Table 5

Top 5 challenges and facilitators

ChallengeSolutionRationaleFocus group comments
Staff too busyUse of a multidisciplinary teamBundle initiated more consistently and less impact on one person's workload“Having multidisciplinary people get involved helps with the initiation of the bundle. Because even if one person misses it a physio or nurse comes and starts it and even a pharmacist can say this patient isn't on a bundle and start one” (Physiotherapist, group 1)
Staff shortagesNone identifiedViewed as out of staff control“There are some things we will never have solutions for… because we can’t, we don’t have any power over that” (Nurse, group 2)
Staff engagementChange perception of the bundle from research to best practice
Finding project champions
Having a CQUIN in place
Educating the staff on the benefits of the bundle
Demonstrated to staff that this should be done for every patient regardless of the bundle
Aided in getting people on board and motivating staff to complete the bundle
Allowed the staff to see the financial importance of bundle delivery and was key in gaining support from managers
Allowed staff to recognise the improvement the bundle makes to patient's care
“It was about educating and changing the perceptions…that really the two things we asked them to do, are what they should be doing during their everyday work anyway like inhaler technique and smoking cessation...So once the perception was changed and actually it was part of their everyday role, they didn't see it as an add-on to what they were already doing” (Nurse, group 1)
“If you are going to do it, find a champion on the ward. Nurses do not respond to someone who comes on to the ward as much as they do to someone they already work with” (Consultant, group 3)
“When the CQUIN was introduced there were financial penalties for non-completion which meant managers were more interested in encouraging staff to complete the bundle” (Physiotherapist, group 2)
“If nurses don’t understand something they are not going to do it. The benefits of PR(Pulmonary rehab), inhaler technique, of course they want to do it because they want to provide the best care but if they don't understand it they aren’t going to do it. If you have someone there explaining than it is much better” (Clinical Nurse Specialist, group 2)
Added workload of the bundleChanging the perception of the work involved in delivering the bundleNo longer considered extra work but as part of the standard of care required for all patients“A large part was changing the perception of the bundle, they envisaged it as more time consuming than it actually was, because they are constantly being given more paperwork around various diseases and to them it was just another piece of paper that they thought would be a lot of work” (Nurse, group 1)
Patient coding issuesEngaging coders in the project
Educating junior doctors on coding technique
Coders aware of the bundle project and able to properly code patients
Eligible patient accurately coded and started on the bundle
“The team asked the coders to talk us through their process…by understanding their process we were able to help them understand ours” (Nurse, group 1)
“Making sure that education is paramount for junior doctors… so that they are aware how to code the conditions” (Consultant, group 2)
  • CQUIN, Commissioning for Quality and Innovation.