Table 2 Facilitators and barriers that affected the process of developing and implementing a transmural palliative care consultation service

Intervention characteristics

The relative advantage of implementing the intervention

Facilitators:

Healthcare professionals perceived the added value of the intervention as

• improving continuity of care for patients with a limited life expectancy, regardless of the care setting;

• a potential vehicle function for other activities in the field of palliative care;

• promoting more transmural collaboration between palliative care experts from hospital and from primary care.

Perceived difficulties of the intervention

Barriers:

• Healthcare professionals had different views on goals and activities of the transmural palliative care consultation service.

• Scientific evidence for a complex intervention such as a transmural palliative care consultation service is scarce.

• Where the researchers presented scientific evidence that supported (part of) the complex intervention, project teams often questioned presented findings and doubted whether these were applicable in their case.

Inner setting

The implementation climate: the level of priority attached to the intervention, organisational incentives, the degree to which goals are clearly communicated

Facilitators:

• Networks identified transmural collaboration as an important challenge.

• Initial support from the management of involved care organisations was perceived as supportive.

Barriers:

• Healthcare professionals experienced limited positive stimuli from involved care organisations.

• Involved care organisations sometimes had limited interest/doubts/resistance regarding the development of a transmural consultation service, because they felt there was insufficient evidence to demonstrate its benefits and cost-effectiveness.

• Project teams experienced a lack of ‘best practices’ or other guidance in how to organise the service.

Readiness for implementation

Facilitators:

• Networks voluntarily opted to participate in the project.

Barriers:

• The management of involved care organisations sometimes turned out to be reluctant when concrete efforts were required.

• Registration of transmural consultations in patients’ medical files was found to be complex because of different registration systems within and outside the hospital.

Outer setting

Relevant external policies and incentives

Facilitators:

• Project team members considered the Netherlands Quality Framework Palliative Care and the Multidisciplinary Standards for Oncological Care in the Netherlands (SONCOS norms) for hospitals as very supportive.

Barriers:

• Healthcare professionals and other participants involved expressed a need for national guidance, but also wanted to adapt the intervention to the local situation.

• Separate funding streams for the financing of intra- and extramural palliative care consultations made the administrative part of the transmural consultation service complex.

• On top of the regular reimbursement, extra financial support was needed, but often lacking.

Characteristics of individuals involved in the implementation

Individuals’ knowledge and beliefs about the intervention

Facilitators:

• Palliative care experts participating in the transmural palliative care consultation service experienced collaboration and mutual exchange of information as important.

Barriers:

• Professionals from different care organisations having different views on palliative care, working procedures and about who was in control over the initiative made collaboration sometimes more complex.

• (After implementation:) Several extra efforts being required from healthcare professionals participating in the transmural palliative care consultation service, without diminishing their regular tasks, made healthcare professionals reluctant to do, for example, extra tasks for the transmural consultation service such as attending meetings.

• Different participants (healthcare professionals, coordinators, managers) asked for different motivators for the actions needed.

Individuals’ identification with ‘their’ organisation

Facilitators:

• Project team members wanted to share their clinical expertise and experience within the project team and/or the transmural consultation service.

Barriers:

• Identification of project team members with other than their own care organisation in the palliative care network was limited.

• Roles and responsibilities of project team members regarding the development of transmural procedures were not clear.

Implementation process

Planning

Executing

Reflecting

Evaluating

Facilitators:

Professionals from different care organisations were dedicated and enthusiastic about the initiative.

Barriers:

• Professionals had difficulties to arrive at a problem definition, a concrete goal and appropriate actions. Professionals perceived limited/no guidance on how to write a project plan and how to develop and implement a transmural consultation service in the relatively complex area of palliative care.