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OP48 Implementation of hip fracture services: a qualitative study using extended normalization process theory
  1. Sarah Drew,
  2. Fiona Fox,
  3. Celia Gregson,
  4. Rachael Gooberman-Hill
  1. Musculoskeletal Research Unit, Translational Health Sciences, University of Bristol, Bristol, UK


Background Hip fractures are a devastating injury with high healthcare costs. Despite national standards and guidelines, there is substantial variation in hospital delivery of hip fracture care and in patient outcomes. This study aimed to understand organisational processes that help or hinder the implementation of hip fracture services, using extended Normalization Process Theory (eNPT), which specifies four constructs that impact on successful implementation: capacity, potential, capability and contribution.

Methods Thirty semi-structured interviews were conducted with healthcare professionals involved in delivering hip fracture care at four hospitals across England. Staff were purposively sampled from across the care pathway, and comprised emergency department staff, orthogeriatricians, orthopaedic surgeons, physiotherapists and discharge coordinators. Data were analysed thematically and themes transposed onto constructs from eNPT.

Results The capacity of healthcare professionals to co-operate and co-ordinate their practice was achieved using formal mechanisms including shared information systems, multi-disciplinary team (MDT) meetings and integrated MDT documentation and protocols. Trauma coordinators organised important processes of care and facilitated MDT co-working. Transfer of patient information was compromised when these systems were not effectively implemented. Shared working spaces promoted frequent and spontaneous communication. Individual potential and commitment to operationalise services occurred through multiple processes. Training, mentoring and support for junior staff, particularly rotating doctors, helped their engagement in patient care. Shared commitment was undermined by complex dynamics between different professional groups, particularly medical and surgical staff. Clinical leads bridged these professional boundaries and promoted shared patient goals. Capability to deliver care was compromised by under-staffed and under-resourced services, including lack of geriatric and therapist input, particularly out-of-hours and at weekends, and lack of bed capacity. Staff identified strategies to mobilise existing resources including ‘upskilling’ of staff, effective prioritisation of patients and systems to track outlying patients on other wards. Bringing patients together on specialist wards enhanced workability by concentrating staff knowledge and expertise.Healthcare professionals made contribution by driving change and developing services through MDT meetings and consistent monitoring and auditing. Clinical leads were integral to service development by disseminating audit data, engendering enthusiasm and engaging staff from individual directorates. Ongoing development was shaped by executive support. Benchmarking services based on key performance indicators and linking clinical activity to funding mechanisms helped leverage executive support.

Conclusion Findings identify elements needed to implement hip fracture services successfully. Information will assist services in overcoming organisational barriers when implementing sustainable high-quality services to improve patient care.

  • Implementation Science
  • Service delivery
  • Orthopaedics

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