Table 5 The development and implementation of a GDM dietitian-led model of care using the i-PARIHS framework

 Overview

Starting point:

• Minimum schedule of dietetic appointments (Queensland Clinical Guideline for GDM)

• Goal to increase women’s access to dietetic support and reduce pharmacotherapy requirements.

Organisational fit:

• Task duplication identified

• Low and high-risk models of care (diet-controlled vs pharmacotherapy + diet)

• Models of care: Low risk as dietitian-led, high risk as diabetes educator and physician led

• Increased surveillance for low-risk GDM patients (due to third dietetic appointment)

• Timing of appointments and changes to ongoing monitoring of all women with GDM.

Supporting material:

• Escalation of care flow chart for dietitians

• Low and High-risk model of care summary flowcharts

• Updated patient information

• Pre-implementation checklists

Recipients (Staff):

• Diabetes team members: Dietitians, Diabetes Educators, Nursing Unit Manager, Clinical Nurse Consultant, Director of Endocrinology, Obstetric Physicians, Administration Officers.

• Working party: Clinical Nurse Consultant (opinion leader/ authority), Dietitians (champions/ opinion leader), Nursing Unit Manager (authority), Diabetes Educators (champions)

Local:

• Increasing GDM diagnosis requiring efficient model of care

• Task duplication within the team

• Leadership change

Organisational:

• Change to organisational structure.

• Period of transition (opening of new hospital).

External Health Systems:

• State-wide publication of Clinical Guideline for GDM (2015)

Problem identification:

• Clinical guideline recommendation for MNT not met

Acquiring/appraising evidence:

• Literature review [7, 8, 22, 32, 33]

• Prior research (Surveys) [12, 23]

• Service mapping

Consensus building:

• Stakeholder mapping and engagement

• Team meetings

• Goal setting

• Local context assessment:

• Diagnosis using i-PARIHS guidance

• Model of care development meetings

• Working party contributions

 Barriers

• Staff resourcing

• Education/knowledge

• Managing schedule of appointments

• Some resistance to change (minor)

• Competing interdisciplinary priorities

• Differences of opinion

• Perceived workload pressures

• Motivation and engagement

Local:

• Historical resistance to change

• Team culture

Organisational:

• Period of high organisational change and transition

Project management:

• Increase to dietitian FTE/ clinic days

• Appointment template changes

• Working party meetings

• Newsletters/ email updates

Improvement methods:

• Professional development sessions

• Team meetings

Conflict management and resolution:

• Leadership involvement

• One-on-one meetings

Team building

• Team meetings

• Acknowledging key contributions

 Enablers

• Strong evidence-base

• State-wide guidelines

• Well-established team

• Dedicated researcher

• Leadership support

• Local opinion leaders/ champions

• Minimal disruption to usual workflow

• Individuals and team able to implement change

• Low staff turnover

Local:

• Team autonomy

• Leadership support

Organisational:

• Executive support

• Alignment with organisational and research priorities

External Health System:

• State-wide mandate

Team building:

• Acknowledging enablers

• Feedback

 Intervention/ change in practice

• New schedule of dietetic appointments and reduction of diabetes educator appointments

• Dissemination of supporting materials

• Increase to dietetic staffing time for GDM

• Procedures and policies to inform local system changes

• Procedures and policies to inform local system changes

• Informed stakeholders and executive of change to model of care

Communication and feedback:

• Fortnightly meetings

• Newsletters/ email updates

Conflict management and resolution:

• One-on-one meetings

• Leadership involvement

 Successes

• Adherence to schedule of dietetic appointments (29% vs 88%)

• NoMAD survey: familiar, understanding of purpose, support for the model of care, change in negative perceptions

Local:

• Dietitian-led model of care adopted as standard practice

 Confounders

• Appointment timing deviated from original Academy of Nutrition and Dietetics Nutrition Practice Guidelines

• Initial education as group rather than individual

• Fidelity: patient satisfaction survey not implemented

• Sustainability: FFQ data collection not completed at second review

• Lack of perceived value for understanding patient satisfaction and FFQ

• Significant differences in baseline characteristics between pre-and-post intervention groups (early diagnosis, family history of diabetes mellitus, previous diagnosis of GDM)

Local:

• Increased surveillance of women with GDM to the end of their pregnancy

Communication and feedback:

• Newsletters/ email updates

• Post-implementation presentation to team members