Corresponding author: Wilma ten Ham-Baloyi, Nelson Mandela University, Faculty of Health Sciences, Private Bag x 77000, Port Elizabeth, 6031, South Africa, Tel: +27 (0) 41 504 2959, Fax: +27(0)41 504 2960, Cell: +27(0)79 074 5905. az.ca.alednam@iyolab-mahnet.amliw
Copyright © 2020 Ten Ham-Baloyi W et al.Licensee African Health Sciences. This is an Open Access article distributed under the terms of the Creative commons Attribution License (https://creativecommons.org/licenses/BY/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Best practices comprise recent, relevant, and helpful nursing practices, methods, interventions, procedures or techniques based on high-quality evidence. Best practices should be implemented to improve individual patients' health outcomes the overall quality of health care, and to strengthen the health system at large. Four facilitators (benefit levers) to effectively roll-out best practices in healthcare organizations were identified: alignment, permeation plans, leadership for change, as well as supporting and reinforcing structures.
To develop and review a guide for an operational plan to facilitate the roll-out of best practices in healthcare organizations.
The content of the guide was based on findings of an integrative literature review and interviews. This article discusses the development of the guide using the logic model as format (phase One) as well as its review including five key informants using the Delphi method (phase Two).
The Logic Model provided a feasible format for the guide. Two Delphi rounds were required to review the guide's design and content. This guide addresses pre-roll-out resources; pre-roll-out activities, best practices (outcomes) during and after roll-outs; and impact.
The guide should be tested in different healthcare organizations and adapted accordingly to have an impact on improved patient and health outcomes. The guide can be used by managers wishing to roll-out best practices in their healthcare organizations to achieve improved health outcomes for individual patients.
Keywords: Best practices, guide for an operational plan, healthcare organizations, implementation of best practices, roll-out of best practices
A best practice is more than practice based on evidence. It represents quality care which is deemed optimal. 1 Best practices are health practices, methods, interventions, procedures or techniques based on high-quality evidence in order to obtain improved patient and health outcomes. 2 However, evidence alone is not sufficient to ensure evidence-based decision making but requires uptake and sustained implementation of the evidence. 3 Globally evidence-based products such as best practice guidelines or standards are developed and made available, but the challenge remains to get evidence implemented and then rolled-out into everyday practice and clinical decision making. 4 Numerous barriers to the implementation and roll-out of best practices have been reported, such as the complexity of practice environments, the lack of support of management and buy-in, resistance to change, and the suitability of the best practice for an individual patient. 5 Furthermore, tailoring best practices to the needs and preferences of diverse populations requires further research and testing before rolling out and scaling up the best practice in a specific institution. 6
Rolling-out or “spreading”, involves the active disseminating of best practice and knowledge about an intervention and implementation of this intervention in every relevant available care setting in order to provide more patients with evidence-informed care. 7 , 8 Roll-out of best practices further requires a point when evidence is accepted by most individuals and cannot be turned back and therefore change is inevitable: the so-called tipping point. 9 To create that tipping point towards successful adoption, implementation and roll-out of evidence and to ensure that innovations (such as best practices) in the health system are rolled-out, certain facilitators are required.
The “Evidence Informed Model of Care” which was developed by Edwards and Grinspun, 8 is supported by evidence and identifies the following four facilitators for roll-out (the so-called benefit levers): alignment, permeation plans (plans for roll-out), leadership for change and reinforcing and supporting structures. Alignment implies alignment among stakeholders (personal alignment), between top management, middle management and government (organizational alignment), and with the external environment, financial incentives, regulations and public reporting professional norms (contextual alignment). Permeation plans include three phases: 1) preparing the roll-out of best practices; 2) developing the plan; and 3) executing the plan. Leadership for change includes characteristics such as leadership types, leadership strategies, the position of leadership, the attitude of the leader and support for the leader in the organization. Supporting and reinforcing structures include various requirements such as: resources, time, education, communication, feedback and evaluation about the best practice. 8 , 10 According to the model, roll-out of best practices occurs at certain levels in organizations and systems, such as individual level (the health professional in the unit of the organization), management level (the unit and the healthcare organizations at large), provincial level (such as the provincial Departments of Health) and national level (such as the National Departments of Health). 8
Globally, and in South Africa, the roll-out of best practices remains challenging as developed best practices might remain inaccessible and unidentified for use. 2 , 8 This, coupled with contextual factors creating barriers for implementation and roll-out, results in the best practice not being implemented and rolled-out and therefore practice is not changed. 6 A guide, where these factors in the form of benefit levers are considered, could help organizations or departments to develop an operational plan that facilitates the roll-out of best practices in a certain context. An operational plan can be regarded as part of a strategic plan specifying how to operate in practice to implement actions and monitor plans. It will also define what the organisation's human, financial and other capacity requirements are and how to engage these resources. 11 This operational plan could enhance the roll-out of best practices to improve patients' and health outcomes. Using a search on Google and GoogleScholar, no published guide for an operational plan could be found that facilitates the roll-out of best practices in South Africa.
This study aimed to develop and review a guide for an operational plan that facilitates the roll-out of best practices in a healthcare organization.
The content of the guide is based on the findings of two methods. Firstly, an integrative literature review regarding the benefit levers' characteristics for system-wide roll-out of best healthcare practices was conducted. 10 A comprehensive search using multiple sites such as Scopus, EBSCOhost, ProQuest, ScienceDirect, Cochrane Library, Nexus, SAePublications, Sabinet, Google Scholar and grey literature was conducted (January-March 2012) and updated (December 2014). After a thorough search and selection process, 40 documents met the inclusion criteria. Thirty-five documents remained after critical appraisal. Data revealed characteristics about alignment (personal, organizational and contextual attributes), permeation plans (three phases: 1. Preparing for spread; 2. Developing the plan; and 3. Executing the plan), leadership for change (types of leaders, strategies for spread of best practices used by leaders, position of the leader in the organisation, attitude of the leader and support from the leader and to the leader) and supporting and reinforcing structures (types, including organisational structure and culture, contextual structure, individuals as structure and the innovation itself as a structure as well as requirements, including resources, time, education and development, communication, networking and cooperation as well as feedback and evaluation). 10 Secondly, twelve individual semi-structured interviews were conducted with healthcare professionals' from various South African healthcare levels about their perspectives concerning the requirements for facilitating the roll-out of kangaroo mother care as a best practice. Content analysis were guided in terms of the four requirements for roll-out of best practices, identified in Edwards and Grinspun's Evidence Informed Model of Care. 8 , 12 The requirements for the successful rollout of best practices mentioned by the participants in this study concur with the requirements of Edwards and Grinspun: personal alignment and protocol/policy alignment with the best practice; a roll-out plan; leadership; and supporting and reinforcing structures such as: resources, communicating, education and development regarding the best practice, and the organisational structure. The requirements were identified at four different levels: individual level (e.g. the nurse and medical specialists), management level (of the hospital), provincial level and national level. 12 This article discusses the development of the guide using the Logic Model as format (phase 1) as well as its review using a Delphi method (phase 2). Both phases were conducted by the first author under supervision of the second and third authors.
A Logic Model is a systematic and visual way of presenting and sharing an understanding of the relationships among the resources required to operate a certain program, the activities planned, and the changes or results expected to achieve the change. 13 Logic Models can therefore be used for program planning and design, such as a program to implement and roll-out a best practice. The Logic Model has four steps: Step 1: Preparation for the development of the Logic Model; Step 2: Development and assembling information; Step 3: Creation of the Logic Model; and Step 4: Reviewing and revising the logic model. 14 A description and application of these steps in order to develop the guide is outlined in Table 1 .
The steps of the Logic Model applied to the guide 13 , 14