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Abstract：
BACKGROUND: Quality in healthcare is a subject in need of continuous attention. Quality improvement (QI) programmes with the purpose of increasing service quality are therefore of priority for healthcare leaders and governments. This study explores the implementation process of two different QI programmes, one externally driven implementation and one internally driven, in Norwegian nursing homes and home care services. The aim for the study was to identify enablers and barriers for externally and internally driven implementation processes in nursing homes and homecare services, and furthermore to explore if identified enablers and barriers are different or similar across the different implementation processes.
METHODS: This study is based on an exploratory qualitative methodology. The empirical data was collected through the \'Improving Quality and Safety in Primary Care - Implementing a Leadership Intervention in Nursing Homes and Homecare\' (SAFE-LEAD) project. The SAFE-LEAD project is a multiple case study of two different QI programmes in primary care in Norway. A large externally driven implementation process was supplemented with a tracer project involving an internally driven implementation process to identify differences and similarities. The empirical data was inductively analysed in accordance with grounded theory.
RESULTS: Enablers for both external and internal implementation processes were found to be technology and tools, dedication, and ownership. Other more implementation process specific enablers entailed continuous learning, simulation training, knowledge sharing, perceived relevance, dedication, ownership, technology and tools, a systematic approach and coordination. Only workload was identified as coincident barriers across both externally and internally implementation processes. Implementation process specific barriers included turnover, coping with given responsibilities, staff variety, challenges in coordination, technology and tools, standardizations not aligned with work, extensive documentation, lack of knowledge sharing.
CONCLUSIONS: This study provides understanding that some enablers and barriers are present in both externally and internally driven implementation processes, while other are more implementation process specific. Dedication, engagement, technology and tools are coinciding enablers which can be drawn upon in different implementation processes, while workload acted as the main barrier in both externally and internally driven implementation processes. This means that some enablers and barriers can be expected in implementation of QI programmes in nursing homes and home care services, while others require contextual understanding of their setting and work.
METHODS: This study is based on an exploratory qualitative methodology. The empirical data was collected through the \'Improving Quality and Safety in Primary Care - Implementing a Leadership Intervention in Nursing Homes and Homecare\' (SAFE-LEAD) project. The SAFE-LEAD project is a multiple case study of two different QI programmes in primary care in Norway. A large externally driven implementation process was supplemented with a tracer project involving an internally driven implementation process to identify differences and similarities. The empirical data was inductively analysed in accordance with grounded theory.
RESULTS: Enablers for both external and internal implementation processes were found to be technology and tools, dedication, and ownership. Other more implementation process specific enablers entailed continuous learning, simulation training, knowledge sharing, perceived relevance, dedication, ownership, technology and tools, a systematic approach and coordination. Only workload was identified as coincident barriers across both externally and internally implementation processes. Implementation process specific barriers included turnover, coping with given responsibilities, staff variety, challenges in coordination, technology and tools, standardizations not aligned with work, extensive documentation, lack of knowledge sharing.
CONCLUSIONS: This study provides understanding that some enablers and barriers are present in both externally and internally driven implementation processes, while other are more implementation process specific. Dedication, engagement, technology and tools are coinciding enablers which can be drawn upon in different implementation processes, while workload acted as the main barrier in both externally and internally driven implementation processes. This means that some enablers and barriers can be expected in implementation of QI programmes in nursing homes and home care services, while others require contextual understanding of their setting and work.
摘要：
背景：医疗保健质量是一个需要持续关注的主题。因此，以提高服务质量为目的的质量改进（QI）计划是医疗保健领导者和政府的优先事项。本研究探讨了两种不同QI计划的实施过程，一个外部驱动的实现和一个内部驱动的实现，在挪威的疗养院和家庭护理服务。该研究的目的是确定养老院和家庭护理服务中外部和内部驱动的实施过程的促成因素和障碍，并进一步探索识别出的推动者和障碍在不同的实施过程中是否不同或相似。
方法：本研究基于探索性定性方法。经验数据是通过“改善初级保健的质量和安全-在家庭和家庭护理中实施领导干预”（SAFE-LEAD）项目收集的。SAFE-LEAD项目是对挪威初级保健中两个不同的QI计划的多案例研究。一个大型外部驱动的实施过程补充了一个跟踪项目，该项目涉及一个内部驱动的实施过程，以确定差异和相似之处。根据扎根理论对经验数据进行了归纳分析。
结果：发现外部和内部实施过程的促成因素是技术和工具，奉献,和所有权。其他更多实施过程特定的促成因素需要持续学习，模拟训练,知识共享,感知的相关性，奉献,所有权,技术和工具，系统的方法和协调。只有工作量被确定为外部和内部实施过程中的重合障碍。实施过程的具体障碍包括营业额，应对给定的责任，员工种类繁多，协调方面的挑战，技术和工具，标准化与工作不一致，广泛的文档，缺乏知识共享。
结论：这项研究提供了一些促进因素和障碍存在于外部和内部驱动的实施过程中的理解，而其他则是更具体的实施过程。奉献,订婚,技术和工具是一致的推动者，可以在不同的实施过程中借鉴，而工作量在外部和内部驱动的实施过程中都是主要障碍。这意味着在养老院和家庭护理服务中实施QI计划可能会出现一些促成因素和障碍，而其他人则需要了解他们的环境和工作。
方法：本研究基于探索性定性方法。经验数据是通过“改善初级保健的质量和安全-在家庭和家庭护理中实施领导干预”（SAFE-LEAD）项目收集的。SAFE-LEAD项目是对挪威初级保健中两个不同的QI计划的多案例研究。一个大型外部驱动的实施过程补充了一个跟踪项目，该项目涉及一个内部驱动的实施过程，以确定差异和相似之处。根据扎根理论对经验数据进行了归纳分析。
结果：发现外部和内部实施过程的促成因素是技术和工具，奉献,和所有权。其他更多实施过程特定的促成因素需要持续学习，模拟训练,知识共享,感知的相关性，奉献,所有权,技术和工具，系统的方法和协调。只有工作量被确定为外部和内部实施过程中的重合障碍。实施过程的具体障碍包括营业额，应对给定的责任，员工种类繁多，协调方面的挑战，技术和工具，标准化与工作不一致，广泛的文档，缺乏知识共享。
结论：这项研究提供了一些促进因素和障碍存在于外部和内部驱动的实施过程中的理解，而其他则是更具体的实施过程。奉献,订婚,技术和工具是一致的推动者，可以在不同的实施过程中借鉴，而工作量在外部和内部驱动的实施过程中都是主要障碍。这意味着在养老院和家庭护理服务中实施QI计划可能会出现一些促成因素和障碍，而其他人则需要了解他们的环境和工作。
