Implementation challenges to patient safety in Guatemala: a mixed methods evaluation

Abstract

Background: Little is known about factors affecting implementation of patient safety programmes in low and middle-income countries. The goal of our study was to evaluate the implementation of a patient safety programme for paediatric care in Guatemala.

Methods: We used a mixed methods design to examine the implementation of a patient safety programme across 11 paediatric units at the Roosevelt Hospital in Guatemala. The safety programme included: (1) tools to measure and foster safety culture, (2) education of patient safety, (3) local leadership engagement, (4) safety event reporting systems, and (5) quality improvement interventions. Key informant staff (n=82) participated in qualitative interviews and quantitative surveys to identify implementation challenges early during programme deployment from May to July 2018, with follow-up focus group discussions in two units 1 year later to identify opportunities for programme modification. Data were analysed using thematic analysis, and integrated using triangulation, complementarity and expansion to identify emerging themes using the Consolidated Framework for Implementation Research. Salience levels were reported according to coding frequency, with valence levels measured to characterise the degree to which each construct impacted implementation.

Results: We found several facilitators to safety programme implementation, including high staff receptivity, orientation towards patient-centredness and a desire for protocols. Key barriers included competing clinical demands, lack of knowledge about patient safety, limited governance, human factors and poor organisational incentives. Modifications included use of tools for staff recognition, integration of education into error reporting mechanisms and designation of trained champions to lead unit-based safety interventions.

Conclusion: Implementation of safety programmes in low-resource settings requires recognition of facilitators such as staff receptivity and patient-centredness as well as barriers such as lack of training in patient safety and poor organisational incentives. Embedding an implementation analysis during programme deployment allows for programme modification to enhance successful implementation.

Keywords: health services research; implementation science; paediatrics; patient safety.

Figure 1

Diagrammatic representation of mixed methods concurrent triangulation design. Semistructured interviews (SSIs) and the Evidence-Based Practice Attitude Scale-36 (EBPAS-36) survey were administered concurrently at the time of the comprehensive patient safety programme implementation. Follow-up focus group discussions (FGDs) in two units were conducted 1 year later to probe for modifications to programme design and implementation. CFIR, Consolidated Framework for Implementation Research.

Figure 2

Evidence-Based Practice Attitude Scale-36 (EBPAS-36) Likert scale responses. Item responses range from 0 (strongly disagree) to 4 (strongly agree). Sample size ranges from 71 to 82 due to missing data.

Figure 3

Valence of Consolidated Framework for Implementation Research (CFIR) constructs as represented in semistructured interviews (SSIs). Valence magnitude and direction are further delineated by influence to the implementation process as either a positive or negative sentiment. Valence criteria by Damschroder were adapted and applied as described: −3, the construct is a strong negative influence on the implementation effort; −2, the construct is a moderate negative influence on the implementation effort; −1, the construct is a minor negative influence on the implementation effort; 0, the construct is a neutral or no influence on the implementation effort. Alternatively, +1, the construct is a minor positive influence on the implementation effort; +2, the construct is a moderate positive influence on the implementation effort; +3, the construct is a strong positive influence on the implementation effort.