Background
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What do managers in municipalities and hospitals experience as success criteria in the implementation of mobile radiography services?
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What do managers in municipalities and hospitals experience as barriers to implementing mobile radiography services?
Method
Context: The Norwegian healthcare system
Participants and local context
Area | Number of municipalities included in the service | Population in the area [31] | Size of the area (km2) [32] | Participant | Management position | Experience as a managera |
---|---|---|---|---|---|---|
A | 10 | 369,714 | 1823 | 1 | Hospital administratorb | Long |
2 | Municipal administratorc | Long | ||||
B | 2 | 135,248 | 694 | 3 | Municipal administratorc | Long |
10 | Manager of x-ray departmente | Long | ||||
C | 10 | 230,899 | 2174 | 4 | Manager of nursing homed | Long |
7 | Manager of x-ray departmente | Long | ||||
D | 8 | 212,109 | 2004 | 5 | Manager of nursing homed | Long |
6 | Manager of nursing homed | Short | ||||
11 | Manager of x-ray departmentd | Long | ||||
E | 5 | 315,462 | 1402 | 8 | Municipal administratorc | Long |
9 | Project manager at the hospitalf | Just for the project |
Data collection
Analysis
Stage | Who and how |
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Transcription | EK transcribed the recordings verbatim |
Familiarization | All researchers familiarized themselves with the data by reading through the transcripts |
Coding | Two researchers coded openly three transcripts |
Developing the working analytical framework | All 4 researchers met to discuss and agree on a set of codes grouped into categories in a working analytical framework. In addition, the researchers met to engage in reflexivity discussions. Using this analytical framework and further open coding, two researchers coded the next four transcripts. Then, after a new discussion, the team revised and refined the framework. This process was repeated until all transcripts were coded. Finally a final thematic framework was agreed upon. The framework consisted of six categories with 4–10 codes each. These are available in Additional file 1 Table A2. |
Applying the analytical framework | EK indexed all transcripts using QSR International’s NVivo Pro version 11 software (NVivo). |
Charting the data into the framework matrix | EK charted the data into 33 matrices consisting of cases in the rows and codes in the columns using NVivo. |
Interpreting the data | Thematic analysis for descriptive purposes was performed by EK supported by AMM, as described by Ritchie [24]. Elements were detected in the data summaries in the matrices. These elements were sorted according to underlying dimensions and key dimensions were identified. Then categories and higher order classifications were identified. All the researchers met to discuss findings and to reach a consensus. |
Trustworthiness
Results
Macro level
National health policy
“The reimbursement system was not made for mobile services… It was made for an old-fashioned system in which things happen within four walls, such as in hospitals”.
“The funding facilitated it [mobile radiography services]”.
Regional and municipal policy and conditions
“This must also be supported at the chief municipal executive level. And when councilors change jobs or when new municipal councils come into power and so on, there is a risk that these kind of projects disappear, because they have such weird financing”.
Micro level
Experienced outcome
“So here we are working with placing the patient in the centre, and thinking holistically about the patient. And this [mobile radiography] is very patient friendly. And I think that’s an important argument … It [mobile radiography] saves us a lot of frustration in relation to transportation, waiting for an ambulance, and finding someone to accompany the patient. It is much easier when we can just call and they say we’re coming rather than using family members or the volunteer centre”.
Professional skills and personal characteristics
“We had a doctor who was enthusiastic, an elderly physician at the time, who was really into this [mobile radiography] …, she was very motivated and tried to persuade me to say that we had to have this”.
“Those who come here are very nice, very helpful and very welcoming. It mean a lot that those who provide the treatment [mobile radiography] also think that this is a great service”.
Meso level
Collaborative implementation projects
“When the decision was made, when we decided, yes we will have a project, and we have the money, then we had to ensure that all the structures were in place first. So we established a project with a steering committee and project group”.
Economic aspects
“Perhaps the challenge with this kind of project was that it came from an enthusiast. It lacked anchorage in top management. It was a good project and it was nice to talk about it. But the lack of anchorage in top management made the funding a challenge”.
“For the part that was not externally funded, we agreed on a 50-50 economic model. The municipality covered half of the costs and the hospital trust covered the other half… This was really important for the hospital trust”.
“If we had contracts with several municipalities, the contracts would need to be revised and kept up to date. We were not actually talking about much money, so the disadvantages of the bureaucracy outweighed the benefits”.
Collaborative culture
“You must have enthusiasm all the way, if not you will fail”.
“It was very important to involve them [the nursing home staff]. They could point out their needs and the importance of having x-ray as a diagnostic tool in the nursing home. I think that was very important”.
Planning an efficient service
“This is a typical example of mobile services being cost-effective in densely populated areas, quite the opposite of what people think”.
“We’ve said that these are semi-acute examinations. Our aim is to carry out the examination within the course of the next day, but it is not guaranteed, it’s one of those semi-acute services”.
“Yes, if you are at the bedside you get to see the image and that’s ok… we need the results quickly, we get the results mostly the same day. She [the radiographer] looks at the images there and then as well, and lets us know if there is anything special”.
“Transfer of images was also a challenge in other projects. We have not yet come so far either. So we are still working on this, and we have the money, but we haven’t got the solution up and running yet… Now we use a memory stick”.
Developing routines and procedures together
“They [nursing home physicians and nurses] were involved in defining the service and talked about their needs in relation to the type of examinations they envisioned, how cooperation with the radiographer should be in the nursing home and with our radiologists here in relation to the results when we did not have wireless image transfer”.
Piloting and evaluating the service
“So there was talk of testing to be able to deploy this [mobile radiography services] in a sensible way. We tested it in two municipalities first”.
“We thought that it was important to have one designated person in the service who would drive around and establish contact with the nursing homes. It was important to have continuous dialogue, to get them to use us [the mobile radiography service]”.
“We received regular reports from the project manager, showing how much the service was used. This was a good parameter for asking questions in our own organization: Why are we not using mobile radiography? And we could compare ourselves with others. This has been a good tool”.