El Kebir Ghandour, MD, PhD1,2, Sara Leblond, IA, MSc.Inf, IIWCC3,4, Sébastien Binette, MSc5, Josée Rivard, MSc(A)6, John Joanisse, MD3,4, Louise Carreau, IA, MSc.Inf, IIWCC3, Laetitia Bert, MSc2,7, Véronique Boutier, MSc2,8, Jean-Paul Fortin, MD, MPH, MBA, FRCP5,7, Jean-Louis Denis, PhD, FCAHS, MRSc9, Samir Sinha, MD, DPhil, FRCPC10,11,12,13,14, Patrick Archambault, MD, MSc, FRCPC2,4,5,7,8,15,16
1Institut national d’excellence en santé et en services sociaux (INESSS), Québec, QC, Canada
2Centre de recherche intégrée pour un système apprenant en santé et services sociaux—SASSS du CISSS de Chaudière-Appalaches, Lévis, QC, Canada
3Hôpital Montfort, Ottawa, ON, Canada
4Institut du Savoir Montfort, Ottawa, ON, Canada
5VITAM—Centre de recherche en santé durable, Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale, Québec, QC, Canada
6Centre intégré de santé et de services sociaux de la Montérégie-Centre, Greenfield Park, QC, Canada
7Université Laval, Québec, QC, Canada
8Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
9Département de gestion, d’évaluation et de politique de santé (DGEPS), École de santé publique—Université de Montréal, Montréal, QC, Canada
10Sinai Health, Toronto, ON, Canada
11Department of Medicine, University of Toronto, Toronto, ON, Canada
12Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
13Department of Institute of Health Policy and Management, University of Toronto, Toronto, ON, Canada
14Division of Geriatric Medicine and Gerontology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
15Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
16Department of Anesthesiology and Intensive Care Medicine, Université Laval, Québec, QC, CanadaDOI: https://doi.org/10.5770/cgj.26.679
ABSTRACT
Background
In 2016, two Canadian hospitals participated in a quality improvement (QI) program, the International Acute Care for Elders (ACE) Collaborative, and sought to adapt and implement a transition coach intervention (TCI). Both hospitals were challenged to provide optimal continuity of care for an increasing number of older adults. The two hospitals received initial funding, coaching, educational materials, and tools to adapt the TCI to their local contexts, but the QI project teams achieved different results. We aimed to compare the implementation of the ACE TCI in these two Canadian hospitals to identify the factors influencing the adaptation of the intervention to the local contexts and to understand their different results.
Methods
We conducted a retrospective multiple case study, including documentary analysis, 21 semi-structured individual interviews, and two focus groups. We performed thematic analysis using a hybrid inductive-deductive approach.
Results
Both hospitals met initial organizational goals to varying degrees. Our qualitative analysis highlighted certain factors that were critical to the effective implementation and achievement of the QI project goals: the magnitude of changes and adaptations to the initial intervention; the organizational approaches to the QI project implementation, management, and monitoring; the organizational context; the change management strategies; the ongoing health system reform and organizational restructuring. Our study also identified other key factors for successful care transition QI projects: minimal adaptation to the original evidence-based intervention; use of a collaborative, bottom-up approach; use of a theoretical model to support sustainability; support from clinical and organizational leadership; a strong organizational culture for QI; access to timely quality measures; financial support; use of a knowledge management platform; and involvement of an integrated research team and expert guidance.
Conclusion
Many of the lessons learned and strategies identified from our analysis will help clinicians, managers, and policymakers better address the issues and challenges of adapting evidence-based innovations in care transitions for older adults to local contexts.
KEYWORDS: care transition, frailty, older adults, transition coach, implementation evaluation, multiple case study, quality improvement collaborative
Frail older Canadians have complex health and social needs.(1,2) Frailty is a common geriatric syndrome characterized by age-associated declines in physiologic reserve and function across multiple organ systems, leading to increased vulnerability for adverse health outcomes when exposed to endogenous or exogenous stressors.(2,3) Frail older adults are at high risk of hospitalization(2,4) and are more likely to experience organizational failures in access, integration and, especially, coordination and continuity of care.(2,5) In particular, care transitions are high-risk moments in the care continuum that expose frail older adults to avoidable adverse events, threatening their autonomy and lives.(6–8)
The Acute Care for Elders (ACE) program(9) is a widely recognized evidence-informed quality improvement care model that addresses the many issues facing older adults across the continuum of care. In 2010, Sinai Health in Toronto, Canada, developed a context-adapted ACE strategy guideline.(10) Their ACE strategy is a multicomponent intervention within the continuum of care to reduce functional decline, hospital readmissions, emergency room visits, functional disability, and long-term care (LTC) admissions. The ACE strategy includes 1) emergency department (ED) care components; 2) inpatient care components; and 3) community-based interventions.(10) To improve post-discharge care, inpatient care components include care transition interventions involving a “transition coach”—an advanced practice nurse who educates and helps hospitalized patients develop self-management skills.(11) After implementing the ACE strategy, Sinai Health significantly improved overall care quality, reduced inappropriate resource use, and lowered costs.(10)
In 2015, the Canadian Foundation for Health Improvement (CFHI) (now Healthcare Excellence Canada) partnered with the Canadian Frailty Network (CFN) and Sinai Health to launch the International Acute Care for Elders (ACE) Collaborative, a twelve-month quality improvement (QI) program to help implement effective practices leading to better patient outcomes. The CFHI-CFN-Sinai Health partnership provided 18 improvement teams (17 in Canada and 1 in Iceland) with funding (CAD $40,000), coaching, educational materials, and tools to adapt Sinai Health’s ACE strategy to their local contexts. Two francophone hospitals participated: Hôpital Montfort (HM) in Ottawa, Ontario, and Hôtel-Dieu de Lévis (HDL), in Lévis, Québec. Both hospitals aimed to improve their hospital-to-community care transitions for a growing frail elderly population. Both hospitals chose to implement a Transition Coach Intervention (TCI) based on Sinai Health’s ACE strategy. The HM team successfully implemented the TCI, introduced practice changes, and achieved positive organizational outcomes, while the HDL team experienced many challenges and failed to move beyond the pre-implementation phase.
One of the implementation barriers limiting the spread of evidence-based innovations is the difficulty of adapting knowledge tools (e.g., practice guidelines) to other cultural and organizational contexts.(6) How to effectively adapt the ACE strategy TCI component to different cultural and provincial contexts is still poorly understood. Although a previous study has been conducted to determine the effectiveness of the ACE strategy at Mount Sinai Hospital,(10) to our knowledge, no study has previously analyzed the process of adaptation and implementation of the TCI in other Canadian contexts. This study was also the first to be conducted in two francophone hospital settings which adds an additional challenge to translate knowledge implementation material from one language to another.
We aimed to compare the implementation of the ACE TCI in these two Canadian hospitals to identify the factors influencing the adaptation of the intervention to the local contexts and to understand their different results. This study provides a unique opportunity to learn more about the process of implementing and adapting the ACE TCI to different settings and cultural backgrounds.
We conducted comparative analyses to highlight the strengths and weaknesses of each implementation process. We used a retrospective evaluation approach with a multiple case study design, following Yin’s methodology,(12) to identify factors influencing the TCI implementation and adaptation, and to understand the different outcomes in both contexts. According to Yin, case study methodology allows us to use multiple data sources, both qualitative and quantitative, to explore complex relationships between contexts, processes, and outcomes of interventions.(12) Sites selected represented two Canadian provinces with different health systems but many similar characteristics. Both hospitals 1) selected the same ACE TCI; 2) shared a common cultural and linguistic background; 3) were university-teaching hospitals; 4) received the same support and funding. The ethics committees of both hospitals approved our study. We used the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) to report our findings.(13)
We used the Strategic Framework for a Useful and Used Evaluation(14) to analyze the following key elements: 1) stakeholders; 2) issues identified for different stages and levels (local, regional, provincial); 3) strategies for implementation and knowledge-sharing; and 4) contexts and environments that influenced the project’s implementation. This framework also analyzes the theoretical approaches, methods, and strategies tailored to complex projects.(14)
We conducted 1) a documentary analysis (e.g., progress and final reports, CFHI documents); 2) semi-structured interviews until thematic saturation; and 3) two focus groups to validate interview findings. Documentary analysis helped document the project (history, context, actors, decisions, and outcomes), identify organizational and environmental factors, and better plan and understand interviews and focus groups.(12)
Quantitative data were obtained through documentary analysis. Both hospitals identified measures that allowed them to monitor activities and identify areas for improvement. HM selected 6 indicators, while HDL selected 3. Only the 30-day hospital readmission rate was common to both organizations (Table 1). Management teams, supported by the organization’s data analysis specialists, led the ongoing collection and analysis of field measurements.
Table 1 ACE project organizational target achievement
We conducted qualitative interviews and focus groups with key stakeholders identified by each local ACE team leader, including clinicians, patient partners, and managers. We developed the interview guides based on our theoretical framework. Interviews and focus group discussions were recorded and transcribed verbatim. We simultaneously collected and analyzed the data using an iterative approach. This helped in refining our interview guide.
Two independent researchers (EKG and SB) performed thematic analysis according to Braun et al.(15) using Nvivo 12.0 (QSR International, Victoria, Australia). We used a hybrid inductive-deductive approach to identify themes based on our theoretical framework. The researchers developed a coding structure with themes based on the framework and refined it as new themes emerged.(12) We used a descriptive and interpretive approach to assign codes before grouping similar codes into broader themes and theme categories. Disagreements were resolved by discussion (EKG, SB, PA, LB).
Both sites adapted the ACE TCI based on their local contexts and various organizational goals.
The documentary analysis allowed us to describe the context, document the QI project governance decisions and adjustments, access the reported quantitative data, and examine how each organization implemented the project. Documentation supporting this and all analyses is available on request.
The Director of Medicine, Rehabilitation, Geriatrics, Therapeutic Services, Palliative Care and Discharge Planning supported the project at HM. HM slightly modified the original intervention to fit the local context. The HM team hired an advanced practice nurse to serve as a transition coach. Her role focused on pre-discharge patient education, chronic disease self-management, and coordinating post-discharge follow-up. The intervention targeted people aged ≥65 years, scoring 3–7 on the Clinical Frailty Scale(16) scheduled for discharge from an acute medical unit to the community, and able to attend health and medication management education sessions. Patients discharged to a nursing home, rehabilitation unit, intensive care unit, psychiatric unit, or palliative care unit were excluded. The ACE project was integrated into Montfort’s Senior Friendly Hospital strategy and managed by two teams: (1) an implementation team responsible for the project’s local planning and implementation; and (2) a project management team.
At HDL, the ACE project was initiated by an embedded clinician researcher and supported by the Director of Nursing, the Chief Executive Officer, and the Director of the Support for Elderly Autonomy Program. The HDL team did not hire a transition coach. Discharge planning and coordination were already initiated by nurse discharge coordinators. Instead, the team offered patients access to a telemonitoring service managed by a nonprofit, community-based organization (Télésurveillance-Santé-Chaudière-Appalaches), in partnership with Info-Santé-811, a free province-wide telephone helpline. Telemonitoring connects older patients or their family members with a nurse for non-emergency health or social issues 24 hours a day, seven days a week for a monthly fee (CAD $25/month in 2017). To meet eligibility criteria for the telemonitoring service, the HDL intervention targeted patients aged 50 years and older, at high risk for 30-day hospital readmission determined by a modified LACE Index Score (7/12 or higher),(17) able to give consent or have a caregiver who could provide proxy consent. Patients were excluded if they did not speak French or English, or were transferred to a long-term care home or to palliative care.
Since 2013, HDL had been implementing Quebec’s Specialized Approach to Senior Hospital Care (SASHC), aiming to improve the quality of hospital care of older adults.(18) Quebec’s SASHC is heavily influenced by the ACE strategy and included seven objectives overlapping with Ontario’s Senior Friendly Hospital Strategy.(19) HDL’s ACE project was seen as another lever for Quebec’s SASHC and was managed through two subcommittees: (1) an executive committee responsible for designing and implementing the local ACE initiative; and (2) an extended committee involving hospital executives, managers, and advisors.
Each hospital set measurable targets to assess the effectiveness of its respective TCI. Table 1 compares how the two hospitals achieved these targets.
At HM, over a nine-month period (July 1, 2016, to March 31, 2017), the transition coach accompanied 128 patients (14.2 patients per month), whereas the initial goal was 20 patients per month. The transition coach dedicated the last month of the project (March 2017) to knowledge transfer activities to transfer her knowledge to the new discharge management team. HM met three of its six goals: reducing hospital readmission rates by 24%, reaching 88% of patients with a scheduled follow-up appointment with a family doctor or specialist, and exceeding its goal for patient satisfaction measured by the three-item Care Transition Measure (CTM-3) (mean score 3.8). The average length of stay for frail seniors in the care unit was stable. Medication reconciliation worsened; however, the small sample size analyzed does not allow for a robust analysis. The Transition Coach referred several patients to the Rapid Response Nurse Program—Community Care Access Centers (CCACs) (average of 2.6 patients/month). This service was almost unused before hiring the Transition Coach (average 0.9 patients/month, 2014–2015). The CTM-3 was used to monitor patient satisfaction after discharge. This self-report measure was administered by the coach during the follow-up call within 24–48 hours after discharge. The team achieved the CTM-3 target early and it remained stable until the end of the project. HDL achieved two of its three targets: reducing emergency department visits within 30 days of hospital discharge from 22% to 20.5% and hospital readmissions from 14% to 12%. Figure 1 summarizes the ACE project results.
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FIGURE 1 ACE Project Results at the Two Hospitals
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The next sections summarize the characteristics of the participants interviewed, their initial expectations and perceptions, and the factors that contributed to the difference in achieving the two hospitals initial goals.
A single interviewer conducted 13 semi-directed individual phone interviews with HM key informants (May–September 2018; length: 40 to 90 minutes); and eight semi-directed individual phone interviews with HDL key informants (November 2018–April 2019; length: 40 to 75 minutes). We also conducted a focus group in each hospital to validate our interview findings and to gather additional information. Table 2 summarizes the characteristics of key informants at both hospitals.
TABLE 2 Individual interview and focus group participants’ characteristics
Main initial organizational expectations at both hospitals were implementing a standardized approach supporting safe transitions of care, improving the quality of care, and reducing hospital readmissions; improving elderly people and families’ satisfaction; and developing and strengthening links with community health resources. Actors were committed to developing QI initiatives to support older adults and families. At HM, clinicians expressed interest in strengthening the nurses’ role in elder care transitions. At HDL, participants wanted to collaborate on an integrated research project that was led by the senior author (PA) and the CISSS-CA Director of Nursing (JR) who proposed evidence-based strategies to assist decision makers in adapting and implementing the TCI.(6) Integrated research (a.k.a. embedded research) assumes that knowledge that is collected and generated in the field, through daily interaction and negotiation with clinicians, decision-makers and patients, provides better insight into the issues affecting these stakeholders, is more relevant to the local context, and is thus more easily translated into practice.(20,21) This is also the concept underlying the creation of Learning Health Systems, which was the basis for this project.(6) Appendix A summarizes both hospitals’ organizational and personal expectations and perceived ACE strategy results.
We analyzed the project facilitators and barriers according to our framework: actors and resources, theoretical approaches, issues and challenges, strategies, and knowledge transfer approaches.(14) Key barriers and facilitators are detailed in Appendix B. Appendix C provides citations for the dimensions and sub-dimensions of barriers and facilitators identified in our analysis.
We identified the following facilitators, actors and resources: (1) the project manager’s clinical and organizational competencies, which facilitated project planning and implementation; (2) the transition coach’s clinical experience, skills, and knowledge; (3) the clinical and management teams’ openness to change; (4) the collaboration among clinicians and managers; (5) the decision-makers’ commitment, support, and responsiveness; and (6) the support and contributions of the CFHI, CFN and of Sinai Health. Theoretical approaches: Both the evidence-based ACE TCI and project management supported by the NHS Sustainability Model (NHS-SM) supported implementation. Strategies: Effective change strategies included (1) participative co-design and implementation; (2) mitigation of resistance to change; (3) continuous internal and external communication; (4) continuous QI approach; and (5) early focus on sustainability. Knowledge transfer approaches: The team used SharePoint (Microsoft, Redmond, CA, USA), a collaborative authoring and knowledge management platform that saved time and facilitated the sharing of data and documents.
We identified the following barriers for actors and resources: (1) high human resource turnover (more than half of the initial team members changed positions); (2) the transition coach was only part-time; (3) additional workload for clinicians and team members; and (4) difficulty engaging medical staff and establishing community-based linkages (Community Care Access Centre (CCAC) home care providers). Issues and challenges: We found that: (1) the ACE project was limited in time and hampered by insufficient and non-recurrent funding; (2) adapting the intervention to local context proved challenging; (3) the transition coach’s role overlapped with the responsibilities of other professionals; (4) time constraints undermined the efforts of many stakeholders to help design and implement the project; (5) clinicians faced challenges in identifying frail elderly people; and (6) the project failed to demonstrate the impact on some organizational goals.
We identified the following facilitators regarding actors and resources: (1) nursing director and skilled project manager; (2) integrated research team; and (3) CFHI-CFN-Sinai Health financial support and mentorship. Theoretical approaches: We found that developing a guideline-based transition pathway (i.e., using the Registered Nurses’ Association of Ontario Care Transition Guideline(22)) facilitated local acceptability. Strategies: (1) Hiring a research nurse facilitated patient recruitment; (2) telemonitoring referrals; and (3) patient/caregiver completion of the telemonitoring referral form. Developing a video explaining the telemonitoring service was another helpful strategy. Knowledge transfer approaches: Using a Google Sites collaborative writing platform to support team knowledge management and document sharing facilitated the implementation of the ACE care transition component.
The HDL team faced several difficulties that led to significant delays. Actors and resources: Major obstacles included: (1) limited human and financial resources; (2) changes in organizational leadership; (3) frequent turnover in key management roles; (4) changing governance structure; (5) lack of stakeholder involvement in project design and planning; (6) lack of involvement of frontline clinicians and physicians; (7) work overload from other concurrent initiatives; and (8) change in the intervention implementation site (the emergency department was changed to a regular medical ward). Issues and challenges: Quebec’s 2015 health-care reform (Quebec, Bill 1)(23) negatively impacted the project. Merging all Chaudière-Appalaches hospitals, community services and long-term care homes into one large health organization while eliminating many management positions created uncertainty and disorganization. Many newly appointed managers were not empowered to fully support the ACE project many months after the reform. There was also perceived overlap with the Quebec Specialized Approach to Senior Hospital Care, and existing liaison nurses’ duties. The lack of access to timely performance data was another barrier. There was also confusion about whether the project was a research project or a QI project. The ethics committee also struggled to understand the dual integrated research and QI status of the project, thus delaying the approval of the project. Finally, using Google Sites as the team’s knowledge-sharing platform raised cybersecurity risk issues. Strategies: Participants identified the following barriers: (1) lack of clear communication; (2) lack of clinical champions; (3) lack of communication between departments involved in the dysfunctional care transitions (e.g., hospital care to community care); (4) poor project planning to address clinical and operational concerns; and (5) selecting a technology-based intervention (i.e., telemonitoring) with complex care coordination challenges, access, and cost issues.
Table 3 shows the main conditions for success and determinants of sustainability for both QI projects identified through our qualitative analysis based on the theoretical framework. The findings are based on direct interviews with participants regarding their perceptions of the success and sustainability of the TCI.
TABLE 3 Main conditions for success and sustainability for both quality improvement projects
In both hospitals, the ACE project demonstrated alignment with clinical and organizational priorities. Stakeholders at both hospitals cited access to external support, CFHI/Sinai Health experts, learning sessions, and access to knowledge tools and evidence-based strategies as facilitating factors for improvement. Participation in a national collaborative project allowed stakeholders to network, learn from other organizations, and discover the challenges different teams face and their strategies for overcoming them. Both hospitals used a collaborative approach to project development and implementation. Although the two projects had different outcomes, both teams learned numerous QI best practices and strategies. These continue to support sustainable change at both organizations. Understanding the key facilitating conditions and strategies used in both hospitals will benefit other centres planning the implementation of complex care transition interventions.
HM’s implementation strategies provided timely and effective guidance. HM undertook minor adjustments to the TCI design and implementation. In providing telemonitoring services to support older adults care transitions, HDL had to make significant project adjustments. Local stakeholders underestimated the complexity of new care transition projects especially when new technology is introduced.(24)
Both hospitals favoured a bottom-up approach to driving change. Adopting a bottom-up or top-down approach can make a big difference in driving clinical improvements in collaborative improvement projects.(25) To engage stakeholders, HM management team worked collaboratively and frequently communicated. Discussing evidence was key for ensuring project acceptability.(26) Senior management and CFHI experts helped HM overcome local barriers.(27) HM also used iterative implementation cycles.(28,29) Project milestones and accepted quality indicators were regularly tracked by all stakeholders. A recent review identified this as a facilitating factor.(30)
Prior to the ACE project, HM had a strong innovation and QI culture, all important in improving elder care transitions.(26,30,31) Like HM, HDL also embraced innovation and change. However, HDL’s efforts were focused elsewhere due to a major health reform (Quebec, Bill 1) and organizational restructuring. With high staff turnover and changing roles and responsibilities, many managers didn’t have enough time to fully understand their new roles or engage clinical leadership, a critical success factor for QI initiatives.(28) Establishing a governance structure and team composition took many months. Such systemic changes and team member instability disrupt QI projects.(28)
The ACE project was also one of HDL’s first experiences with an innovative form of integrated research supporting evidence-based organizational change. The integrated research team played a major role in engaging stakeholders, and in designing and implementing the ACE project. Involving an embedded clinician-researcher was confusing to some professionals who felt they were contributing to research rather than organizational QI. Although integrated research promises to support learning health-care organizations, many challenges remain, including creating a collaborative research/clinical culture where stakeholders work together in a trusting and open relationship to sustainably improve health system outcomes.(32) This first integrated research experience provided a strong, sustainable foundation for future integrated research. Several ongoing spin-off projects continue the work started during the ACE project.(6,33)
Finally, sustainability was an early concern for CFHI leaders. MH used the NHS-SM to monitor and manage change.(34) Addressing sustainability early helps participants avoid wasted effort and highlight the collective benefits of QI initiatives.(29,34) In both centres, three issues limited organizational capacity to measure sustainability: (1) barriers to accessing timely data; (2) lack of data systems for project performance monitoring and data analysis; and (3) lack of interoperable information systems to measure care continuity across transitions.
Our results complement the conclusions of the Acute Care for Elders Strategy Sustainment and Sustainability Study (ACES-SSS).(35) Similar to our study, ACES-SSS compared the sustainability of two different in-patient ACE interventions at two other ACE Collaborative intervention sites: a rural and remote community hospital (Whitehorse General Hospital) and an academic-affiliated hospital (Thunder Bay Regional Health Sciences Centre). Our study differed from ACES-SSS because we only focused on a TCI in two different hospitals with similar academic backgrounds, while ACES-SSSS studied the sustainment and sustainability of two in-patient care interventions in two different academic settings: the Braden Skin Assessment at the Thunder Bay Regional Health Sciences Centre and an ACE unit to offer optimal evidence-based in-patient acute care for older adults at the Whitehorse General Hospital. The ACES-SSSS found that adaptations to evidence-based interventions which respect as much as possible the fidelity of the original intervention are more likely to be sustainable. We also found this to be the case at HDL, where the TCI was adapted to the point that it differed significantly from the TCI implemented at HM and quite differently from the original TCI developed by Coleman et al.,(11) ultimately leading to successful sustainability at HM compared to HDL. Similar to Rappon,(35) we also found that frequent staff turnover and rapidly changing organizational priorities were major barriers to sustainability in both HM and HDL study sites. A common facilitator identified in both studies was the highly valued support of CFHI and Sinai Health experts in the form of additional funding, clinical expertise, and change management expertise. Our study adds to the ACES-SSS and existing implementation science literature by suggesting several facilitators to consider when adapting an evidence-based innovation to new organizations with different provincial contexts and change management cultures: minimal adaptation to the original evidence-based intervention; use of a collaborative, bottom-up approach; use of a theoretical model to support sustainability; support from clinical and organizational leadership; a strong organizational culture for QI; access to timely quality measures; financial support; use of a knowledge management platform; and involvement of an integrated research team and expert guidance.
Our study has several strengths. First, we interviewed a large sample of key participants representing a range of clinical, policy, and managerial stakeholders. We also included the patient perspective by involving a patient partner from HM. We used rigorous qualitative analysis methods, including focus group validation of our findings. Our rigorous approach and large sample size support generalizability to other Canadian francophone hospitals.
We also acknowledge some limitations. First, our retrospective analysis could be exposed to recall bias. Second, we were only able to report on the perspective of a single patient partner. Finally, analyzing other ACE Collaborative sites’ experiences, including international sites, would have provided more diverse and generalizable results.
We compared the implementation of a care transition intervention in two French-Canadian hospitals participating in an Acute Care for Elders QI collaborative. Emerging lessons and strategies will help clinicians, managers, and policymakers better address the challenges of implementing complex evidence-based care transition interventions. Notably, minimizing adaptations to original evidence-based interventions, using a bottom-up collaborative approach supported by strong clinical and organizational leadership, strong organizational culture for quality improvement, access to timely quality indicators, financial support, use of a knowledge management platform, and involvement of an integrated research team and expert guidance are key factors to successful care transition quality improvement projects.
The authors would like to thank the two hospitals for supporting this study, as well as everyone who agreed to participate as key informants. We would also like to thank Thérèse Antoun and Linda Lessard for their assistance with access to key informants and the relevant data, and Denis Roy for supporting the first author and feeding our reflections during the writing of the manuscript.
We have read and understood the Canadian Geriatrics Journal’s policy on conflicts of interest disclosure and declare we have none.
El Kebir Ghandour received a CIHR Health System Impact Fellowship Award from the Canadian Institutes of Health Research (CIHR) in collaboration with the Centre intégré de santé et de services sociaux de Chaudière-Appalaches, from 2017 to 2018 (#388533). Patrick Archambault received a CIHR Embedded Clinician Researcher Award (#370937) and a Fonds de recherche du Québec—Santé (FRQS) Clinical Scholar Award (#283211). This project was supported by an Institut du Savoir Montfort—Pilot Project Grant (2017-10). The Institut du Savoir Montfort had no role in the design and conduct of the study, in the analysis and interpretation of the data, or in the approval of the manuscript and the decision to submit the manuscript for publication.
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Correspondence to: EL Kebir Ghandour, MD, PhD, Institut national d’excellence en santé et en services sociaux (INESSS), 2535 boulevard Laurier, Québec, QC G1V 4M3, E-mail: elkebir.ghandour@inesss.qc.ca
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This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.
Canadian Geriatrics Journal, Vol. 26, No. 4, December 2023