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

From: An implementation science approach for developing and implementing a dietitian-led model of care for gestational diabetes: a pre-post study

  Innovation Recipients Context Facilitation activities
Development Phase
 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
Implementation Phase
 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
Evaluation Phase
 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
  1. GDM Gestational diabetes mellitus; FFQ Food frequency questionnaire