groups […] In case of little patients filling out PROM, there is a large change we forget to discuss completed PROMs. The decision is to start with the current patient groups, then evaluate whether we see enough patients, and if needed per January expand with diabetes gravidarum patients” |
Communal appraisal | CP’s and patient’s experiences were leading in evaluating PROM value Overall, the value of PROM for daily practice and QI were seen but did not way the extra workload due to IT issues and the burden of an external system | Evaluation report, OCN3, CM: “As midwifery practice, we perceived that the use of PROM could lead to women preparing more consciously for a visit. As CP, we experienced that we sometimes gained more information in visits with PROM than without. Hence, topics like pain, urine and stool problems were discussed more often” |
Individual appraisal | Many CP appreciated value of group-level PROM results for QI Appraisal for individual-level PROM was various across CP: in general, more valuable to hospital CP than community midwives PROM were considered unsuitable for women with low health literacy/non-Dutch speaking, whom CP believed would most benefit | Evaluation report, OCN3, CM/PL: “The QI sessions were inspiring and binding for our OCN and really led to positive action points for the OCN. Many of the attending CP reported afterwards to be enthusiast about using this method” |
Reconfiguration | Learning from practice experiences and other regions, adaptations were made in close collaboration with the IT system Appeared hard to improve IT functionality, allocate administrative tasks and PROM content/timing At the end, conditions for future restart were formulated in evaluation reports to their OCN management | PTM7, OCN3, OB: “I had expected that it [the IT system] would be more developed, the technique works quite difficult. This whole meeting was about IT, it’s disturbing it can’t be tackled now. It has to be easy, and at the moment, I don’t experience it that way. X (PL) and X (OBR) are constantly on top of it: that really takes an excessive amount of time” |