Examples of the challenges encountered during the implementation of the Clinical Information Network related to preservice training, hospital norms and national policies
Level | Examples of challenges |
Preservice training | The training of junior medical staff sometimes conflicts with the apparent restrictions on clinical autonomy encompassed by guidelines and their learning experience in tertiary settings where evidence-based guidelines may be looked down on as ‘too simple’. Concerns that increasing student numbers is affecting the quality of undergraduate training exemplified by a paediatrician’s comments: ‘The interns we are getting are very poor. What I have seen in the last 5 years, I don’t know what kind of training they get.’ Highly variable graduation dates for clinical cadres within and across institutions challenge planning for orientation of the newly qualified clinicians before their rotation on the wards (and see below). Postgraduate (consultant) training includes little emphasis on management skills such as how to give effective feedback at group or individual levels and in how to foster teamwork among junior clinicians and nurses. Each hospital retained the primary data on its admissions but utilisation of local data by the hospital clinicians and management for more local quality improvement cycles or planning and resource allocation was limited. This was related to relatively poor computer and data analytical skills and limited capacity in hospital records departments with reliance on more intuitive management based on historical contingencies. |
Hospital contexts and practical norms | Hospitals often lacked printers/projectors making wide dissemination of feedback reports problematic with a continued reliance on receipt of limited numbers of hard copies. Challenges in local planning and resource mobilisation in hospitals where access to and control over financial resources is very limited. This can impact the continuous supply of hospital stationery such as structured admission (paediatric admission record (PAR)) and discharge forms as well as undermine efforts to improve practices (eg, testing for hypoglycaemia). There is very high turnover of the medical and clinical officer interns such that almost the entire junior clinical team may change every 3 months. Continued role (and in some cases reliance on) of pharmaceutical companies’ support for continued education meetings that may undermine guideline adherence. Practical norms sometimes conflict with practices being promoted such as:
Competing priorities—the role of heads of paediatric teams is often not perceived as including quality improvement and are given no dedicated time or training for these activities while they also have multiple competing priorities. |
National/county governments | Historically weak systems for disseminating policies and monitoring their uptake linked to weak systems for promoting and regulating quality of care. Insufficient capacity for generating and using information as part of decision-making in resource allocation (staff and equipment) to ensure minimum standards of care are achieved. |