HARMONIZATION OF GROUP PERSPECTIVES: A CASE STUDY OF CLINICAL
PRACTICE GUIDELINE IMPLEMENTATION AT A LARGE REGIONAL
HEALTH AUTHORITY
by
Fraser Bell
B.A. Economics, Wilfrid Laurier University, 1984
B.Sc. Biology, McMaster University, 1988
M.B.A. McMaster University, 1991

THESIS SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
IN
HEALTH SCIENCES

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
December 2022
© Fraser Bell, 2022

i
Abstract
Policy makers, health industry leaders, clinicians and researchers struggle to
understand how new evidence-based practices, including Clinical Practice Guidelines
(CPGs), can be implemented more quickly and more consistently. This retrospective
qualitative case study explored sepsis CPG implementation at a British Columbia Regional
Health Authority (RHA) between 2011-2017 to understand how individuals and teams with
various functions and decision-making purviews come together to implement a prioritized
CPG in a large RHA. The study was informed by practice theory and designed to provide
practical guidance as to how CPG implementation might be better supported. Interviews
involved 38 participants reflecting three functional groups: academics, regional managers
and support staff, and clinicians. Over 350 documents and implementation process and
outcome data were analyzed.
The CPG implementation process was dynamic, involving different activities and
intensities of involvement of individuals from each of the three groups. The three groups
each behaved in a manner consistent with what some practice theorists call a community of
practice. Individuals from each community of practice (COP) had a different perspective
about the implementation along five dimensions (focus and rationale, vision, priority,
appropriate balance and application of power, and goals, strategies and actions to be taken).
The different COPs undertook actions that were consistent with their own COP perspective
but not sufficiently aligned to ensure adherence to the CPG. The result was a discordant, and
unsuccessful implementation. CPG adherence was not achieved. The differences in
perspectives among the three COPs were substantial and appeared to have been deeply
rooted in the beliefs, functions, experiences, and day-to-day realities of each of these groups
of participants. The discordance in the implementation resulted from an insularity of each

ii
COP from the others, brought about by inadequate engagement among participants;
insufficient connections across COPs to support shared understanding and alignment of
action.
Without some intervention, differences in perspectives will prevail and discordance is
the likely outcome of any complex CPG implementation. This dissertation proposes the
novel concept of harmonization as a means of achieving more successful CPG
implementation; a process intended to reduce insularity of individual COPs within and
beyond a RHA. Harmonization is conceptualized as a process comprised of many
harmonizing activities that support engagement, relationship-building and explicit reflection
and reconciliation of key differences in perspective among the three COPs. As a relational
process, harmonization is largely determined by longstanding, contextual factors that support
connections and collaboration among COPs. Widely engaging, horizontal, service-oriented
improvement structures (with clear supporting roles and processes) establish a foundation for
harmonization. Ongoing local interprofessional learning and improvement activities are
essential to ensuring that the service improvement benefits from strong clinical engagement.
RHA managers, particularly clinical managers, can support harmonization by encouraging
open sharing of perspectives and managing in a way that is responsive to the realistic ebbs
and flows of the implementation process. Harmonization integrates and builds upon many
known CPG implementation determinants and strategies to bring a practical focus for future
research and action.

iii
Table of Contents
Abstract ...................................................................................................................................... i
Table of Contents ..................................................................................................................... iii
List of Tables ......................................................................................................................... viii
List of Figures .......................................................................................................................... ix
Glossary .................................................................................................................................... x
Acknowledgements................................................................................................................. xii
Chapter One: Introduction ........................................................................................................ 1
The Problem with Implementation of Clinical Practice Guidelines ..................................... 2
Research Focus and Scope .................................................................................................... 3
The Regional Health Authority ............................................................................................. 4
Research Approach and Results ............................................................................................ 5
Dissertation Overview .......................................................................................................... 5
Chapter Two: What is Known About EBP Implementation? ................................................... 7
Clinical Practice Guideline and Evidence Based Practice Implementation .......................... 7
Determinants of Successful EBP Implementation ............................................................ 8
A Determinant Framework Supporting Implementation Research ................................... 9
Determinants Most Relevant to Health Organizations .................................................... 12
The Limitations of EBP Implementation Determinants .................................................. 20
Evidence-Based Practice Implementation Strategies ...................................................... 22
The Limitations of EBP Implementation Strategies........................................................ 23
Gaps in the EBP Implementation Literature ................................................................... 24
EBP Implementation From an Organizational Perspective ................................................ 26
Understanding EBP Implementation as Socially Situated Learning ............................... 27
Recognizing Differing Perspectives and Power Dynamics ............................................. 29
Spanning Boundaries Between Groups and Organizations ............................................. 30
Designing Structures and Processes to Promote Participation ........................................ 31
Gaps in Knowledge About Implementation From an Organization Perspective ............ 32
Summary ............................................................................................................................. 33
Chapter Three: Questions and Concepts Guiding the Research ............................................. 34
Research Questions ............................................................................................................. 34
Conceptual Underpinnings for the Research ...................................................................... 34

iv
Practice Theory................................................................................................................ 35
Sensitizing Concepts From Practice Theory ................................................................... 39
Consolidated Framework for Implementation Research ................................................. 42
A Loose Conceptual Framework ........................................................................................ 42
Positionality Statement ....................................................................................................... 45
Chapter Four: Research Design .............................................................................................. 47
Qualitative Case Study ........................................................................................................ 47
Methods ............................................................................................................................... 49
Defining the Case and Participant Groups ...................................................................... 49
Selecting the Regional Health Authority......................................................................... 50
Selecting the Clinical Practice Guideline Set .................................................................. 50
Selecting the Hospital Site for Case Study ...................................................................... 52
Identifying Participants Relevant to Each Functional Group .......................................... 54
Selecting Participants for the Case Study........................................................................ 55
Participants ...................................................................................................................... 56
Interviews ........................................................................................................................ 59
Documents ....................................................................................................................... 60
Sepsis Guideline Set Implementation Performance Data................................................ 61
Data Management............................................................................................................ 62
Data Analysis .................................................................................................................. 62
Research Quality ................................................................................................................. 66
Variations From The Study Protocol .................................................................................. 68
Ethical Considerations ........................................................................................................ 68
Chapter Summary ............................................................................................................... 69
Chapter Five: Advancing Implementation.............................................................................. 71
The Dynamic Evidence Informing the Sepsis Guidelines .................................................. 72
Defining Sepsis: Consensus Conferences ....................................................................... 73
Treating Sepsis: Early Goal-Directed Therapy and Beyond ........................................... 75
Revisiting the Treatment Evidence ................................................................................. 76
Revisiting Definitions and Treatments, Again ................................................................ 76
Academic Advocacy for Sepsis Management .................................................................... 77
The Surviving Sepsis Campaign ..................................................................................... 77

v
Evidence to Excellence: A British Columbia Grassroots Collaborative ......................... 79
Provincial Policy Mobilization ........................................................................................... 81
The British Columbia Patient Safety and Quality Council’s Measurement Dilemma ....... 83
Advancing Implementation and the Practice of Academics and Advocates ...................... 86
Chapter Summary ............................................................................................................... 88
Chapter Six: Managing Implementation ................................................................................. 89
Regional Structures Steering Clinical Practice Guideline Implementation ........................ 91
Program Management Structure ...................................................................................... 91
The Clinical Policy Office ............................................................................................... 92
Implementation Process From the RLS Perspective ........................................................... 93
Originating: Early Sepsis Care Improvement at Select Health ....................................... 93
Developing Plans and Supports: Getting Ready for Implementation ............................. 96
Assessing and Activating: Communicating Through Organization Structure .............. 107
Prioritizing: Deciding and Resourcing a Regional Priority........................................... 114
Executing Plans: Following Standard Implementation Process .................................... 115
Monitoring and Reviewing Performance: What Happened? ........................................ 123
Managing Implementation and the Practice of Managers ................................................ 128
Chapter Summary ............................................................................................................. 131
Chapter Seven: Learning, Becoming Competent ................................................................. 133
City Hospital and the Local Context ................................................................................. 134
Back “In the Early Days” .................................................................................................. 135
Implementation is Delegated to the Clinical Nurse Educators...................................... 135
Educating and Communicating About the Sepsis Guidelines ....................................... 137
Collaborating with the British Columbia Patient Safety and Quality Council.............. 139
Performance Monitoring: Summary Metrics and Case Review .................................... 140
Not So Much Lately ...................................................................................................... 142
Building Competence ........................................................................................................ 142
Continuous Development of Competence and the Nurse Clinician .............................. 143
Pre-Specialization: Selecting for Potential .................................................................... 144
From “When I Was a Student” ...................................................................................... 146
Orientation: Learning the Ropes at City Hospital ......................................................... 147
Keeping current: communication and professional development. ................................ 149

vi
Reinforcing Practice: The Importance of Team ............................................................ 151
Now it’s “Just What We Do” ............................................................................................ 153
Becoming Ingrained ...................................................................................................... 154
Sepsis and the Busy Emergency Department ................................................................... 155
Motivation: “Why” Matters........................................................................................... 155
Missing Research Culture Amongst the Direct Care Group ......................................... 157
Workload and Workflow ............................................................................................... 157
Bundling for Focus and Communication ...................................................................... 161
Sepsis Care in the Emergency Department: How Did It Go? ....................................... 162
Becoming Competent and the Practice of Direct Care Providers ..................................... 164
Chapter Summary ............................................................................................................. 166
Chapter Eight: Understanding the Roots of Discordance in CPG Implementation.............. 169
Discordance in CPG Implementation ............................................................................... 169
The Consequences of Discordance in CPG Implementation ............................................ 171
Perspectives Underlying Discordance .............................................................................. 172
Perspectives and Practice Theory ..................................................................................... 179
Limitations of CPG Implementation Process ................................................................ 183
Connections and Disconnections Between and Within Communities of Practice ........... 185
1.

Service-Oriented Improvement Structures, Processes, and People ....................... 186

2.

Professional Learning and Development ............................................................... 188

3.

Quality Improvement Collaboratives and Networks ............................................. 190

4.

Evidence Review and Impact Assessment ............................................................. 192

5.

Prioritization and Resourcing CPG Implementation ............................................. 193

6.

Clinical Management ............................................................................................. 195

Avoiding Discordance, the Need for a Process................................................................. 196
Chapter Summary ............................................................................................................. 200
Chapter Nine: Conclusion and Implications ......................................................................... 202
Harmonization and Enabling, Harmonizing Activities ..................................................... 203
The Processes Underlying Harmonization ........................................................................ 204
Enabling Harmonization ................................................................................................... 206
Study Implications by Community of Practice ................................................................. 208
Implications for Academics........................................................................................... 208

vii
Implications for Regional Managers and Support Staff ................................................ 209
Implications for Clinicians ............................................................................................ 211
Harmonization and Practice Theory .............................................................................. 212
Harmonization and the Consolidated Framework for Implementation Research ......... 215
Harmonization and Implementation Strategies ................................................................. 216
Future Research Opportunities ......................................................................................... 217
Reflections on Positionality .............................................................................................. 220
Study Limitations .............................................................................................................. 221
Conclusion ........................................................................................................................ 222
References............................................................................................................................. 226
Appendices ........................................................................................................................... 244
Appendix A: Effective Practice and Organization of Care Strategies .............................. 245
Appendix B: BC Sepsis Guidelines .................................................................................. 246
Appendix C: Participant Data Collection Tool and Interview Guide ............................... 247
Appendix D: Interview Consent Form .............................................................................. 251
Appendix E: Examples of Coding Method and Flow ....................................................... 259
Appendix F: Missing Guideline Set Implementation Process Activities .......................... 261

viii
List of Tables
Table 2.1: Consolidated Framework for Implementation Research (CFIR) .......................... 10
Table 6.1: Clinical Decision Support Tool Development Process ......................................... 97
Table 6.2: Summary of Scorecard Measures for Select Health and City Hospital............... 125
Table 8.1: Dimensions of Different Perspectives Regarding CPG Implementation ............ 174
Table 9.1: Dimensions of Perspectives and Proposed Harmonizing Process Sets ............... 206

ix
List of Figures
Figure 3.1: Conceptual Framework for CPG Implementation Research Study ....................43
Figure 4.1: Participants by Initial Setting, Functional Group, and Profession .....................57
Figure 4.2: Participant Relevant Years Present (2011-2017) by Functional Group ............. 58
Figure 4.3: Interview Content Sufficiency Analysis ............................................................ 65
Figure 5.1: Aspects of Evidence, Advocacy, and Policy from 1990 to 2017 ....................... 72
Figure 6.1: Regional Leadership and Support Perspective ................................................... 90
Figure 6.2: Clinical Decision Support Tool Development and Implementation Process ... 100
Figure 6.3: Program Standing Committee Structure 2011-2015 ........................................ 111
Figure 7.1: Direct Care Participant Perspective ................................................................. 134

x
Glossary
AAP: Academic, Advocacy and Policy community of practice described in this study.
BCPSQC: British Columbia Patient Safety and Quality Council. A Council and secretariat
established in 2010 to promote and support quality improvement in health service in British
Columbia.
Boundary: Applied by practice theorists as a conceptual and very loose demarcation of the
people, processes, and structures considered to constitute a community of practice.
Boundary Spanning: An activity that can involve people, processes, and/or structures (e.g.,
boundary objects) that helps to bring about sharing of information between two or more
communities of practice while meeting the needs of each. Boundary spanning activity can
involve activity situated between the two communities of practice (as a broker might operate
between two parties) or as varying degrees of overlapping or shared activity.
CCM: Clinical Care Management. An initiative promoting clinical care improvement,
including clinical practice guideline implementation, among British Columbia Regional
Health Authorities from 2011-2017.
CFIR: Consolidated Framework for Implementation Research.
CLAHRC: Collaborations for Leadership in Applied Health Research and Care.
CNE: Clinical Nurse Educator.
Community of Practice (COP): a fluid but tangible network of individuals learning,
negotiating meaning, and establishing personal identity in situated, social practice. A
community of practice is recognized by the degree to which its participants demonstrate
mutual engagement, joint enterprise, and shared repertoire (Wenger, 1998).
Constellation of practices: Also constellation. A loosely defined set of practices or
communities of practice that demonstrate some degree of mutual engagement, joint

xi
enterprise, and shared repertoire (Wenger, 1998). The three communities of practice
described in this study – academics, regional managers and support staff, and clinicians –
together, might be considered a constellation of practices when referring to participants
involved in implementation of a Clinical Practice Guideline (CPG).
CNS: Clinical Nurse Specialist.
CPG: Clinical Practice Guideline.
DC: Direct Care community of practice described in this study.
EBP: Evidence-Based Practice.
Practice: “Doing in a historical and social context that gives structure and meaning to what
we do” (Wenger, 1998, p. 47). Other definitions introduce, as important, concepts of routine
and interaction with “the material elements that co-constitute the practice” (Spaargaren et al.,
2016, p. 55).
RHA: Regional Health Authority. Terminology used for each of five large, multi-service
and multi-hospital, geographically defined regional health organizations in British Columbia.
Select Health (pseudonym) is one of the five.
RLS: Regional Leadership and Support community of practice described in this study.
Situated Learning: Learning that takes place in the same social context and setting as it is
applied (Lave & Wenger, 1991).

xii
Acknowledgements
This thesis could not have been completed without the contributions of many. I am so
thankful for the time and openness offered to me by all study participants. The keenness of
all to engage and reflect in search of improvement gives me much hope for the future.
I want to thank my PhD supervisor, Dr. Martha MacLeod for your leadership and
ongoing encouragement. I can only see clearly now how sensitively you pushed when I
needed pushing and gave me space when I needed time to work things through. Thanks also
to the members of my thesis committee, Doctors Ian Graham, Dave Snadden, and Steven
Cronshaw, and Neil Hanlon for your deep insight and guidance, and for your endless
patience.
I want to acknowledge the time and encouragement that I have been honoured with
by my employer, Northern Health. I can only hope that what I have learned during this
process can be helpful as we continue to work to serve the people of northern British
Columbia. I am grateful for the financial assistance provided by the Integrated Knowledge
Translation Research Network (iKTRN). This trainee grant was an invaluable support
throughout the course of the study.
Finally, thank you and love to my wife, Teresa, my son Fraser, and daughter
Elisabeth, who have made sacrifices to support me in this effort, encouraging me through it
all the way.

1
Chapter One: Introduction
Sackett and Rosenberg first defined and described processes for evidence-based
medicine in 1995 as “the integration of best research evidence with clinical expertise and
patient values” (Sackett & Rosenberg, 1995, p. 2). While debate is ongoing about what
constitutes evidence, the concept that, to the greatest extent possible, clinical practice should
be based on the best available evidence has spread across healthcare professions and the
industry overall (Rycroft-Malone, 2004; Stannard, 2019). With the spread of the concept
beyond medicine, the term evidence-based practice (EBP) has become commonly used.
CPGs are part of a broader base of EBPs. The U.S. Institute of Medicine (IOM)
defines clinical practice guidelines as “Statements that include recommendations intended to
optimize patient care that are informed by a systematic review of evidence, and an
assessment of the benefits and harms of alternative care options” (Institute of Medicine,
2011). Clinical practice guidelines (CPGs) are well-established EBP tools in support of
quality improvement in healthcare through the reduction in unnecessary practice variation,
which can lead both to improved clinical outcomes and reduced costs (Eddy et al., 2011;
Grimshaw & Russell, 1993; Martin et al., 2017).
When adopted by health practitioners and organizations, CPGs can lead to better
health outcomes (Eddy et al., 2011; Grimshaw & Russell, 1993; Martin et al., 2017). CPGs
have been the focus of extensive research in recent decades as researchers seek to understand
the factors that affect successful implementation (Ellen et al., 2014). As a result, much is
known about the many determinants of success and potential strategies for CPG
implementation. Though CPGs offer great promise, industry-wide uptake of them is limited
and slow (Braithwaite et al., 2020; Ebben et al., 2018; McGlynn et al., 2003; Rogers et al.,
2020). There remains a need for a better understanding of CPG implementation from the

2
organizational perspective, to help inform health organization decision-makers of the
people/roles, structures, and processes they can establish to support better CPG
implementation.
The Problem with Implementation of Clinical Practice Guidelines
Better clinical outcomes could result, and thousands of complications, even deaths,
could be avoided in Canada if CPGs and the broader family of EBPs could be implemented
more reliably (Baker et al., 2004; Ebben et al., 2018; Fonarow et al., 2011). Yet consistently
across locations and services in healthcare, CPG/EBP uptake tends to be partial and slow
(Ebben et al., 2018; McGlynn et al., 2003; Runciman et al., 2012). Rogers et al. (2020) note
literature indicating a 17-year gap between the generation of evidence and implementation
and routinization (Slote Morris et al., 2011). Braithwaite et al. (2020) describe a “60-30-10
challenge” in CPG implementation, where 60% of care conforms to guidelines, 30% is waste,
and 10% of people/patients are harmed.
As a result of significant research activity, there is a wide base of knowledge about
implementing CPGs and EBPs in a variety of settings, beginning with a robust understanding
of determinants (barriers and enablers) of successful CPG and EBP implementation (e.g.,
Ellen et al., 2014). Research into determinants is now sufficiently rich to enable meta-review
of systematic reviews (Ciro Correa et al., 2020). Similarly, researchers have documented and
synthesized strategies used to implement CPGs and EBPs in a variety of settings (Cassidy et
al., 2021; Ebben et al., 2018; Powell et al., 2015; Sarkies et al., 2017; Spoon et al., 2020).
Some strategies have been evaluated for effectiveness, though evaluation is difficult as
strategies are often inconsistently defined in the literature and methodological issues have
limited comparison and evaluation against implementation outcome (Prior et al., 2008;
Proctor et al., 2013).

3
Little is known about the interplay among the many implementation factors (e.g.,
determinants and strategies) that have been identified by researchers (Helfrich et al., 2010;
Nadalin Penno et al., 2019; Sarkies et al., 2017). Nor is there a good understanding of how a
multi-site regional health organization’s multiple actors, teams, and hierarchical decisionmaking purviews could come together toward the realization of better implementation
processes (Helfrich et al., 2010; Leonard-Barton, 1990; Li et al., 2018; Miake-Lye et al.,
2020). As a result, there is a continuing lack of clarity, particularly for decision-makers
within large complex regional health organizations, as to how to practically use all this
information to bring the people, processes, and structures of the organization together toward
effective implementation, or what the most important conditions for success might be. A
more organizational, relational view of CPG implementation is needed.
Research Focus and Scope
The research was designed as a retrospective qualitative case study to understand
CPG implementation at the organizational level, specifically within one large regional health
organization (known in British Columbia as a Regional Health Authority). The focus was on
CPG implementation, as CPGs have become common ways of conveying, for
implementation, evidence-based practices, particularly those that involve multiple
recommendations affecting a range of organizational stakeholders.
The overarching research question was: How do individuals and teams with various
functions and decision-making purviews come together to implement prioritized clinical
guidelines in a Regional Health Authority?
Specific research questions were:

4
•

How do organizational leaders and support personnel, structures and processes
interact (or not) to facilitate or inhibit successful guideline implementation at the
clinical practice level where the change must occur to affect patient care?

•

What does the guideline implementation process look like from the organization’s
various actors’ and teams’ perspectives? Who is involved? When are they involved?
What do they do, or not do? Who wasn’t involved and why?

The Regional Health Authority
A Regional Health Authority (RHA) is defined as an organization with the
responsibility for the provision of a variety of health services, including hospital care, for a
geographically defined population. Regional Health Authorities tend to be large, with
multiple sites/locations and significant differentiation and distance among local teams
providing care and regional teams available to lead and support. In western Canada and in
many jurisdictions around the world the organizational unit for health services provision is
the RHA or some similar geographic aggregation (e.g., provincial, state). The RHA is
comprised of various components of healthcare service usually including public and
population health and health care services ranging from acute specialist and hospital care
through to residential and community care services including mental health, substance use
and in-home nursing care and living support. Pharmaceuticals outside of the care setting,
ambulance, and general medical care vary in their placement depending on jurisdiction but in
British Columbia, Canada’s westernmost province, they operate outside of the RHA
mandate.

5
Research Approach and Results
The case study focused on the implementation of a clinical practice guideline (CPG),
the Sepsis Guideline Set, within Select Health (pseudonym), a British Columbia RHA. The
Sepsis Guideline Set was established by the British Columbia Patient Safety and Quality
Council (BCPSQC) and was later mandated for implementation in the health authorities by
the provincial Ministry of Health. One of Select Health’s hospitals, City Hospital
(pseudonym), was selected as the site for investigation of CPG implementation at the site of
patient care (the hospital’s Emergency Department). Three functional groups of individuals
were identified initially to organize the study: a group reflecting academic, advocacy, and
policy activities, another reflecting RHA leadership and support activities, and one reflecting
direct care activities.
Implementation of the Sepsis Guideline Set took place within Select Health and City
Hospital between 2011 and 2017. Data collection for this study proceeded between February
2017 and April 2018 through 35 individual and group interviews involving 38 participants
from across Select Health and beyond.
Dissertation Overview
This dissertation is comprised of nine chapters. Following this introductory chapter,
Chapter Two presents a discussion of the current implementation science literature to identify
gaps in knowledge about CPG implementation in health organizations. Chapter Two also
includes an examination of a body of literature related to the United Kingdom’s
Collaborations for Leadership in Applied Health Research and Care (CLAHRC) initiatives to
gain a better understanding of EBP implementation from a more organizational, relational
view. Chapter Three presents a discussion of the questions and concepts guiding the research,
outlining a conceptual framework drawing on practice theory and the Consolidated

6
Framework for Implementation Research (CFIR) to loosely organize and guide this inductive
study. Practice theory examines the implications of understanding society as people in dayto-day collective activity as they work in various social associations to learn and to negotiate
meaning and identity. CFIR is a widely-used framework of determinants of EBP
implementation. Chapter Four then presents the methodology and methods used to conduct
the retrospective, qualitative case study. Chapter Five describes the evolving evidence about
sepsis care and the entities and actions from outside the organization that had an impact on
Select Health’s Sepsis Guideline Set implementation. Chapters Six and Seven present
description of the perspectives stemming from Select Health’s regional leadership and
support staff, and direct care provider participants. Chapter Eight provides a consolidation
and discussion of these findings, relating back to both the EBP implementation literature and
the conceptual framework. The discussion draws out the differences among the perspectives
of individuals within three groups (academics, regional leaders and support staff, and
clinicians) about the objectives and activities of CPG implementation and the impact that
these differences had on the implementation’s success. Drawing upon practice theory,
particularly Wenger (1998), I recognized and interpreted the three groups as communities of
practice. Together they constituted a constellation of practices. Chapter Nine concludes this
dissertation by proposing harmonization as a process that is critical to successful CPG
implementation in Regional Health Authorities. Harmonization is a relational process that
can be supported by RHA decision-makers to explicitly address the differences in perspective
of individuals within and among the three communities of practice. The implications of
harmonization are described to help inform RHA and other decision-makers of the people,
processes and structures they might promote to better support CPG implementation.

7
Chapter Two: What is Known About EBP Implementation?
A wealth of literature has been established about CPG and EBP implementation,
though research on CPG implementation is largely subsumed and described in the
implementation literature as EBP implementation or, occasionally, innovation spread. The
literature related to EBP implementation is organized around research into determinants barriers and enablers to successful implementation - and strategies for successful
implementation (Waltz et al., 2019). This chapter begins with an overview and critique of the
literature regarding EBP implementation determinants and strategies, identifying limitations
in knowledge about the organizational dynamics and relationships affecting CPG
implementation with a practical focus for health organization decision-makers. The chapter
then presents discussion and critique of a unique body of literature that does explore EBP
implementation from a relational, organizational perspective. This literature offers unique
insights about EBP implementation at the organizational level, but significant gaps remain.
The chapter ends with a discussion identify the compelling need for research into EBP
implementation at the organizational level, examining the relationships among, and activities
of, stakeholders across and beyond the health organization – particularly those from different
groups and decision-making purviews.
Clinical Practice Guideline and Evidence Based Practice Implementation
Research aimed directly at clinical practice guideline (CPG) implementation is
limited, having largely been subsumed as a category of the more commonly used term
evidence-based practice (EBP). Where studies focus specifically on CPG implementation,
they tend to be indistinguishable from the broader EBP literature or focused on the
advantages of implementing a CPG and are outside the scope of this review. The term EBP

8
will be used for the remainder of this discussion. The next sections provide an overview and
critique of the literature regarding EBP implementation determinants and strategies.
Determinants of Successful EBP Implementation
The EBP literature is rich in original research and syntheses describing and seeking to
assess the relative importance of a variety of determinants of EBP implementation success.
Determinants have been variously described as barriers, facilitators/enablers, and contextual
attributes, all pointing to some characteristic of the context surrounding EBP implementation
that has been found by researchers to have an impact on implementation success (Gagliardi
& Alhabib, 2015; Waltz et al., 2019).
Many determinants have been identified. Squires et al. (2019) identify, through multistudy analysis, 62 features of context, organized into 14 unique contextual attributes,
reflected in most healthcare settings: resource access, work structure, patient characteristics,
professional role, culture, facility characteristics, system features, healthcare professional
characteristics, financial, collaboration, leadership, evaluation, regulator or legislative
standards, and societal influences. While informative, lists of attributes and features provide
little direction for health organization decision-makers to determine what actions to take to
better support EBP implementation (Baumann et al., 2019; Lengnick-Hall et al., 2020). With
a focus on the perceptions of healthcare professionals (physicians, residents, nurses and
organ donor coordinators), the Squires et al. (2019) study does not reflect potential
similarities and differences among other groups of individuals across and outside the health
organization (e.g., managers, support staff, academics) that might be instructive for health
organization decision-makers seeking to support better EBP implementation).

9
A Determinant Framework Supporting Implementation Research
As researchers identified more and more determinants affecting EBP implementation,
some worked to establish ways to organize and categorize them. The Consolidated
Framework for Implementation Research (CFIR) is one of the “most well-operationalized
and widely used” determinant frameworks (Waltz et al., 2019) – organizing 39 constructs
into five domains meant to capture the breadth of the system affecting EBP implementation.
The Consolidated Framework for Implementation Research (CFIR) was developed by
Damschroder, Aron, Keith, Kirsch, Alexander and Lowery (2009) drawing extensively from
Implementation Science (IS), Innovation/Spread, and Knowledge Translation (KT) syntheses
including Greenhalgh, et al. (2004), Rogers (2003) and Kitson (1998). CFIR is a meta-model
which maps system-wide evidence-based factors related to research implementation
organized in five major domains: intervention characteristics, inner setting, outer setting,
characteristics of individuals and process. The five domains provide a guide to the kinds of
issues that might arise and should be considered when examining a clinical guideline
implementation. The domains and constructs of CFIR are presented in Table 2.1.

10
Table 2.1
Consolidated Framework for Implementation Research (CFIR)
Domain
Constructs
Domain
Constructs
Intervention
Process
Intervention Source
Planning
Characteristics Evidence Strength &
Engaging
Quality
Executing
Relative Advantage
Reflecting &
Adaptability
Evaluating
Trialability
Complexity
Design Quality &
Packaging
Cost
Inner Setting
Structural Characteristics Outer Setting
Patient Needs &
Resources
Networks &
Communications
Cosmopolitanism
Culture
Peer Pressure
Implementation Climate
External Policy &
Incentives
Readiness for
Implementation
Characteristics Knowledge & Beliefs about
Individual Identification with
of Individuals
the Intervention
Organization
Self-efficacy
Other Personal Attributes
Individual Stage of Change
Note. From Damschroder et al., (2009).

Since its inception in 2009, the CFIR has become a focus of collaborative
development, published on the CFIR website at https://cfirguide.org/constructs/. It has been
expanded from its original form to provide more detailed construct descriptions and, where
available, research coding instructions and potential quantitative evaluation measures. The
inner setting domain constructs have been further expanded to include a) implementation
climate detail regarding: tension for change, compatibility, relative priority, organizational
incentives and rewards, goals and feedback, and learning climate; and b) readiness for

11
implementation detail regarding: leadership engagement, available resources, and access to
knowledge and information.
As a determinant framework CFIR likely captures in some way most of the things
that affect or must be considered when assessing and conducting an CPG implementation.
CFIR, however, remains taxonomical, and lacks specificity when considering EBP
implementation at the organization level. Constructs related to the healthcare organization are
largely captured within the vast inner setting domain with no reflection on organizational
decision-making layers or clinical/support teams. As noted by Ashok et al. (2018), CFIR
sheds little light on how implementation success might be achieved, as its reflection on
process (planning, engaging, executing, reflecting & evaluating) appears rudimentary, linear,
and offers no direct link to outcome.
A common criticism of CFIR is that the framework does not consider the interactions
among its domains and constructs (Esmail et al., 2020; Havers et al., 2019). CFIR does,
however, offer some useful insights – particularly in the arrangement of its five domains –
that can help organizational decision-makers to understand the areas of focus they might take
support better EBP implementation. CFIR distinguishes between the inner and outer settings
of EBP implementation. While CFIR promotes adaptable interpretation as to what constitutes
“inner”, the framework’s inner and outer setting domains can prompt health organization
decision-makers to consider both aspects of the organization itself (inner) and its relationship
to other organizations and actors outside of the its boundaries (outer) (Damschroder et al.,
2009). CFIR also prompts, but does not incorporate, consideration of the relationship
between the characteristics of the intervention (EBP) itself, and the knowledge and beliefs of
individuals about the intervention, a construct of the characteristics of individuals domain.
Not only are the objective merits of the intervention itself important to implementation

12
success, but how the intervention is perceived by individuals within and beyond the health
organization is relevant (Consolidated Framework for Implementation Research, 2020).
Finally, CFIR introduces the importance of the implementation process itself in supporting
successful implementation. While limitations of CFIR’s process domain have been noted
(Ashok et al., 2018), the process domain at least prompts consideration of EBP
implementation from a processual perspective, and draws attention to the relationships
among process and the other, more contextual, domains. Despite the intriguing potential for
understanding of relationships among its domains, CFIR does not examine them in any detail
and remains largely taxonomical.
Determinants Most Relevant to Health Organizations
Li et al. (2018) note that researchers have yet to reach consensus about the most
important determinants of EBP implementation success for the health organization. Nor is
there an understanding of how key determinants work, alone or in combination, within the
health organization to affect implementation (Li et al., 2018). In response, they undertook an
integrative review of the EBP implementation determinant literature to identify what
appeared to be the most important determinants (CFIR constructs) for health organizations,
and how they are inter-related. Li et al. (2018) prioritized six “features,” they describe as
consistent with CFIR constructs, as most important: leadership; culture; networks and
communication; resources; evaluation, monitoring, and feedback; and champions. The
researchers further noted that leadership appeared to take primary importance, strongly
influencing the nature and impact of the other five features. The six determinant features
identified by Li et al. (2018) are discussed below, identifying the impact they described for
each, and supplemented with the findings of other relevant studies.

13
Culture. The culture, or cultures, promoted and prevailing in the setting within which
the CPG are implemented significantly determine implementation success (Ellen et al., 2014;
Nadalin Penno et al., 2019; Raveis et al., 2014). Culture refers to the “beliefs, values and
perceptions” within the organization or unit (Nadalin Penno et al., 2019, p. 11). Li (2018)
find that a culture that supports successful EBP implementation promotes innovation,
learning, and clarity of organizational values and beliefs. Li et al. (2018) note that internal (to
the organization) collaboration is important for EBP implementation success, and that high
degrees of individual autonomy can be detrimental. Cammer et al. (2014) argue that EBP
implementation appears to be facilitated by culture that recognizes and positively addresses
flux, ambiguity and multiple underlying perspectives. Researchers, including Cammer
(2014), have identified that multiple individual and group perspectives can exist within an
organization, and these might relate to EBP implementation success. Limited research has
explored this relationship deeply to better understand the perceptions and perspectives that
exist among groups of individuals within health organizations, and how they interact and
affect the actions individuals take toward EBP implementation. Argyris and Schön (1996)
described “theories of action” to establish a theoretical link between individuals’ underlying
perspectives and their actions, contrasting the theories that underlie different actions by
professionals and academics. Similarly, Bamford and Forrester (2003) contrast planned and
emergent change approaches and recognize that EBP implementation success within the
health organization may depend on some hybrid of the two. While promising, these
relationships between perspectives of different organizational groups and their actions toward
CPG implementation have not been well researched. Little is known about the nature of these
groups – the perspectives they hold and the different actions they might promote related to

14
CPG implementation - or what actions organizational decision-makers might take in response
to better support EBP implementation in response.
Leadership. Committed leadership and clear accountabilities are important enablers
of CPG implementation (Li et al., 2018). Leaders introduce new knowledge and have a role
in facilitating cross-department connections that can lead to the adoption of new processes
(Li et al., 2018). Leadership most commonly relates to the formal actions of organizational
leadership and managers or “decision-makers” (Ellen et al., 2014; Nadalin Penno et al.,
2019). Leaders can facilitate implementation through their own facilitative behaviours (Ciro
Correa et al., 2020; Gifford et al., 2006; Nadalin Penno et al., 2019) and through their
decision-making actions, leading to prioritization and focus (Moore et al., 2016; Raveis et al.,
2014), and to the commitment of resources (Ellen et al., 2013; Ellen et al., 2014; Gifford et
al., 2006). Resources can be applied by leaders to support a culture that promotes the use of
evidence in practice, and to enable specific EBP implementation initiatives. Leaders can
support stakeholders to build skills that are supportive of EBP implementation culture (Li et
al., 2018).
Middle managers and supervisors can facilitate or impede effective CPG
implementation. Most research findings eschew directive or disciplinary approaches to
implementation (Dopson & Fitzgerald, 2006), favouring a more facilitative role for middle
managers and supervisors. In their team leadership roles, middle manager and supervisors are
well positioned to act as proactive “change agents” (Birken et al., 2013). More specifically,
these mid-level leaders can facilitate CPG implementation by diffusing information,
synthesizing and contextualizing evidence to the work unit, mediating between the team and
other parts and levels of the organization, and justifying or “selling” the implementation
(Bunger et al., 2019; Li et al., 2018; Meza et al., 2021). Middle managers also support CPG

15
implementation by exercising their local/team resource allocation role and by initiating and
authorizing required changes in policy and procedure (Urquhart et al., 2014).
Votova (2019), argued, in a published editorial, that implementation should be
considered a “core competency” for organization leaders and managers. Given the
importance of leadership for EBP implementation, Aarons et al. (2014) established the
Implementation Leadership Scale (ILS), a survey-based approach to assess unit-level
managers’ leadership capabilities. The scale has been successfully applied to develop and test
models of implementation leadership (Gifford et al., 2017), and leadership development
programming (Aarons et al., 2015).
Researchers have established many of the important attributes of leadership that can
affect CPG and broader EBP implementation success and progress is being made toward
assessing and developing health organization leaders to manifest the desired attributes.
Guerrero et al. (2020) have begun to theorize and test a model about the various leadership
roles and inter-relationships among top managers, middle managers, and employees,
establishing that middle managers mediate a relationship between top managers and
employees. To-date researchers have primarily focused on manager training and development
(Aarons et al., 2015; Gifford et al., 2017), surely just one of the ways to support the health
organization’s managers in facilitating EBP implementation. Much remains to be understood,
though, about the interactions and relationships among leaders and groups across and outside
the health organization toward successful EBP implementation, or the structures and
processes that support them.
Networks and Communication. Implementation of evidence-based practices
including CPGs is a “dynamic, fluid, interactional, and reactive” process (Raveis et al., 2014,
p. 551). As such, success is highly dependent upon both intra- and inter-organizational

16
relationships. The Consolidated Framework for Implementation Research (CFIR) identifies
two settings across which networks and communication might be considered: the inner
setting (the department, site, or organization implementing the EBP) and the outer setting
(other organizations or aspects of the health system that may affect the implementation)
(Damschroder et al., 2009).
Within the organization or organizational unit – the inner setting - implementation is
facilitated by strong communication, collaboration, social interaction and positive interpersonal relationships (Cammer et al., 2014; Evenblij et al., 2016; Fischer et al., 2016; Li et
al., 2018). Researchers have also recognized the need for strong, ongoing relationships and
partnerships between knowledge users and researchers and other organizations (Ellen et al.,
2014; Higuchi et al., 2017; Li et al., 2018) constituting elements of CFIR’s outer setting
(Damschroder et al., 2009). Bowen et al. (2019) go further, to call for healthcare leaders and
academics to collaboratively “reimagine” research to ensure greater relevance for health
service design and improvement. Zamboni et al. (2020) note that a quality improvement
collaborative is a particular type of network involving a broad range of academic and
healthcare provider stakeholders collaborating on a focused improvement initiative. Quality
improvement collaboratives can help facilitate successful improvement through propensity
for building health professionals’ knowledge and problem-solving, teamwork and leadership
skills and attitudes (Zamboni et al., 2020).
There is little doubt that, in some way, intra- and inter-organizational relationships are
critical to successful CPG implementation. Lost in the CPG implementation research,
however, is how any of these approaches to strengthening relationships might be aligned with
other organizational, or inter-organizational structures and processes, and what their strengths
and limitations might be. It is often unclear what relationships within and beyond the

17
organization must be targeted, or why they must be targeted – and what activities or actions
are dependent on them. Drawing from the previous section on culture, researchers have
identified but not yet examined rigorously how the perspectives of groups of individuals
with, and amongst organizations, might affect action toward CPG implementation, and how
collaboration and relational strategies can then be used to help. If, as Bowen et al. (2019)
suggest, a reimagining of research is necessary to facilitate evidence-based practice, it will be
essential to better understand the mechanisms, people, structures, and processes, with which
they must more robustly inter-relate.
Resources. The lack of resources is commonly seen as an impediment to EBP
implementation success (Cammer et al., 2014). Li et al. (2018) delineate four resource types
that are important determinants of EBP implementation success: staffing and workload, time,
financial, and education & training. In a scoping study, Fischer et al. (2016) highlight that
human resources (support personnel, freeing participants from time constraints, ensuring
appropriate deployment of skilled staff) and financial resources (including appropriate
incentives), have been deployed in support of EBP implementation and underlying culture
development. Education and training resources described in the literature often include:
printed, video and other electronic materials, educational meetings, education huddles and
outreach, games, workshops, automated, written and verbal reminders (Hermens et al., 2015;
Higuchi et al., 2017; Provvidenza et al., 2020; Suman et al., 2017; Sungkar et al., 2018;
Vaughan et al., 2012). Potentially because many researchers seek to address the problem of
CPG implementation from a perspective of pushing evidence into the health organization,
many of the competency development resources described above appear didactic, oriented
toward teaching or otherwise transferring information to individuals. This focus is
unfortunate since Prior et al (2008) identified through a synthesis of systematic reviews

18
regarding CPG implementation, that passive communication/dissemination and didactic
education alone were found to be ineffective in improving guideline adherence.
Lists of potential financial and human resources are of limited value for health
organization decision-makers when considered separate from the broader organizational
processes of financial and human resource management (Fixsen et al., 2005). Greenhalgh et
al. (2004) recognize the need to align EBP implementation with the organization’s broader
resource management processes when arguing the importance of assessing any given
implementation’s relative advantage (Greenhalgh et al., 2004). Relative advantage is the
degree to which a particular EBP’s benefit outweighs the cost of implementation, assessed
relative to the benefit/cost of others (Greenhalgh et al., 2004). More guidance is required
from research to inform health organization decision-makers how specific enabling resources
articulate with each other, and with other organizational roles, processes and structures.
Evaluation, Monitoring, and Feedback. Evaluation, monitoring, and feedback work
to preserve engagement among stakeholders involved in implementation. Evaluation
promotes the review of qualitative and quantitative evidence to guide assessment of
effectiveness of the implementation and to focus future efforts. Evaluation oriented enablers
include: audit and feedback, activity logs, performance and outcome monitoring, supervision,
clinical incident reporting, and chart audits (Bunger et al., 2017; Higuchi et al., 2017; Spoon
et al., 2020; Sungkar et al., 2018).
To support successful implementation and evaluation, evidence must be assessed and
linked to patient outcomes and practice (Jeffs et al., 2013). A key component of evaluation is
the establishment, dissemination, and engagement with process and outcome measures (Jeffs
et al., 2013; Zhou et al., 2018). Such measures enable assessment of both the adherence to the
expectations set out in the CPG (process measurement), and the degree to which the

19
implementation is having the desired clinical effect (outcome measurement) (Donabedian,
1988; Zhou et al., 2018). Researchers examining organizational CPG and broader EBP
implementation processes continue to find, however, that this prescribed measurement
approach is rarely followed (Knudsen et al., 2019), and that actual outcomes are seldom
monitored and reported (Ashok et al., 2018). Research continues to be needed to better
understand EBP implementation measurement and evaluation within the health organization,
to observe how evidence actually flows to, and within, the organization, how its assessment
might be better enabled to stimulate implementation action, if, and how, it is acted upon, and
why action so often fails to achieve the anticipated results. Little is known as to how different
individuals from different groups across, and beyond, the organization interact with the
evidence, or the degree to which they have the same definitions of success and/or needs as
they evaluate success.
Champions. CPG implementation functions can be performed by a variety of
individuals regardless of formal role. Li et al. (2018) describe champions as important to
successful EBP implementation as they steadily advocate for change and draw from their
expertise and local presence to promote adherence. As influential peers, champions and local
opinion leaders can be effective implementation enablers through problem-solving,
promoting change – both organizationally and within individual work units, peer-to-peer
coaching, and formal and informal education (Cunningham Goedken et al., 2019; Hendy &
Barlow, 2012; Nadalin Penno et al., 2019; Sarkies et al., 2017). In a qualitative research
study, Bonawitz et al. (2020) identified six key attributes of effective champions: influence,
ownership, physical presence at the point of change, persuasiveness, grit, and participative
leadership style.

20
The role of champions in adherence monitoring has been found by Cunningham
Goedken (2019) to be important, yet precarious. The researcher, drawing from a case study
of a hand hygiene implementation, recognized an important distinction between the
champion-appropriate function of monitoring in the sense of peer-to-peer coaching and a
more supervisory posture of compliance auditor that can undermine the champion’s
effectiveness as a peer (Cunningham Goedken et al., 2019). Santos et al. (2022) find some
evidence of champions in EBP implementation but express concerns about opportunity costs
if resources are over-committed toward champions as a sole implementation strategy.
Champions appear to impact EBP implementation by applying their knowledge of the
EBP research and their professional influence at the local/clinical team level (Hendy &
Barlow, 2012). However, Li et al. (2018) note that champions are dependent upon, and
influence, broader leadership and resource decisions that often fall outside of their own
decision-making purview; within the purview of management. Champions, then, characterize
and intimate the importance of the intersection among three groups or decision-making
purviews – research/academia, local clinical practice, and management. Little is known about
the relationships and activities among individuals at the intersection of these three groups that
can inhibit or enable successful EBP implementation.
The Limitations of EBP Implementation Determinants
Reflected in the EBP implementation literature, researchers have identified many
enablers and facilitators – determinants – of EBP implementation (Powell et al., 2015). The
Consolidated Framework for Implementation Research (CFIR) organizes and defines many
such determinants under five domains of the health system (Consolidated Framework for
Implementation Research, 2020; Damschroder et al., 2009). Understanding the determinants
of EBP implementation is a useful step toward understanding how more timely and adherent

21
use of evidence-based practices might be achieved. But the literature to-date presents
determinants largely as lists of “things” that might impact EBP implementation at some time
and place in the health system. What is understood about EBP implementation from the
perspective of the health organization arises from syntheses of findings from discrete parts
(e.g., clinical unit) or professions (e.g., nursing). While instructive, this approach results in a
loss of context and practicality for health organization decision-makers. Studies of EBP
determinants are often criticized for ignoring the interactions and inter-dependencies among
them, and for having a limited focus at the organizational level (Gagliardi & Alhabib, 2015).
Researchers are just beginning to investigate how EBP implementation determinants interact
with one-another. A gap in understanding exists for health organization decision-makers,
examining what they might need to do to support more successful implementation; the
processes, structures, and people they might need to put in place, and how these supports are
to interface with other organizational processes (e.g., financial decision-making,
prioritization, human resources management processes), structures, and roles to be effective.
Further, some researchers have identified that differences in perspective and
philosophy might exist among groups of individuals involved in EBP implementation
(Cammer et al., 2014; Li et al., 2018) and that various organizational levels and decisionmaking purviews affect EBP implementation differently (Guerrero et al., 2020).
Unfortunately, perspectives and philosophical differences within and beyond the health
organization have not yet been well elucidated, and, to-date, the health organization’s
multiple levels and decision-making purviews have primarily been a formative consideration
for leadership training and development (Aarons et al., 2015; Guerrero et al., 2020).
Together, the EBP implementation determinants are suggestive that it might be
important for researchers and health organization decision-makers to better understand the

22
perspectives, relationships, and activities at the intersection of different groups including
academia, management, support, and clinical care. To-date, EBP implementation researchers
have not set their focus on this point of activity (or inactivity) directly.
Evidence-Based Practice Implementation Strategies
As with determinants, EBP implementation researchers have enumerated and
described many strategies that might be applied to enhance the potential for successful
implementation. Powell et al. (2015) drew from the EBP implementation strategy literature
and conducted a modified Delphi process with an expert panel to arrive at a listing of 73
unique implementation strategies reported from the Expert Recommendations for
Implementing Change (ERIC) project. The ERIC listing is useful in understanding the
breadth of potential strategies, and as a foundation for establishing consistent language and
definitions (Powell et al., 2015), but does not offer health organization decision-makers an
organizing framework, assessment of effectiveness, or conditions for use.
The Cochrane organization has developed the Effective Practice and Organization of
Care (EPOC) taxonomy (Cochrane Effective Practice and Organization of Care, 2015) which
identifies over 100 organizational attributes deemed to be important for effective health
practice. The framework addresses delivery arrangements, financial arrangements,
governance arrangements, and implementation strategies – all of which affect effective health
practice, arguably including EBP implementation. EPOC organizes 22 implementation
strategies into three categories, those targeted at: healthcare organizations (1 strategy),
healthcare workers (19 strategies), and specific types of practice, conditions, or settings (2
strategies). A listing of the EPOC strategies is provided for reference in Appendix A. The
EPOC taxonomy has been used to guide several syntheses regarding EBP implementation
strategies (Ebben et al., 2018; Grimshaw et al., 2006; Spoon et al., 2020; Watkins et al.,

23
2015). Like the ERIC listing, EPOC is a listing of attributes, including implementation
strategies, but providing little guidance on interdependencies among, or appropriate
application of, strategies (Cochrane Effective Practice and Organization of Care, 2015).
Studies on the use of EBP implementation strategies note that the most widely used strategies
are educative in nature (Spoon et al., 2020; Watkins et al., 2015), but lament poor research
quality (Grimshaw et al., 2006; Watkins et al., 2015) and weak association to the
determinants described by researchers (Waltz et al., 2019).
The existing research on EBP implementation strategies offers limited utility for
health organization decision-makers seeking clear direction how EBP implementation might
be better supported. EPOC, for instance, offers a single strategy aimed at the organization
level – change organizational culture (Cochrane Effective Practice and Organization of Care,
2015). Waltz et al. (2019) suggest that gains might be achieved by identifying groups of
strategies targeted to address sets of identified barriers. Sarkies et al. (2017) draw from EBP
implementation literature to offer a theoretical hierarchical flow that might be used to
categorize and consider EBP implementation strategies: establishing an imperative for
practice change, building trust between implementation stakeholders, developing a shared
vision, and actioning change – underpinned by: employment of effective communication
strategies, and provision of resources to support change.
The Limitations of EBP Implementation Strategies
To-date, the research on EBP implementation strategies is weak (Grimshaw et al.,
2006; Watkins et al., 2015) and unsupportive of an approach that seeks to align, in any
simple fashion, individual implementation strategies with determinants or assessed barriers
(Waltz et al., 2019). Existing lists of strategies appear rudimentary and fragmented, and are
not yet organized in a way that is helpful for health organization decision-makers to

24
understand what they might do to improve EBP implementation success. While researchers
have described many strategies related to EBP implementation, much remains to be learned
about any given strategy’s effectiveness, to which determinants it relates, how or why it may
or may not work, or how strategies work together within a successful regional health
organization CPG implementation process (Sarkies et al., 2017).
While the hierarchical flow proposed by Sarkies et al. (2017) is, as yet, untested, it
points to a primary importance of collaboration and alignment among stakeholders with
respect to the case for change, trust, and vision. The relational strategies proposed by Sarkies
et al. (2017) is consistent with indications established earlier in this chapter that it might be
important for researchers and health organization decision-makers to better understand the
perspectives, relationships, and activities toward EBP implementation at the intersection of
different groups or decision-making purviews including academia, management, support, and
clinical care. The hierarchical flow established by Sarkies et al. (2017) highlights the
potential for considering EBP implementation in a processual way (action over time) and
with a view to ultimately having an impact on what actually happens in practice.
Gaps in the EBP Implementation Literature
Research on determinants and strategies has evolved to a place where multiple
syntheses have been conducted, and organizing frameworks proposed, for both. Researchers,
including Harrison and Graham (2021), describe an ideal EBP implementation process that
involves: assessment of readiness for successful implementation based on known
determinants; identification of barriers; and agreement and implementation of
implementation strategies, tailored to context. But the relationship between determinants and
strategies is not straightforward (Waltz et al., 2019). Efforts to design and tailor strategies
based on assessment of determinants have met with limited success (Wensing, 2017).

25
Rapport, et al. (2018) note that implementation researchers have struggled to establish a
shared understanding and common terminology surrounding EBP implementation. Further,
work to-date on EBP implementation determinants and strategies is largely taxonomical
(listing, categorizing, ordering); researchers are just beginning to describe the interplay and
interdependencies among determinants (Li et al., 2018) and strategies (Sarkies et al., 2017).
Evaluations from the Tailored Implementation in Chronic Diseases (TCID) project suggest
that the relationship between determinants and implementation strategies (interventions to
use Wensing’s terminology) is complex and fluid, requiring dynamic and ongoing
assessment and reaction to contextual determinants over time (Wensing, 2017). As a result,
there are significant limitations to the practicality and consistency of understanding
underlying the ideal EBP implementation process, especially for health organization
decision-makers looking to understand how they can better support EBP implementation.
Most research to-date has treated the health organization itself as contextual
background – a “structural factor” to which the EBP must be adapted – as opposed to
something that can adapt to support more successful EBP implementation (Baumann et al.,
2019; Lengnick-Hall et al., 2020). Syntheses described as “organizational” or “cross-setting”
tend to be amalgams – blending findings from individual studies that each have limited scope
(e.g., a particular clinical setting) and informants (a particular profession, or group within the
organization). The result is that a variety of individual characteristics about organizations are
known to have some impact on EBP implementation success (e.g., Li et al., 2018) and some
strategies are known to have been applied successfully across some settings or organizational
types (e.g., Spoon et al., 2020). But there is limited research to inform how, and why, these
characteristics and strategies inter-relate to affect EBP implementation, much less what
health organization decision-makers can do prospectively to facilitate organizational

26
adaptation to better support EBP implementation. With some exceptions, little is known
about the people most involved in CPG implementation – who they are, where they are, with
whom they interact, the activities they perform, and the structures and processes that guide
and support them.
A better understanding is needed of CPG implementation from a perspective of the
health organization, reflecting the people and relationships, processes, and structures that
must come together to affect action toward successful implementation. Such an
understanding promises to illuminate how the various determinants and strategies described
above interact in situ. Greater focus is needed on the groups of individuals within and beyond
the health organization that need to act if the implementation is to be successful. If, as
Cammer et al. (2014) suggest, these individuals and groups may hold different perspectives
about implementation, a better understanding of these perspectives, and how they affect the
actions people take, is likely critical to better understanding what it would take – and from
whom - to better support CPG implementation.
The EBP implementation literature offering a processual, relational view of EBP
implementation at the organizational level is limited. The next section provides a discussion
or another body of literature that, while limited, provides some useful findings that begin to
fill gaps in EBP implementation in healthcare organizations.
EBP Implementation From an Organizational Perspective
A body of literature that relates to EBP implementation at an organizational level has
been established, drawing from evaluations of the Collaborations for Leadership in Applied
Health Research and Care (CLAHRC) initiatives in the United Kingdom. CLAHRC
initiatives were partnerships between organizations – academic health centres and the health
services in a geographic area. This literature highlights how various groups of people,

27
relationships, processes, and structures effect action toward EBP implementation. Such a
focus may offer further insight into the impact of the different perspectives of individuals
within the health organization to which Cammer et al. (2014) allude.
The CLAHRC initiative, established and funded in 2010 by the UK National Institute
for Health Research (NIHR) sought to promote collaboration between researchers and health
provider organizations toward better creation and uptake of evidence-based practice (Kislov
et al., 2018). Nine collaborations were funded by the NIHR and evaluated to understand the
impact of, closer ties among participants from researcher and health provider organizations
on EBP implementation and related patient outcomes (Soper et al., 2015). As an initiative
promoting inter- and intra-organization level collaboration with an explicit focus on the
dynamic, relational, and processual nature of EBP implementation (Kislov et al., 2018), the
CLAHRC evaluations offer opportunities for insights into EBP implementation beyond
single determinants and strategies discussed earlier in this chapter. The following sections
outline and critique CLAHRC findings regarding EBP implementation at the organizational
level, including: socially situated learning, differing perspectives and power dynamics,
boundaries within and across practices, and designing structures and processes to promote
participation.
Understanding EBP Implementation as Socially Situated Learning
The CLAHRC collaboratives were conceived and implemented under the
conceptualization of the challenges of EBP and CPG implementation as a “know-do” gap; a
mismatch between what is known about the processes of care that lead to improved patient
outcomes, and the actions that actually take place in practice (D'Andreta et al., 2013; RycroftMalone et al., 2016). Collaboration among researchers and health decision-makers and
providers was seen as key to mobilizing knowledge more effectively and that learning,

28
particularly collaborative learning, is essential to addressing the know-do gap (RycroftMalone et al., 2013; Sinfield et al., 2012; Soper et al., 2013).
Several researchers studying the CLAHRC collaboratives framed their studies with a
view that learning processes related to EBP and CPG implementation are strongly situated in
day-to-day social activity or practice (Rowley et al., 2012; Sinfield et al., 2012). In contrast
to a didactic model of learning based on information transfer from teacher to learner, situated
learning is dependent on context (D'Andreta et al., 2013; Rycroft-Malone et al., 2013); it is a
social and political process among people as they continually negotiate to establish meaning
and identity that influences, and is influenced by, the actions they take (Rowley et al., 2012).
In a synthesis of CLAHRC evaluations, Kislov et al. (2018) note that most
evaluations focused on structures and activities that were formed between participants of the
collaborating research and health delivery organizations, and a limited focus on the processes
and practices that affected knowledge mobilization or the outcomes achieved. This
overarching focus on inter-organizational relationships and the limited examination of intraorganizational practice limited the ability to gain insights about situated learning within the
health organization itself. Instead, researchers learned more about the inter-organizational
(e.g., university and health organization) and interprofessional (e.g., academic and practicing
clinicians) aspects of collaboration that were visible to them (Kislov et al., 2018). The
CLAHRC studies suggest that much could be gained by further considering EBP
implementation with a focus on socially situated learning, but with more emphasis on
understanding relationships among practices within the organization along with those
between organizations.

29
Recognizing Differing Perspectives and Power Dynamics
A significant implication of the situated, practice-based nature of learning described
by researchers investigating CLAHRC collaborations, is that people who practice in different
social contexts developed and held different perspectives about knowledge and its use
(D'Andreta et al., 2013; Fitzgerald & Harvey, 2015). Like Cammer et al. (2014), researchers
studying the CLAHRC collaborations describe various different groups of people engaged in
collaboration as presenting different perspectives. Rycroft-Malone et al. (2016) described
“professional and epistemic differences between higher education and practice.”
D’Andreta et al. (2013) describe underlying philosophical differences between
professional groups, specifically noting that these differences lead to different interpretations
of knowledge and how that knowledge is acted upon, indicating a potential for mismatch of
action among the collaboration’s participants. Several CLAHRC researchers observe that the
differences among groups of people who need to work together in collaboration toward the
mobilization of knowledge create challenging power dynamics. Fitzgerald and Gill (2015)
note these dynamics as different disciplinary and/or organization groups come together to
negotiate the use of knowledge. Currie (2014) describes differing perspectives and resulting
power dynamics and concomitant behaviours including conflict, subordination, and
ambivalence, of different categories of researchers including health service researchers and
organizational scientists.
Most CLAHRC researchers identifying differing perspectives among collaboration
participants highlighted the importance of relationship-building amongst participants, toward
the negotiation of a shared vision of the objectives and pathways for knowledge mobilization
(Currie et al., 2013; Kislov et al., 2018; Martin et al., 2013). In designing collaborative
structures and processes, power dynamics and social position must be recognized (Currie et

30
al., 2013; Racko, 2018) and structures must be power-balanced (Fitzgerald & Harvey, 2015).
The concept of power-balanced structure is consistent with the concept of horizontal
structure described by Greenhalgh (2004). McGivern et al. (2016) have pointed to the
importance of the manager’s open “stance” toward facilitating better relationships among
participants holding different perspectives.
Given the focus of most CLAHRC researchers on inter-organizational relations,
structures, and activities, there is little clarity regarding how they apply practically toward
knowledge mobilization within the health care organization ultimately responsible for taking
relevant clinical actions. A more granular view of group or perspectives and their
implications extending deeper into the health care organization would be beneficial to a
robust understanding of knowledge mobilization.
Spanning Boundaries Between Groups and Organizations
Given the focus of CLAHRC researchers on the collaborative efforts between
participants from two types of organization (universities and health care organizations) it is
not surprising that most describe organizational or group boundaries and each organization’s
efforts to work across them (Kislov et al., 2018; Rycroft-Malone et al., 2016; Sinfield et al.,
2012). CLAHRC researchers described a variety of roles that were established to work across
two organizations or groups to improve communication and shared activity as part of the
NIHR-funded collaborations. These boundary spanning (Star & Griesemer, 1989; Wenger,
1998) roles differed in their positioning within and/or between the participating
organizations. Coordinators and knowledge brokers worked between the collaborating
organizations to promote collaboration activities including the transfer of knowledge from
researchers to providers (Racko, 2018; Sinfield et al., 2012). Diffusion fellows were attached
to research teams to prepare and promote research for use by clinicians within the health care

31
organization (Rowley et al., 2012). Hybrid roles work legitimately within multiple groups
and, so, might be able to support the interchange of information and meaning between them
(Currie, Burgess, et al., 2014; Kislov et al., 2018).
The CLAHRC research, usefully, draws attention to some different groups involved
in EBP implementation, and the boundaries and interactions among them. Approaching CPG
implementation as knowledge mobilization involving multiple groups with different
perspectives that create boundaries among them offers great promise toward an
understanding of how CPG implementation may be more effectively supported. The focus,
however, of CLAHRC research on the boundaries between academia and health care largely
overlooks important groups and perspectives, boundaries, and gaps within the academic and
health care organizations themselves. Without this degree of granularity, the specific roles
described appear to be overlapping and imprecisely defined. Lengnick-Hall et al. (2021) call
for further research into factors that bridge inner and outer contexts. An opportunity exists to
examine CPG implementation in more granular manner to better understand other groups and
boundaries that may exist to make clearer the types of boundary spanning roles that might be
necessary.
Designing Structures and Processes to Promote Participation
Some CLAHRC researchers have identified that a rich environment of interlinked
structures, processes, and people must be in place to truly span boundaries to support
effective mobilization of knowledge. Rycroft-Malone et al. (2013) describe the need to align
organizational structure and cognitive processes over time to establish a shared history for
knowledge mobilization collaboration to be effective. Kislov et al. (2018) add that an
objective of structural alignment must be to establish shared vision and values between
academic and health care organizational boundaries. D’Andreta et al. (2013) speak to the

32
need for clear, collaborative governance to guide engagement across organizational
boundaries. With this collective, relational model of knowledge mobilization, RycroftMalone et al. (2016) highlight the important facilitative role that can be played by credible
people in boundary spanning roles.
Martin et al. (2013) offer similar observations about the need for shared vision and
aligned structures and processes to affect better knowledge mobilization. Importantly, Martin
et al. (2013) note that because the barriers for success are so institutionalized, and since the
health organization is ultimately responsible for mobilizing knowledge in a way that can
affect outcome, much of the impetus and support for these activities and alignments must
come from proactive effort by the health organization. If this is the case, there is a great need
for research that looks more deeply at the practices and perspectives within, as well as
beyond, the health organization to understand how structures, processes, and
people/relationships can be better designed and supported to affect the mobilization of
knowledge toward better CPG implementation.
Gaps in Knowledge About Implementation From an Organization Perspective
The CLAHRC research emphasized differences in perspectives among groups of
people in practice within and across the collaborating organizations. The focus on practice
and sensitivity to relationships helped to bring clarity to how processes, structures, and
people came together in the CLAHRC collaborations. While promising to an organizational
understanding of CPG implementation, the CLAHRC research focused on interorganizational relationships, leaving much that remains to be understood about the relational
dynamics within the health organization, and how they may relate to those between
organizations.

33
Summary
The literature points to, but is sparse on information regarding, the importance of
different group perspectives related to CPG and broader EBP implementation in determining
success (Cammer et al., 2014). A better understanding is needed of relationships among, and
activities of, stakeholders across and beyond the health organization – particularly those from
different groups and decision-making purviews. Research on EBP implementation
determinants suggests that academia, management and support, and clinical care might be
important groups to consider.
An opportunity exists to greatly inform CPG and EBP implementation through
organizational case study informed by known determinants of success, but oriented using an
approach that builds on the unique organizational and relational insights of the CLAHRC
studies, recognizing situated learning within and across groups and practices, and the
importance of understanding perspective and power dynamics, spanning boundaries between
groups and organizations, and a critical focus on designing and maintaining supportive
organizational and inter-organization processes and structures. Such a study promises to offer
new insights particularly for health organization decision-makers seeking to support better,
more successful CPG implementation.

34
Chapter Three: Questions and Concepts Guiding the Research
This chapter presents an overview of the research questions, describes the theories
and concepts guiding the research, with specific attention to those concepts that were
sensitizing. Charmaz (2003) defines sensitizing concepts as “those background ideas that
inform the overall research problem.” (Charmaz, 2003). A final section
offers a researcher positionality statement.
Research Questions
The study was guided by the following overarching research question:
How do individuals and teams with various functions and decision-making purviews come
together to implement prioritized clinical guidelines in a Regional Health Authority?
Specific research questions were:
•

How do organizational leaders and support personnel, structures and processes
interact (or not) to facilitate or inhibit successful guideline implementation at the
clinical practice level where the change must occur to affect patient care?

•

What does the guideline implementation process look like from the organization’s
various actors’ and teams’ perspectives? Who is involved? When are they involved?
What do they do, or not do? Who wasn’t involved and why?

Conceptual Underpinnings for the Research
The research questions reflect an overall sensitivity to the gaps in knowledge
identified through review of the literature:
• Understanding CPG implementation at the health organization - with a practical focus
on informing health organization decision-makers how they might better support
successful CPG implementation,

35
• A focus on process – in contrast to the extensive knowledge that already exists listing
things (determinants and strategies) that can have an impact on success, and
• Examining perspectives and relationships among relevant groups within and across
organizations, recognizing the importance of recognizing socially situated practice as
highlighted by the UK CLAHRC studies. Potential groups identified in the EBP
implementation literature include academics/policy-maker, and health organization
decision-makers, managers, and clinicians.
The study was further informed by practice theory and the Consolidated Framework
for Implementation Research (CFIR). The next sections provides a brief overview of the
origins and key concepts underlying practice theory, followed by identification of several key
concepts that were drawn from practice theory to sensitize the research.
Practice Theory
Practice theory is a term used to describe a relatively wide base of sociological and
anthropological theory that avoids traditional dualisms such as subject/object,
thinking/acting, by recognizing the inter-dependence between person and world (Østerlund &
Carlile, 2005). As described by Ortner, practice theory seeks “to conceptualize the
articulations between the practices of social actors “on the ground” and the big “structures”
and “systems” that both constrain those practices and yet are ultimately susceptible to being
transformed by them” (Ortner, 2006, p. 2). An understanding of the foundations of practice
theory is important for exploration of organizational change as it offers a theoretical
orientation for understanding the creation and flow of knowledge within social environments
(Nicolini, 2017).

36
Practice theorists argue for a focus away from both individualist and universal
structural explanations for social change (of which CPG implementation might be an
example), toward a view that the day-to-day actions of people within their social contexts
constitute the root of all phenomena of society (Schatzki, 1997). Many definitions of practice
speak of “doing” – to highlight action within a social context. For instance, Wenger (1998)
defines practice as “doing in a historical and social context that gives structure and meaning
to what we do” (p. 47). Other definitions introduce, as important, concepts of routine and
interaction with “the material elements that co-constitute the practice” (Spaargaren et al.,
2016, p. 55). Practice is a salient concept within healthcare given the common reference to
“clinical practice,” yet for practice theorists, practice is something we all do, it is not the
exclusive domain of the clinician.
Pierre Bourdieu is usually credited with the founding of practice theory. Bourdieu’s
comprehensive explication implicates agents within practice with the development,
production and reproduction of that practice. Bourdieu describes practice as taking place at
the nexus of multiple force fields – a unique expression of each actor’s knowledge and
experience. Each actor involved in practice is positioned within practice based on “habitus,”
that actor’s internalized system of “dispositions” based on the totality of historical experience
(Bourdieu, 1977, pp. 72-86).
Anthony Giddens drew upon Bourdieu to expand on aspects of practice theory.
Giddens’ work includes a focus on understanding how a practice-oriented view on sociology
might shed new light on the establishment, production, and reproduction of large, stable
entities he calls institutions (Giddens, 1984). Like Bourdieu, Giddens describes a
fundamental duality (as opposed to dualism) between object and action. However, Giddens
brings a degree of agency to his actors-in-practice that Bourdieu did not. Where action in

37
Bourdieu’s duality related to the “dispositions” actualized within structures (Bourdieu, 1977),
Giddens’ duality flows between structure and agency (Giddens, 1984, pp. 25-29). Giddens
coined the term “structuration” to reinforce his concept that structure and agency are not a
dualism (opposites), but a duality (aspects of the same thing). Giddens describes an iterative
cycle where individual agents assume certain structures (rules and resources) to be real and
important, based on historical experience, and act in practice according to them. Through
practice, groups re-create existing structures or create new ones that will, in turn, guide future
practice. Giddens describes this cycle as iterative and re-productive over time and space.
From a practice theory perspective, institutions (e.g., health organizations) are great, large,
and enduring only because of the practices that make them so.
Building from Bourdieu and Giddens, a variety of writers have drawn from their own
empirical work to build on the fundamentals of practice theory set out since Bourdieu. Most
have served to synthesize, detail, and provide case study or ethnographic evidence to
established theory. In the 1990’s Jean Lave, and Etienne Wenger drew largely on the
epistemological underpinnings of practice theory to challenge common learning models. The
result of their work was not only a proposed revival and embellishment on concepts of
apprenticeship as a critical learning modality they named “legitimate peripheral
participation,” but also a significant development in practice theory itself, namely the concept
of “community of practice” (Lave & Wenger, 1991). Etienne Wenger built on his empirical
work with insurance claims processing teams to expand on the philosophical framework he
had developed with Lave. Wenger developed a framework he describes as a “social theory of
learning” that is bounded by two dualities: theories of practice/theories of identity and
theories of social structure/theories of situated experience (Wenger, 1998, p. 12). Into this
framework he then positions other key sociological concepts: power, meaning, collectivity.

38
and subjectivity (Wenger, 1998, p. 14). The resulting theory yields the “community of
practice” which builds significantly on the practice theory concepts described by other
writers, but more clearly expresses the community of practice as a critical nexus for
establishment of meaning, learning, knowing, identity development, and the interplay
between social structures and practice described so clearly by Giddens.
Like Bourdieu’s fields, Wenger’s communities of practice are many, and any given
social interaction is influenced by the confluence of predispositions stemming from each
actor’s current and past community of practice involvement. Unlike fields, Wenger’s
communities of practice have a more practical character. While it is not possible to perfectly
see or define a particular practice community, it can be reasonably defined by its participants
and seen by the scope of its activities (Wenger, 1998, p. 49). While defying perfect, objective
definition and measurement, a community of practice is a reasonably intuitive concept; most
people could describe a variety of communities within which they practice. Wenger’s
community differs somewhat from its colloquial meaning (e.g., a residential community) in
that it relates to social collectives of:
a) Mutual engagement: actors in inter-relationship with diverse and constitutive roles
b) Joint enterprise: a collective, negotiated, emergent objective involving mutual
accountabilities
c) Shared repertoire: sufficient collective history to establish internal explicit and tacit
ways knowledge and practice (Wenger, 1998, pp. 72-85).
The concept of community of practice adds much to practice theory. Community of
practice becomes a fluid but tangible site for learning, for the development of meaning, for
the establishment of personal identify and the continual, interplay between structure and
action. Recognizing the existence and ubiquity of communities of practice, Wenger and other

39
practice theorists draw attention to the boundaries, and interactions, among them. Wenger
builds on earlier work by Star & Griesemer (1989) to incorporate the concepts of boundary
and boundary spanning among various teams or communities of practice into his practice
theory (Wenger, 1998). Given the fluid, interpersonal nature of communities of practice, they
present significant overlaps and interconnections, described by some practice theorists as
constellations of practices (Gherardi & Nicolini, 2002; Wenger, 1998, pp. 126-133).
Sensitizing Concepts From Practice Theory
Sensitizing concepts enable researchers to establish some structure and direction to
research studies, while remaining highly inductive in their approach (Charmaz, 2003).
Consistently, I did not undertake this research study to substantiate or apply practice theory.
Instead, I was informed by the theory throughout the study and was sensitized at the outset to
several key concepts: focus on practice, observing participants’ situated interpretations,
revealing tacit understanding, reflecting on people, structures, processes, and activity
between groups, and zooming in and out.
Focus on Practice. Consistent with the findings of the UK CLAHRC studies, the
concepts of practice and socially situated learning were sensitizing. Schmidt (2016) warns
against over-defining a practice such that it might be seen as a fixed object; conceptually
losing its loose, practical nature and tempting abstractions or reifications that obscure the
people and their actions, or inactions, that construct, and re-construct them. For this
organizational research I included, in the study design, several groups of individuals based
largely on function as a means of identifying participants and to situate understanding of
perspectives about CPG implementation and participants’ associated day-to-day activity.
Wenger (1998) defines practice as “doing in a historical and social context that gives
structure and meaning to what we do” (p. 47). Consistent with these views on practice, the

40
interview guide for this study facilitated inquiry into group and inter-group relations and
actions. The analytic process involved investigation of each participant’s understanding of a
CPG implementation activity over time, the social interactions and relationships involved,
and the people, structures, and processes that were, or were not, there to guide, and be
affected by, the implementation activity.
Recognizing Participants’ Situated Interpretations. Wenger (1998) highlights that
practice involves not only day-to-day action (divorced of thought), but also ongoing learning,
as negotiation of meaning and sense-making, among participants. Schmidt (2016) notes that
researchers should be sensitive to the interpretations that participants make and to examine
how those interpretations underpin their actions. This study’s interview approach was
designed to enable me to be sensitive to situated interpretation through open and loosely
structured interview style, enabling participants to describe events in their own way, then
encouraging them to relate back to actions taken. During analysis I reflected on
commonalities and differences in the way participants from different practice settings recount
the implementation process or describe its strengths, weaknesses, and outcomes.
Revealing Tacit Understanding. While situated interpretation and action is often
described as socially “negotiated,” the process of negotiation in practice is not always
explicit. Schmidt (2016) warns researchers to be aware of, and draw out, where
understanding may be implicit, or tacit. In day-to-day practice, people may, individually and
collectively, act in a practice-appropriate manner without being fully able to see that, or
explain why, they did so. In this study I sought to reveal instances of tacit understanding by
identifying discontinuities between the actions, outcomes, and explanations described by, and
among, participants. During analysis, such discontinuities were examined within the context

41
of the day-to-day practice described by various participants, seeking to reveal any internal
logic within which the actions (or inactions) made sense.
Reflecting on People, Structures, and Processes Acting Between Groups.
Consistent with observations of the CLAHRC researchers, practice theory’s focus on practice
raises the potential, at least conceptually, of boundaries between, and relations among,
different groups in practice. Schmidt (2016) notes that researchers using a practice theory
lens need to be sensitive to, and reflect on, situated and trans-situated activity. The activity to
which Schmidt is referring is most commonly described as boundary activity or boundary
spanning (Star & Griesemer, 1989; Wenger, 1998). To reflect boundary and boundary
spanning activity, I organized this study to capture the perspectives of participants within
broad functional groups within and outside the organization, and to compare and contrast
their views about the people, structures, and processes that were important to the
implementation.
Zooming In and Zooming Out. Latour (2005) and Schatzki (2016) describe practice
theory as a flat ontology, explaining that all of human activity and accomplishment is
attributable to the day-to-day social connections and activities of people in practice, not by
some higher level organizing social laws. Practice theorists and researchers, then, must look
to day-to-day, situated, social connections and action (or the lack thereof) to understand any
phenomenon. The focus on everyday practice does not negate the ability of the practice
theory researcher to consider large, complex phenomena such as CPG implementation in a
regional health organization. Provided the theoretical orientation of practice as the root are
maintained, the researcher can “zoom in” on individual people in practice, or “zoom out” to
consider larger networks – interconnected individuals and practices - and their implications
(Nicolini, 2011, 2012). I designed, conducted, and documented the research study to reflect

42
this approach, iteratively examining accounts and emerging themes from an individual, intragroup, and inter-group level.
Consolidated Framework for Implementation Research
In addition to practice theory, the study was influenced by the Consolidated
Framework for Implementation Research (CFIR). Within CFIR determinants of
implementation success are organized in five major domains: intervention characteristics,
inner setting, outer setting, characteristics of individuals and process (Damschroder et al.,
2009). As described earlier, the five domains provided a guide to the kinds of issues that
might arise and should be considered when examining a clinical guideline implementation.
Additionally, I drew the five domains into a loose conceptual framework guiding my
approach to the study. The domains were adapted somewhat to ensure consistency with
practice theory and to reflect the study’s focus on: process, health organization decisionmaking purviews (groups or teams), and the interactions and relationships that might be
important among domains for successful CPG implementation.
A Loose Conceptual Framework
The tenets of practice theory and the five CFIR domains and the organizational
levels/groups described above come together as depicted in Figure 3.1.

43
Figure 3.1: Conceptual Framework for CPG Implementation Research Study
Outer Setting

Intervention
(Guideline(s))

Inner Setting

Implementation Process (Action Over Time)

Individual and
Group
Perceptions
and Actions

Direct Care Team
Support Teams
Management
RHA Board

In this framework the domains described by CFIR were helpful as organizing
concepts but I reworked them to reflect the action/process orientation espoused by practice
theory (Giddens, 1984; Wenger, 1998) and the dynamics among the multiple teams and
decision-making purviews upon which this study is focused. From a practice theory informed
perspective, the organization’s multiple groups or teams simply reflect individuals in
practice. Individuals situated in social groups are, in some way, the means through which all
action takes place – from initial introduction of the intervention (in this case, a guideline or
set of guidelines) into the organization through to its successful (or not) implementation.
Given the “how” question upon which the research is based, and its multi-group
nature, the process and inner setting domains were a useful starting point from which to build
and examine barriers and success factors for guideline implementation within an
organization. The four constructs within the process domain - planning, engagement,

44
execution and reflection/evaluation (Damschroder et al., 2009) - sensitized me to what others
have found to be important and served as useful probes in data collection. The five
organizational groups or teams (4 inner and 1 outer) were established based largely on
function within (and outside) the organization, reflecting: academia and policy (outer
setting), clinical practice, management, governance, and clinical practice. The five groupings
guided participant sampling and selection across the RHA. Participants were selected based
on their participation in these broad groups. The groups were considered directly during data
collection, analysis and reporting.
The intervention domain served as a guide in the selection and description of the
study’s clinical intervention focus – a Clinical Practice Guideline. Source, evidence strength,
complexity and relative advantage, all CFIR constructs, are attributes that guided the selected
focus on clinical guidelines and influenced the selection of a specific guideline or guideline
set for the study (Consolidated Framework for Implementation Research, 2020; Damschroder
et al., 2009). Having made the selection, however, these characteristics were viewed as
constant throughout the study as the same guideline was studied across a Regional Health
Authority. The intervention domain remained important, however, to ensure that I paid
attention to how individual and group perspectives (perceptions, according to CFIR) about
the intervention arose as factors within the implementation process and/or its eventual
successful adoption (Greenhalgh et al., 2004; Rogers, 2003).
Finally, as practice theory points to the importance of the social groups to which
individuals belong (Bourdieu, 1977; Giddens, 1984; Wenger, 1998), I have added groups to
CFIR’s individual domain. This addition was made to recognize the social groups in which
individuals participate at work. The interdependency between individuals and their practice

45
group was important to the study’s design and its implementation. Participant selection was
influenced by group role and, in some instances, an assessment of the candidate’s status and
position within the group (Bourdieu, 1977; Wenger, 1998). The concept of action orientation
(Giddens, 1984) served as a reminder during data collection and analysis to remain attuned to
the way in which any potential success factors for KT manifest in action through individuals
and groups. The framework served as a loose guide (Miles & Huberman, 1994) to qualitative
investigation while in no way restricting inductive, data-driven learning arising from the
experiences of study participants and demonstrated in organizational documentation.
Positionality Statement
I undertook this research study as part of my PhD studies in Health Sciences. The
PhD was a continuous learning opportunity for me, as I continued my career of over 30 years
in health services management. The study’s focus on CPG implementation stemmed from an
interest in quality improvement that extended throughout my career. The focus was also
consistent with my position (at the time, and now) as a Regional Health Authority VicePresident with responsibilities in quality, planning, and information management.
With post-secondary training in economics and business, and a career in management
consulting, government, and health organization senior management, I entered the study with
a strong practical understanding of organization, bureaucracy, governance, and management.
While I am intellectually drawn to constructivist philosophy, there is no doubt that I have
been engaged in a lifetime of education, social, and employment worldview, norms, and
activities that stem from more deductive, positivist leanings.
I embarked on PhD studies to learn and to challenge myself, so I decided to study
CPG implementation qualitatively and inductively – allowing the participants, and the data
they provide, to guide me. Practice theory’s focus on socially situated learning underscored

46
this inductive approach by drawing my attention continually back to what participants said
about what they thought, what they did, and with whom they related. My training and career
had conditioned me to be well aware of, and potentially biased toward, the perspective of
management; my research question and conceptual framework positioned me to see, and to
try to process, CPG implementation from other points of view. In research, I sought to look at
CPG implementation inductively, from different perspectives – to see what I might learn, and
inform others, about management.
Over the course of the study my initial sense of how implementation within an
organization happens (with executives and managers leading and managing the change) was
challenged as accounts of participants outside of regional management roles differed
considerably from those of managers. I had to trust the data when what I was seeing/hearing
clashed with my preconceived notions about how implementation should happen in a RHA.

47
Chapter Four: Research Design
This chapter presents the methodology and methods used to conduct a retrospective,
qualitative case study regarding CPG implementation. The chapter begins with a description
of the research methodology and methods. The chapter ends by describing the strategies used
within the study to ensure rigour, and a strong ethical foundation.
Qualitative Case Study
The research was conducted using retrospective, qualitative case study (Merriam,
2009) design undertaken at one British Columbia Regional Health Authority (RHA). A
qualitative research approach was selected for this study as it is best suited for the study’s
focus on the perspectives of individuals and teams within and beyond the regional health
organization, and how those perspectives might have influenced action. As noted by Merriam
(2009), “qualitative researchers are interested in understanding how people interpret their
experiences, how they construct their worlds, and what meaning they attribute to their
experiences” (p. 5). Case study design was selected for this study for its merits in gaining
holistic understanding of complex phenomena (Merriam, 2009; Smith, 1978; Stake, 2008)
such as CPG implementation within a regional health organization, and for its applicability
for studies of “how” questions such as that described for this study (Yin, 2014). Case study is
defined by Merriam (2009) as “an in-depth description and analysis of a bounded system” (p.
50) used when there is “a problem that we are interested in and we feel that an in-depth study
of a particular instance or case will illuminate that interest” (p 81). Merriam’s (2009)
rigorous case study method guided study design, data collection and analysis methods, and
report writing. Merriam’s constructivist approach to case study was more consistent with this
study’s conceptual framing using practice theory, and with my worldview (if not my
experience base as an executive), than Yin’s (2014) realist approach. Merriam’s detailed

48
approach provided more useful guidance than Stake (2008), particularly given my status as a
novice researcher.
Data were collected for the study using individual and small group interviews, and by
reviewing a wide range of documents and process/outcome measures relevant to the topic of
guideline implementation. Participants were identified, with the assistance of a RHA project
liaison, from a wide variety of relevant service areas and from multiple organizational
decision-making levels to capture and describe the activity holistically and to enable analysis
that reflected these multiple perspectives. Data were analyzed through a qualitative
descriptive approach with theme development (Merriam, 2009). This case study presents
quantitative data related to CPG process and outcome measures. Quantitative information,
however, is presented and discussed only inasmuch as it was available and interpreted (or
not) by study participants. Given the limited and specific use of quantitative information, the
study does not fit common categories of mixed methods investigation (Tashakkori & Teddlie,
2010), and remains qualitative.
Merriam (2009) outlines several types of qualitative case study depending on the case
and the researcher’s needs. The study was conducted using retrospective, single case, design.
The single case study was undertaken at one Regional Health Authority (RHA) in British
Columbia, Canada.
The case study involved examination of a CPG implementation retrospectively, over
a 7-year period (2011-2017). The retrospective approach offered a high degree of sensitivity
to temporality and process (Langley, 1999; Pettigrew, 1990). The CPG implementation case
study was undertaken to inform understanding generally, but with a specific interest in
informing RHA decision-makers about how they can better support CPG implementation to
be more successful.

49
Methods
This section provides a description of the case definition and site, CPG, and hospital
selection, participant selection, attributes of participants, data collection, data management,
and data analysis methods.
Defining the Case and Participant Groups
Given the intent of the study was to inform RHA decision-makers, the primary focus
of the case study was on the inner setting of the RHA itself. However, attention was also paid
to the people, processes and structures outside (outer to, using CFIR’s terminology) the
organization’s boundaries interacted with RHA participants in CPG implementation. This
outer participant group was named Academic, Advocacy and Policy (AAP) group for this
study. With the focus of the research question on the interactions of “individuals and teams
with various functions and decision-making purviews,” the inner (RHA) setting was initially
organized for study design into three broad, function-based practice groups (the first two
were subsequently combined based on consistencies in the way participants described the
CPG implementation):
• Regional Leadership comprised of a Regional Health Authority’s governors,
executive and senior managers, including individual hospital site leaders
• Regional Support functions comprised of middle managers and providers of
departments that provide services that support direct patient care (e.g., laboratory
services, information technology, quality improvement) and administration
• Direct Care comprised of localized clinicians, managers, and support staff organized
as a unit toward the delivery of direct patient care.

50
While functional groupings do not necessarily correspond with the rich concepts of
learning, meaning, and identity underpinning practice, they often promote the proximity and
sense of purpose that underpins practice (Wenger, 1998).
Selecting the Regional Health Authority
The British Columbia healthcare system and regional health organizations (known as
Regional Health Authorities) offered an ideal environment within which to study clinical
guideline implementation due to proximity (to the researcher) and because the province’s
RHAs gained rich experience with CPG implementation resulting from a provincial CPG
implementation initiative known as the Clinical Care Management (CCM) initiative, which
ran between 2011 and 2017. The CCM initiative, overseen by the British Columbia Patient
Safety and Quality Council (BCPSQC), established a provincial expectation and some
provincial infrastructure for the implementation of several leading CPGs understood at the
time to have a significant impact on healthcare quality and safety.
Of the province’s five British Columbia RHAs, I purposefully selected Select Health
for the study because it is not my place of employment, its executive team had expressed an
explicit strategic commitment to evidence-based practice, it is comprised of many relatively
large sites any of which would be likely to experience high patient volumes relative to any of
the BCPSQC CPGs (the CPG was selected after the RHA) and the organization’s Chief
Executive Officer expressed to me a willingness to participate. To ensure confidentiality for
participants engaged in the study, the name of the British Columbia RHA has been replaced
with the pseudonym “Select Health.”
Selecting the Clinical Practice Guideline Set
The British Columbia CCM initiative encompassed twelve sets of clinical guidelines,
or guideline “sets” – collections of recommendations each reflecting specific clinical actions.

51
The study examined implementation of the Sepsis Guidelines (British Columbia Patient
Safety and Quality Council, 2011), also referred to as the Sepsis Guideline Set, for four
reasons. First, the Sepsis Guideline Set had been in existence as a CCM initiative since the
inception of the provincial guideline initiative in 2011, so opportunities to study
implementation over time were maximized. Second, most of the operational changes
indicated by the recommendations of the Sepsis Guideline Set were well within the control of
the RHA but they involved various departments and professions. This balance of scope and
complexity presented a good opportunity for learning about multi-level implementation.
Third, at the time, this CPG appeared to offer some of the most compelling research evidence
linking process and outcome (Rivers, 2010) of all the CCM guidelines at the time of
selection. Fourth, the Select Health liaison – a Select Health Executive appointed by the
Chief Executive Officer to assist with CPG, site selection, and logistics - identified during an
initial start-up interview that the sepsis CPG was one of the CCM guidelines upon which they
had focused most, and the organization’s low sepsis mortality rate indicated a high degree of
success in managing sepsis patients.
Sepsis is a term referring to the “the systemic response to infection” (Bone et al.,
1992). The underlying source (site and type) of infection is not specified; the term relates to
the system responses and, ultimately, failures that can arise from escalating infections.
According to a study conducted by the Canadian Institute for Health Information (Canadian
Institute for Health Information, 2009), sepsis, which is detectable and preventable through
the prescribed guidelines, results in 30,000 people being hospitalizations in Canada every
year of whom 30% will die.
The Sepsis Guideline Set (British Columbia Patient Safety and Quality Council,
2012) incorporates several recommendations involving: rapid identification of at-risk patients

52
in the emergency department based on a variety of criteria (e.g., elevated heart rate,
temperature, respiratory rate). The guidelines further specify key diagnostic and treatment
responses including:
•

Test of lactate within 30 minutes of presentation

•

Blood culture followed by antibiotics within 1 hour of presentation

•

Early initiation of IV fluid.
Appendix B includes further detail regarding the BCPSQC Sepsis Guideline Set. The

selection of the Sepsis Guideline Set helped to specify the case study timeframe. Since this
CCM guideline set was mandated in 2011, that date constituted the study’s retrospective
starting point. Although the Sepsis Guideline Set was updated in 2016 (Gotts & Matthay,
2016), the 2011 Sepsis Guideline Set was used as it was in force during the case study
timeframe. Where relevant, participants were asked about subsequent changes to the
guidelines during interviews.
Selecting the Hospital Site for Case Study
Select Health is comprised of several hospital sites spread across a large population
base and a wide geographic area. Management and supports are organized into a multitude of
regional departments. Given its organizational focus, this study investigated Sepsis Guideline
Set implementation both from the perspective of those involved in regional leadership,
management, and support services, and at one hospital site where the Sepsis Guideline Set
was implemented by a group providing direct care. In collaboration with the Project Liaison,
I selected City Hospital (pseudonym) for the study based on the following criteria:
•

Size/volume. While one of the most common complications leading to death, sepsis
and sepsis death remain relatively infrequent within a hospital’s day-to-day caseload.

53
Based on sheer numbers a large site providing a high volume of emergency and
inpatient service offered the most exposure to patients with sepsis and, hence, the
greatest opportunity to experience and understand the effectiveness of their guideline
implementation strategy. City Hospital is the largest site within Select Health,
experiencing the highest volume within their Emergency Department, and the highest
raw number of sepsis cases.
•

Confirmation of guideline implementation activity. Early-stage interviews with
regional quality improvement executives and managers led to the identification of
Select Health sites most referenced as being perceived by the organization’s leaders
to have demonstrated leadership and activity in implementing the Sepsis Guideline
Set, and opined to be the most successful. Among those early interview participants,
City Hospital was identified consistently as the Select Health site most relevant for
study based on this criterion.

•

Sepsis outcomes. Select Health applied BCPSQC measurement criteria to assess
sepsis outcomes defined by sepsis mortality rate (sepsis related deaths/sepsis cases x
100%). Averaging 6.4% over the study period (2011 – 2017) based on Select Health
data and definitions, City Hospital sepsis outcomes were favourable both among
Select Health hospitals and when compared to the rates of up to 30% described in the
literature (Canadian Institute for Health Information, 2009).

•

Willingness to participate. The hospital’s management team expressed a willingness
to participate. While the Select Health Chief Executive Officer provided
organizational approval, the RHA’s research operational review and approval
processes required sign-off from the operational sites most affected.

54
Identifying Participants Relevant to Each Functional Group
Once the Sepsis Guideline Set was selected as the CPG for the research, it was
possible to determine the most relevant inner and outer setting functional groups from which
to recruit and select participants. The inner setting Direct Care (DC) group of interest for City
Hospital was the Emergency Department team as the sepsis CPG related to emergency care.
The DC group included clinicians (nurses and physicians), physician leaders, team managers,
and clinical support team members including Clinical Nurse Educators and the Nurse
Clinicians available to support newer staff in professional development and becoming
comfortable in clinical practice.
Along with members of the Select Health Regional Leadership (RL) group comprised
of members of the executive team and senior managers, the inner setting Regional Support
(RS) group relevant to sepsis guideline implementation included:
•

Regional Emergency Medicine Program/Service Network leads. Like many RHAs,
Select Health provided regional quality networking and leadership/support activities
for a variety of key services including emergency services. During the study
timeframe, Select Health moved from a service program to a network model.

•

Laboratory and Pharmacy Department managers and staff, as they had important
clinical support functions integral to the detection and management of sepsis.

•

Information Technology (IT), Health Information Management Services (HIMS),
Clinical Education, Professional Practice, Research and Evaluation, and change
support department (e.g., Quality Improvement and Healthcare Business Analytics)
managers and staff, as these support department/service teams had roles in planning
and supporting organizational change.

55
The most relevant outer setting group, Academic, Advocacy and Policy (AAP)
participants related to this study of Select Health’s Sepsis Guideline Set implementation were
academic and quality leads who were involved in the development and provincial guidance
for sepsis.
Selecting Participants for the Case Study
Participants were purposefully selected for interview based on their: RHA/hospital
role, tenure with Select Health during the study timeframe, and willingness to participate.
Interviews with people reflecting the outer setting included provincial academic and quality
leads. Interviews with people reflecting the inner setting were conducted at the regional and
hospital site level. Regional-level interviews included members of the Select Health
executive team, the Emergency Medicine Program/Service Network clinical, and medical
leadership, Quality, Education, Policy, Analytics, and Research team managers and staff,
along with senior managers and staff from the organization’s Information Technology,
Health Information Management Services, Pharmacy, and Laboratory Departments. Due to
attrition, no members of the Select Health Board of Directors had significant experience
during the study timeframe, so Board members were not interviewed. Hospital site level
interviews included representation from City Hospital’s administrative and medical senior
leaders, and relevant directors. For the perspectives of the group providing direct care,
interviews were conducted with representation from the Emergency Department’s
management, educators, triage and care nurses, physician leadership and physicians.
Potential interview participants were approached initially by the Select Health Project
Liaison. The Project Liaison provided each potential participant with an e-mail describing the
study and noting that they would be contacted by the researcher through follow-up e-mail.
Once contacted, e-mail was used to contact each candidate; again providing them with an

56
overview of the study, including a one-page study summary, and the ethics-approved
interview consent form. During this contact, e-mail or telephone response was sought
indicating interest or declining participation in the study. Where interest was indicated,
participants were contected by e-mail or telephone to organize the interview location (Select
Health site or telephone) and date/time. All but one candidate approached to participate in the
study expressed interest and consented to participate.
Participants
In total, 38 individuals participated in the study. Consistent with the definition of
“case” for the case study, and its organizational focus, most (36) of the participants fell
within the three inner setting functional groups (RL, RS, and DC). Two participants from
outside Select Health were interviewed as the most applicable aspect of outer setting AAP
functional group given the research questions. Figure 4.1 presents the number of participants
interviewed within each setting and functional group (AAP, RL, RS, and DC), along with
their professional background.

57
Figure 4.1
Participants by Setting, Functional Group, and Profession
Setting/Functional Group

Number
2

Inner Setting: Participant Profession

Number

1

Respiratory Therapist

8

Physician

Inner Setting:

23

Nurse

Outer Setting (AAP):

38

Total

8

Direct Care Team (DCT)

19

Regional Support (RS)

9

Regional Leadership (RL)

Physiotherapist
Management/Administration

Total

1
5

38

Note. Three inner setting functional groups were originally described (RL, RS, and DC). During analysis, based
on consistency of perspective, the RL and RS groups were combined and described as a Regional Leadership and
Support (RLS) group.

Nurses and physicians constituted the largest proportion of study participants, with
others having backgrounds in allied health service or non-clinical, management professions.
Within the study’s inner setting, 22 individuals were interviewed whose positions were of a
regional nature and 14 individuals who worked at City Hospital, a more site-specific level.
All interviews were conducted using one of three modalities: in-person individual (23
individuals), in-person group (5 individuals) or telephone interviews (10 individuals). 25
(65%) of the study participants were female, 13 (35%) were male.
Given the retrospective nature of the study, it was important to involve participants with
direct experience with the sepsis guideline implementation during the study timeframe of
2011 to 2017. Figure 4.2 presents the number of years each of the study’s 38 participants was
present during the study period, arranged by organizational team affiliation.

58
Figure 4.2
Participant Relevant Years Present During Study Period 2011-2017 by Functional Group
Participant Relevant Years Present During Study Period by Team (max = 7)
0

1

2

3

4

5

6

7

Support

Academic,
Advocacy & Policy

Regional
Leadership

Direct
Care

DCT
DCT
DCT
DCT
DCT
DCT
DCT
DCT
MGMT
MGMT
MGMT
MGMT
MGMT
MGMT
MGMT
MGMT
MGMT
OUTER
OUTER
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT
SUPPORT

Note. Each of the 38 study participants’ years of experience with Sepsis Guideline Set implementation is plotted
with seven years (the full study timeframe) being the maximum. Line colours delineate functional group.

Given the study timeframe was a seven-year period, the maximum “relevant” years
present is seven. Relevant years were defined as the number of years the participant held a
role that was defined in the study participant selection methods. This definition recognized
that some participants may have changed roles during the study timeframe but still served in
roles that were directly relevant (e.g., an Emergency Department (ED) physician who
subsequently took an Emergency Medicine Program leadership role). Of the 38 study
participants, 29 (76%) held relevant roles for the full seven years. The remaining nine
participants either joined Select Health later during the study timeframe, or moved to

59
different, less directly applicable roles sometime during that time. Given the organizationwide, multi-level character of the study, it was important to ensure depth of experience not
only overall, but within each of the functional groups defined (AAP, RL, RS, and DC).
Figure 4.2 presents the relevant years’ experience demonstrated by interview participant
organized by team. For most teams there was relative stability; most participants had held
their roles for the full seven years or nearly so. Proportionately, less stability was apparent
among the management group as turnover was higher among that category.
Interviews
Most interviews were organized as person-to-person interviews with two interviews
structured, with consent of the participants, as small group sessions. A semi-structured format
was used for interviews (Merriam, 2009, p. 89). Appendix C presents the data collection tool
and interview guide. The interview guide incorporated concepts of action over time, and
relationship drawn from practice theory and was adapted with the advice of a Critical Care
program lead from another British Columbia RHA. The interview guide was pilot tested with
a BCPSQC informant and remained consistent throughout the study. Each interview included
a brief structured component to capture elements of background from each participant (name,
role within RHA, professional designation(s) and employment history over seven-year
retrospective period), followed by the semi-structured interview. The interview was
conducted to gain an understanding of the individual’s own role in the clinical guideline
implementation and their experience, knowledge and perceptions regarding the
implementation process. The interviews ranged from 45 to 70 minutes. During each
interview further input was sought about implementation success factors and barriers, people,
structures, and processes involved, and relationships within and among groups.

60
At the beginning of each interview the study consent form was reviewed with the
participant and consent was sought. Consent was provided in writing during in-person
interviews or recorded verbally during telephone interviews (See Appendix D). Interviews
were audio-recorded and transcribed by a professional transcriptionist to enable information
retention and detailed analysis. During these interviews notes were taken to capture key
points and to guide follow-up and probing. One participant declined consent to record. In
this situation extensive notes were taken, with consent.
Follow-up was conducted by telephone and e-mail with one participant from each of
the BCPSQC, the region, from City Hospital, to address details and developing themes – a
research quality process known as member-checking (Merriam, 2009, p. 217). Selection of
participants for follow-up was theoretically based; based on the topic and details required
(Corbin & Strauss, 2008; Lincoln & Guba, 1985; Streubert & Carpenter, 2011). Participants
confirmed interpretations and occasionally offered further elaborations.
Documents
Documents complemented interview data. Documents that may be relevant to Sepsis
Guideline Set implementation were identified in collaboration with, and subsequently
requested from, the Project Liaison who coordinated identification and collection within
Selection Health. 365 documents were collected. All documents were obtained in electronic
format, either from Select Health’s or the BCPSQC’s external websites, through the Project
Liaison, or from individual regional or City Hospital informants.
Documents received included: Select Health strategic plans during the study period;
Board minutes, Executive minutes, Board, regional management and City Hospital quality
committee minutes; copies of provincial and Select Health sepsis guidelines and order sets;
communiques and newsletters regarding the BCPSQC and Ministry of Health Clinical Care

61
Management initiative, including Sepsis Guideline Set implementation guidelines and
directives. Documents spanned, or proved relevant to, the seven years 2011-2017,
recognizing 2011 as the date the BCPSQC guideline set was established (British Columbia
Patient Safety and Quality Council, 2011).
Three published studies were identified and acquired that drew from the province’s
experience with implementing Clinical Care Management (CCM) including the BCPSQC
Sepsis Guideline Set. Best, et al. (2016) examined the CCM implementation from a
provincial systems perspective. McKeown, Shergill and Sweet (2016), and Gorley et al.
(2016) studied the Sepsis Guideline Set implementation provincially to understand the impact
of gamification and networks respectively. None of these studies were specific to RHA
organizational implementation, nor were they focused specifically on Select Health or City
Hospital, however they were reviewed for insight with respect to sepsis guideline
implementation and for relevant background.
Sepsis Guideline Set Implementation Performance Data
Electronic sepsis guideline performance monitoring information (“report cards”)
were obtained. The data were aggregated to fiscal period and quarter spanning from period 7
2013/14 to period 4 2016/17 (there are 13 periods per year beginning April 1 each year). The
performance data were derived from Select Health’s clinical management system and a chart
audit process used by the organization. The report cards included information regarding
sepsis case definitions, sepsis mortality and implementation performance data regarding
adherence to guideline recommendations including time to: lactate measurement, fluids,
blood culture and delivery of antibiotics.

62
Data Management
During field work on-site (at Select Health), documents and the voice recorder were
held on-person at all times. These items were stored in a locked filing cabinet at a private
location during all other times. Consent forms were filed in a locked filing cabinet. All hard
copy documents will be destroyed upon completion of this dissertation. Interview recordings,
transcripts, documents, and performance data have been stored electronically on a single
secure server at the University of Northern British Columbia accessible only through a
password protected laptop using secure VMware. In compliance with Research Ethics Board
expectations, digital data will be destroyed five years after completion of the dissertation.
Data Analysis
The following sections outline the methods used for analyzing case study data. While
the study was primarily qualitative, some process and outcome data were acquired and
analyzed.
Data Analysis: Interview and Document Data.
Qualitative analysis of interview and document data began as soon as data were
obtained. Analysis continued throughout the investigation with focused periods of intensive
analytic activity occurring between study stages and during the finalization stage.
As an initial step prior to data analysis, each document collected was reviewed for
material of topical relevance. This initial screen was for information mentioning: guidelines,
CPGs, evidence, improvement priorities, improvement initiatives, sepsis, Select Health’s
relationship with the BCPSQC and Ministry of Health with respect to the Clinical Care
Management initiative. Documents containing references of interest were flagged for analysis
in the same manner as for interview transcripts described below.

63
Interviews and documents were analyzed using qualitative coding and the constant
comparison method described as qualitative description by Merriam (2009). Merriam draws
significantly from qualitative grounded theory analysis methods described by Corbin and
Strauss (2008). Analysis was aided by the use of the NVivo 12 Pro™ qualitative data analysis
software. Coding proceeded using the reviewed/corrected transcript. Two overlapping types
of coding were conducted: open and analytical coding as referenced by Merriam (2009). An
example of this coding approach is provided in Appendix E. With open coding, each element
of data (e.g., each interview transcript or document) was divided into individual data units
(sentences or paragraphs conveying unique concepts deemed relevant to the research
questions) to which were attached short meaningful name or “category.” This coding process
involved the attachment of some degree of interpretation and meaning to individual data units
through the names selected (Boyatzis, 1998; Merriam, 2009). This early coding is considered
“open” coding because the meaning attached arises from the data itself rather than an overarching theory. As analysis proceeded, the data units arising from new sources were assessed
against those previously identified, to determine if a new category was warranted or if the
new unit could be appropriately named with an existing category.
As codes were developed they were then compared to one-another (a process known
as analytical coding): combining, re-organizing and re-naming to capture inter-relationships
and to deepen meaning (Merriam, 2009; Corbin & Strauss, 2008). Through this process it
was possible to develop key themes that were important to the organizational Sepsis
Guideline Set implementation process; its enablers and its challenges.
Given the study’s focus on implementation and its underpinning in practice theory, it
was important to introduce an analytic strategy specific to the understanding of process. For
this process orientation, visual mapping was used as an ongoing analytic tool using MS

64
PowerPoint. Visual mapping involves analysis and presentation of significant amounts of
data into visual formats recognizing various dimensions including time (often the horizontal
axis of a visual map) and organizational team/level (often addressed through sections along
the map’s vertical axis) (Langley, 1999; Miles & Huberman, 1994). Plotting and analyzing
implementation decisions and activities over time provided rich, visual information in
support of understanding the importance of timing and inter-relationship of activity.
Information regarding individual roles or functions was often overlaid onto visual maps of
process, providing an additional layer of information informing the study’s “how” question –
often paraphrased as “who did what to whom.” Several such maps are included Chapters 5-7.
As a final analytic approach, themes emerging from open and analytical coding were
reviewed against the sensitizing conceptual framework. Theme content was compared and
contrasted by functional group, noting consistencies and differences within, and among,
groups that might be indicative of unique perspectives established and reinforced in practice.
This analysis helped in continually refining and deepening insight into Sepsis Guideline Set
implementation.
Interview Content Sufficiency Analysis.
The number of interviews conducted was determined to ensure participation from the
functional groups identified, and continually examined and compared to data collected todate. A saturation analysis was conducted (Figure 4.3). Saturation involves a marginal
assessment of the unique content gained through the conduct of one additional data collection
activity – in this case, one additional interview. Saturation was reached when additional
interviews provided little new knowledge/content (Streubert & Carpenter, 2011).
Upon completion of 35 interviews, the code set developed at that point was analyzed
to determine the degree to which latter interviews were adding new content. The interviews

65
were organized into an Excel™ spreadsheet in order from the first to the 35th. On a vertical
spreadsheet axis, were listed each of the 149 categories that had been developed. In the
spreadsheet cells a counter (a “1”) was used to note the interview through which the category
was established. Where the category was applied in subsequent interviews it was noted with a
“0” for visual reference. The counter indicated the number of new categories brought forward
from each interview and a cumulative number and percentage of total categories identified.
As demonstrated in the figure, fewer new categories were generated from the last few
interviews. The 31st of 35 interviews had identified 99% of the full code set. The final 4
interviews resulted in a single new category. The new category was very specific to the
participant’s unique role and did not represent a new conceptual topic that could benefit from
further investigation.
Figure 4.3
Interview Content Sufficiency Analysis
Interview #

1

2

3

4

5

6

7

8

Number of new categories

22

9

2

6

0

3

0

16

4

Cumulative new categories

22

31

33

39

39

42

42

58

62

15%

21%

22%

26%

26%

28%

28%

39%

42%

Interview #

10

11

12

13

14

15

16

17

18

Number of new categories

5

3

11

4

3

0

1

4

5

Cumulative new categories

67

70

81

85

88

88

89

93

98

45%

47%

54%

57%

59%

59%

60%

62%

66%

Interview #

19

20

21

22

23

24

25

26

27

Number of new categories

3

2

6

9

8

3

0

2

3

Cumulative new categories

101

103

109

118

126

129

129

131

134

% of total categories established to this point

68%

69%

73%

79%

85%

87%

87%

88%

90%

Interview #

28

29

30

31

32

33

34

35

Total

Number of new categories

4

4

2

4

0

0

0

1

149

Cumulative new categories

138

142

144

148

148

148

148

149

149

% of total categories established to this point

93%

95%

97%

99%

99%

99%

99%

100%

100%

% of total categories established to this point

% of total categories established to this point

A similar analysis was done at the functional group level. The 35 interviews were
organized by setting and functional group – recognizing Academic, Advocacy & Policy;
Direct Care; and Regional Leadership and Support groups. This analysis yielded similar

9

66
results to those presented in Figure 4.3. In all but one setting/service team saturation was
reached by the final interview.
Data Analysis: Process and Outcome Data.
Analysis and display of process and outcome data was supported using Microsoft
Excel™. Given the process/temporal focus for this study, run charts were used as the primary
mode for organizing and analyzing Sepsis Guideline Set outcome and process data. Run
charts, as described by Balestracci and Barlow (1996), plot performance over time with
statistically calculated bands indicating the range within which variation is considered normal
(not the result of unusual circumstances such as a focused change activity). Additionally,
summary statistical measures (mean, median, variance) were developed to make general
comparisons (e.g., Select Health measures vs. those reported in the literature).
Research Quality
This research study has incorporated approaches to address each of the dimensions of
quality specific to qualitative research: consistency (reliability), credibility (internal validity),
and transferability (external validity) (Lincoln & Guba, 1985; Merriam, 2009).
Consistency is defined by Merriam (2009) as “the extent to which research findings
can be replicated” (p. 220). To address consistency, written analytic notes and memos were
captured, organized and retained to document observations, ideas, and decisions related to the
interpretation of data. In this way, a clear, reconstructable audit trail exists between data
collection and findings/results. In addition, the findings chapters of this document were
constructed in a manner that incorporates a high degree of a technique known as
“signposting.” Signposting involves the provision of sufficient description and flow to paint a
logical path between data and conclusions (Koch & Harrington, 1998). As the study was
executed by a PhD candidate, it was conducted with the guidance of a highly experienced,

67
credible supervisory committee. Opportunities were taken to obtain their assessment and
guidance as to approaches to enhance research rigour and credibility. During the study the
research Supervisor reviewed interview technique and initial analysis and provided feedback
for ongoing development. Finally, this dissertation is written in compliance with published
standards for reporting qualitative research (O'Brien et al., 2014).
Credibility, the degree to which “findings are credible given the data presented”
(Merriam, 2009, p. 213), was addressed through the use of triangulation, member-checking,
reflexivity, high researcher engagement with the data, and ongoing research committee
review (Merriam, 2009). Triangulation was facilitated between data collected through
interview and document review. Member-checking was conducted through e-mail and inperson follow-up to confirm details with interview participants as required. Near the final
stage of data collection six individuals previously interviewed were contacted to fact-check
and to validate and expand upon themes that had been developed.
Finally, transferability, defined by Merriam (2009) as “the extent to which the
findings of one study can be applied to other situations” (p. 223) has been address through
several steps to provide the reader with the level of detail needed to determine the degree to
which findings might be applicable within his/her own context. The findings have been
reported using rich description so the basis upon which any theming or abstractions are clear.
The study’s 35 interviews, 38 participants, and 365 reviewed documents, provided
considerable variety in perspective, approach and context.
As noted in the researcher positionality statement at the end of Chapter 3, my race,
position, and 30 years of progressively senior administrative roles in the health industry
could lead to certain perspectives and biases. To counter potential conscious or unconscious
biases I might have brought to the research, I used a reflexivity checklist that itemized a

68
variety of such potential biases (e.g., bias favouring or disfavouring certain professions or
hierarchical levels) for ongoing reflection during data collection, analysis, and reporting
activities. I also used memos extensively throughout the study to track ideas, observations,
developing themes and changes. Memos were instrumental to analysis, and they serve as an
audit trail for the study.
Variations From The Study Protocol
The study involved two significant variations from the original study protocol. First,
the original protocol proposed that two case studies would be conducted, to enable
comparison of sepsis guideline set implementation at two sites within Select Health. The
cases studies were to be conducted sequentially. Following completion of the first study (City
Hospital), I found the participation and data to be so voluminous and rich that I determined a
second case to be unnecessary. Second, the original protocol proposed to conduct detailed
process mapping of the sepsis guideline set implementation with a group of participants from
across the Regional Health Authority. Following initial interviews with BCPSQC, regional,
and site participants, I determined that a collective process mapping exercise would be
unhelpful. At an early stage I realized that the different groups of participants were
describing the implementation process very differently. This difference in group perspectives
about CPG implementation became the substantive premise of my research.
Ethical Considerations
Throughout the study the student researcher’s methods and behaviours reflected the
highest ethical standards consistent with the policies set out by the Canadian Research TriCouncil policy statement on ethics (Canadian Institutes of Health Research, Natural Sciences
and Engineering Research Council of Canada, and Social Sciences and Humanities Research
Council of Canada [Tri-Council], (2014). The study obtained harmonized ethical and

69
operational approval through University of Northern British Columbia and Select Health
ethics/operational review prior to initiation (reference #2016-099). The Select Health CEO
provided written organizational support and consent. Written invitations to participate were
sent electronically (e-mail) to potential interview participants. The researcher followed a
documented process to obtain informed consent. See Appendix D for a copy of the interview
consent form used throughout the study. Participants were provided the opportunity to
confirm or withdraw consent at each stage. For notes taken during interviews a coding
system was applied to eliminate the use of individual names. This dissertation applies
organization, site and individual pseudonyms to protect confidentiality.
Although an ethical review the study was assessed as low risk, it did involve some
potential social risk to participants as they discussed matters that were related to the success
or failure of the Sepsis Guideline Set implementation. For instance, anticipating that should it
be known or suggested that an individual attributed, or admitted to, some blame for problems
arising in implementation, the individual’s social or professional standing could have been
compromised. Few such instances arose. Where they did arise, the risk was minimized by:
•

Ensuring anonymity and security of documentation through physical and electronic
security measures, and

•

Maintaining confidentiality of participants including avoidance of any identifying
references in discussions, working documents or interim and final reporting.

Chapter Summary
This chapter set out the methodology and methods used to conduct a retrospective,
qualitative case study of Sepsis Guideline Set implementation at Select Health in British
Columbia, Canada. The next chapter is the first of three outlining the findings of the study,

70
beginning with the sepsis guideline evidence itself – how it came to be and how participants
at Select Health came to know about it.

71
Chapter Five: Advancing Implementation
This chapter, the first of three chapters that offer findings, presents a description of
the landscape of evolving research evidence and activism that proved relevant to advancing
the implementation of the CPG intervention, the Sepsis Guideline Set, at Select Health. The
chapter provides the perspective of, and about, participants of the outer (to Select Health)
setting Academic, Advocacy and Policy (AAP) group. I characterize this perspective as one
about “advancing implementation.” The Sepsis Guideline Set did not originate at Select
Health so the way the guidelines were developed and disseminated is germane to a study of
their implementation at the Regional Health Authority. Participants holding AAP roles
described their efforts to advance and influence implementation by the province’s Regional
Health Authorities, including Select Health. AAP participants described activities related to
synthesizing and disseminating information about the Sepsis Guideline Set through electronic
communications (website, e-mail), and through networking and ongoing performance
measurement.
The AAP participants incited, and helped to shape, the Sepsis Guideline Set
implementation at Select Health. To gain a rich understanding of the AAP roles, activities
and structures that influenced Sepsis Guideline Set implementation, it was necessary to
examine events that extended well beyond the planned study timeframe of 2011 to 2017.
Figure 5.1 provides an overview of these factors from 1990 to 2017.

72
Figure 5.1
Aspects of Evidence, Advocacy, and Policy from 1990 to 2017
“Advancing Implementation”
1990

Defining Sepsis

Treating Sepsis

Academic
Advocacy

2017

Year
Sepsis Consensus
Conference (1991)

Standard
Therapy

Sepsis Consensus
Conference (2001)

Early Goal-Directed
Therapy (2001)

Sepsis Consensus
Conference (2015)

Ongoing clinical research and debate to refine sepsis
response drawing on consensus definitions

Surviving Sepsis
Campaign (2002)

Global Sepsis
Alliance (2010)
Evidence to
Excellence (2008)
BCPSQC
Established (2008)

Provincial Policy
Mobilization

BC Sepsis
Network (2011)

MOH Innovation &
Change Agenda (2010)
BCPSQC Sepsis
Guidelines (2010)
MOH Sepsis
Mandate (2011)

BCPSQC Sepsis
Guideline
Revisions (2016)

Sepsis Data Guide (2012)

Acronyms:
BCPSQC – British Columbia Patient Safety & Quality Council
MOH – British Columbia Ministry of Health

Figure 5.1 serves as a useful guide to the description of the dynamic evidence on
sepsis, academic advocacy for sepsis management, and provincial policy mobilization that
influenced the Sepsis Guideline Set implementation that ultimately took place within Select
Health.
The Dynamic Evidence Informing the Sepsis Guidelines
While the formal implementation of the BCPSQC Sepsis Guideline Set in British
Columbia and, specifically, Select Health, began in 2011 the clinical foundation for the
implementation was established more than a decade earlier. Within the health industry, sepsis
had long been a known clinical concern, best addressed through early identification and
treatment. The late 1990’s and early 2000’s marked, however, a period of growing

73
recognition of sepsis as a focus for guideline-based care given its high mortality rate and a
building clinical understanding of its preventability.
Defining Sepsis: Consensus Conferences
The first step in better addressing sepsis care was to refine the way it was identified in
the clinical setting. By 1991, clinicians and researchers had begun to express concern about
the proliferation of ambiguous terms with some relation to sepsis. “Infection, bacteremia,
sepsis, septicemia, septic syndrome, and septic shock” were all used commonly but had
unclear definitions (Bone et al., 1992). Without clear terminology and diagnostic criteria
there was little hope of advancement in treatment of this disorder which was recognized as
the most common cause of mortality in non-cardiac Intensive Care units (Bone et al., 1992).
In 1991 the American College of Chest Physicians (ACCP) and the Society of Critical Care
Medicine (SCCM) collaborated to hold a consensus conference aimed at establishing a
common nomenclature for sepsis-like illness. International experts were brought together to
review the available evidence and to provide recommendations regarding sepsis definitions
(Levy et al., 2003).
In 2001 a second international consensus conference was held, based on a premise
that since 1991 scientific advances may have led to better ways to define and diagnose
sepsis-like illness. The conference reviewed many potential biomedical indicators but
ultimately came to the conclusion that the 1991 definitions continued to be the most
clinically relevant available at the time (Levy et al., 2003). The prevailing definitions
revolved around two related indicators: infection and Systemic Inflammatory Response
Syndrome (SIRS). As sepsis is defined as a response to infection, the first indicator is selfexplanatory. The SIRS criteria were established in the 1991 consensus conference to better

74
inform clinical assessment of the escalating systemic response to the infection. The SIRS
criteria were defined as:
•

Temperature > 38 degrees or < 36 degrees Celsius,

•

Heart rate > 90 beats per minute,

•

Tachypnea (rapid breathing) > 20 breaths/minute, and

•

White cell count > 12,000 or < 4,000 or > 10% immature neutrophils (“bands”) (Bone
et al., 1992).
A positive SIRS score was achieved when two or more of these criteria were met. The

1991 consensus conference went on to recommend discontinuation of a variety of terms
deemed confusing or non-specific, and proposed the following clarifications:
•

Severe sepsis: sepsis (infection + 2 or more SIRS criteria) plus organ dysfunction, and

•

Septic shock: severe sepsis plus persistent hypotension (low blood pressure) where
systolic blood pressure remains less than 90 mm Hg even when fluid resuscitation has
been given (Bone et al., 1992).
The definitions provided in the 1991 conference and confirmed in 2001 set a direction

for clinical treatment where various steps might be considered not only to address the
underlying infection (standard therapy) but to also address the escalating systemic response
by managing fluids and blood pressure, sometimes rather aggressively. Some such treatment
regimens were outlined in the form of protocols or guidelines and were rigorously examined
for effectiveness (Zhang et al., 2017).

75
Treating Sepsis: Early Goal-Directed Therapy and Beyond
Interest in guideline-based sepsis care culminated with the publication of Rivers et al.
(2001), the results of a study regarding early goal-directed therapy for the treatment of severe
sepsis and sepsis shock.
Rivers et al. (2001) gained international attention as it reported the compelling results
of a single-centre randomized control trial (RCT) comparing what was then considered
standard therapy for severe sepsis and septic shock against a proposed goal-directed therapy
regimen aimed aggressively at hemodynamic resuscitation (Zhang et al., 2017). The widely
cited article brought widespread attention and debate to its recommended therapy and to
goal-directed therapy in general. Rivers et al. (2001) also served to further spark interest in
the preventability of sepsis mortality through early identification in the Emergency
Department. It prompted interest in the most appropriate indicators and definitions for sepsis,
severe sepsis, and septic shock building from the SIRS (systemic inflammatory response)
criteria (Dellinger et al., 2017; Levy et al., 2003; Shankar-Hari et al., 2016). It also prompted
attention to the appropriateness and details of elements of resulting therapy including further
elements of hemodynamic resuscitation and antibiotic administration (Zhang et al., 2017).
The Rivers et al. (2001) study not only provided compelling evidence related to the goaldirected therapy espoused by the authors (a 16% drop in sepsis-related in-hospital mortality)
but served as a stark call-to-action to reduce sepsis-related mortality overall, given the
significant mortality rates being considered (sepsis mortality rates of 46.5% pre-intervention
and 30.5% post-intervention).
The Rivers et al. (2001) study brought greater profile to sepsis and sepsis care. It was an
inciting force for quality improvement in emergency care in British Columbia and within
Select Health.

76
I think this goes back to, so basically there is a study by a physician by the name of
Dr. Rivers, the quintessential study with regards to goal-directed therapy and that’s
where that term came called goal-directed therapy. (RLS, Regional Quality
Improvement Department Lead)
Revisiting the Treatment Evidence
While Rivers et al. (2001) did much to spur on interest in improving sepsis
outcomes, subsequent clinical trials were yielding results that drew the effectiveness
of the Rivers view of early goal-directed therapy for sepsis into question. By 2010,
academic clinicians were questioning the practicality, value, and potential deleterious
effects of aggressive hemodynamic control and the required invasiveness of central
line insertion (Reade, 2010; Rowan et al., 2017; Sweet et al., 2012). The academic
literature was moving toward a much more moderate view of early identification and
intervention based on some key elements:
• Algorithm-based screening, triage and response
• Identifying and controlling the source of sepsis
• Fluid resuscitation
• Monitoring serum lactate clearance
• Antibiotic administration (Sweet et al., 2012)
Revisiting Definitions and Treatments, Again
In February 2016, the results from the third international consensus conference on
sepsis and sepsis definitions were reported in the Journal of the American Medical
Association (JAMA). The new definitions became known as Sepsis-3 (Seymour et al., 2016;
Shankar-Hari et al., 2016). The Sepsis-3 definitions built from previous consensus definitions

77
but refined the definition of septic shock to be more specific and clinically relevant – as the
earlier definition proved to work better for researchers than for clinicians (Sweet et al., 2012).
The consensus definition of septic shock became:
•

Severe sepsis as before plus hypotension requiring vasopressor therapy to keep
systolic blood pressure above 65 mm Hg, and

•

Serum lactate level greater than or equal to 2 mmol/L (Shankar-Hari et al., 2016).
The consensus conference reviewed tools/scales available to clinicians to assist in the

identification of potential sepsis patients. Upon review of the available evidence, the
consensus opinion moved to the use of the quick Sepsis-Related Organ Failure Assessment
(qSOFA) scale in addition to SIRS criteria for identifying sepsis outside of the hospital’s
Intensive Care Unit (Seymour et al., 2016). Noting significant overlap between the symptoms
of those with infections in general (not necessarily sepsis) and the SIRS criteria, Vincent,
Martin, and Levy (2016) explained that the added qSOFA assessment facilitated greater
accuracy of sepsis diagnosis in the busy clinical environment; reducing the potential for false
positives which were found to distract and overwhelm clinicians in busy hospital
environments.
Academic Advocacy for Sepsis Management
Given the growing attention to, and investigation of, sepsis in the late 1990’s and
early 2000’s, clinicians and researchers were invested in seeking ways to raise awareness of
sepsis clinically and publicly and in facilitating use of evidence-based care approaches
through the implementation of sepsis guidelines.
The Surviving Sepsis Campaign
In 2002 the Society of Critical Care Medicine partnered with the European Society of
Intensive Care Medicine (ESICM) to form and promote the Surviving Sepsis Campaign

78
(SSC). The objective of the SSC was to promote sepsis awareness and to establish and
promote the implementation of evidence-based guidelines aimed at moving from standard
therapy toward more aggressive mitigation of the related systemic responses. The SSC was
established around a very clear mandate:
To reduce mortality from sepsis by 25% via a 7-point agenda including:
-

Building awareness of sepsis

-

Improving diagnosis

-

Increasing the use of appropriate treatment

-

Educating healthcare professionals

-

Improving post-ICU care

-

Developing guidelines of care

-

Implementing a performance improvement program (Levy et al., 2010;
Society of Critical Care Medicine, 2018).

The SSC gained a considerable following during the first decade of the second
millennium through multi-media awareness efforts and continued efforts to build clinical
knowledge about sepsis and to translate that knowledge into practice (Levy et al., 2010). The
SSC has been credited for having a significant impact on the quality of sepsis care in the
United States and beyond (Levy et al., 2010). The Surviving Sepsis Campaign also had an
influence on clinicians and researchers in British Columbia’s health system and on Select
Health.
My sense is that a lot of Sepsis Guidelines arose from post-Rivers trial and early goaldirected therapy and the Surviving Sepsis campaign that we sort of associated with
that. (RLS, Regional Program/Service Network Lead)

79
The Sepsis Guidelines generally came to my attention with the Surviving Sepsis
campaign and through media during my residency training. (DC, Hospital Emergency
Department Physician)
In 2010, the international Global Sepsis Alliance was formed as an alliance of many
prominent provider and academic organization members from across the world. The mandate
of the Alliance was, and is, to promote awareness of sepsis toward reduction in mortality
worldwide. In 2012, the Global Sepsis Alliance established World Sepsis Day – September
13 of each year – to serve as a focal point for awareness activities.
The Global Sepsis Alliance has been influential in the creation and support of another
academic advocacy group more specific to British Columbia: the “Evidence to Excellence”
(E2E) initiative.
Evidence to Excellence: A British Columbia Grassroots Collaborative
The work of clinical researchers on sepsis definition and treatment and the Surviving
Sepsis Campaign met fertile ground at the University of British Columbia (UBC), a researchintensive university with British Columbia’s only accredited medical training program and
related faculties and departments. As the SSC was building momentum, the UBC Department
of Emergency Medicine began working with the British Columbia Ministry of Health
(“Ministry”) and Health Authority partners to form the Evidence to Excellence (E2E)
initiative. With interested UBC academic clinicians in the lead, the E2E was aimed at
improving quality in British Columbia emergency departments (University of British
Columbia Department of Emergency Medicine, 2018).
I think we were looking at best practices way back in the Evidence to Excellence
initiative which actually started in 2008, and then I think these best practices were

80
probably compared with the Surviving Sepsis guidelines and other sort of national
and international best practices and evidence and literature. (AAP, Quality Lead)
E2E, founded with an overarching interest in redesigning emergency flow and
quality, quickly picked up on the potential for improvement in the identification and
treatment of sepsis.
With leadership from an engaging critical care specialist who was also a member of
the UBC Department of Emergency Medicine holding practice privileges at multiple
southern British Columbia hospitals, E2E established a grassroots1 collaborative comprised
of practitioners and decision-makers from large and medium-sized Emergency Departments
from across the province aimed at improving sepsis care. The E2E collaborative drew from
the SSC to establish a guideline set and supporting tools to promote evidence-base sepsis
care. With support from the Ministry and from some Health Authority champions, they
continued to broaden their informal network to 18 provincial Emergency Department teams
and facilitated two in-person collaborative sessions between 2008 and 2011 that were
attended by two Clinical Nurse Educators from Select Health (Sweet et al., 2012).
And then there was a collaborative called the Evidence to Excellence collaborative
that I want to say was 2008 to 2010ish where it was sort-of a provincially initiated
Emergency Department collaborative where they’d tried to sort-of bridge the urbanrural divide and had different clinical topics they wanted to improve quality of care
with. And so, Emergency Department sepsis was one of those. So, we ran two IHI-

1

Grassroots is defined as “the basic level of society or of an organization especially as viewed in relation to
higher or more centralized positions of power” (Merriam-Webster, 2019).

81
style collaboratives2 over that period of time to implement sepsis protocols in the
province. I want to say I think there were 18 sites that were involved in and it was
more ground-up and just personal contacts to get different departments involved in
that. (AAP, Quality Lead)
Provincial Policy Mobilization
In 2011, as the E2E groups were coming together in grassroots collaboration, the
British Columbia Ministry of Health was concerning itself with the challenge of quality
improvement at the provincial policy level. Having formed the British Columbia Patient
Safety & Quality Council (BCPSQC) in 2008 to “provide system-wide leadership to
efforts designed to improve the quality of health care in British Columbia ” (British
Columbia Patient Safety and Quality Council, 2018), the Ministry was looking for
ways to quickly show progress in quality improvement. To signal its interest in ra pid
quality improvement, the Ministry identified a key priority – “High Quality Hospital
Services” – as a significant component of the their strategic “Innovation and Chang e
Agenda” (British Columbia Ministry of Health, 2012). The Agenda established the
Clinical Care Management (CCM) initiative, described as “a guideline -driven clinical
care management system to improve the quality, safety, and consistency of key
clinical services and improve patient experience of care” (British Columbia Ministry
of Health, 2012, p. 4). CCM was a Ministry-directed initiative working through the
BCPSQC to identify and prioritize leading practice guidelines in key clinical areas,
and to guide implementation. The BCPSQC developed implementation support

2

Follow this link for information related to the Institute for Healthcare Improvement (IHI) collaborative model.
http://www.ihi.org/resources/Pages/IHIWhitePapers/TheBreakthroughSeriesIHIsCollaborativeModelforAchievi
ngBreakthroughImprovement.aspx

82
strategies incorporating information exchange, collaboratives, and performance
measurement.
The CCM initiative was guided by a Steering Committee comprised of
members from the Ministry, BCPSQC and each of the province’s Health Authorities.
At the outset of the CCM initiative, a Steering Committee - the CCM Steering
Committee – was established, comprised of Health Authority Quality Improvement
executive leads and BCPSQC and Ministry leadership. The CCM Steering Committee
decided that the best way to proceed would be to build upon improvement initiatives
already taking place in the province. Given the potential benefit and the early success
of the E2E collaborative, Sepsis Guideline Set implementation was an obvious
candidate and was prioritized as one of CCM’s twelve improvement initiatives. The
collaborative network that had been established through the E2E initiative was
formalized and expanded as the BC Sepsis Network under the BCPSQC to connect
people across the province interested in improving sepsis care and to guide the
ongoing refinement and monitoring of sepsis guideline sets and implementation
supports.
By the time the BCPSQC was asked to lead the CCM initiative, the evidence
with respect to sepsis management had evolved to a more moderate position than
originally described by Rivers et al. (2001). In keeping with the prevailing literature
of the time, the BCPSQC drew from the work of E2E and established a formal
provincial Sepsis Guideline Set (British Columbia Patient Safety and Quality Council,
2012). A letter from the then Assistant Deputy Minister of Health to the Select Health
Chief Executive Officer dated April 01, 2011 mandated the implementation of the

83
Sepsis Guideline Set. British Columbia Health Authorities, including Select Health,
were to undertake implementation activities ensuring:
“… Patients receiving antibiotics by time goal ; Patients with blood cultures
taken before IV antibiotics initiated; Patients with second litre of crystalloid
initiated by time goal; and Patients with appropriate lactate measurement by
time goal.” (British Columbia Ministry of Health, 2011)
The British Columbia Patient Safety and Quality Council’s Measurement Dilemma
In 2012 a Clinical Expert Group was struck comprised of Emergency and
Critical Care clinicians from each Health Authority. The group was established to
provide ongoing advice to the Steering Committee and Ministry regarding clinical
aspects of sepsis management and improvement. A priority for the BCPSQC Steering
Committee was the development of measures to align with the implementation of the
Sepsis Guideline Set. The Clinical Expert Group was asked by the Steering
Committee to advise the development in conjunction with a Data Working Group
(including a blend of clinicians and analysts) and BCPSQC staff. While a
measurement set was established and published, there was broad recognition that
measurement of Sepsis Guideline Set implementation in British Columbia suffered
from three substantial challenges. First, like many health organizations in Canada,
British Columbia Health Authorities continue to work with a combination of paper
and electronic records. Having only modest levels of clinical record automation, data
collection to support Sepsis Guideline Set implementation measurements tended to be
quite labour intensive. Second, the identification of sepsis patients through both
electronic and paper records was challenging because sepsis develops as a result of a

84
variety of types of infection. Patients were often identified in their record by the
underlying infection (e.g., pneumonia) rather than by sepsis.
Measurement for sepsis was always very difficult. And it’s difficult for many
reasons. One of the reasons is that when you come into the emergency
department with a condition that can lead to sepsis, such as an infection
somewhere in your body, for example, pneumonia or some other type of
respiratory infection, or whether you know it’s sort of a localized infect ion that
then spreads, it’s often coded as the event that you come in with rather than
coded as a definition of sepsis. (AAP, Quality Lead)
The third significant challenge for Sepsis Guideline Set measurement was the
apparent need to meet two distinct measurement objectives – adherence monitoring
and quality improvement. Measures were expected to be submitted on a regular basis
to the Ministry for monitoring purposes. For adherence monitoring, the Ministry
needed a set of measures that were comparable across Health Authorities and could be
reported on a regular basis for statistical analysis. For quality improvement, local
teams needed current information relevant to their own units and reflective of local
changes and dynamics.
We were using the data for dual purpose though. It was accountability data that
was going back to the Ministry of Health through the CCM Steering Committee
and Clinical Expert Group to inform feedback or inform quality improvement
at a provincial level. And then we were also recommending that the sites
measure locally and use their local data to look at results and test some change
as they improved their systems. (AAP, Quality Lead)

85
In spite of the challenges, the BCPSQC and CCM Steering Committee
developed and published a data guide for Sepsis Guideline Set implementation
measurement in 2012. The guide provided detailed instructions for measuring Sepsis
outcome and guideline implementation process measures as follows:
•

In-hospital mortality rate for patients investigated for sepsis in the Emergency
Department, stratified by level of risk,

•

Percent of patients with antibiotic received by time goal sp ecified in BC Sepsis
Guidelines,

•

Percent of patients with confirmed severe sepsis/septic shock or admitted for
IV antibiotics with blood cultures taken before antibiotics ,

•

Percent of patients with confirmed severe sepsis/septic shock with 2 nd litre of
crystalloid initiated by time goal as specified in BC Sepsis Guidelines, and

•

Percent of patients with appropriate lactate measurement by time specified in
BC Sepsis Guidelines (British Columbia Patient Safety and Quality Council,
2012).
BCPSQC Sepsis Guideline Set definitions and measures, established in 2011

and 2012, remained consistent for a period of approximately four years – until 2016,
when the Sepsis-3 Consensus Conference took place (Singer et al., 2016). As the
industry became aware of the new definitions and assessments, the BCPSQ C
committed to refine the provincial guidelines. Refinements were underway when
interviews for this research study were being conducted at Select Health. Many
participants noted that a period of uncertainty had set in as the guideline s were being

86
revised and the Ministry announced that submission of adherence measures would no
longer be required.
Advancing Implementation and the Practice of Academics and Advocates
Participants from the AAP group described a perspective of Sepsis Guideline Set
implementation that reflected their efforts to advance implementation through influence and
advocacy. AAP participants informed Regional Health Authority (RHA) clinicians and
managers about the evidence supporting the guidelines and influenced action toward
implementation by engaging RHA participants in peer networking and improvement
collaboratives. AAP participants were successful in drawing attention to sepsis management
among Select Health clinicians and managers, as information about the guidelines cascaded
through large international groups of clinical researchers, including the Global Sepsis
Alliance and the Surviving Sepsis Campaign, to a more localized group in British Columbia,
the Evidence to Excellence (E2E) network. The E2E network stimulated a variety of
grassroots improvement initiatives at British Columbia RHAs including Select Health,
drawing on a common set of guidelines and support materials (e.g., pre-printed orders). The
E2E and Sepsis Networks promoted a high degree of engagement in Sepsis Guideline Set
implementation among those who participated. The BCPSQC Quality Leads worked across
AAP, RLS, and DC group boundaries to the extent that time and resources allowed. With just
two Quality Leads – one physician and one nurse – the BCPSQC was limited in the number
of events, participants, site-specific dialogue, and supports they could provide. Participation,
and, hence, engagement with Select Health RLS managers and DC clinicians was limited, as
only two Clinical Nurse Educators participated directly in the network activities (e.g.,
collaborative sessions) and physicians were able to interact with the physician Quality Lead
only sporadically.

87
The evidence informing Sepsis Guideline Set implementation proved compelling, yet
insufficiently stable for Select Health participants. The Rivers et al (2001) study and
subsequent dialogue and advocacy from academia, advocacy groups, and the Ministry of
Health established strong awareness and a clear moral and policy imperative for Sepsis
Guideline Set implementation. Yet, the continuing debate regarding sepsis definitions, case
identification and measurement, and specifically what needed to be implemented to achieve
what outcomes, led to questions among Select Health participants about the degree to which
the guidelines were evidence-based or practically implementable. AAP advocacy and
networking activities did not lead to resolution of these fundamental questions for Select
Health participants.
In support of implementation, the E2E network and, later, the BCPSQC Sepsis
Network, provided RHA participants with literature synthesis and summarized, and
periodically facilitated discussion about, the sepsis guidelines among clinicians. The
BCPSQC Quality Leads worked with an expert panel to develop and share templates for
clinical decision support tools, and to develop and disseminate measures to monitor each
RHA’s and hospital’s performance in implementing the guidelines. Sepsis Guideline Set
implementation measurement proved challenging for the BCPSQC and for Select Health
participants. The dual objectives of adherence monitoring and quality improvement emerged
as an issue for BCPSQC and Select Health participants as the Ministry sought consistent,
aggregate information with which to emulate the researchers’ statistical analysis and to hold
RHAs accountable for implementation, while clinical teams sought more timely, granular
information with which to assess their own sepsis care. Difficulties in sepsis identification
and data collection made measurement problematic and time-consuming for Select Health
Leads and Analysts.

88
Chapter Summary
This chapter provided a description and interpretation of the Sepsis Guideline Set
implementation from the perspective of participants from the Academic, Advocacy and
Policy (AAP) group. Participants from this group sought to advance implementation of the
guidelines by influencing the behaviour of various participants through advocacy and
networking activities. These activities proved very effective at creating awareness about
guidelines and generating engagement in implementation among network participants.
Limitations in resources challenged the breadth of engagement within Select Health, with
very little ability to support engagement of Direct Care clinicians directly. Repeated
revisiting by academics of the evidence supporting the Sepsis Guideline Set, led Direct Care
clinicians to hold uncertainties about the necessity and practicality of following the
guidelines explicitly. These uncertainties remained unresolved throughout the 2011-2017
implementation timeframe. A directive from the Ministry of Health to Regional Health
Authorities to implement the guidelines appears to have reduced the amount of clinical
dialogue that could have enhanced engagement and helped participants to find solutions to
address their significant practical concerns. Instead, the BCPSQC turned quickly from
activities aimed at engaging and problem-solving, to efforts to align implementation
provincially through performance measurement and support tool standardization.
The next two chapters present and discuss how Select Health’s response was
described, first from the perspective of participants from the organization’s Regional
Leadership and Support group, then from the perspective of participants involved in Direct
Care at City Hospital.

89
Chapter Six: Managing Implementation
This chapter presents the Select Health Sepsis Guideline implementation as it was
described by members of Regional Leadership and Support (RLS) participants, including
those in Select Health regional and site executive and senior leadership roles, those involved
in regional leadership for relevant clinical services (especially those for the Emergency
Medicine Program/Service Network), and those involved with key regional support services
such as quality improvement, professional practice, information management and
diagnostics.
While a diverse group involving people with different organizational functions and
roles, participants involved in Regional Leadership and Support provided a consistent,
coherent perspective of Sepsis Guideline Set implementation. I characterize the RLS
perspective as one of “managing implementation.” Participants holding regional management
and support positions described a managed implementation involving prioritizing the
Guideline Set, activating work toward implementation, and communicating through
established organization structure and interlocking committees, developing and implementing
standardized processes and tools, and monitoring adherence using structured measurement
scorecards. RLS leaders took a creative approach to enable measurement of outcome and
process adherence and to provide this information as site-specific scorecards throughout the
organization. At a broader regional level, efforts were made to further convey priorities to
Select Health stakeholders and to reinforce the importance of individual accountability for
safe, high-quality care.
Figure 6.1 depicts the implementation process as described by RLS participants.
Figure 6.1 highlights the processual aspects of implementation described, above along with

90
an indication of the roles participants indicated were involved. The figure only includes those
roles that were described as integral to the implementation, based on multiple and extensive
reference.
Figure 6.1
Regional Leadership and Support Perspective
“Managing Implementation”

PROCESS FLOW
Assessing
and Activating

ACADEMIC, ADVOCACY &
POLICY CONSTELLATION
ROLES

Quality Executive
Lead

REGIONAL LEADERSHIP & SUPPORT
CONSTELLATION ROLES
CEO &
Executive

Prioritizing

Program/Network
Executive Director
(Emergency)

Clinical Nurse
Specialist
(Emergency)

Evidence to
Excellence and
BCPSQC Leads

Developing Plans and
Supports (e.g. Decision
Support Tools)

Collaborating

DIRECT CARE
CONSTELLATION ROLES

Directors,
Pharmacy & Lab
Health Business
Analyst

Executing Plans

Originating

Site 2 Clinical
Nurse Educator

Directors
(Emergency)

Program/Network
Medical Director
(Emergency)

City Hospital Clinical
Nurse Educator
(Emergency)

City Hospital
Emergency
Department Manager

Program Data Analyst
(Emergency)

Monitoring and
Reviewing
Performance

City Hospital Chief
of Staff
(Emergency)

Note. Chronologically the figure is to be read beginning with Originating, working to Developing Plans and
Supports (City Hospital specific) and Assessing and Activating (toward regional prioritization). Listed are the
DC, RLS, and AAP roles most consistently identified by RLS participants as involved in the implementation.

Implementation was prioritized and managed through the region’s program
management structure following a structured process supported by the organization’s Clinical
Policy Office. Adherence was monitored using scorecards conveying site-specific process
and outcome measures. The City Hospital Emergency Department Clinical Nurse Educator

91
(CNE), Manager, and the Chief of Staff were pivotal, acting as the primary, even exclusive,
conduits between regional entities and the Direct Care Team.
Regional Structures Steering Clinical Practice Guideline Implementation
Almost invariably, participants from the Select Health Regional Leadership and
Support Team began their accounts of Sepsis Guideline Set implementation by describing
two structures that were in place between 2009 and 2015:
•

A program management organization structure providing oversight for a variety of
clinical programs, including the Emergency Medicine Program, and

•

A Clinical Policy Office that guided development and support of Clinical Decision
Support Tools – including those related to the Sepsis Guideline Set.
These structural aspects were important contextually to Sepsis Guideline Set

implementation at Select Health – particularly from the perspective of Regional Leadership
and Support (RLS) participants.
Program Management Structure
Between 2009 and 2015 Select Health was organized in a structure known as
program management. Program management is an organizational structure where the
primary management stream is along program or service lines. Programs cut across
multiple sites with line authority (authority for operational units) rolling up to
regional program leadership. Site/community leaders hold largely an integrative role;
weaving the various programmatic units into an integrated whole at the
site/community level. Most relevant to the Sepsis Guideline Set implementation was
the Emergency Medicine program which had oversight for Select Health’s 12
emergency departments. The Select Health p rogram management organization
structure was mirrored by the medical staff structure. Program medical d irectors held

92
authority for the activities of department chiefs in departments relevant to the program
in each facility.
The Emergency Medicine Program of Select Health was established in 2009 as
part of the organization’s move to clarify responsibility for efficient, effective, and
standardized operations of emergency services across the organization’s twelve
hospital facilities. From the perspective of RLS participants, it was instrumental in the
Sepsis Guideline Set implementation. The program was led by an Executive Director,
three Emergency Service Directors (each having oversight of emergency services in
three or four facilities) and a Program Medical Director. A Clinical Nurse Specialist
(CNS) was recruited to provide full time leadership and support to the program. Each
facility’s Emergency Department Manager reported to one of the Directors.
Supervisory staff, operational staff and educators reported through the program line
through the manager. Facility Emergency Department Chiefs (physician leaders)
reported through to the Program Medical Director and upwards to the Vice President
of Medicine. Site-specific leadership was provided at the time by site Executive
Directors, each with oversight over multiple facilities, in partnership with physician
Medical Coordinators.
The Clinical Policy Office
The Clinical Policy Office was a clinical practice support team that operated under
the auspices of Select Health’s Professional Practice Department. The team developed a
variety of materials, technologies and processes, and a wide array of contacts across the
organization, to assist clinicians in the development, approval and dissemination of Clinical
Decision Support Tools such as policies guidelines and pre-printed orders:

93
•

Guidelines are defined by the Clinical Policy Office as: “a systematically
developed statement to assist practitioners and patients/residents/clients make
decisions about appropriate intervention/treatment options in health care specific
circumstances.

•

Pre-printed orders or “order sets” are defined as: “a precise set of instructions
detailing action(s) for prevention, care and/or treatment of a clinical condition.”
Pre-printed orders often include medications and are “individualized to the person
receiving care/treatment” (Clinical Policy Office, May 2017).

The Clinical Policy Office served as a guide and gatekeeper in the Clinical Decision
Support Tool development process. The Clinical Policy Office sought to align most of its
resources toward supporting Clinical Decision Support Tool development work that aimed at
establishing regional practice standards. The Clinical Policy Office was central to the way in
which the Sepsis Guideline Set was implemented at Select Health.
Implementation Process From the RLS Perspective
Having described the organization’s structural context for Sepsis Guideline Set
implementation, the following sections describe several relatively discrete stages of activity
identified through analysis of data from RLS participants.
Originating: Early Sepsis Care Improvement at Select Health
The origination of formal work on the Sepsis Guideline Set at Select Health can be
traced to early participation of Select Health clinical nurse educators with the E2E
collaborative in 2008/09, well before the Ministry of Health had contemplated a Clinical
Care Management (CCM) initiative or the mandating of specific guidelines.

94
Evidence to Excellence (E2E), a network led by clinical academics in the University
of British Columbia Department of Medicine, sought engagement through personal
relationships with staff and physicians in British Columbia hospital Emergency and Critical
Care Departments. Effort was made by the E2E organizers to involve sites from each of the
province’s RHAs with emphasis placed on site-level, operational, participants. The E2E
Medical Lead, drawing on his extensive personal connections among the province’s
Emergency/Critical Care Departments, including those at Select Health and City Hospital,
identified and recruited potential participants for the E2E sepsis collaborative. He made
himself available to speak with hospital medical staff and other team members to build
interest in collaborative improvement in sepsis care. Having contacts at Select Health
hospitals, the E2E medical lead was able to bring several Select Health facilities into the E2E
network, to begin work toward sepsis care improvement, beginning with the creation of a
provincially consistent Sepsis Guideline Set.
Clinical Nurse Educators (CNEs) at two Select Health sites, including City Hospital
(for anonymity, the second hospital will be referred to as “Site 2”), were particularly active in
early work with E2E toward sepsis care improvement and Sepsis Guideline Set development.
The leadership role taken by the two site CNEs in Sepsis Guideline Set implementation was
not unusual for Select Health. The two were part of a group of CNEs with a longstanding
tradition of multi-site information sharing. Since the early 2000’s – when Select Health had
just been established as a RHA – CNEs supporting emergency services came together
monthly to network and share information, experiences and approaches. The tradition
continues to this day though the regional CNE network meetings have taken on a somewhat
more formal role with respect to regional standardization.

95
We have forever – as far back as 20 years or so – all the educators from all of the
emergency departments come together once a month to meet and part of that is to
review what regional implications are ongoing, what practice standards are coming
down the pipe, who’s going to take the lead on developing so there’s a new practice
guideline for this, who’s going to take the lead on that (DC, Hospital Emergency
Department CNE).
It was at one of these regional network meetings that the Select Health Emergency
Department CNEs decided that two CNEs, including a CNE from City Hospital, would work
with the E2E collaborative to build from province-wide work on a Sepsis Guideline Set and
further develop and standardize the guidelines and supports for sepsis management within
Select Health. The E2E collaborative was used by the CNEs as a source of credible evidence,
input and materials in support of what was considered a normal continuous quality
improvement activity of the City Hospital, and other facility, CNEs.
So, when you start out, you say we’re noticing a gap between practice
recommendations that are out there and the best practice and the evidence and that’s
something we do as educators, we’re often looking. And that’s part of what we, that’s
our job is to align evidence to practice. (DC, Hospital Emergency Department CNE)
The two CNEs worked together, attending the E2E collaborative meetings and working
with E2E leaders and other RHA and academic participants to build from existing materials
(which were widely available thanks to organizations like the Surviving Sepsis Campaign) to
develop regionally standard Sepsis Guideline Set materials and supports for use in sites
across Select Health. Together the two CNEs began working with the Select Health Clinical
Policy Office staff to create and formalize the regional Sepsis Guideline Set, pre-printed

96
order, and nurse-initiated order – all of which are considered Clinical Decision Support Tools
- following the Region’s standard development process.
Developing Plans and Supports: Getting Ready for Implementation
As Figure 5.1 depicts, development activities – those oriented toward preparing
materials and processes for implementation – began prior to the move to program
management in 2009 and extended to 2011/12. The development work began in 2008 under
the volunteer leadership of the two site CNEs described above - as a logical extension of their
collaboration with E2E. When the Emergency Medicine Program was established in Select
Health, the authority for Sepsis Guideline Set implementation fell under the program Medical
Director and Clinical Nurse Specialist (CNS), though the two CNEs remained involved.
Standard Clinical Decision Support Tool Development Process. The Clinical
Policy Office team members guided development of Clinical Decision Support Tools
following process organized into three phases they named: develop, review, and publish. The
various activities within each phase are summarized in Table 6.1.

97
Table 6.1
Clinical Decision Support Tool Development Process
Development Stage
Develop

Review

Publish

Activities
• Register initiative
• Conduct gap analysis – need for Clinical Decision Support
Tool (CDST)
• Develop Shared Work Team (SWT)
• Review best practice
• Develop content
• Develop implementation plan
• Draft CDST
• Seek and obtain stakeholder feedback
• Review feedback
• Finalize content; confirm medications
• Submit for approval, follow-up, approvals
• Establish go-live date
• Finalize arrangement with Clinical Policy Office, Forms on
Demand, Order-entry
• Go-live, fan-out communication activities
• Initiate implementation plan
• Confirm implementation/review on 3-year basis

Note. Adapted from Clinical Policy Office materials November 2015.

The Clinical Decision Support Tool development process was triggered, either
through management direction or voluntarily, by the establishment of a Shared Work Team –
intended to be a multi-site, multi-disciplinary group with named individuals overseeing the
clinical content of the developing Clinical Decision Support Tool.
So, we take the guidelines on we go back and then we have to figure out, sort of, the
scope of who is going to sign off on whatever we suggest. So, looking at what we
have as best practice, develop a Shared Work Team, log the development of said team
through the Clinical Policy Office to make sure somebody isn't also doing the same
work. And then we go through - if there's medications involved, it has to go through
pharmacy review. If there's a lab work involved it goes through a lab review - all that

98
kind of stuff. But essentially it goes through a final sign off at the director level as
well as the medical director and they approve what you've written, like yeah, that
seems to be in line with what we know, and good practice and we can move forward
with what's in there. And then it comes down to us to figure out how it rolls out. (DC,
Hospital Emergency Department CNE)
Once the Shared Work Team had registered their initiative with the Clinical Policy
Office, the office team drew together available information and evidence and initiated a
development and review process to ensure rigour and help to create buy-in across the
organization.
It ensures that anyone that would be impacted by a tool could provide feedback on it.
And that’s really engaging the right people, getting the right people at the table,
providing feedback, making changes if they’re necessary and then from there, it goes
back to the Shared Work Team to make those discussions about how they’re going to
be addressing the feedback. We’ve kind of got, it’s almost like we’re an octopus, we
kind of, you know, reach out to a multitude of different groups and we work with
them to get the tool finalized. (RLS, Clinical Policy Office Team Member)
Contacts, including relevant clinicians and support team members who might be
impacted by the Clinical Decision Support Tool, were identified and accessed by the Clinical
Policy Office based on a stakeholder impact assessment for the proposed Clinical Decision
Support Tool. For pre-printed orders, formal involvement and sign-off was required from the
region’s pharmacy department. Clinical Decision Support Tools involving specific
diagnostics and/or response times needed to have formal sign-off by the region’s Laboratory
and/or Diagnostic Imaging leaders.

99
The Clinical Policy Office operated an electronic portal and repository on Select
Health’s intranet to facilitate the Clinical Decision Support Tool development process and to
enable access to Clinical Decision Support Tools once they are finalized. Templates were
available for various types of decision support tools and the team assist the Shared Work
Team with evidence collection and assessment, and with aspects of the development process
including team development, stakeholder assessment and contact, formatting, communication
and implementation planning and evaluation. A Clinical Decision Support Tool process
guideline assisted developers through these various processes. While the Clinical Policy
Office arranged and supported the elements of the Clinical Decision Support Tool
development and dissemination, the process and content remained very much “developerled.” The members of the Shared Work Team did not delegate development to the Clinical
Policy Office, they continued to own and lead the content and development process.
Select Health had achieved a modest degree of automation in processes related to
Clinical Decision Support Tool use. Pharmacy order sets could be built in the organization’s
Clinical Information System to improve efficiency and reduce the chance of transcription
error. The region’s Health Information Management Services offered “Forms on Demand”
which enabled a Clinical Decision Support Tool to be printed and attached to the patient’s
chart with appropriate patient information imprinted on the document. The Clinical Policy
Office provided the Shared Work Team with required liaison services to enable these
functions to be realized as appropriate.
The standard process of development, which could take anywhere from 3 months to
over a year, (depending on priority, Shared Work Team involvement and degree of feedback)
ended from the Clinical Policy Office’s perspective when the Clinical Decision Support Tool
was communicated, “fanned out,” to relevant departments and stakeholders. The Clinical

100
Decision Support Tool was uploaded as final on the Clinical Policy Office’s SharePoint™
site and order sets and Forms on Demand were activated. A depiction of the Clinical Policy
Office’s standard development and implementation process is provided in Figure 6.2.
Figure 6.2
Clinical Decision Support Tool Development and Implementation Process

For the Sepsis Guideline Set implementation process, a Shared Work Team was
established that was initially comprised only of the two CNEs (from City Hospital and Site
2). When program management came into effect, the Shared Work Team was expanded to
include one of three Emergency Medicine Program Directors, and the newly appointed
program Clinical Nurse Specialist (CNS) and Medical Director. The Shared Work Team
True to the Clinical Policy Office process, considerable work was invested by the
Shared Work Team, using templates available through the E2E collaborative, toward the
development of regional Clinical Decision Support Tools. Clinical Decision Support Tools
included a guideline statement in alignment with published directions at the time, and four
supporting tools:
•

An automated approach to identify patients who have sepsis-like illness,

•

A pre-printed order meant to guide physician and nurse activities and orders for the
suspected sepsis patient,

101
•

A nurse-initiated order enabling nurses to authorize specified activities upon
suspicion of sepsis, and

•

Performance measures and scorecards to enable provincial, regional and local Sepsis
Guideline Set implementation progress monitoring.
Sepsis Case Identification. Early in the development process, in 2008, the two CNEs

recognized the need to be able to identify in “real time” and record potentially septic patients
so that key actions could be triggered as quickly as possible, and to enable subsequent
performance tracking. The process of tracking potentially septic patients was challenged by
the fact that clinicians would often categorize patients based on the underlying infection they
suspected, rather than the inflammatory response to the infection (sepsis). To overcome this
challenge, the two CNEs worked with the Clinical Information Systems team to establish an
emergency department diagnosis: “sepsis-like illness” that could be entered electronically.
While this was somewhat unconventional as a diagnosis it was the best way the two CNEs
could find at the time to trigger the early intervention response as the electronic entry could
be programmed to automatically engage decision-support materials including nurse initiated
orders. Sepsis-like illness was identified based on the Systemic Inflammatory Response
Syndrome (SIRS) criteria – a set of evidence/consensus-based criteria that were best known
for sepsis identification at the time (Levy et al., 2003; Shankar-Hari et al., 2016).
Select Health kind-of illegally added to our [clinical information] system. We added
sepsis-like illness as a chief complaint and basically started looking at sepsis as a
disease – or at least in the emergency department as a disease unto itself. We ask at
triage whether this patient could be septic and, if so, we do stat bloodwork. Over the
years, this kind-of got entrenched as more hospitals started doing it. If you make a

102
change for one hospital, you make a change for all the hospitals in terms of the way
the computer system works. We developed nurse-initiated orders, but those came
later. (DC, Hospital Emergency Department CNE)
Pre-Printed Order. The two lead Select Health CNEs worked with the Clinical
Policy Office to iteratively develop a regional sepsis guideline set and a pre-printed order
meant to standardize and simplify sepsis care and orders in the region’s emergency
departments. The Guideline Set described the clinical decision-making flow for sepsis care
while the pre-printed order enabled nurses and physicians to quickly signal the patient for
sepsis care while ensuring evidence-based orders for laboratory testing, medications and fluid
management.
There was no shortage of materials from which to build. Several sites across Select
Health had done initial work on sepsis care and the E2E initiative drew extensively from
documents available through advocacy organizations like the Surviving Sepsis Campaign.
For the most part, the development process went positively, though the developers faced
modest frustration with Clinical Policy Office feedback and sign-off processes as a plethora
of input arrived from Pharmacy Department stakeholders. At the time, the leaders of the
regional Pharmacy Department promoted widespread involvement of local Pharmacy Leads
in the development of pre-printed orders. Unfortunately, the process offered little direction as
to how developers might move toward a final solution when contention arose, as it did when
working with the region’s local Pharmacy leads to determine the most appropriate antibiotic
choices for the pre-printed order.
This caused a great debate. You got 12 very divergent opinions. Then I have to go
and look up what the references were for these opinions. Right now we’re on
something like version H of the protocol. I don’t know how many million drafts there

103
were. Each pharmacist would give a different opinion. They wouldn’t necessarily tell
the other pharmacist in the other sites what their opinion was. The local Pharmacy
committees at one end were saying “no, no, no, we should have this, this, and this.”
And then at the other end they’re saying “no, no, no, we should have that, that, and
that.” And the guys in the middle are, like “well, you can do this or this, we could put
them both down.” So, we struggled getting consensus opinion from them. But they
seemed to have come back with something that they’re alright with. (DC, Hospital
Emergency Department CNE)
From the perspective of the two CNEs, Clinical Decision Support Tool development
interaction with the region’s Laboratory Department was less problematic. Meeting response
time standards became an improvement issue later in the implementation process, but the
standards expressed in the guidelines themselves were consistent with normal Laboratory
Department operations and were not contentious. While the region’s Laboratory Department
was not supportive of the CNE’s first proposal for “point-of-care” lactate testing to help meet
the guideline-based turnaround times, they did work to automate the ordering process and to
ensure quick specimen-collection response. This response was satisfactory to the CNEs and
was more in keeping with the Laboratory’s mandate and quality assurance practices as they
had generally found point-of-care testing to be difficult to assess and monitor for reliability.
In 2009/10 the finalization and movement toward implementation of the regional
Sepsis Guideline Set and pre-printed order was reinforced by the formalization of
implementing the sepsis guideline as a quality improvement priority under the organization’s
new Emergency Medicine Program and, soon thereafter, as the provincial Ministry of Health
pursued a new Clinical Care Management (CCM) strategy.

104
Nurse-Initiated Orders. In 2012, the establishment and support of nurse-initiated
orders derived from the pre-printed order, was a critical element of facilitating a practical,
timely response toward fulfilment of the sepsis guidelines. The nurse-initiated orders
presented a set of activities, treatments or diagnostics that could be started by nurses prior to
physician involvement. Nurse-initiated orders enabled clinical teams to quicken response
times -particularly in cases, like sepsis, where evidence suggests the time to treatment
matters.
Since Select Health had long implemented a system of triage by nurses within their
emergency departments, considerable focus was placed on early identification of potentially
septic patients during triage and the quick, systematic response initiated by the triage nurse
staff to meet key elements of the guidelines. A checklist was developed by the Shared Work
Team and automated regarding the following guideline elements:
•

Triage rating (Canadian Triage and Acuity Scale (CTAS) of 1 or 2 depending on
severity),

•

Monitoring of vital signs,

•

Lactate measurement,

•

Blood culture to assess and type infection in advance of antibiotics, and

•

Initial application of fluids.
The other big piece of work was standardizing it in our electronic system, so we had
an order-entry of the labs and diagnostics that needed to be ordered as a set. So, a
nurse didn’t have to pick every single lab or diagnostic that was required. It was in
what we called an “order set.” They just had to pick the sepsis order set, “sepsis-like
illness” we called it. (RLS, Regional Program/Service Network Lead)

105
The nurse-initiated orders established a quick, standard response triggered by
identification of someone as potentially septic. The orders were automated so that they
became available automatically within the Select Health clinical information system when
sepsis-like illness was entered at triage as an emergency department diagnostic code.
Performance Measures and Scorecards. In 2012, the BCPSQC was able to publish
a data guide for Sepsis Guideline Set implementation monitoring comprised of five
indicators:
•

In-hospital mortality rate for patients investigated for sepsis in the emergency
department (ED), stratified by level of risk,

•

Percentage of patients with antibiotic received by time goal specified in Sepsis
Guidelines,

•

Percent of patients with confirmed severe sepsis/septic shock or admitted for
Intravenous (IV) antibiotics with blood cultures taken before antibiotics,

•

Percent of patients with confirmed severe sepsis/septic shock with 2nd litre of
crystalloid initiated by time goal as specified in Sepsis Guidelines, and

•

Percent of patients with appropriate lactate measurement by time specified in Sepsis
Guidelines (British Columbia Patient Safety and Quality Council, 2012).
Select Health took an early interest in moving forward with Sepsis Guideline Set

measurement. In fact, participants from the BCPSQC considered Select Health to be a leader
among the province’s RHAs in measurement. The organization’s level of automation, while
not considered ideal, offered sufficient information to apply the SIRS criteria to identify
potential sepsis patients.

106
We did a lot of work so that at least at triage we could identify patients who were
hypertensive, or tachycardic, or febrile, and match it to some of their laboratory data
so if they’re lactate high and so that was helpful in terms of us only evaluating data
that was truly sepsis. (RLS, Regional Program/Service Network Lead)
While automation enabled a listing of potential sepsis patient candidates, verification
and follow-up was conducted manually through chart audit, a labour-intensive data-gathering
approach where each patient’s chart had to be pulled and reviewed manually. Data elements
were found in a variety of locations within the chart and sometimes required clinical
knowledge to find and/or interpret. Fortunately for Select Health, a registered nurse became
available and was interested in conducting this review just at the time the Program Leads and
Director were deliberating how best to manually collect the information required for
monitoring BCPSQC Sepsis Guideline Set implementation. Resources from the Emergency
Medicine Program were identified in 2012 to enable a Nurse Analyst to take on this role – a
role she continues to fulfill today.
The Nurse Analyst worked closely with the Program Medical Director, and the
Program Clinical Nurse Specialist (CNS) to develop the logic and approach for data
collection. They worked with the organization’s analytics team - Healthcare Business and
Analytics – to establish a mechanism for drawing potential sepsis charts, for pre-loading data
that was available electronically, and for receiving and processing data input by the nurse
analyst.
According to an AAP quality lead, Select Health gained a reputation on the CCM
Steering Committee as the most effective and timely reporter of ongoing provincial
monitoring measures. The measurement work also proved helpful in informing the
organization’s ongoing facility-by-facility implementation of the guidelines. Again, with the

107
help of the Select Health Healthcare Business and Analytics team, the data collected was
effectively transformed into a report card format for each Select Health facility. On a fiscalperiod basis (a fiscal quarter is divided into 3-4 periods – totalling 13 periods per year) each
of the 12 emergency departments received their sepsis outcome (mortality rate) and
performance (antibiotic timing, blood culture before antibiotics, lactate timing,
administration of 2nd litre of crystalloid) measures for the prior period. The report card came
with confidential identification of patient codes, so it was possible, for quality improvement
purposes, to refer retrospectively to individual patients and their charts to better understand
factors affecting performance. Due to the time required to produce the report card,
retrospective review lagged the actual incident by several weeks. The report cards were
circulated each period to each facility’s Emergency Department Director, Manager and
Clinical Nurse Educator (CNE) for review and follow-up as part of Select Health’s
implementation and quality assurance process.
Assessing and Activating: Communicating Through Organization Structure
As program management was initiated in 2009, the new Emergency Medicine
Program slowly acquired a regional leadership team who reinforced the importance of sepsis
management improvement and worked alongside the CNEs to finalize and implement the
guidelines and supporting tools.
The provincial Sepsis Network, they got started, I believe, in 2011 and 2012. It kindof tied nicely with the beginning of my role as a quality standardization person for
Select Health. I had the time finally and the span of control in my role to actually link
into what the province was doing. We were in the new program structure at the time,
so we had a regional medical director who very strongly advocated to implement the

108
sepsis guidelines that the province was promoting, in our twelve emergency
departments. (RLS, Regional Program/Service Network Lead)
With its new mandate to lead Sepsis Guideline Set development and
implementation provincially, the BCPSQC appreciated Select Health’s Emergency
Medicine Program regional leadership and their apparent direct-to-site authority.
So, for example, there’s an Emergency Medicine Program, right? There’s one
person who’s head of that program for all of Select Health and each hospital
had representation from their hospitals to this central program. So, it seemed
like, for example, within Select Health, dissemination and buy -in was easier. If
whoever was in-charge of that program said this is going to happen, it’s going
to happen.” (AAP, Quality Lead)
The Sepsis Guideline Set implementation initiative was, indeed, taken up as a
priority by the Select Health Emergency Medicine Program leadership. In 2011 the
program Executive Director, Emergency Department Directors and Medical Director
all recognized that the Sepsis Guideline Set was to be implemented and began to put
the processes and supports in place to move it forward.
It was somewhat mandated by the Minister of Health that we would implement
sepsis guidelines. Not that we wouldn’t want to, but as you can imagine,
there’s a lot of competing priorities. Basically, we took the information from
the BC Patient Safety Council and there already were sepsis guidelines around.
Plus, the Ministry mandated that there would be reporting on sepsis data that
was collected on outcomes, on times, etc., etc., which everybody in the
province was supposed to do. So that was also an important incentive for us to

109
try and comply with those initiatives. (RLS, Regional Program/Service
Network Lead)
The program management structure placed operational authority with the program
leaders (Emergency Medicine Executive Director, Medical Director, Directors, Managers,
supported by the CNS) with operational responsibility for Sepsis Guideline Set
implementation.
Most participants described the structure as positive in ensuring focus on quality
improvement through achievement of standards, including the Sepsis Guideline Set. A Select
Health executive team member, for instance, described the program management structure as
having been good for “recruitment, standardization, and quality.” Other participants had
similar views.
There were some things that programs did very well. Programs, for example,
standardized a lot of things like the pre-printed orders. “These are the pre-printed
orders that need to be used in all of the sites.” It brought some of these specialist
groups closer together, particularly some groups like surgery. By doing that you cause
some standardization of procedures, techniques, policy, processes. It allowed, I think,
people to see variations in care. (RLS, Regional Quality Improvement Department
Lead)
Communicating Through Structure. In addition to providing a mechanism for
decision-making with respect to priorities, Select Health’s structures enabled paths for clear
and consistent communication about the Sepsis Guideline Set as a priority for
implementation. The program’s reporting relationships, accountabilities and committee
structures provided mechanisms for communication across the organization in two-way
fashion – “from up above” (flowing from senior leaders to front line leaders) or “down

110
below” (flowing “up” to senior leaders from front line leaders). It was notable that
participants could consistently describe the program’s role relationships and how information
was to flow among them.
All of these things would, for argument sake, whether it comes from “down below” or
from “up above”, they would go through various committees such as Health
Authority Medical Advisory Committee, local department meetings, regional
department meetings, etc. My view of the most important role for leadership,
whether it’s local or regional, is the dissemination of information above and below.
And so, the local department heads feed up to the regional department input from
their members and, conversely, notify their members of information coming from
higher up the food chain. (RLS, Select Health Executive Team Member)
In 2009 Select Health created a committee structure to complement the organization
structure, enabling appropriate involvement and collaboration in communication and
decision-making. Figure 6.3 provides a summary of some of Select Health’s most relevant
committee structure that pertained most directly to the Emergency Medicine program and
Sepsis Guideline Set implementation.

111
Figure 6.3
Program Standing Committee Structure 2011-2015

Regional Quality &
Performance

•
•
•
•

Program Executive Director
Medical Director
Program Directors (3)
Clinical Nurse Specialist

Regional Executive

Regional Medical
Advisory

Program Leadership

Program Operations
Committee

•
•
•
•

Program Directors (3)
Program Medical Director
Clinical Nurse Specialist
ED Managers

Program Medical Chiefs
Committee

Program Educators
Committee

• Program Medical Director
• ED Chiefs (12)
• Clinical Nurse Specialist (by
invitation)

• Clinical Nurse Specialist
• ED Clinical Nurse Educators
(about 15)

Each of the committees or groups met monthly with broad involvement to ensure that leaders
were connect to support:
•

Administrative decision-making and action, through the Emergency Department (ED)
site managers

•

Clinical decision-making and action, through the ED CNEs

•

Medical decision-making and action, through the ED Chiefs
The Select Health Executive intentionally built considerable overlap in participation

among the various program committees with clear, connecting roles identified for the CNS
and the Program Medical Director.
We have monthly meetings with our operational team which is the managers and
directors from all the emergency departments. We have monthly meetings with our
emergency physician heads, chiefs. We have monthly meetings with our educators. I
attend almost all of them. The physician ones I attend ad hoc. [The program medical

112
director] is kind-of the lead of that, our physician, so I only attend if I need to talk
about a certain initiative we’re doing. But all the other ones, I’m kind-of the link, the
glue between them all, and making sure that things are developed in a very
standardized approach. (RLS, Regional Program/Service Network Lead)
Participants pointed to their respective committee(s) as the key conduits through
which they came to understand about Sepsis Guideline Set prioritization and about its
subsequent implementation expectations, processes and tools. While participants recognized
that meeting time was significant, most indicated that they were important to ensuring strong
working relationships and information flow across the region and among various roles and
functional streams.
Change in Structure, But Not Focus. In 2015 a new Chief Executive Officer moved
the organization back to a structure oriented toward site/community autonomy and
integration. While the new structure strengthened site/community authority, Select Health
retained a region-wide Emergency Medicine structure. The Emergency Medicine Program
was renamed the Emergency Medicine Network. While no longer having operational
authority, the Emergency Medicine Network continued to steward standards and quality
improvement and to guide implementation. Some participants saw this change as a
diminution of the authority of the program and program leaders. However, most participants
were reconciled to the importance of greater site/community authority for leadership, culture
development, and service integration. Most participants were positive about the change,
indicating that little momentum had been lost in Sepsis Guideline Set implementation as a
result.
With consistent staffing and retention of a variety of structures including regular
regional committee meetings, the Emergency Medicine Network was able to maintain

113
momentum and continues to be seen broadly today as the organization’s most functional
network.
And, in all fairness, those systems were in place prior to reorg so they were in place
with the program management structure and I think we leveraged that as a network
and really begged participation across the system that we didn’t throw it all away
because it was a place for us to support knowledge transfer. In the absence of that, we
didn’t have a place for that to occur. (RLS, Regional Program/Service Network Lead)
Promoting Inclusiveness and Relationship. The previous sections highlight the
importance attributed to structure by Regional Leadership and Support Team participants.
But some participants emphasized other aspects with a tendency toward flexibility, greater
inclusiveness, and relationship. City Hospital site leaders, particularly, recognized the
importance of the Program/Service Network structure but highlighted the importance of
deeper relationships and integration, particularly at the site.
I spent the past two-and-a-half years [timespan of roughly 2015-2017] trying to
establish a community of physicians and operational partners that would be able to
discuss problems with each other and create a sense of community in the hospital.
(RLS, Hospital Medical Leader)
Participants noted that relationships build over time, and that trust among team
members is critical. Several clinician participants noted that relationships and trust are often
strained among clinicians and management due to frequent turnover of the operational
managers with whom they work.
The most important thing you need at an institution is the belief that everyone is
rowing in the same direction. I mean it’s very simple, trust between colleagues that
you’re trying to achieve the same endpoint and that your silos are actually aligned.

114
Trust is built through relationship, people need to know who their colleague is. Docs
are lifers. Wherever a doc goes they end up staying for the rest of their lives. But
operational leaders are more transient. When a person is shuffled the relationship gets
shattered, and there’s a bit of grieving that goes on. So, you know, that breeds
mistrust of the senior leadership team. (RLS, Hospital Medical Leader)
Study participants, particularly those at the site and DC levels, described the
importance of having a shared vision of what improvement could be made in sepsis
outcomes, and relationships sufficient to enable all teams to work through differences and to
know that, once agreed, each participant and team could be trusted to do their part.
Prioritizing: Deciding and Resourcing a Regional Priority
The prioritization of Sepsis Guideline Set implementation by Select Health was
formalized during the executive’s Program Quality Performance Committee in June of 2012.
The importance of executive prioritization was a tone set explicitly by a Select Health
executive member, as they explained that a select number of priorities must be “driven from
the top.” RLS members concurred that explicit prioritization – ideally in alignment with
government direction - was critically important, particularly to ensure focus and to obtain
resources to support implementation.
The best success, I think, the reason why this has worked so far, is because we’ve had
the senior executive support, right. So, this has been mandated, that we implement
this tool and then they put the resources into it, right. Having that makes so much
difference. When you go to the units or you go to the sites, everybody’s aware that
this is coming and where it’s coming from and it’s not just like, “hey, what do you
think? Would you like to try this?” There’s just more buy-in. (RLS, Regional Quality
Improvement Department Lead)

115
Participants felt that a government mandate helped to reinforce a synergistic
relationship between the profile of the issue and its implementation and success, and the
broader provincial and public context.
If it’s not a priority Ministry of Health-wise, no one’s going to give you resources to
do those. So, it really needs to come as a priority from a very strategic place. And the
reason for it being a priority needs to be really clear. (RLS, Regional Program/Service
Network Lead)
The concept of drawing and maintaining attention in the face of ongoing workload
and other competing priorities was a common theme among interview participants in favour
of clear prioritization.
Executing Plans: Following Standard Implementation Process
By 2012, two Select Health CNEs had worked with E2E to originate interest in sepsis
care improvement and to undertake early development work toward a regionally standard
Sepsis Guideline Set and supporting Clinical Decision Support Tools. Program management
had also taken root and the work of the CNEs was aligned, prioritized, and
activated/communicated under the auspices of the Emergency Medicine Program. Following
Clinical Policy Office process, the Decision Support Tools were finalized. The Shared Work
Team, now fortified with Program leadership, was prepared to move to the second stage of
the Clinical Policy Office process, Implementation.
Standard Implementation Process. The Clinical Policy Office did not oversee the
implementation of the Clinical Decision Support Tool beyond initial fan-out communication.
The Clinical Policy Office did, however, require the completion of an implementation plan as
part of the Clinical Decision Support Tool development process. The implementation plan
fell under the auspices of the Shared Work Team and is comprised of four sub-plans:

116
•

Resource plan

•

Education plan for practice change

•

Access and roll-out plan

•

Communication plan (Clinical Policy Office, August 2016)
The process involved a variety of group and individual activities surrounding and

following a selected regional go-live date. There was recognized variation among the various
Select Health sites but, in principle, all sites proceeded with implementation at the same time.
We set a timeline, we put an implementation date and then typically we’ll have
regular connection and huddles during that period. Lots of prompts, lots of reminders.
Here’s how we’re doing; this is what we need you to do. We check in with places that
are being challenged. (RLS, Regional Program/Service Network Lead)
The organization of implementation around a go-live date was largely driven by the
need to align communication and training activities with availability of new forms and order
sets that are automated; they needed to be uploaded or turned on at a specific time. The golive date was established by agreement among Shared Work Team members, taking into
consideration other local and regional activities and priorities and in conjunction with the
Clinical Policy Office and Information Technology departments who needed to be involved.
All our forms are in an electronic filing cabinet on the computer, so we’ll tell them
that this form number is being replaced by this draft and they’ll tell us we can upload
it on this day and then we distribute out to say on Wednesday – it always happens on
Wednesday – whatever date, you’ll find your new order set. Go-live is then. (DC,
Hospital Emergency Department CNE)

117
By mid-2012, the Sepsis Guideline Set and related tools were published and
communicated according to Clinical Policy Office standard. Communications about the
upcoming change and go-live date began well prior to the actual go-live date as efforts took
place to ensure that clinicians were not taken by surprise. A month prior to go-live the City
Hospital Emergency Department CNE and Emergency Department physician Chief of Staff
began communicating with Direct Care participants (nurses and Emergency Department
physicians involved in providing direct care in the Emergency Department). The CNE joined
the Chief of Staff at a physician emergency department meeting to review the Sepsis
Guideline Set and related expectations, the pre-printed order, the nurse-initiated orders, and
the systems supporting their use. The CNE undertook similar activities with the Emergency
Department nurses but given the large number of nurses (approximately 500), the busyness
of the department, and the realities of 24/7 operation the strategies were briefer, more varied,
and exercised over a longer time frame.
On the go-live date, and for a period thereafter, the CNE undertook an educative
strategy involving in-service huddles, increased personal support “on the floor,” and
communication reinforcement through the Weekly Rant, the department’s weekly newsletter.
For the Sepsis Guideline Set implementation huddles of approximately 15 minutes were held
beginning between 6:30-6:45 am. Repeated sessions would be held – first to involve staff
finishing a night shift, then to involve staff beginning their day shift. “For sepsis, it would’ve
been a 15-minuter. We’d bring the actual order set down and discuss what’s on there” (DC,
Hospital Emergency Department CNE).
In-services were opportunistic, engaging staff members who were able to free
themselves for the 15-minute session. Because City Hospital’s busy Emergency Department
sees little down-time, the process of in-service was carried on over approximately a two-

118
week period. During the same time the emergency department CNEs made themselves
available to guide staff members in the use of the new materials and to respond to questions
or issues that arose.
Collaborating: Working with the Quality Council. For the British Columbia
Patient Safety and Quality Council, 2012 was a formative time as the Clinical Care
Management (CCM) initiative got underway. Steering, expert advisory, and measurement
groups were established to oversee and advise all twelve of the CCM improvement priorities
including implementation of the Sepsis Guideline Set initiated earlier by E2E. Given the
work that had already been done, the BCPSQC primarily needed to revise and brand the early
Sepsis Guideline Set, develop outcome and process performance measures for period-byperiod reporting, and migrate the E2E collaborative into a renamed province-wide “Sepsis
Network.” The BCPSQC Sepsis Network was a provincial collaborative and was different
from the Select Health Emergency Medicine Network that formed from the Emergency
Medicine Program during the 2015 reorganization. The Sepsis Guide document that
communicated important information about the Sepsis Guideline Set and measurement
processes was released on April 27, 2012. The BCPSQC Sepsis Network was kicked off in
June 2012.
With the finalization and dissemination of the BCPSQC guidelines early in 2012, the
BCPSQC Sepsis Network first focused on ways to promote the work and to encourage
participation. The Global Sepsis Alliance (GSA) World Sepsis Day was a natural opportunity
for the BCPSQC to organize around for its promotional and improvement activities. In 2012,
BCPSQC began with a poster campaign – providing informative and creative posters
regarding sepsis to be posted in Emergency Departments across the province. Select Health
and City Hospital participated in the campaign.

119
We sent posters out to every Emergency Department around the province and a funny
anecdote is that even today whenever I have a friend or a colleague who ends up in
Emergency department for a personal visit, they often will send me a picture of some
of our resources and tools that they see still on the walls today. (AAP, Quality Lead)
By 2013, the BCPSQC Sepsis Network was well underway and drawing from the
supports available through the BCPSQC to develop communications and implementation
support materials, while continuing to refine the guidelines and tools based on feedback and
emerging evidence. As results and feedback began flowing to the BCPSQC through the
Sepsis Network, a clear line of concern began to arise. Consistent with feedback from other
initiatives and the literature, facilities were finding through their audits that the pre-printed
orders were not being used as much as anticipated given estimates of likely sepsis volumes.
But we had a challenge with how does the frontline clinician remember to use the preprinted order and how do they actually complete it? Because, again, in that initial
phase, often a physician doesn’t want to actually use it because they’re still not
exactly sure the patient has sepsis. They don’t want to go down that path. But that
takes up time. So how do we get more buy-in, get more people to use the pre-printed
order? I was part of the provincial network team, and we strategized how we could
get more people to use pre-printed orders for sepsis? One of the ideas was this 150
Lives challenge. (RLS, Regional Program/Service Network Lead)
To address Sepsis Guideline Set awareness and use, including the use of the preprinted order, the BCPSQC designed and executed an initiative entitled “150 Lives in 150
Days” announced on World Sepsis Day - September 13, 2013. The initiative is well
described by McKeown, Krause, Shergill, Siu, and Sweet (2016). The initiative drew from
evidence-based sepsis morbidity and mortality estimates to establish a benchmark that one

120
life is saved by every four times patients are appropriately assessed using the sepsis protocol.
Over a 5-month period (150 days) participating Emergency Departments tracked and
reported a variety of metrics related to sepsis guideline use. The objective was, based on the
benchmark, to “save” a target of 150 lives through sepsis protocol use during that time.
BCPSQC monitored progress and introduced a variety of gamification principles to enlist,
encourage and celebrate participation and results. The provincial 150 Lives target was
reached by March 2014. Positive qualitative and quantitative findings were reported
(McKeown et al., 2016).
Select Health took on the 150 Lives in 150 Days challenge, with participation across
larger Emergency Departments, including City Hospital’s. The initiative was seen as a
success by the regional leadership.
The 150 Challenge pitted sites against each-other and we used Select Health as a
whole in terms of every time you actually use a pre-printed order for sepsis, you filled
in this card and completed the challenge. We collected cards for the challenges as part
of the game. We had some pizza and stuff like that. We actually did really well in
Select Health. I think we were one of the top for the province. We had increased
awareness. It encouraged people to understand: this is sepsis, this is what we’re
doing, and if you show you used a pre-printed order, we could win a pizza party.
Little things like that help increase awareness. It was a strategy and it did help us use
more pre-printed orders. (RLS, Regional Program/Service Network Lead)
The BCPSQC continued sepsis awareness activities and Sepsis Guideline Set
promotion during 2013 and in subsequent years. 2013 and 2014 saw a variety of learning
sessions in webinar format that were referenced by Select Health staff and members of the
City Hospital Direct Care team.

121
I know between 2013 and 2014 there were six different learning sessions and so these
would be available to anyone in the network or beyond who was interested. They
were typically done on sort-of a WebEx type of platform. (AAP, Quality Lead)
In the years following, a sepsis “quick reference card” (2014) and a “cinemagraph”
(2015) were released by the BCPSQC. These items were not specifically referenced by study
participants, suggesting that they had not been particularly influential for Select Health.
Throughout 2015 the BCPSQC and members of its Sepsis Network turned their
attention to the admitted inpatient as a new focus for sepsis management improvement. For
years, sepsis had been a significant focus for Emergency Department physicians and
clinicians and they were of the impression that sepsis management had been significantly
improved. Concern was being raised within and beyond Select Health, however, that
worrisome, preventable sepsis morbidity and mortality continued to be seen, not in the
emergency department, but in the hospital’s own inpatient services.
We’re still catching these people at the front door, but then you start to see this other
group of individuals. And you’re, like, “okay, that’s weird, that guy is really sick. He
looks like sepsis, feels like sepsis, but he came from the ward. What’s going on?”
Now we have this group of individuals inside our facilities who had surgery. They
came out and, for the first eight hours, they were doing okay. But now they’re not so
well anymore. And it was weird. We saw lots of sepsis in ED practice in the 90’s and
now were seeing it again and the nurses didn’t quite know what it was. (RLS,
Regional Quality Improvement Department Lead)
In keeping with this shift in focus, the BCPSQC team developed guidelines and a
toolkit for the management of sepsis on inpatient wards. The guidelines and toolkit were
launched on September 13, 2016.

122
And 2016, we launched the inpatient sepsis toolkit. So, a resource that we had put
together that included updated guidelines for people to recognize and treat sepsis on
hospital wards. That was part of a year-long collaborative pilot project where we
worked with seven or eight teams from around the province and helped them test
different ways to recognize and treat sepsis on inpatient wards. And then we took the
tools and resources developed through that pilot project and launched them on World
Sepsis Day in 2016. (AAP, Quality Lead)
In February 2016, the results from the third international consensus conference on
sepsis and sepsis definitions were reported as Sepsis-3 (Shankar-Hari et al., 2016). The
BCPSQC began work to assess the impact of new definitions and evidence to update the
guidelines for Emergency Department sepsis management. Updates were made through the
subsequent year and were released on September 13, 2017.
One participant noted that by 2017 the Emergency Department Sepsis Guideline Set
implementation had lost much of its original focus and attention. Changes were impending
given the Sepsis-3 consensus conference, and the Ministry of Health rescinded its directive
regarding mandatory reporting. New priorities came to the fore, including mandatory
response to significant morbidity and mortality resulting from opioid overuse.
R:

Did you just say the regional network currently doesn’t seem to have put a lot
of focus on revising and moving forward more on the sepsis?

I:

No. So, the overdoses kind of have taken the front for a lot of people. (DC,
Hospital Emergency Department CNE)

While refocusing Select Health Emergency Departments on opioid overdose response
made sense, this reality affecting Sepsis Guideline Set implementation speaks to the dynamic
nature of CPG evidence and the organization’s often-changing priorities.

123
Monitoring and Reviewing Performance: What Happened?
Once site CNEs and Chiefs of Staff had taken on the education and implementation of
the Sepsis Guideline Set, the regional leaders – the Program Director, Medical Lead and
Clinical Nurse Specialist, focused on support efforts related to ongoing communication,
monitoring, and reporting using the Sepsis measurement scorecards. Scorecards were
circulated on a period-by-period basis providing outcome and process performance metrics
for each Select Health site and for the region as-a-whole. BCPSQC and Ministry of Health
Leads, Select Health Executives, site Executive Directors and Medical Directors, Emergency
Department Directors, site Emergency Department Managers and Chiefs of Staff, and
Clinical Nurse Educators all received the scorecard information for review at relevant
internal and external (e.g., BCPSQC Clinical Care Management) committee meetings. Site
leaders were free to follow-up as they deemed appropriate.
Regional support was provided largely through the program committee structures
described earlier. On rare occasions either the Medical Lead or the Clinical Nurse Specialist
(or both) joined their Chief of Staff and CNE counterparts at individual sites – including City
Hospital – to reinforce the importance of the Sepsis Guideline Set and to help with follow-up
with individual clinicians when individual cases were reviewed. For the most part, while site
Managers received adherence scorecard information and discussed progress at the Program
Operations Committee, site CNEs were seen by the region’s leaders as the primary
implementer at the site level. As described in the Select Health Program Quality Performance
Committee minutes for August 2014: “Sepsis orders have been revised to identify and
prioritize fluid resuscitation and antibiotic administration. CNE’s will continue to highlight
this population of patients as one to focus education and improvements.”

124
When asked about Sepsis Guideline Set implementation performance, Regional
Leadership and Support Team (RLS) participants offered two categories of response:
•

Quantitative assessment based on their overall interpretation of the scorecard
measures of sepsis mortality outcome and guideline adherence measures; and

•

Experiential reflection related to the process of Sepsis Guideline Set Clinical Decision
Support Tool development and implementation through site CNEs and physician
Chiefs of Staff.
Based on scorecard measures, participants in RLS roles were well aware of a

consistent, perplexing result: Select Health and individual site (including City Hospital)
sepsis mortality measures were comparatively strong – even modestly improving – while
measures were in place (period 7 2013/14 to period 4 2016/17), while individual guideline
adherence measures were disappointing. Table 6.2 provides a summary of scorecard results
for the region overall and for City Hospital. The Analytics team provided the same summary
level of statistical analysis to Select Health teams through the period scorecards.

125
Table 6.2
Summary of Scorecard Measures for Select Health and City Hospital 2013-2017
Key Performance Indicator
High
Low
Average

Target

Select Health Regional*
Sepsis 1: In-hospital mortality rate for patients
35%
investigated for sepsis in the Emergency
Department (ED), stratified by level of risk
Sepsis 2: Percentage of patients with antibiotic
45%
received by time goal specified in Sepsis
Guidelines
Sepsis 3: Percent of patients with confirmed
94%
severe sepsis/septic shock or admitted for IV
antibiotics with blood cultures taken before
antibiotics
Sepsis 4: Percent of patients with confirmed
33%
nd
severe sepsis/septic shock with 2 litre of
crystalloid initiated by time goal as specified in
Sepsis Guidelines
Sepsis 5: Percent of patients with appropriate
41%
lactate measurement by time specified in Sepsis
Guidelines
City Hospital*
Sepsis 1: In-hospital mortality rate for patients
investigated for sepsis in the Emergency
Department (ED), stratified by level of risk
Sepsis 2: Percentage of patients with antibiotic
received by time goal specified in Sepsis
Guidelines
Sepsis 3: Percent of patients with confirmed
severe sepsis/septic shock or admitted for IV
antibiotics with blood cultures taken before
antibiotics
Sepsis 4: Percent of patients with confirmed
severe sepsis/septic shock with 2nd litre of
crystalloid initiated by time goal as specified in
Sepsis Guidelines
Sepsis 5: Percent of patients with appropriate
lactate measurement by time specified in Sepsis
Guidelines

0%

8%

N/A

5%

26%

80%

59%

75%

90%

0%

15%

80%

8%

35%

80%

67%

0%

6%

N/A

67%

0%

24%

80%

100%

33%

79%

90%

50%

0%

15%

80%

57%

0%

41%

80%

Note: wide data ranges are often indicative of small sample sizes. City Hospital sepsis volumes varied
between 6 to 18 per period. Regional volumes varied between 16 to 53.

126
RLS participants widely held what appeared to be an accurate perception that Select
Health and City Hospital sepsis mortality rates were favourable. While measurement
methodologies differ, Select Health average mortality rates ranging in single digits and teens
compared very positively considering Canadian national averages and Rivers et al. (2001)
discussion of figures in the 30-40% range.
We noticed that when you look at our overall mortality for sepsis, we do really well,
compared to the national average. I think the national average is up to 30 and ours is
consistent. When you look at it, it’s in the teens. So, we do really well. (RLS,
Regional Program/Service Network Lead)
Paradoxically participants recognized that the remaining four key performance
indicators (KPIs), the adherence measures, were not positive. While reasonably strong
(though usually below-target) performance was recognized for KPI 3 (ordering blood
cultures prior to antibiotics) due to the automated Nurse Initiated Order available, the
remainder of the KPIs remained consistently well below target.
R: How did the sites feel they were doing over the time?
I: Terrible. We never met any targets. We weren’t even close. Ever. (RLS, Regional
Program/Service Network Lead)
RLS participants were able to look past paradoxical scorecard results to find a
positive interpretation. Low sepsis mortality rates confirmed a general sense that Select
Health was providing good sepsis care. While participants were concerned about poorer
adherence measures, they recognized that these adherence measures suffered from
definitional and collection challenges.
A lot of them were difficult to collect because they’re based on a hand-written note
because we don’t have electronic for all of our things. So, we found throughout the

127
years that some of the data is much more pertinent to collect than others. (RLS,
Regional Program/Service Network Lead)
Seeing that sepsis outcomes were favourable in spite of apparently poor adherence to
many of the Sepsis Guideline Set expectations, many DC participants questioned the value of
rigorously interpreting the Sepsis Guideline Set’s clinical implications. While the research
supporting the guidelines was not in doubt, participants recognized a difference between
measurement and activity within a controlled, statistically oriented research environment and
a busy clinical setting where sepsis is one of many clinical concerns to be addressed at any
given time. Given Select Health’s positive mortality results it was believed that the Sepsis
Guideline Set had led to a sufficient level of attention and action to ensure that good care was
provided.
What was interesting though – and I think that it’s not hard to understand – our
mortality was very good, and our mortality went way down, even though time to
antibiotics, to fluids, etc. continue to be awful. But because you, even though you’re
not meeting those timelines, you are giving the patient better care than you would’ve
without thinking about it at all. Our mortality stats were good but our times were
always dreadful. (RLS, Regional Program/Service Network Lead)
For many RLS participants, the paradoxical results led to some ongoing questioning
as to just what Sepsis Guideline Set elements were most important; what needed to be
implemented and how. Experientially, participants in RLS positions expressed positive
feedback about the Sepsis Guideline Set implementation at Select Health. All feedback was
positive about the development and implementation process, including the way:

128
•

The Emergency Medicine Program structure and related committee structures enabled
strong clinical and medical leadership, prioritization, accountabilities and
communication,

•

Regionally standard Clinical Decision Support Tools were developed with broad
input from a variety of support departments, and communicated, and

•

Scorecards were developed and distributed – providing useful information to inform
outcome and adherence monitoring to the site level, even if the value and validity of
many of the adherence measures were in question.
In retrospect, while some positive interaction and work among AAP, RLS, and DC

participants at times throughout the implementation process, members from these three
practice domains never did engage together long enough to establish a shared understanding
of the goals of the CPG implementation, or how success would be achieved or assessed. As a
result, participants, including those from the RLS group, were free to establish their own
definitions of success and to draw their own conclusions.
Managing Implementation and the Practice of Managers
Participants from the RLS group described a perspective of Sepsis Guideline Set
implementation that reflected their efforts to manage implementation largely through
standard process, regional roles, structures, and tools, and hierarchical authority. Participants
holding regional management and support positions tended to describe a managed approach
to implementation of the Sepsis Guideline Set that built on early originating work led by
Direct Care group Clinical Nurse Educators, but that moved on to involve more regionally
guided activities that could be organized into activity groups. Activity groups included:
developing plans and supports using standardized development and implementation

129
processes and tools, assessing and activating through established organization structure and
interlocking committees, prioritizing, executing plans, and monitoring and reviewing
performance using structured measurement scorecards. Aspects of Select Health’s
implementation efforts, including the Program/Service Network, management organization
structure, and adherence measurement approaches, were described as provincial exemplars
by AAP Quality Leads. The Emergency Medicine Program/Service Network leadership
team, including a Program Executive Director, a Medical Director, a Director, and a Clinical
Nurse Specialist directed regional implementation activities.
Study participants in RLS roles consistently spoke of the important roles played by
site/department Clinical Nurse Educators (CNEs) and Chiefs of Staff. These individuals were
referred to as critical development partners and conduits between RLS participants and the
DC participants themselves. Individuals in these roles, particularly CNEs, were strongly
involved with early Select Health originating activities toward Sepsis Guideline Set
implementation, in collaboration with the provincial improvement network – Evidence to
Excellence (E2E). The CNEs’ and, to a lesser extent, Chiefs’ activities extended not only
temporally - throughout the implementation process timeframe - but also spanned boundaries
of the DC, RLS and AAP groups.
Between 2013 and 2017 scorecard measures were widely monitored by RLS
participants at Program/Service Network meetings to assess statistics about outcome and
Sepsis Guideline Set adherence performance. Paradoxically, good outcomes were reported in
spite of generally poor adherence to externally set adherence standards. Participants from the
RLS group were positive about the clinical decision support tools and measures they had
worked to develop. However, RLS participants expressed frustration about the poor
adherence to the guidelines as indicated by process measures, and the DC clinicians’ limited

130
use of the decision support tools that had been developed. RLS participants held a
perspective about implementation success that focused primarily on achieving guideline
adherence (process indicators), though they were able to achieve implementation “wins” as
tools were developed and approved, and as communication and training was delivered. The
Policy Office served to coordinate implementation activities initiated by DC and RLS
participants, though their efforts to facilitate broad regional engagement and decision-making
frustrated some DC participants who wanted expeditious decisions. Through this account of
the Sepsis Guideline Set implementation, it is clear that the there was some discordance
between what the RLS participants and those from other groups thought was important for
implementation, and the actions they took in response (e.g., RLS participants celebrated
development of a pre-printed order to which clinicians, particularly physicians, appeared
uncommitted). These differences in perspective resulted in some evident frustration.
While RLS participants consistently described a logical implementation process and
aligned supports, there were discrepancies between the implementation standard and what
actually took place. Significant limitations to the implementation process were apparent. The
DC Emergency Department Managers were not engaged in the implementation work even
though they were described by many RLS participants as a critical component of the
Program/Service Network structure. The Shared Work Team, comprised, initially, of two
CNEs, with some subsequent additions, only minimally met the expectation of multi-site,
inter-professional participation established by the Policy Office and few mechanisms for
interprofessional engagement of DC clinicians were available generally as part of the
organization’s ongoing activities, or specifically in support of Sepsis Guideline Set
implementation. Reference to evidence review was sparse, and concerns expressed about the
practicality of implementing the guidelines were not directly addressed by any participants.

131
Ultimately, what RLS participants described as strong structure, prioritization by senior
leadership, robust communication and in-service education, some engaging reinforcement
through the Sepsis Network, and well-developed approved clinical support tools, failed to
generate the actions on-the-ground required for guideline adherence. DC participants
ultimately did not align with the expectations of the AAP or RLS leaders. While RLS
participants were positive about these strategies and the organization’s actual sepsis
outcomes, most remained uncertain as to why adherence remained a challenge.
Chapter Summary
This chapter provided a description and interpretation of the Sepsis Guideline Set
implementation from the perspective of participants from the Regional Leadership and
Support (RLS) practice group. Participants from this broad but coherent group sought to
manage implementation of the guidelines, directing the behaviour of various participants
through hierarchical authority, guided by structure and process. A small group of people
holding specific roles (CNS, Medical Lead, Chiefs of Staff, and CNEs) worked across the
boundaries of AAP, RLS, and DC groups to communicate, develop tools, educate, and
monitor the implementation. These activities and actors proved very effective at creating
awareness about guidelines and establishing regionally standard clinical decision support
tools that could have been used to guide Sepsis Guideline Set implementation. Unfortunately,
these activities and actors proved insufficient to affect the change required to make
significant progress in guideline adherence. Compromises were made in the implementation
process imagined by RLS leaders. Managers were not engaged meaningfully. The Shared
Work Team and subsequent implementation involved few DC clinicians who would be called
upon to enact the guidelines, and concerns raised about the need or practicality of the
guidelines were not addressed. The existing workflow, workload, and degree of automation

132
in the City Hospital Emergency Department clearly did not support full adherence to the
guidelines. In spite of a commitment made by the region’s Executive Team to implement the
guidelines, there was a mismatch between the resources required to fully implement the
guidelines and those invested. While the managing implementation perspective of RLS
participants translated to effort toward many positive aspects of implementation, the result
was insufficient to support the changes required for full Sepsis Guideline Set adherence by
DC clinicians.
The next chapter describes another perspective on the Sepsis Guideline Set
implementation at Select Health – the perspective of participants of the City Hospital Direct
Care group.

133
Chapter Seven: Learning, Becoming Competent
In this chapter, the Select Health Sepsis Guideline Set implementation is presented as
it was described from the perspective of a Direct Care (DC) group – the Managers,
Educators, Clinical Leaders, and Clinicians at the City Hospital Emergency Department. The
Direct Care group is the nexus for implementation in the case of the Sepsis Guideline Set.
Study participants from the Direct Care (DC) group described a process which I
characterized as a process of learning – building on a strong interest among DC participants
to build and reflect clinical competence regarding sepsis management. Competence was
paramount for the members of this clinical group of doctors and nurses - as they described a
development process building from general knowledge gained as a student and during early
orientation or implementation activities, through to the point where knowledge is reflected
naturally as ingrained behaviour. In these accounts of the implementation process, the
leadership and support provided by the Clinical Nurse Educator (CNE) within the Emergency
Department specifically for Sepsis Guideline Set implementation was seen to be transitory, to
be further woven into a more enduring process of individual and group competency
development. Participants described this more foundational process as a natural progression
of professional development where new department employees (or physicians) built on what
they learned, including what they learned about sepsis care, as students, to incorporate new
knowledge that they incorporate into practice. Through continued experience and in
conjunction with department supports and other DC participants, clinicians move from what
they described as novice to experienced – and toward the expression of knowledge into
normal, ingrained practice. Figure 7.1 depicts the implementation process as described by
participants of the DC group. The figure highlights the processual aspects of implementation

134
described above along with an indication of roles involved. Roles are those that were
described as important by members of the DC.
Figure 7.1
Direct Care Participant Perspective
“Learning: Becoming Competent”

Academic
Instructors

Physician Chief of Staff
(Emergency)

Clinical Nurse Educator
(Emergency)

PROFESSIONAL
COMPETENCE

Evidence to
Excellence and
BCPSQC Leads

ROLES: City Hospital
Emergency
Department supports

Novice

PROCESS
FLOW

ACADEMIC,
ADVOCACY &
POLICY
CONSTELLATION
ROLES

DIRECT CARE
CONSTELLATION ROLES

Recruiting and pre-screening Teaching/Preceptorship

Experienced

Pre-Specialization

ROLES: City Hospital
Pre-team and
Emergency
Department intra-team
supports

Student

Emergency Practitioner

Orienting and Mentoring

Learning in practice
Professional Development
Continuing Medical Education

Nurse Clinician
Student Preceptors

Nurse Clinician
Buddy Shift Partners

Patient Care Coordinator

Team Members

Note. Direct Care participants described Sepsis Guideline Set implementation primarily as a learning process, as
clinicians gain competence from novice to experienced. Listed are the DC, RLS, and AAP roles most
consistently identified by DC participants as involved in the implementation.

City Hospital and the Local Context
City Hospital is a large urban community hospital providing primary, secondary and
tertiary inpatient and ambulatory care for a large and rapidly growing community. By the
early 2000’s, the hospital’s Emergency Department had outgrown its useful life and a new
Emergency Department had been developed – expanding the unit’s floor space significantly,
and necessitating significant staff grown and workflow redesign.

135
There will probably be a lot of themes based on the timing of this. We were opening a
new Emergency Department. We were probably more than doubling our workforce in
this time preparing for the new Emergency opening. So, our staffing increased just
humongously, and currently we have about, in-total, maybe close to 500-550 staff.
Not all nursing staff, but nursing staff would probably be over 300-350. (DC,
Hospital Emergency Department Manager)
The Emergency Department’s size, busy-ness and redevelopment proved to be
contextually relevant to the Sepsis Guideline Set implementation that took place at City
Hospital between 2011 and 2017.
Back “In the Early Days”
Members of the Direct Care (DC) group described a time beginning in 2012 when a
significant focus was placed on sepsis and Sepsis Guideline Set implementation, championed
largely by one of the department’s CNEs and by the department’s physician Chief of Staff.
Sepsis had always been a significant concern in emergency care, so the DC clinicians were
careful not to leave the impression that this work was the beginning of sepsis awareness and
care. It was, however, described as a period of consolidation and documentation of
knowledge and focused action prior to which care was individual clinician-driven, focused
primarily on diagnosis and treatment of the underlying infection rather than rapid, aggressive
action to address the systemic response of sepsis. City Hospital Emergency Department
nursing staff described the primary role of the CNE in leading the CPG implementation.
Implementation is Delegated to the Clinical Nurse Educators
The Emergency Department’s CNEs (including the CNE who was involved in initial
Sepsis Guideline Set development) acted to implement the Sepsis Guideline Set prompted by
the regional Emergency Medicine Program Clinical Nurse Specialist (CNS) and with the

136
delegated authority of the City Hospital Emergency Department managers. As one
Emergency Department manager described the CNE role:
My perspective when I see a new initiative coming up, like Sepsis, is to connect with
the educators and say “you guys got this?” And our educators are good. There are
different ones, like [CNE Name], for example, leads sepsis and our other educator,
she would lead stroke. So, I would know who to go to, and my role as their supervisor
is just to make sure that they’re going to roll it out and they do. That’s their job. (DC,
Hospital Emergency Department Manager)
The delegation of the Sepsis Guideline Set implementation to the CNEs seemed like a
logical step to the Emergency Department management at the time. Sepsis Guideline Set
implementation proceeded in 2011 - just prior to a move to a new Emergency Department
and the coincident need to expand the department’s staff. With the move, the managers
(manager and coordinators) at the City Hospital Emergency Department had many other
priorities. Management of the site relocation and subsequent stabilization required ongoing
management focus. Meanwhile, the day-to-day obligations of managing a busy Emergency
Department with over 30 staff on during any given shift and about 500 patient visits per day
continued to be significant. Additionally, the Emergency Medicine Program had a concurrent
priority regarding enhancement of patient flow through the Emergency Department which
also required the time of managers. As noted by a City Hospital Emergency Department
manager: “I did the patient flow stuff, our educators did the sepsis stuff.” While not
specifically aimed at sepsis care, some participants recognized an important synergy between
the two priorities – as better Emergency Department flow could lead to quicker responses
and more time for clinical care, both being clear success factors for Sepsis Guideline Set
implementation.

137
Educating and Communicating About the Sepsis Guidelines
Participants of the DC group, particularly the nursing staff, experienced a variety of
activities as the City Hospital CNEs prepared for and delivered Sepsis Guideline Set
implementation education on the unit.
I’m remembering a couple years ago the clinical educators came down and said there
was some new guidelines being set. They’d found out that a lot of people, a lot of
patients, we weren’t meeting their needs and the demands of treating a septic patient.
So, they brought out criteria and a set of guidelines that we, as bedside nurses, could
initiate without having a doctor’s order. The timeframe for this was one hour, two
litres bolus, and then, to at least speak to a physician and get one dose of antibiotics.
(DC, Hospital Emergency Department Nurse)
Introductory information was provided primarily through e-mail and the Department’s
newsletter, the Weekly RANT. The Weekly RANT was, and remains, a weekly newsletter
created by the City Hospital Emergency Department CNEs as a regular, reliable
communication vehicle to overcome the complexities of communicating with a large team
working in various roles, locations, and shifts. The Weekly RANT was circulated to all ED
staff by e-mail every Friday. It was a go-to device for City Hospital ED nursing staff for
ongoing communications, information dissemination, and as a catch-up device for staff with
irregular shifts or for those returning from vacation or other absences.
I think personally, the e-mails are sent out, we do have these e-mails that are sent by
the CNE’s every week. They’re called the Weekly RANT and the in the Weekly RANTs
we do get notifications of new guidelines, new protocols, new skillsets, any new tools
or things that we’re going to be using, that are going to be new on the unit. So that’s a
really excellent way to communicate, for me anyways. Because we get a lot of e-

138
mails so that’s usually my go-to. The RANT, that’s where it’ll tell us, okay, starting
next week we’re going to implement this. (DC, Hospital Emergency Department
Nurse)
About a month before go-live, the CNE prepared City Hospital Emergency
Department staff for the upcoming in-service and initiation of Sepsis Guideline Set
implementation.
Going live the first of October, so in September we start and say “did you know that
the latest Sepsis Guidelines include this? Did you know they also include this?” So,
each week you’d get a tidbit so I kind-of say it’s like planting a seed and then we
bring the in-services and culminate and say “here you go, this is what we’re going to
talk about now” and they’re all, like, “oh ya, you talked about that in the RANT,
right?” (DC, Hospital Emergency Department CNE)
This foreshadowing of the go-live through the Weekly RANT and through e-mail, built
preparedness and recognition among staff before on-unit, in-service activities.
I know we had in-services on them and a bunch of e-mails. I remember getting a
bunch of e-mails. We’ll be doing in-service on these dates. And I know we had an inservice on them. Like the educators upstairs came down, showed us the paperwork of
it all and it was like a few pages long and everything like that and just told us when
the start-date was going to be. (DC, Hospital Emergency Department Nurse)
On the go-live date and for a period thereafter, the CNE undertook an educative
strategy involving in-service huddles, increased personal support on the floor, and
communication reinforcement through the Weekly RANT. For the sepsis guideline, in-service
huddles of approximately 15 minutes were held beginning between 6:30-6:45 am. In-services
were opportunistic, engaging staff members who were able to free themselves for the 15-

139
minute session. Because City Hospital’s busy Emergency Department saw little down-time,
the process of in-service was carried on over approximately a two-week period. During the
same time the Emergency Department CNEs made themselves available to guide staff
members in the use of the new materials and to respond to questions or issues that arose.
Direct Care physicians also experienced a period of heightened activity in the early
years of Sepsis Guideline Set implementation, though different paths and processes were
followed than the nursing staff. City Hospital Emergency Department physicians often
practice in more than one hospital and are reimbursed on a fee-for-service basis – limiting the
time available for unremunerated team learning activities. Given these constraints, the
Emergency Department physician leadership relied on monthly staff meetings and e-mail
reminders for disseminating knowledge about the Select Health Sepsis Guideline Set.
Collaborating with the British Columbia Patient Safety and Quality Council
In 2013, subsequent to the initial Sepsis Guideline Set implementation by the CNEs,
the City Hospital Direct Care (DC) group participated in the BCPSQC’s 150 Lives in 150
Days campaign.
There was also a competition run throughout Select Health about the treatment of
septic patients and I know that there were some posters that were put up as well about
who was winning and the volume of patients come in that met the septic criteria and
how we would treat them and how well we were treating them in terms of the onehour guideline. (DC, Hospital Emergency Department Nurse)
Nurses within the City Hospital Emergency Department recall the campaign as a time
of increased promotion and focus on sepsis.
Well, it’s definitely like kind-of playing medical bingo and it’s just, like, okay, so I
mean we’ve lost a lot of senior staff over the years so we have a lot of new, willing

140
junior staff that come here to work that are fresh out of the program, the [British
Columbia Institute of Technology (BCIT)] Emergency Nursing Program, and so it’s
just a matter of when you see that on, I think we had it on the glass window for the
medication room, when you see that, it kind-of just prompted you. And then the
clinical educators would also send us e-mails as well. (DC, Hospital Emergency
Department Nurse)
The BCPSQC continued sepsis and sepsis guideline awareness promotion and, in
2013 and 2014, conducted several online learning sessions in webinar format that were
referenced by members of the City Hospital DC.
Performance Monitoring: Summary Metrics and Case Review
While there was no evidence that performance measures were posted or discussed
regularly, between 2013 and 2017 City Hospital CNEs occasionally referenced the
department’s Sepsis Guideline Set performance (report card) metrics in the Weekly RANT,
nurse in-service sessions, and physician rounds.
So, there’s a dashboard [report card] and it says across the sites, this is your incidents,
this is your numbers, these are your results and there’s certain things that they have
pulled as your sort-of sentinel events that need to have happened, they look at timings
of so like time to identify them as septic, time to get their bloodwork drawn, were the
blood cultures drawn before the antibiotics, were your fluids within 60 minutes? (DC,
Hospital Emergency Department CNE)
Report card data provided useful reminders about aspects of Sepsis Guideline Set
implementation during early regular in-service and RANT updates. More focused learning
opportunities were described by DC clinicians when specific patient experiences were

141
identified for review. The CNEs occasionally identified areas of concern through the
scorecard (e.g., a period where the mortality rate was higher than usual) and pulled the actual
patient charts for review with the nurse staff involved to see if opportunities to learn and
reinforce good sepsis care practices existed.
It’s helpful. It tells us where our gaps are. Just sometimes I look at it and find outliers
that are, like, way out. I ask them [Health Business Analytics] to unveil the data so I
can pull the chart and go back and look at why that happened. So, I do use it for
quality improvement purposes. I’m looking to see whether a particular nurse has a
knowledge gap that I need to work with? Is this a process thing that’s not working?
(DC, Hospital Emergency Department CNE)
Also occasionally, the CNE held an in-service huddle with nursing staff to review
specific incidents as a learning opportunity.
There was a patient who was septic but somehow it was missed between triage and
when the patient got seen by the doctor. The patient ended up getting treated and
cured but I remember one of the staff, I think it was a CNE, she came in to the care
and treatment zone and just gave us an alert to keep an eye out for septic patients. She
said this was because a septic patient was missed and the patient turned sour pretty
quickly. We were able to resolve that situation and the patient was treated but that
was when our antennas came back on again to be like, okay, let’s keep an eye out for
sepsis. (DC, Hospital Emergency Department Nurse)
Participants noted limited review of data and a lack of interprofessional work related
to performance improvement. The approaches used by the CNEs and Chief of Staff were
oriented toward clinical learning. Initial intensive communication and teaching of the

142
attributes of, and support tools for the Sepsis Guideline Set, followed by communication
reminders and case review.
Not So Much Lately
Participants noted a significant drop-off in implementation strategy activity after
2015, and a reliance primarily on the knowledge embedded in practice that had been
achieved by the team and its more experienced practitioners.
I don’t remember when we last had a follow-up or feedback on how we treat the
septic patients. The focus right now is working with patients receiving TPA [tissue
plasminogen activator, a thrombolytic medicine] and doing better with stroke. That
seems to be the thing that we need to work on right now. So, the sepsis patient seems
to have taken a back seat. I don’t know whether that’s because we’re doing okay and
we’re meeting the criteria and the numbers of it, or if this is just the new thing to talk
about. (DC, Hospital Emergency Department Nurse)
Participants noted that, as with Sepsis Guideline Set implementation, this was often
the way when individual guidelines or improvement initiatives were undertaken. Priorities
change and the focus moves on to something else.
Building Competence
The previous section describes from the perspective of the DC, activities that took
place particularly between 2012-2015 to raise awareness and promote practice change
specifically with respect to the Sepsis Guideline Set. DC participants, however, described
these activities as a transitory part of a broader process of building competence in emergency
practice beginning from their time as a student through to a point where, as an experienced
clinician, practice is ingrained.

143
When describing Sepsis Guideline Set implementation, members of the City Hospital
DC participants consistently and naturally moved into discussing competence or “knowing
what to do.” Given this perspective, DC participants seemed to initially consider the
discussion as an examination of their individual knowledge or competence and how that
knowledge came to be – how it was built over time. Building competence was described as a
progression of learning and experiential reinforcement gained through basic and specialty
training, pre-qualification, orientation, and ongoing education and development. Many
aspects of this progression fell within the purview of City Hospital’s Emergency Department
CNE and Chief of Staff. Another role, however, bears introduction – the Nurse Clinician –
for its relevance to the in-practice development of nurses within the Emergency Department.
Continuous Development of Competence and the Nurse Clinician
City Hospital offered a variety of mechanisms to build competence among junior
nurses. Much of the effort was placed on the transitional points between which a student
nurse becomes a practicing nurse in the City Hospital Emergency Department. To help new
nurses to make the transition from student to practitioner, City Hospital, and Select Health
more broadly, developed a supportive Nurse Clinician role. The Nurse Clinician was a senior
practicing nurse who had a formal responsibility with respect to recruit preparation, student
orientation and ongoing at-the-elbow coaching. The Nurse Clinician focused primarily on
student and novice nurses but was available as a member of the clinical team to reinforce
good practice for all.
The Nurse Clinicians worked daily from 9:30 am to 8:45 pm. They shared a work
area with the City Hospital Emergency Department CNEs and so there was a natural
tendency to work together to align the Nurse Clinician’s at-the-elbow activities with the
CNE’s learning priorities.

144
So, it’s a support, it’s at the frontline. So, I guess, to compare, the educators are up
dealing with regional stuff. The clinicians deal with bedside support so we’re almost
like, they’re the brains and we’re the brawn, almost! We kind-of reinforce what has
already been taught. Considering that we would’ve had that education as well. (DC,
Hospital Emergency Department Nurse Clinician)
In performing all their support functions, nurse clinicians sought to foster critical
thinking among practitioners, using leading practice case studies – including cases involving
sepsis – as practical guides. The work of the Nurse Clinician began with encouraging
promising new nurses to take further training in emergency nursing.
Pre-Specialization: Selecting for Potential
From the perspective of the DC participants, competence in emergency care –
including good sepsis management – began with the identification, assessment, and support
of novice nurses with an interest in emergency nursing and demonstrating the critical
thinking skills believed necessary. The City Hospital Emergency Department leadership team
had exposure to many junior medical/surgical nurses, as they provided general nursing care
in the department’s lower acuity unit, the Care and Treatment Zone (CATZ). Through this
exposure, Emergency Department Managers identified strong potential candidates and asked
the nurse clinician to work with them to provide both assessment and encouragement.
The ED Coordinators are the ones who decide when the nurses, well they ask for
feedback, so they pull these names, the nurses who have mentioned that they’re
interested in going to the [British Columbia Institute of Technology (BCIT)
Emergency Nursing] program, what do you think? And then I focus on these nurses to
complete their CAPE [Competence Assessment, Planning, Evaluation] tools, to have

145
the case studies and then to provide information whether they still need to strengthen
certain areas of their practice. (DC, Hospital Emergency Department Nurse Clinician)
The Nurse Clinician worked with promising graduate nurses to conduct a competency
assessment using a standardized CAPE tool developed by the College of Registered Nurses
of British Columbia. The Nurse Clinicians supplemented the assessment with a case study
tool they developed themselves. Case studies were discussed with the candidate to help
assess and nurture critical thinking skills needed for success in the Emergency Nursing
training program and for emergency nursing practice.
That’s my role. That is my baby. I hope for the nurses to practice well and not just be
task-oriented. And I gear them so they’re ready for the [BCIT] emergency program to
be successful in the program and so we have these discussions. (DC, Hospital
Emergency Department Nurse Clinician)
As an important and relatively common presentation in the City Hospital Emergency
Department, a sepsis case was established as one of the studies used by the Nurse Clinicians.
I make sure clinical presentation stuff I know are common in emergency are covered
and then after that I have another piece of paper that is eight case studies with
common presentations [one of the cases relates to sepsis]. So, a patient comes in, with
recent chemo, was febrile, now tachy, what do you think is happening? Name three
things that could be happening. (DC, Hospital Emergency Department Nurse
Clinician)

146
From “When I Was a Student”
Both nurses and physicians related the Sepsis Guideline Set implementation back to
an expression of clinical knowledge, and to competencies they had gained during their
respective professional training, particularly the part of their specialty training focused on
emergency care. As noted by a City Hospital Emergency Department physician “It came to
my attention probably like 2009, 2010 during my residency.”
I wouldn’t say the in-services. I guess it’s just nursing theory as well. I’m sure that we
learned this in the emergency course as well. Maybe that’s something I should’ve
mentioned before. It’s a big focus when we do our emergency training. (DC, Hospital
Emergency Department Nurse)
Physician emergency specialty training is organized through a variety of university
specialty training programs in alignment with accredited teaching hospitals. Similarly,
emergency nurse training involves delivery of specialist training where students receive
didactic training through an academic institution (typically the British Columbia Institute of
Technology (BCIT) in British Columbia) and clinical practicum placements. Because City
Hospital provides practicum placement opportunities, Nurse Clinicians and the CNEs had
some input into ensuring that the curriculum addressed any important knowledge gaps,
including those related to Clinical Practice Guidelines such as those for sepsis care.
The training received by new recruits to the City Hospital Emergency Department
during the emergency training program was foundational, then, to Sepsis Guideline Set
implementation from the perspective of the DC. In the BCIT curriculum, sepsis is addressed
as part of Emergency Nursing Theory 3 – as they explore the care of the critically ill patients.

147
You have people coming back from the emergency program, “hey, this guy looks
septic.” It’s taught right at the ground level with the baby emerg nurses that “hey this
is a big thing.” You know, there’s protocols. (DC, Hospital Emergency Department
Nurse)
Clinicians referred to the skills they gained themselves, and they recognized the skills
with which new trainees were arriving in new positions within the Emergency Department.
Upon graduation the CNEs provided “re-orientation” to the Emergency Department “to share
things that are new in scope to them (compared to before the left) and to ensure they are
practicing in a manner consistent with our Select Health and site standards of practice” (DC,
City Hospital Emergency Department CNE). Two days of re-orientation was provided to new
specialty-trained nurses, who would have already had general orientation to the unit before as
Care and Treatment Zone general duty nurses.
Orientation: Learning the Ropes at City Hospital
Orientation at the City Hospital Emergency Department was another transition point
during which professional competencies – including sepsis management per the Sepsis
Guideline Set – are assessed and reinforced. New staff members were provided a series of
seminars to review practice standards, including sepsis management.
If I remember correctly when I was transitioning from becoming a student nurse to a
full-time staff, there was a series of classes. We had seminars about certain topics and
sepsis was one. (DC, Hospital Emergency Department Nurse)
While physicians new to the City Hospital Emergency Department were expected to
practice self-sufficiently from the outset, they also undertook an orientation with the Chief of
Staff – guided by an orientation package which includes introduction to key clinical
standards and tools, including those related to the Sepsis Guideline Set.

148
Certainly all the new docs, probably since we opened the new department and we
hired a lot of new docs at once. We put together an orientation package for docs. It
has evolved since then, but certainly a key feature of it then and now is what are the
pre-printed orders that are available and important? And so, they get a copy of those
prior to starting in the department. Then, I go through and show them the pre-printed
orders. Sepsis would be a common one for sure. (DC, Hospital Emergency
Department Physician Leader)
Along with eight orientation seminars, nurses new to the City Hospital Emergency
Department had eight “buddy-shifts” during which they were partnered with a senior nurse to
become progressively more and more independent (DC, City Hospital Emergency
Department Nurse). At the same time the Nurse Clinician worked with new staff members to
provide at-the-elbow orientation and coaching.
They’re doing check-ins with our new staff and making sure that they’re doing okay.
They’re having them speak about their patients to see what level they’re at. If they’re
feeling comfortable. And a lot of review. They do a lot of review with staff. They go
through their tools, their CAPE tools. It’s just basically a self-evaluation and our
educators help them with that. Self-reflection on what they needed to work on in the
future. (DC, Hospital Emergency Department Nurse)
Orientation was a key time during which the nurse clinician worked with new staff
members to conduct self-assessment and competency development planning using the British
Columbia standard CAPE tool.

149
Keeping current: communication and professional development.
Following specialized training and orientation, City Hospital DC participants,
including physicians and nurses, worked to keep current through ongoing departmental
communications and through formal and informal professional development activities. These
activities appeared to differ somewhat between nurses and physicians. For nurses in the City
Hospital Emergency Department, the Weekly RANT continued to serve a vital function.
Communicating Through the “Weekly RANT.”
The newsletter was described by every member of the department’s nursing staff
interviewed as a critical means through which they acquire information to enable them to
keep up-to-date with department activities and priorities.
We do read the weekly e-mails and it is a part of the culture here that you need to
know. Like, if you say, oh, I didn’t know about this, and they say it was in the RANT,
then it’s on you. It’s your fault. Which I agree with. I think if they’re going to
summarize what we need to know week by week and e-mail with a lot of comics and
jokes, it’s great, I’ll read it. They do a pretty good job with it. (DC, Hospital
Emergency Department Nurse)
Members of the department nursing staff described this locally constructed and
distributed newsletter as a “part of the culture” – mandatory reading for team members for
which they hold each other accountable in a serious, yet good natured way.
I:

So, it’s kind-of a touch point and now you have to go back and if you missed that
e-mail, can you send it to me or whatever the case is. Now you go back and read
it.

R: Oh, excellent.

150
I:

I know it’s happened to me twice, actually in the last maybe two years. They’re,
like, oh, didn’t you read your Weekly RANT? We hit each other with that. Go read
your Weekly RANT! And that’s how I knew about it. The Weekly RANT I find is a
really, really good way. (DC, Hospital Emergency Department Nurse)

There was no evidence that the Emergency Department physicians engaged with the
Weekly RANT. Instead, physicians referred to the monthly department meetings and e-mails
from the chief of staff as their primary source of information for keeping current about
important department priorities and activities. Physicians also described a tendency to access
sources external to City Hospital and Select Health for learning and competency
development. Rounds of a teaching hospital outside of Select Health and well packaged,
highly credible online sources (e.g., University of California in Los Angeles (UCLA)) were
cited by one physician respondent as his primary sources of professional development
information.
Competency Checklist. Many nurse members of the DC spoke of a checklist that had
been established by the organization’s Emergency Medicine Program CNEs.
And as far as keeping up-to-date with our clinical skills, we’ve got, there’s a checklist
that we have that we need to have done. You can see exactly what is required of you
and what you need to be up-to-date. (DC, Hospital Emergency Department Nurse)
The Competency Checklist was developed between 2012 and 2015 by the CNEs
within the Emergency Medicine Program and has been retained as an important tool for
education within the ongoing Emergency Medicine Network. The checklist included
education regarding the Sepsis Guideline Set. In collaboration with management, the CNEs
developed a scheme for ensuring a reasonable degree of adherence – aligning completion of
all checklist modules with payment and with admission to valued programs like Advanced

151
Cardiovascular Life Support (ACLS). “Unless you finish the whole list, you don’t get paid
(DC, Hospital Emergency Department Nurse).
Reinforcing Practice: The Importance of Team
With Nurse Clinicians available for most shifts and many other clinical, education and
management staff the nurses of the DC group described a rich environment for learning and
ongoing clinical support. Nurse clinicians focused their efforts on novice nurses in the City
Hospital Emergency Department, but they made themselves available for all – filling in when
clinical demands peaked and coaching staff through specific issues when necessary.
So, they’re basically supports for our staff. Our new staff, old staff, they’re there in
terms of just any issues like somebody is not feeling comfortable with a specific
intervention, or they’re not really understanding what’s happening with a patient, or
there’s a change in patient status. (DC, Hospital Emergency Department Nurse)
While DC participants recognized the availability and importance of formal support
through the nurse clinicians and, Emergency Department coordinators, they were also quick
to recognize the supportive nature of the other Emergency Department team members
themselves. Participants from the City Hospital DC spoke of the critical importance of
teamwork in ensuring mutual support and shared responsibility.
In City Hospital, we have a very strong sense of shared responsibility between us and
we work well together on the nurse management side, operations side, and the
medical side (DC, Hospital Emergency Department Physician).
R:

Is there anything that supports that teamwork? How do you learn to be a team?

I:

Each other. It’s all about each other. We have a mandate here. We just have
to. If I was to take you for the entire day and just plopped you in one spot in

152
the CATZ area, and you just watched and listened and watched, you would
see that if we didn’t do it altogether, one, two, three people would just be
drowning. You can’t be here as a nurse if you don’t. There have been people
who have not fitted. They don’t fit, so they’ve done what they need to do, and
they’re gone. You either like being here or you don’t. (DC, Hospital
Emergency Department Nurse)
Participants noted a lack of formal mechanisms to engage team members
interprofessionally, particularly physicians with nurses. While they recognized that such
engagement would be beneficial, barriers of time and physician remuneration were identified
as obstacles. The teamwork that developed and affected Sepsis Guideline Set implementation
was described as having developed out of necessity based on the hectic and often emotional
needs faced by team members in the Emergency Department day after day. Key senior team
members were described by some Emergency Department nurses as having a memorable role
in promoting the work ethic and rules of mutual support that enable the team to provide
quality services in spite of the ever-increasing demands of the busy department.
It’s just a culture we’ve always had. Even when I came, when I started here, I
remember my orientation. The lady that was orientating me said “if you’re sitting
there doing nothing and you see someone who’s busy, you get off your behind and
you get up and you help.” It’s become an expectation and it’s just sort of passed on.
(DC, Hospital Emergency Department Nurse)
Teamwork within the DC was described as a matter of “survival” – a cultural
expectation shared by Emergency Department team members contained to the clinical team
members but cutting across team professional boundaries.

153
Teamwork here is the culture and it’s very, it’s how we can, what’s the word? It’s
how we can cope with the volume and with the tragedies. Honestly, it sounds so
gushy, but we really do support each other. From the doctors – the doctors support the
nurses, the nurses support the doctors. It’s quite impressive. (DC, Hospital
Emergency Department Nurse)
The DC participants’ lack of reference to other site or regional levels of activity was
quite striking. Asked specifically about changes that took place regionally, one City Hospital
Emergency Department nurse responded indifferently:
I can’t speak to any of the upper stuff, like, I can’t speak to any of that. That’s not my
thing. As for changes in how we, management and stuff up top, I don’t think that
would trickle down to affect our day-to-day practice for our patients. I didn’t notice
anything that would affect how well I follow guidelines or how I would treat a
patient. (DC, Hospital Emergency Department Nurse)
Now it’s “Just What We Do”
From the perspective of participants of the DC, interview conversations about Sepsis
Guideline Set implementation moved consistently and naturally into conversations about
competence. Given this perspective, DC participants seemed to initially consider the
discussion as an examination of their individual knowledge or competence. Study DC
participants described a trajectory of competency-building from students learning about the
guidelines explicitly to a point at which they considered the practice to be ingrained – a
natural response to the situation in front of them.
For a lot of us who are Emerg trained, I feel like it’s almost automatic. Like, you’ve
got your patient, you’ve got their history and everything like that. You look at it and

154
it’s just, kind-of, there. I don’t know how else to say it. “They look septic. I think they
might be septic. We should start a protocol.” (DC, Hospital Emergency Department
Nurse)
Becoming Ingrained
The idea that the Sepsis Guideline Set practices had become incorporated into
individual and team practice to the extent that the behaviours had become innate, “just what
we do,” was raised by all participants of the DC group – physicians and nurses. Many
participants noted explicitly that they don’t think specifically about the guidelines in practice
but that they inherently act in a manner that is consistent with them, for reasons which they
are hard-pressed to describe. “I think that we follow the guidelines and I think we’re
probably meeting all the criteria, what needs to be done and I think all the nurses are
onboard” (DC, Hospital Emergency Department Nurse).
Competence was reflected as a part of the clinician’s identity as a clinician or
professional. Among DC participants, the experience was not always described as a purely
personal journey. While skills and knowledge were ascribed to individuals, participants
allude to other team members, including other nurses and physicians, as part of a collective
journey toward innate or normalized behaviour. There was a consistent use of the term “we”
rather than “I” when sharing perspectives on competence and action with respect to Sepsis
Guideline Set implementation.
While participants spoke of the ingrained behaviour that has been achieved in the City
Hospital Emergency Department with respect to Sepsis Guideline Set implementation, they
recognized that there was a point where this was not the case – that the team had come to this
level of ingrained behaviour through education and practice experiences gained over time.
This normal, ingrained behaviour was always described as a positive professional

155
achievement resulting from experience – and was often contrasted to rigid use of Sepsis
Guideline Set tools.
The form might not necessarily get put on the chart at triage, and we don’t necessarily
always print the paperwork out anymore because we all kind-of, like the majority of
us and especially the docs know, like it’s just, ‘cause it’s an old guideline, you know
you get a lot of the experienced docs, a lot of the experienced nurses and it’s just “this
guy sounds septic, I’ve started the two-litre bolus on him.” We’ve started it without
printing off the paperwork because we just know, it’s just ingrained. I don’t know
how to explain it, it’s just there. (DC, Hospital Emergency Department Nurse)
Sepsis and the Busy Emergency Department
Just as naturally and consistently as DC participants described the Sepsis Guideline
Set implementation as a matter of competency building and learning, they related it as an
individual and team balance between doing what is best for a given patient within the
practical realities of their daily work lives. Ultimately, DC participants reported that they
reached a point where they believed the implementation was successful in that they were able
to achieve a balance between perfect care for the individual, and coping - within the time and
resources available, with the needs of all patients within a given day.
Motivation: “Why” Matters
Some DC participants described a personal process through which they assessed the
practical value of the Sepsis Guideline Set. Both nurses and physicians looked at the
guidelines with a view to understand and evaluate how “truly useful” they were to help meet
the clinical needs of patients particularly within the high-pressure work environment of the
Emergency Department.

156
I got the feeling for myself personally and the people that I’ve worked with is this
[following the Sepsis Guideline Set] is how we can treat patients and make them
better quicker. (DC - Hospital Emergency Department Nurse)
I think you have to think that the guidelines are useful. That the flow developed in the
guidelines is extremely what you want for your patient in a situation. And you don’t
do something that’s so obvious that it doesn’t contribute to it or it imposes, like,
unnecessary onerous requirements. (DC, Hospital Emergency Department Physician)
Some clinicians expressed skepticism that some guidelines, including the Sepsis
Guideline Set, are administratively rather than clinically motivated, meant to reduce risk or
comply with government mandates on behalf of the organization, rather than patients and
providers. While managers – even those with clinical backgrounds - describe a logical path
between risk or utilization management and good patient care, some clinicians among the DC
used powerful clichés like “ticking boxes,” and “filling out pieces of paper” and questioned
the true motivation of management in pursuing Sepsis Guideline Set implementation.
A lot of times the guidelines are not changing what we do, because mostly we do
relatively good septic care downstairs. You don’t want to be just filling out more
pieces of paper for the sake of filling out more pieces of paper. (DC, Hospital
Emergency Department Physician)
Physicians and nurses took different paths to determine the applicability and
appropriateness of the Sepsis Guideline Set. There were no forums for broad,
interprofessional examination or discussion of opportunities for improvement or
performance. Physicians described early discussions amongst one-another and drawing on
sources outside of Select Health to understand and interpret the science. One City Hospital
Emergency Department Physician noted that he favoured the emergency rounds at another

157
teaching hospital as an in-person learning activity, while depending on published abstracts
and a paid online service from the University of California in Los Angeles (UCLA) for
broader continuing medical education. Nurses were as eager to understand the underlying
evidence – as one nurse described as the “theory to practice” - but most indicated that they
had not assessed the evidence themselves, but that they trusted the department CNE to
conduct and convey that assessment.
Missing Research Culture Amongst the Direct Care Group
There was a sense among some physician and nurse participants of the DC group that
other, more academically oriented hospitals better supported and championed a culture that
facilitates the implementation of guidelines such as the Sepsis Guideline Set.
When I was at [another British Columbia Teaching Hospital] I definitely felt this
sensation of people really wanting to be dedicated to research. If someone came in
with a study, people did the study. If they said, “you need to fill out this check box for
every patient with these symptoms,” people did it. I think, for whatever reason,
there’s a difference in the health authorities about commitment to research and
improvement. And I don’t really know why Select Health seems to lack it compared
to other places. (DC, Hospital Emergency Department Nurse)
Workload and Workflow
From the outset there was an apparent acceptance of “the science” behind the Sepsis
Guideline Set, but a concern about the degree to which they were fully implementable at City
Hospital given its size and volume of patients each day. Workload and workflows had not
been sufficiently adjusted to meet the significant expectations of the Sepsis Guideline Set.
I think the sepsis one was generally very well accepted and understood and the
science was very convincing. So, I would say it was unanimous acceptance. The

158
[twelve Select Health Emergency Department] Chiefs wondered a lot about how
implementation would go ahead and how to best implement the science. It’s very
different, obviously, in Emerg if you’re waiting for a patient to arrive with Sepsis, and
it’s the only patient you’re seeing. It’s pretty easy to, obviously, meet the standards
100% of the time. But when you have all those patients, and sick patients, then how
do you streamline that to make sure you’re as close to the target as you can be? (DC,
Hospital Emergency Department Physician Leader)
Concerns expressed by a City Hospital physician leader about the practicality of
implementing the Sepsis Guideline Set proved prophetic. The Sepsis Guideline Set was
comprised of a variety of activities that needed to be achieved within specific timelines.
Challenges in meeting these timelines arose and persisted as time and physical constraints
took hold. Especially on days when the Emergency Department was busy, even those patients
identified for quick response experienced delays as staff time was constrained and physical
space became congested.
Say [for instance] at triage, you’ve done a set of vitals on somebody, you’ve listened
to their story [you think] “oh, this person sounds septic.” We’ll bump them up. Well,
even if you’ve bumped them up on the [patient chart] rack to be seen, they still might
be two hours getting to CATZ [Care and Treatment Zone]. Or [you might think] “hey,
I know CATZ is on hold, I’d like to send this patient down.” [to a higher acuity unit.
You ask:] “I think they’re septic, they’re unwell, can we send them down?” Well,
great, you can send them down, but they still might be two hours, three hours before
they see a doctor. Right, like we have no rooms, you can send them down, we can
assess them, we can maybe start an IV and put them back in the waiting room or
when we have a congestion issue, do we have a lag in time of things starting? For

159
sure. But that’s across the board on everything unless it’s super acute, where, “hey,
this guy needs a bed!” right? Like the septic guidelines is one that we might not be
able to start, if they’re mildly meeting the criteria or moderately meeting the criteria,
they might have a lag in time. (DC, Hospital Emergency Department Nurse)
Given the relatively broad clinical triggers for suspecting sepsis (SIRS criteria reflect
symptoms that apply to many conditions, many of which are not related to sepsis) clinicians
questioned the appropriateness of the more aggressive aspects of the Sepsis Guideline Set,
including aggressive administration of fluids and more invasive approaches to physiological
monitoring.
In addition to recognizing the need to achieve a practical balance between the Sepsis
Guideline Set expectations and department workload, during the move to a new City Hospital
Emergency Department site in 2013, efforts were made to reorganize the Department’s triage
roles and workflow to improve the Department’s responsiveness and to expedite early
decision-making. Changes were made to triage nursing duties to reduce the amount of work
performed by them for each patient – to more quickly assign each to the appropriate
emergency department resources. While participants believed this workflow change achieved
the desired benefit of quicker initial patient movement to the “right” service area of the
department, this change challenged performance of key aspects of the Sepsis Guideline Set
workflow.
But the volume we have leads to significant congestion at triage and people wait a
long time before attention – which is a bad idea. So, we changed the triage process to
be quicker. A quick look at triage allowed us to usually get people into the right
place, whether acute or less acute areas quickly. But the downside was it really
impacted our ability to identify patients at the very first contact, and to use nurse

160
initiated order sets. There was no time to say “hey, I think this is sepsis, I’m going to
take the time to go into the computer and print up the sepsis protocol for this patient’s
chart.” So that was a concern. The assessment nurse in a different area [of the
emergency department] then needs to take the time that the triage nurse used to, and
orders sepsis protocol bloodwork or will pre-print that order set for us. (DC, Hospital
Emergency Department Physician)
Triage nurses indicated that, when busy, they would tend to flag the patient as
potentially septic to the receiving nurse and order the sepsis bloodwork. Other aspects of the
Sepsis Guideline Set, particularly the printing of the pre-printed order for inclusion in the
chart (a step which is believed to increase the probability that physicians will follow the
Sepsis Guideline Set), were left to the subsequent care team, with the assumption that they
would be taken up by the receiving nurse and/or physician.
The sheets I find sometimes it’s done at triage. Other times it might not be done. I
don’t see it being done because it’s almost something that is kind-of stuck in your
head, so you enter the sepsis bloodwork right away and then let the nurse who’s going
to be receiving that patient know. So, they are aware but the sheets, I want to say
that’s kind of half-and-half. It depends on how busy it is. (DC, Hospital Emergency
Department Nurse)
Some participants described a tendency among nurses to become task oriented when
workload is high, and resources constrained. A task orientation was seen as a significant
impediment to a clinician’s ability to interpret and respond appropriately to a clinical
situation, hence an impediment to building competence.
It’s just that sometimes it gets so busy that people become so task oriented. This is
one of the things I’ve discussed in the last few weeks, is the nurses here are so good at

161
completing tasks but then it becomes task-focused because it’s so busy. Even for the
new nurses which they are thrown into this kind of scenario. They learn very quickly
but it becomes task-oriented and then you forget to think, oh yes, there’s this protocol
and I need to give antibiotics because it’s, you know, it’s important, shouldn’t be
delayed. (DC, Hospital Emergency Department Nurse)
While all DC clinicians expressed a belief that the Sepsis Guideline Set was well
known and embedded as ingrained practice in the Emergency Department, the use of the
Sepsis Guideline Set pre-printed order often became a fatality of workload challenges and
attitudes. Most clinicians admitted to a feeling that use of the pre-printed order was
inordinately time-consuming and did not confer enough value for the patient to justify the
additional workload in the context of the needs of the many patients in the department.
Bundling for Focus and Communication
Some DC participants noted that, in addition to a limited focus on practical workload
and workflow assessment, priorities seemed to come to the Emergency Department as
transitory, single initiatives – soon to be replaced by others. Opportunities were believed to
exist to bundle initiatives in such a way as to align supports for a variety of priorities at the
same time, if proper consideration was given. One CNE described an effort to improve
effectiveness by grouping Sepsis Guideline Set implementation with other interventions that
require immediate response.
At that time anyways, I was thinking, there were three things that you had to react to
quickly to save people when the arrive in your emergency. There were strokes, sepsis,
and STEMIs [ST-Elevation Myocardial Infarctions (heart attacks)]. The 3 S’s. And
those you had to move on. Everything else, mostly, you could take your time. (DC,
Hospital Emergency Department CNE)

162
There was little evidence that this type of bundling was considered formally for
emergency department Sepsis Guideline Set implementation among other sites or in
alignment with consideration of the workflows involved. The 3 S’s had not come to the
attention of City Hospital DC participants. The potential effectiveness of considering the
interactions among improvement initiatives together was raised by one participant in regard
to later efforts to improve inpatient sepsis rates.
It’s improving, it’s improving. What has changed is the urinary tract infections and
the hospital acquired infections. They have plummeted and because of those two, our
sepsis rates have come down. (RLS, Regional Quality Improvement Department
Lead)
Sepsis Care in the Emergency Department: How Did It Go?
Participants from the City Hospital DC group did not describe the scorecard or its key
performance indicators (KPIs) when asked about the degree to which the implementation was
successful. Those who mentioned the measures at all simply made passing reference to a
belief that the CNEs monitored such things. DC participants were much more inclined to
assess implementation success by the degree of general knowledge obtained and the
reflection of that knowledge in practice as experienced anecdotally.
My understanding from when I started here as a new nurse, basically as a brand-new
nurse to now, I feel the transition has actually been really good in terms of the
implementation of it. Because I feel as though more of the staff are more aware of it
so as soon as, for example, you get a patient with a heart rate of 120 and they’re
febrile, you just order the bloodwork. So, if anything, the bloodwork is always
ordered. From the triage point of view anyways. So, for the most part that is, I feel
like that has been addressed for the most part. I would say on a scale of ten being

163
really good at it and zero, being we’re not, I would say we’re roughly 8 or 9. That’s
how I feel anyways. Because I do triage, so I do know a lot of my colleagues, once
you do, hit two or three of those criteria, you, the sepsis protocol is already initiated in
terms of the bloodwork. (DC, Hospital Emergency Department Nurse)
While clinicians recognized and respected the pre-printed order on a conceptual level,
they believed the compromises made were largely administrative – “ticking boxes” and
“filling out paperwork.” Similarly, while respectful of the research and science behind the
Sepsis Guideline Set, the DC clinicians – doctors and nurses - had drawn the conclusion that
the expectations of the Sepsis Guideline Set were overly aggressive and impractical. The
consensus among both DC physicians and nurses was that they represented a combination of
case identification (SIRS criteria) and clinical actions that were helpful only in that they
pointed in the direction of an appropriate approach to care – guidelines to be considered, not
necessarily followed to the letter.
Given all this practical context, physicians and nurses consistently expressed a belief
that an effective balance had been reached – that good care was being provided in the face of
high workload and an inability to change workflow enough to enable the Sepsis Guideline
Set to be followed more stringently. A single physician who was aware of the hospital’s
relatively low sepsis mortality rates held these up as evidence that, on-the-whole, good sepsis
care was being provided. More of the DC clinicians lacked knowledge of these data but also
asserted a belief, that proved consistent with the evidence presented by outcome data, that the
Emergency Department’s sepsis care was good, citing a lack of evidence to the contrary such
as sepsis-related adverse events.

164
I think patients that I encounter who are septic, I don’t have a lot of moral dilemmas
about it, that I can think of. Or that we’ve missed something huge or anything. (DC,
Hospital Emergency Department Nurse)
In summary, participants of the DC group reported positively on the success of the
implementation as they believed they and their colleagues were well aware of the guidelines
and incorporated them naturally into practice. They recognized a widespread lack of use of
the pre-printed order. While they conceded that more consistent use of the pre-printed order
would be a good thing, they did not consider this to be clinically necessary as the orders
represented “paperwork” reflecting practice that was happening naturally. All DC
participants interviewed differentiated in some way between ideal sepsis care as might be
reflected in the academic research and good sepsis care as can be practically achieved given
the workflows and workload of the busy City Hospital Emergency Department.
Becoming Competent and the Practice of Direct Care Providers
Participants from the DC group described a perspective of Sepsis Guideline Set
implementation that reflected their efforts to learn toward becoming competent, with brief
educative activities focused specifically on the Sepsis Guideline Set, supported by
embedding sepsis management into broader efforts to recruit, orient, and continuously
develop clinical staff who would demonstrate professionalism, expertise, and teamwork on a
day-to-day basis in the busy Emergency Department. DC participants tended to describe a
learning approach to implementation of the Sepsis Guideline Set that, like the
implementation process described by the RLS participants, built on early originating work
led by Direct Care group Clinical Nurse Educators. From the DC perspective, however, the
early work was only part of an ongoing effort to build and reflect clinical competence

165
amongst team members. Competence was paramount for the members of the clinical team –
as they described a professional development process building from general knowledge
gained as a student and during early orientation or implementation activities, through to the
point of expertise, where knowledge is reflected naturally as innate behaviour. There were
many indications that competence was considered not only to be an individual attribute but as
one that is achieved and recognized among the team.
Within the DC group, the process of Sepsis Guideline Set implementation was
supported initially by a variety of time-limited education and communication activities (inservice and discussions in the newsletter “the Weekly RANT”) that then fed into, and were
supported by, ongoing processes of individual and team competency development and
support including staff selection, orientation, and ongoing professional development. These
ongoing processes reflected, but were much broader than, Sepsis Guideline Set
implementation, incorporating sepsis management as part of an ongoing context of active
human resource management, professional development, and peer support/mentorship,
particularly for nurses. For these processes, the expertise and professional credibility of the
Clinical Nurse Educator (CNE), Nurse Clinician, and the physician Chief of Staff were
critical. Nurses looked almost exclusively to the CNEs to assess and introduce new practices
like the Sepsis Guideline Set. Physicians were more likely to consider sources outside of
Select Health for information to assess new practices, though they looked to the Chief to
understand the organization’s priorities. For physicians, time efficiency was critical so they
sought sources that synthesized what they deemed highly credible information into small,
consumable packages (e.g., written briefs or short podcasts).
DC clinicians perceived Sepsis Guideline Set implementation, and their assessment of
the degree to which the implementation was successful, within the realities of their day-to-

166
day work and team activities. The City Hospital Emergency Department workload was such
that they were seldom able to follow the guidelines precisely. Aspects of the Sepsis Guideline
Set – including use of the pre-printed order itself and some of the more aggressive elements
of care – were largely forsaken as they were deemed of dubious clinical necessity, or even
administrative in nature. Overall, however, they felt they had achieved a balance where good
clinical care was being provided in a way that would not compromise the team’s ability to
effectively and efficiently meet the needs of the many sick patients arriving at the department
throughout the day. DC participants defined success largely as the lack of evidence to the
contrary – as participants had experienced few sepsis-related adverse events. Evidently the
DC participants had established their own priorities and goals for sepsis management,
different from the adherence focus of the RLS and AAP participants.
From the perspective of DC participants, the challenges arising from the dynamic
nature of the evidence regarding sepsis described in Chapter Four became evident. While, as
discussed in the previous chapter, RLS participants seemed comfortable with implementation
based on the process specifications of the guidelines, clinicians, particularly physicians,
appeared to resist adherence and use of the approved support tools without clearer evidence
that their local outcomes could be improved.
Chapter Summary
This chapter presented a description and interpretation of the Sepsis Guideline Set
implementation from the perspective of participants from the Direct Care group. Participants
of this group sought to implement the guidelines as a process of learning, toward becoming
competent. They reorganized behaviours of various providers through learning in practice, as
part of their professional responsibility. With an important delegation of implementation
leadership responsibility away from the DC Manager, only two people from the DC group

167
(CNE and Chiefs of Staff) worked substantially across the boundaries of AAP, RLS, and DC
groups to engage with, and align implementation activities regionally. Along with their
regional Program/Service Network counterparts and the Policy Office, these activities and
actors proved very effective at creating awareness about guidelines and establishing
regionally standard clinical decision support tools that could have been used to guide Sepsis
Guideline Set implementation. Within the DC group, the participants involved in Sepsis
Guideline Set implementation expanded, particularly for nurses, to include student
preceptors, orientation buddies and Nurse Clinicians. These individuals worked to
incorporate the guidelines and sepsis awareness and management into their day-to-day
support for training, orienting, and developing clinicians to become competent practitioners
within the team. Unfortunately, these activities and actors proved insufficient to effect the
change required to make significant progress in guideline adherence. The existing workflow,
workload, and degree of automation in the City Hospital Emergency Department did not
support full adherence to the guidelines. Engagement within the DC group was limited as the
group lacked forums for significant conversation and coordination of improvement work
within and among the professions (nurses, physicians, managers); limitations in time and
resources prohibited such activity. While adherence was poor, the DC participants had
established a positive view of the implementation’s success. From their situated, practical
perspective, sepsis management was not a significant improvement concern based on the
outcomes they experienced and what they knew of sepsis mortality rates.
The next chapter provides a discussion and interpretation of the findings from the Select
Health case study findings presented in this and the previous two chapters, highlighting an
important link between the perspectives of people engaged in different groups and the actions
they take toward Clinical Practice Guidelines. Failure to share and align these perspectives

168
led to implementation process weaknesses that compromised the effectiveness of the Sepsis
Guideline Set implementation at Select Health.

169
Chapter Eight: Understanding the Roots of Discordance in CPG Implementation
This chapter begins with a discussion about the discordance that was evident in Select
Health between the perspectives and actions of academics, regional managers and support
staff, and clinicians. While academics, regional managers and support staff, and clinicians
each, as a group, offered a relatively consistent, coherent description of the implementation
that took place, the perspectives differed considerably across the groups. The different
perspectives led to actions that were insufficiently aligned for the CPG implementation to be
successful. The CPG implementation literature, including the Consolidated Framework for
Implementation Research (CFIR), and practice theory, together, offer a useful lens for
understanding the relationship between discordance and perspectives. In this chapter, I
examine academics, managers and support staff, and clinicians as three important
communities of practice as described in the practice theory literature. By considering the
relationships between and within the three communities of practice, the chapter illuminates
the strengths and weaknesses of the Select Health Sepsis Guideline Set implementation
process. At the end of the chapter, I discuss the need for a process to address discordance,
offering a way for Regional Health Authority decision-makers to support CPG
implementation to be more successful.
Discordance in CPG Implementation
The Sepsis Guideline Set implementation process unfolded as a complex flow of
activity involving academics, regional managers and support staff, and clinicians, incited and
informed intermittently by the activities of a provincial quality network. Interested Clinical
Nurse Educators (CNEs) guided early originating activity toward uptake of the CPG, that
was taken up more formally by regional managers and support staff for activation,
prioritization, and planning and support development.

170
At times, alignment existed between the CPG implementation actions of individuals
from each of the three groups: academics, regional managers and support staff, and
clinicians. In this study, alignment is reflected by convergence in how various study
participants described the implementation process. Participants from each of the groups, for
instance, described the individuals and actions involved in the CPG rollout (in-service and
tool deployment) consistently.
Overall, however, I characterize the implementation process by its discordance, the
misalignment or lack of harmony of perspective and action among individuals involved in the
process. Most evident was a discordance amongst the three groups, in their perspectives
about CPG implementation and the actions they took. Most participants described the
implementation process in positive terms but there was a difference between how participants
from each of the three groups described success. Academics spoke positively of the growing
interest and activity they were able to generate among provincial Regional Health Authorities
in sepsis management and the Sepsis Guideline Set specifically. Academics and regional
managers and support staff spoke favourably about the measures they had created to monitor
clinical practice adherence and outcome and the scorecards they designed to convey them.
Regional managers and support staff highlighted, as a success milestone, that clinical
Decision Support Tools such as pre-printed orders and nurse-initiated orders were developed
and approved by the organization’s decision-making bodies including the program leadership
and the Medical Advisory Committee. Regional managers and support staff believed that
organization structure and the Decision Support Tools that had been developed positioned
Select Health for success in implementing the Sepsis Guideline Set.
Clinicians indicated that education and clinical support/mentoring promoted
widespread understanding of the guidelines, which they felt aligned with their daily clinical

171
experience to enhance clinical competence. Clinicians believed that they provided good
sepsis care because, as competent practitioners, they did the right things at the right times,
though their decisions and actions were not always fully adherent to the guidelines. They
noted that this tacit competence was reinforced on a day-to-day basis through strong
teamwork and demonstrated in their perceived success in catching and averting critical
outcomes for deteriorating sepsis patients. Clinicians rationalized that full adherence was
impractical within their day-to-day environment, and likely unnecessary.
Academics, regional managers and support staff, and clinicians had established their
own interpretation of what a successful implementation would look like, and acted
accordingly. While clinicians had clearly acquired explicit knowledge of the guidelines (most
were able to recite the guidelines accurately), their actions were focused on something other
than meeting the CPG’s requirements with full adherence or fidelity. Assessment of the
clinical merits of the clinicians’ actions was beyond the scope of this study. Perhaps
clinicians had settled on the best implementation solution possible given the organization’s
realities and constraints. The essential point about discordance for this dissertation is that
individuals from other groups were clearly expending effort (e.g., developing and monitoring
the use of pre-printed orders, monitoring adherence data that required significant time and
resources) under a belief that full adherence was the objective.
Given the degree of discordance evident in the CPG implementation process, it is not
surprising that, at the end of the day, few of the specific requirements of the CPG – a
guideline to which all had ostensibly committed – were met.
The Consequences of Discordance in CPG Implementation
At Select Health, a discordant implementation process resulted in a technically
unsuccessful CPG implementation; the expectations of the CPG were not achieved.

172
Further, even though overall relationships were described by study participants as
positive, the discordance led to unresolved tensions among individuals within and across the
three groups. In some instances, frustration accompanied assumptions or rationalizations.
Some regional managers and support staff, for instance, described non-adherence to the
guidelines by clinicians as resistance to change or as clinicians acting in their own self
interest. Some City Hospital clinicians assumed that senior leaders pursued guideline
adherence only to manage risk to the organization. Other clinicians described the activities of
managers and support staff with disinterest – viewing them as irrelevant to their day-to-day
lives. As a highly collaborative endeavour, CPG implementation success can be increasingly
challenged if interpersonal tensions and untested assumptions prevail as they influence
perspectives and the scope and nature of actions taken. Unresolved tensions and assumptions
appear likely to build, making subsequent CPG and other change implementations more
difficult.
Perspectives Underlying Discordance
Discordance appeared to stem from deeply rooted differences in the perspectives held
about CPG implementation between academics, managers and support staff, and clinicians,
and the actions that those perspectives promoted. The three perspectives regarding the Sepsis
Guideline Set implementation process had some similarities, and many differences along
several dimensions including:
• Why they implemented the CPG, the outcomes they anticipated,
• For whom they implemented the CPG, the patients/people they targeted,
• How they perceived and approached the CPG implementation:
o The way they talked about the Sepsis CPG in relation to other priorities

173
o The source of power motivating action and the process(es) through which that
power it was enacted
o The activities they undertook
o The objective of the activities they undertook, and
• How they evaluated their progress.
Table 8.1 presents a comparison of the perspectives based on how academics,
regional managers and support staff, and clinicians each predominantly described the
implementation along these dimensions.

174
Table 8.1
Dimensions of Different Perspectives Regarding CPG Implementation
Dimension

Academics:
Advancing CPG
Implementation

Regional Managers and
Clinicians:
Support Staff: Managing Becoming Competent in
CPG Implementation
Sepsis Care

Objective of
implementation

Improved safety and
better health outcomes
for patients
Emergency Department
patients (collective) –
provincial, national,
international

Improved safety and better
health outcomes for patients

Improved safety and better
health outcomes for patients

Emergency Department
patients (collective) –
regional and site

Patients in Emergency
Department (individual)

Relationship to
other priorities

Singular – Sepsis
Guideline Set
implementation

Singular – Sepsis Guideline
Set implementation

Power and
process

Expert Influence,
advocating and
networking
Synthesizing evidence

Authority, managing

Holistic and contextual –
provide good sepsis care
within the context of the busy
Emergency Department
Professionalism, competent
practice and learning

For whom?

Implementation
strategies

Communicating
Developing guidelines
Developing and
monitoring performance
scorecards
Facilitating professional
dialogue
Collaborating - sharing
of knowledge and
supports
Advocating; exerting
social pressure

Creating standard
organization structures and
processes
Coordinating
Prioritizing and allocating
resources – financial and
other supports
Identifying and monitoring
accountabilities
Communicating
Developing clinical decision
tools; aligning supports
Educating

Deteriorating patients in
Emergency Department
(individual)

Communicating
Developing clinical decision
support tools
Automation (testing)
Staff recruiting & prescreening
Preceptorship
Orientating & mentoring
Educating/professional
development
Discussing cases/incidents
Teamwork

Developing and monitoring
performance scorecards
Objective of
activities

Spread – sharing and
growing interest and
understanding

Adherence to regional
standards

Competence – ingrained
practice in response to patient
needs

Statistical analysis – sepsis
rates/outcomes

Case review; story telling

Adherence to provincial
standards
How progress
is evaluated

Statistical analysis
Milestones – growth in
collaborative
participation, guideline
and data methodology
and tools

Milestones - formal
prioritization and approval of
support tools

Milestones – Delivery of inservice, demonstrable
knowledge of standards

175
The perspectives described in Table 8.1 are not meant to imply that all academics,
regional managers and support staff, or clinicians spoke of CPG implementation uniformly.
Physicians, for instance, described the implementation in some ways that were different from
nurses, though they are both captured in this discussion as clinicians. Together as clinicians,
however, nurses and physicians presented a perspective that offered some common
dimensions that could be contrasted with those of academics or regional managers and
support staff.
The three perspectives built upon similar stated objectives: ensuring safety and
improved patient care. Differences appeared, however, when considering the target
population for whom those describing each perspective directed their focus. Regional
managers and support staff, and academics considered large patient populations – many
patients, multiple sites, with a singular focus on improving sepsis care. This perspective and
its focus on a large population of patients, was conducive to using statistical methods of
analysis to evaluate progress. Regional managers and support staff described implementation
activities that tended toward authority-based direction, management, standardization and
performance monitoring/evaluation activities. Academics described implementation activities
that tended toward influence-based advocacy and networking.
The clinicians’ perspective focused on a smaller set of, or individual, patients.
Clinicians considered case review to be more meaningful than statistical analysis to assess
Sepsis Guideline Set adherence and outcomes as learning from the case review can be
incorporated into the clinician’s competent practice. From the perspective of clinicians,
sepsis care was certainly an important focus, but they tended to view it more holistically –
always within the context of the complex realities of the patient, all patients, and the

176
department itself. Clinicians also spoke more specifically of deteriorating sepsis patients as a
subgroup towards which they focused much of their implementation activity.
The three groups, however, differed regarding the source of power motivating action
and the process(es) through which that power was enacted. In advancing implementation,
academics sought to influence health service providers and decision-makers with expert
knowledge - through knowledge synthesis and sharing, as well as through networking
activities (e.g., the BCPSQC Sepsis Network sought to influence health providers in this
manner). Within Select Health, in managing implementation, regional managers and support
staff sought to organize and embed required activities in organization structure and formal
implementation process, established by the Policy Office, and reinforced by authority and
reporting relationships. Clinicians appeared to have been driven by professionalism, a pursuit
of competence through more practical, contextualized learning and professional development
activities (Nurse Clinicians, for instance, sought to reinforce good sepsis care through
mentoring activities on a day-to-day basis). Differences in power and power imbalances in
social situations have been described in other research focusing on inter-group dynamics
(Currie et al., 2013; Fitzgerald & Harvey, 2015; Racko, 2018). While no studies appear to
describe power dynamics of all three groups considered in this study, Currie et al. (2014)
describe power dynamics between academics and clinicians, including tensions between
expertise and practicality, similar to those seen here.
While participants seldom referred specifically to strategies, Select Health Sepsis
Guideline Set implementation activities were consistent with some of the implementation
strategies outlined in the Expert Recommendations for Implementing Change (ERIC)
compilation of discrete implementation strategies (Powell et al., 2015), the Cochrane
Effective Practice and Organization of Care (EPOC) framework (Cochrane Effective Practice

177
and Organization of Care, 2015), and a variety of research syntheses including Spoon et al.
(2020), Ebben et al. (2018), Sarkies et al. (2017), and Sungkar et al. (2018). Strategies
reflected by Select Health activity included: communication and education, audit and
feedback, including evaluation through measurement and scorecards, structure/management
accountability, networks and collaboration, case review, professional dialogue, and
automation and support tool strategies.
Many known strategies were reflected in some way during the CPG implementation
but few appeared to have been purposefully selected or agreed upon by academics, regional
managers and support staff, and clinicians. Implementation scientists promote a more
methodical and purposeful identification of barriers and tailoring of strategies to barriers than
was evident at Select Health (Powell et al., 2017). Communicating and educating were two
strategies that were consistently described by most study participants. Unfortunately, these
strategies alone were not sufficient to ensure alignment of action among academics, regional
managers and support staff, and clinicians, or to ensure successful implementation of the
CPG.
Participants from each of the three groups demonstrated significant differences in
perspective regarding the strategies that they deemed important to the CPG implementation
process, as is evident in Table 8.1. Academics and regional managers and support staff
described strategies and actions that were aimed at supporting and monitoring adherence to
the CPG’s expectations by clinicians. Regional managers and support staff worked to support
the development of Decision Support Tools, including pre-printed orders, to support
adherence by clinicians. Pharmacy support staff worked to inform the tools. Some support
staff, including the laboratory, changed their own processes to ensure that that expectations
of the CPG could be met. Academics, the BCPSQC Quality Leads, designed initiatives to

178
draw attention to the pre-printed order and to promote its use. These efforts to support
adherence, however, were not aligned with clinicians’ apparent intentions or capabilities.
Strategies described by clinicians were not oriented toward adherence, but toward knowledge
acquisition, teamwork, tacit action, and adaptation within the local context, with a focus of
ensuring that the worst patient outcomes were avoided (nurses, for instance, spoke of the
importance of teamwork to ensure that indicators of sepsis patient decline are not missed).
Academics, regional managers and support staff, and clinicians made insufficient effort to
align these approaches, and a discordant, ultimately unsuccessful, implementation resulted.
There was a compelling connection between the perspectives of academics, regional
managers and support staff, and clinicians, and the strategies they chose – evident in the
degree to which each described different strategies listed in Table 8.1. The principle that
groups of people can hold differing perspectives, and that those perspectives can affect how
they seek to enact change, has been established within the literature. Argyris and Schön
(1974), for instance, described “theories of action” to explicate differences between the views
and actions of academics and practitioners. Senge (1990) described “mental models” that all
individuals hold based on their experiences, which drive action and lead to assumptions
about the actions of others. Cammer et al. (2014) discuss the multiple underlying
philosophies that can exist within an organization. The CPG implementation literature does
not, however, discuss differences in the motivations, strategies, or actions toward CPG
implementation of academics, managers and support staff, and clinicians specifically. The
CLAHRC research speaks to the relational challenges involved in collaboration between
academics and health service providers (Soper et al., 2015), but does not systematically
consider their differences in perspective. The CLAHRC research does not address the
differences that may exist between groups within the broader health organization or Regional

179
Health Authority, such as those between managers and support staff and clinicians. Proctor et
al. (2013) provide recommendations for specifying and reporting implementation strategies.
The domains identified by Proctor et al. (2013) – actor, action, target of the action,
temporality, dose, implementation outcomes affected, and justification – offer some similar
concepts as dimensions described in Table 8.1 (e.g., why implement? What outcomes are
anticipated?), but the authors’ purpose is very targeted to specifying implementation
strategies as opposed to considering how perspectives might differ regarding CPG
implementation overall.
The link between differences in academic, regional manager and support staff, and
clinician perspectives as a mechanism promoting discordance in CPG implementation has not
been discussed robustly in the CPG implementation literature. Kouzes and Mico (1979)
theorized three very similar domains – Policy, Management, and Service – relevant to public
service organizations. They further described discordance (interpersonal) as a potential result
of differences among the domains in principles, success measures, structures, and work
modes (Kouzes & Mico, 1979). Domain Theory, however, gained limited attention from
researchers and does not appear to have been incorporated into the CPG implementation
literature. These differences in perspective about CPG implementation, proved very
important for Select Health’s CPG implementation, and may be so for other organizations –
particularly larger regionalized organizations where distance, history and multiple sites for
care provision can promote divergence among the perspectives of academics, regional
managers and support staff, and clinicians.
Perspectives and Practice Theory
Practice theory offers a theoretical foundation for understanding the discordance
observed in the Select Health CPG implementation process, and its correspondence to the

180
different perspectives of academics, regional managers and support staff, and clinicians. To
this point in the dissertation, I have described academics, regional managers and support
staff, and clinicians as three “groups,” established for the research based on organizational
function. The perspectives, however, did not align solely to function, or any other single
descriptor such as profession or location. There was little functional commonality between
regional managers and support staff, yet their perspectives on CPG implementation were
quite consistent. Many of the regional managers participating in the study were clinical
professionals, yet their perspectives seemed different than those of the local Emergency
Department clinicians. Few of the participants were located close to each other for any
substantial amount of time. Instead of being driven by any single factor such as function,
participants from each group appeared to have drawn upon a variety of influences (e.g., their
values and experiences, training, professional affiliations, and organizational functions and
roles) to negotiate ways of seeing and enacting CPG implementation.
The perspectives and actions of academics, regional managers and support staff, and
clinicians, described and discussed in this study, were consistent with, and might be usefully
understood, as reflecting three communities of practice as described by Wenger (1998). Each
community of practice, facing different day-to-day realities, had come to see sepsis
management and CPG implementation differently and acted accordingly. Communities of
practice - loosely defined networks of people participating together in practice - continuously
learn and negotiate meaning through degrees of mutual engagement, joint enterprise, and
shared repertoire (Wenger, 1998, pp. 72-85). Different communities of practice can hold
different perspectives, and these perspectives underlie the actions each might take (Wenger,
1998, pp. 103-121).

181
Similarly, Wenger notes that communities of practice can organize, in some way, into
a broader aggregate he calls a constellation of practices. A constellation of practices shares a
degree of continuity amongst its constituent practices, though they are “too far removed from
the scope of engagement of participants, too broad, too diverse, and too diffuse to be usefully
treated as single communities of practice” (Wenger, 1998, p. 126). Like communities of
practice, the concept of a constellation of practices is helpful to understanding CPG
implementation as it draws attention to the breadth and fluidity of social activity involved,
whether the activity conforms rigidly to organizational boundaries or not. Certainly, together,
regional managers and support staff, and clinicians, might be usefully considered as a
constellation of practices, understood and sustained as an organization named Select Health,
and comprising the inner setting of the Consolidated Framework for Implementation
Research (Damschroder et al., 2009). But by “zooming out” (Nicolini, 2012), a broader
constellation can be considered; a constellation which includes academic participants who
were “outer” to Select Health, but who shared, at a particular place and time, a common
interest in Sepsis Guideline Set implementation.
Wenger notes that continuities and differences across a constellation of practices are
best understood by relationships amongst its constituent practices: how they interact at their
boundaries (Wenger, 1998, pp. 128-129). People, structures, and processes can work across
the (soft) boundaries of communities of practice, spanning boundaries, sometimes helping to
align perspectives and activity (Wenger, 1998, pp. 103-121). Other practice theorists note,
similarly, the critical importance of connections, or associations, among people in practice
toward the integrity or change of any social construct including organizations (Latour, 2005;
Nicolini, 2012). Wenger draws attention to the importance of engagement, imagination, and
alignment of participants and their actions, in any efforts to promote successful learning and

182
change across a constellation of practices (Wenger, 1998, pp. 225-229). Study findings are
consistent with Wenger’s observation: limitations in engagement – especially of a wider
range of clinicians - limited their ability to contribute (their ability to imagine solutions with
other groups), and align with participants from the other groups, leading to discordance.
Interpreted as a constellation of practices, a focus on the connections (and
disconnections) amongst individuals from the constituent communities of practice is
instructive. The findings presented in chapters 5-7 demonstrate that the degree of
collaborative activity of individuals from each of the communities of practice was, at most
times, very limited. The most collaboration (as reflected by consistency in study participant
accounts) was apparent during the implementation 2-3 week “go-live” period. While several
individuals in key roles (BCPSQC Leads, Service Program/Service Network Leads, CNEs,
Chiefs of Staff, ED Department Managers) worked across the boundaries of the academic,
regional management and support, and clinical communities of practice, this activity proved
insufficient to ensure the degree of alignment of people and action required to enable
adherence. In the case of Select Health, the organization’s leaders, ultimately the Executive
Team, had either not established, or marshalled effectively, the system of people, structures,
and processes to ensure the changes required for adherence; what Wenger calls affordances
(Wenger, 1998, pp. 225-240). The result of insufficient engagement across communities of
practice was a discordant and ultimately unsuccessful implementation process.
The next sections examine the Select Health CPG implementation process to
understand the relational connections that were and were not successfully made, to support a
better understanding of how discordance might have been avoided. This examination begins
by summarizing some aspects of the implementation that participants noted to have been

183
weak or limited. These limitations may prove instructive in identifying opportunities for
better connectivity among academics, regional managers and support staff, and clinicians.
Limitations of CPG Implementation Process
Participants identified several activities, detailed in Appendix F, as missing or only
partially realized in the Select Health Sepsis Guideline Set implementation – limiting the
implementation process and encumbering its success. These activities include:
•

Review of research evidence and regional and local implications,

•

Interprofessional forum to enable clinical participants to engage with the evidence
and implementation process,

•

Analysis and practical resolution of workflow issues related to Sepsis Guideline Set
implementation,

•

Automation of diagnostic or care tools, and

•

Staffing adjustments to reflect changes in workload indicated by the guidelines.
Regional managers and support staff, and clinicians described missing or partially

accomplished activities as barriers to CPG implementation success. Clinicians noted that they
had little control or capacity to enact these activities; they required resources only available
from regional managers and support staff including: financial resources to support clinicians
to be paid for involvement, and non-financial supports including changes to their information
systems. Nadalin Penno, et al. (2019) identify human resource and financial/non-financial
resource limitations as common barriers to implementation sustainability.
Several of the activities (detailed further in Appendix E) are consistent with important
implementation strategies identified in literature syntheses of strategies, including:
interprofessional education/development (Spoon et al., 2020), automation (Armson et al.,

184
2018), culture change, and research evidence and assessment (Fischler et al., 2016; Jeffs et
al., 2013). However, workload and workflow assessment are missing activities that are not
well addressed in the ERIC compilation (Powell et al., 2015) or in research syntheses
regarding CPG implementation strategies including Spoon et al. (2020), Ebben et al. (2018),
Sarkies et al. (2017), or Sungkar et al. (2018). Based on the findings of this study, this
appears to be an important omission given that workflow might be seen as the most direct
way for RHA decision-makers to alter the resources and rules that affect practice (Wenger,
1998).
In addition to the five missing or partially accomplished activities (review of research
evidence, interprofessional forum, workflow resolution, automation, and workload
adjustments), the clinical managers had limited involvement in Guideline Set
implementation. Clinical manager involvement was curtailed both by explicit delegation of
leadership of the implementation to CNEs, and by the lack of time managers had available.
Clinical managers proved necessary both locally within the clinical community of practice,
and as conduits to/from regional management and support, and academic communities of
practice for support in implementing the CPG. Regional managers and support staff
consistently described the Program/Service Network structure as involving a flow of
information, activity, and accountability by connecting, and integrating, regional managers
and support staff and clinical managers, educators, and physician leaders. Yet, in practice,
they did not discuss clinical managers substantially in their accounts of how the Sepsis
Guideline Set implementation actually unfolded. Clinicians seldom referenced the clinical
manager in their account of the implementation.

185
Connections and Disconnections Between and Within Communities of Practice
A discordant implementation process resulted at Select Health as engagement across
the constellation of three communities of practice was insufficient to ensure alignment of
action. To better understand how discordance might be avoided, this section examines areas
of activity that were notably discussed by study participants; considering the degree to which
they did, or did not, facilitate engagement among academics, regional managers and support
staff, and clinicians.
Given the importance of interpersonal connections and relationships, it is not
surprising that the areas of activity influencing engagement were not necessarily unique to
the Sepsis Guideline Set implementation. Certainly, some improvement could have been
made through better implementation process (e.g., a more robust Shared Work Team might
have helped to engage more individuals across communities of practice). However, the areas
of activity that proved more important appeared to have been contextual, day-to-day aspects
of organizational activity, not specific to the Sepsis Guideline Set implementation, that did,
or did not, promote sufficient engagement and alignment.
Following are six areas of activity that appeared to be important to the CPG
implementation at Select Health. While each of the six made some positive contribution to
engagement of participants across and within the three communities of practice, they each
had deficiencies – disconnections – that were noted by study participants as limitations.
Consideration of the strengths and weaknesses of each of these areas of activity is helpful to
understanding how RHA decision-makers might seek to establish structures, processes, and
people/roles – the affordances - to better support and enable CPG implementation in future.

186
1. Service-Oriented Improvement Structures, Processes, and People
Organization-wide service improvement conversations were important for facilitating
connections within and among communities of practice at Select Health, though key
opportunities for improvement were apparent. At Select Health such conversations were
facilitated through the organization’s service-oriented Emergency Medicine
Program/Network structures, processes, and people. The service-oriented structure was
organized to ensure engagement of decision-makers from across sites, roles, professions, and
functions toward ongoing service quality improvement. The service-oriented structure helped
to support communication and connections across the organization’s regional management
and support, and clinical communities of practice. Connections were facilitated by
articulating committees (committees with overlapping membership) and meetings, and
supporting processes, which brought together some individuals holding key positions from
the two inner setting communities of practice: regional managers and support staff, and
clinicians. Specifically, managers, physician leaders, educators, and some clinicians from
across the organization were included in the committee activity, to an extent making the
management and support, and clinical communities of practice less insular.
The strength of the service-oriented structure was not its top-down hierarchical
nature, but its non-hierarchical horizontal, facilitative capacity. Greenhalgh (2004) identifies
horizontal, engaging organization structure as important to effective spread of innovation.
The Select Health Programs/Networks were established as a formal, service-oriented part of
Select Health’s organization structure. Specifically, managers, physician leaders, and
educators had the ability to come together through the Program/Network to share information
and to identify and pursue opportunities to improve. The service Program/Network alignment
of regional managers and support staff and clinical stakeholders, particularly educators,

187
physician leaders, and to a lesser extent, clinical managers, contributed to the Sepsis
Guideline Set implementation. These three roles appear to have been important as they
facilitated boundary spanning (Wenger, 1998) connection and interaction among specific
regional managers and support staff, and clinical leaders.
There were apparent shortcomings in the service improvement activities’
effectiveness at facilitating connections given the limited degree to which clinical managers
engaged in Sepsis Guideline Set implementation. Further, during the timeframe of the Sepsis
Guideline Set implementation, the Executive Team had not designed supports to enable very
rich engagement, through the Program/Service Networks, with academics or clinicians. Study
participants reported only very sporadic interaction with BCPSQC leads and virtually no
interaction with post-secondary educators. Similarly, the Select Health Executive Team
might have done more to reinforce the collaborative, iterative local-regional nature of the
Program/Network by supporting further involvement amongst clinicians. A clear connection
between the service-oriented structures and processes, and the local clinical teams’ efforts
toward professional development could have enhanced engagement of clinicians, reducing
the insular nature of each community of practice.
While structure is reflected in CFIR as a construct affecting CPG implementation, the
framework construct offers little clarity regarding optimal organization structure beyond
favouring smaller unit sizes and flat rather vertical hierarchies (Damschroder et al., 2009). In
fact, the CFIR research team identify that “little is known about the interplay between formal
structure, informal networks, and effective communication” (Consolidated Framework for
Implementation Research, 2020). Further, literature is sparse regarding regional health
organization service-oriented structure (e.g., Programs/Networks) and its relationship to CPG
implementation (Humphries et al., 2014). This study suggests that a benefit of a horizontal,

188
service-oriented structure is its ability to draw together and engage a variety of participants
from across the three important groups – offering the opportunity to align their perspectives
and avoid insularity among communities of practice, and the resulting discordant action. To
optimize this impact, it might have been helpful for Select Health decision-makers to have
ensured a formal connection between the service-oriented structure and a formal, rigorous
approach to professional and interprofessional development.
2. Professional Learning and Development
The Emergency Medicine Program/Network structure and processes provided a clear
connection and schedule of meetings among some regional managers and support staff,
clinical managers, nurse educators, and physician leads involved in the provision and
improvement of Emergency Medicine services at Select Health. But beyond these few rolebased relationships, connections between regional managers and support staff and clinicians
were uneven and limited by profession. For nurses, a coherent connection between regional
managers and support staff, and clinicians (nurses) was apparent for learning and
professional development activities. The Sepsis Guideline Set was incorporated by regional
managers and support staff, and nurses into recruitment, training, orientation, and ongoing
professional development materials and activities. These materials and activities helped to
orient nurses to the guidelines, and to reinforce skills important to identifying and meeting
the needs of deteriorating septic patients. This activity is consistent with Fixsen et al. (2005),
who highlight the importance of staff selection, training, coaching to successful
implementation. Regional managers and support staff and Clinical Nurse Educators worked
well together to align ongoing professional development across the Emergency Medicine
Program/Network by establishing, and promoting use of, the education checklist to guide
learning. Further, during day shifts, the Department benefitted from the development and

189
practice support activities of the Nurse Clinician. The Nurse Clinician worked with the CNEs
over time to reinforce CPG knowledge, including that of the Sepsis Guideline Set, in the
minds of nurses on the floor.
While professional development activities for nurses enhanced engagement and
alignment for that profession, gaps existed for physicians. Efforts were made by the
Department Chief to ensure that City Hospital Emergency Department physicians were
oriented to the Department’s CPGs, but physicians lacked the in-practice support available to
the Department’s nurses through the Clinical Nurse Educator and the Nurse Clinician.
Physicians expressed that they felt engaged in, and supported by, the Department’s team
ethic, yet some conceded that few opportunities existed to benefit from professional
development activities at Select Health.
Further, several physicians and nurses reflected that the team did not engage in many
development activities together, interprofessionally. In a systematic review of CPG
implementation strategies, Spoon et al. (2020) notes the importance of interprofessional
education activities to implementation success. Interprofessional education/development
activities might have helped further promote engagement and collaborative learning within
and beyond the local clinical team, creating a context that was more conducive to successful
CPG implementation. It might have been beneficial for Select Health decision-makers to
have facilitated closer connections between clinical and regional managers as important
participants in interprofessional development activities. As there were no such activities at
Select Health, there was limited opportunity for alignment of perspectives among managers
and clinicians, which, ultimately, led to weaknesses in the Sepsis Guideline Set
implementation process and limited success. Robust, engaging interprofessional learning and
development structures and processes might have provided a sensible space and way for

190
RHA participants to engage with academics – both researchers and educators – reducing the
insularity of communities of practice, enabling cross-fertilization across the constellation of
practices, and enhancing the “research culture” that some study participants believed to be
missing at Select Health.
3. Quality Improvement Collaboratives and Networks
The Select Health Sepsis Guideline Set implementation case study findings offer an
opportunity to examine the potential positive impact, within a RHA, of participating in
networks and quality improvement collaboratives with other health organizations and with
academic partners. The influence, within Select Health, of the E2E and BCPSQC network
and quality improvement collaboratives was significant. The Evidence to Excellence and,
subsequently, the BCPSQC Sepsis Network Leads established and promoted a compelling
case for implementation of the CPG. The quality improvement collaboratives they organized
were remarkably effective at building interest among participants in sepsis management, and
in implementation of the Sepsis Guideline Set. Academics and participants from several
RHAs shared information, strategies, and tools. The two Select Health CNEs involved with
the collaboratives drew upon materials and activities provided during the collaboratives to
help influence and support early CPG implementation activity at two Select Health sites. The
activity even caught the attention of the Ministry of Health as they looked to mandate
provincial health quality improvement activities through the Clinical Care Management
initiative.
A variety of research studies, including systematic reviews, corroborate the
importance of networks and quality collaboratives in CPG implementation, recognizing their
capacity for bringing researchers and knowledge users together (Fitzgerald & Harvey, 2015;

191
Rycroft-Malone et al., 2016; Schouten et al., 2008). Yet, there is a limited understanding how
they work to improve the success of CPG implementation (Consolidated Framework for
Implementation Research, 2020). For the Select Health Sepsis Guideline Set implementation,
inter-organizational collaboration and engagement with academics through ongoing
relationship-building and through focused, credible quality collaboratives, worked to promote
the spread of interest and understanding of the improvement opportunity across the
organization. The collaboratives and networks proved engaging for regional managers and
support staff, and clinicians. Collaboratives and networks enabled academics, regional
managers and support staff, and clinicians to work together to merge credible evidence and
analysis with practical knowledge from knowledge users.
While compelling and helpful for those who participated from Select Health, the E2E
and BCPSQC networks and collaboratives were not effective in establishing sustained
engagement among clinicians in CPG implementation activities. For the most part,
involvement in the collaboratives, and direct interaction with BCPSQC Leads, was limited to
the CNEs and Select Health Program/Network Leads. Given the limited capacity of the two
BCPSQC Leads, engagement with the Select Health clinicians, or regional managers and
support staff beyond the Program/Network leadership, was rare. Ongoing involvement of a
broader range of clinicians and regional managers and support staff with BCPSQC and other
academics might have helped establish greater engagement and alignment of perspectives
across communities of practice comprising the RHA.
The Select Health Sepsis Guideline Set implementation experience highlights the risk
of formalizing mandates for quality improvement activities, including engagement with
quality improvement collaboratives, without aligning resources for implementation. The
formal directive appears to have changed the nature of collaborative activities – moving the

192
focus from engaged clinical discourse, information sharing, and voluntary action, to include
more structured activities related to provincial adherence measurement and performance
reporting. The directives appear to have obliged the RHA decision-makers to take unilateral
action without robust engagement of clinicians, assessment of implications, and/or resources
with which regional managers and support staff might provide support.
4. Evidence Review and Impact Assessment
Organizational structures, processes, and people that are supportive of collaboration
among academics, regional managers and support staff, and clinicians in reviewing CPG
evidence and in assessing the CPG’s potential impact appear to be critical for successful CPG
implementation. When considering the discordant Sepsis Guideline Set implementation at
Select Health, it appears that many of the challenges experienced, including the apparent
tensions between regional managers and support staff, and clinicians, stemmed from the
limited degree to which relevant CPG evidence was critically reviewed, and its implications
assessed, both regionally and locally. Without a tangible opportunity to improve outcomes,
clinicians saw the guidelines as an administrative, rather than clinical, imperative. Several
researchers point to the importance of evidence assessment (Fischler et al., 2016; Jeffs et al.,
2013), and of prioritizing by determining the relative advantage of implementing one CPG
over another (Greenhalgh et al., 2004).
Drawing from the study findings, I offer three details about evidence and impact
assessment that are often missed in the literature. First, evidence review and impact
assessment is an ongoing, contextual process as much as it is specific to any particular CPG
implementation process. Prioritization implies that the organization is continually assessing
CPGs using some common set of criteria to inform leaders’ prioritization and resource
allocation decisions. Second, given the nature of the RHA as a single organization with

193
multiple sites, the study findings reflect that there are multiple points upon which decisions
about priority might be made. Findings highlight the importance, particularly for clinicians,
to see the connection between CPG adherence and the potential to improve clinical outcomes
practically, at their own sites. Further, since the clinicians’ perspective favours case review,
the study findings indicate that motivation will be highest when statistical evidence
corresponds to the clinicians’ own experiences. Third, findings highlight the potential
strength of the service network (e.g., Emergency Medicine Program/Service) structure as a
medium for communicating about the evidence and its potential impact, and in bringing
related case experiences to bear, toward alignment between regional managers and support
staff, and clinicians. These three points, taken together, suggest that evidence review and
impact assessment might best be an ongoing and collaborative process across the
constellation of practices, and involving wide engagement from all three communities of
practice.
5. Prioritization and Resourcing CPG Implementation
This study highlights two simple but important findings with respect to CPG
implementation at Select Health:
•

That interest in CPG implementation at Select Health originated from early
engagement of clinicians acting to improve care within their own contexts. These
clinicians undertook much work and testing, and they naturally sought to engage
regional support through the Emergency Medicine Program/Network leadership and
the organization’s Policy Office.

•

That clinicians appeared to hold a critical assumption that formal, regional
prioritization of the CPG for implementation meant that they would have been

194
engaged to determine what resources were necessary, and that appropriate resources
and supports would follow. Clinicians expected that prioritization - by the Executive
Team - of Sepsis Guideline Set implementation would trigger investment and
allocation of financial and non-financial resources to support changes that were
outside of clinician control including management of workload, workflow, and
further automation.
At Select Health the move from early interest and experimentation and investment
and support following regional prioritization did not proceed as anticipated by clinicians. The
Select Health Executive Team could have supported CPG implementation more robustly by
establishing aspects of the organization’s financial and other support planning and
deployment cycles (human resources, information technology, change, analytics, business
process analysis) to better align how the implementation evolved. First, resources and
supports might have been made available to enable local engagement and experimentation
with potential improvements. Such activity could have been designed to promote broader
clinician engagement and could have provided critical information about the supports needed
to implement the CPG and to inform future regional prioritization and resourcing decisions.
Second, planning and resourcing processes could have been further organized to enable full
support of changes required to implement the CPG once it was prioritized for wide-scale
implementation in Select Health. Many researchers note the importance of prioritization, and
leaders’ decision-making with respect to the organization’s resources, to the successful
implementation of EBPs, including CPGs (Ellen et al., 2014; Fischer et al., 2016; Gifford et
al., 2006; Moore et al., 2016; Nadalin Penno et al., 2019; Raveis et al., 2014). The lack of
such resources has been seen as a common impediment to success (Cammer et al., 2014).
This study suggests that resource investment might need to be organized in a way that is

195
transparent, reliable, supportive, and focused on early clinician participant learning and
experimentation, and on supporting broader implementation activities if, and when, the
implementation of the CPG becomes a regional priority. Like evidence review and impact
assessment, prioritization and resourcing CPG implementation might benefit from ongoing,
widespread engagement and participation of individuals from all three communities of
practice. Such involvement could work to reduce insularity within communities of practice,
and establish greater alignment across the constellation of practices.
6. Clinical Management
This study highlights the importance of the clinical manager in both leading aspects of
CPG implementation process, and in establishing a clinical context that is conducive to CPG
implementation success. At Select Health, a variety of challenges arose during the Sepsis
Guideline Set implementation as a result of an organizational delegation of leadership of the
implementation to the Clinical Nurse Educators. While the clinical managers were involved
in the Service Program/Network structure and processes, the delegation appears to have
limited the role clinical managers played within the clinical community of practice as the
link, or mediator, between the clinicians and the region’s decision-makers.
Middle managers and supervisors can facilitate or impede effective CPG
implementation (Birken et al., 2018; Boutcher et al., 2022; Bunger et al., 2019; Votova et al.,
2019). Boutcher et al. (2022) highlight the importance of the middle manager in convincing
others of the benefits of CPG implementation and as strategic influencers. Birken et al,
(2018), describe the importance of diffusing information, selling implementation, and
synthesizing information, while noting that much remains to be understood about the role
played by middle managers in CPG implementation. Had the organization’s leaders not
delegated CPG implementation leadership to CNEs, clinical managers (a particular type of

196
middle manager), could have better facilitated CPG implementation by undertaking essential
activities including those of resource management - informing regional managers and support
staff of implementation support needs; and drawing resources into the clinical department to
support implementation.
Given the variety of perspectives involved, this pivotal role appears to require a
relatively sophisticated approach to facilitating interpersonal relationships. Consistent with
practice theory, McGivern et al. (2016, p. 37) note that organizations that promote an “open”
stance - open to receiving and blending knowledge and perspectives from different
communities of practice (for instance, management and clinical) - were the most successful
in implementation efforts. CFIR describes a learning climate as one where leaders take this
type of stance (Consolidated Framework for Implementation Research, 2020). Nembhard and
Edmondson (2006) relate this approach to management as one that can lead to increased
psychological safety of staff and physicians, and Currie et al. (2007) describe such
positioning by managers as critical to address real or perceived power differentials within the
organization. The Select Health Executive Team might have recognized and further
supported clinical managers to foster interpersonal connections and collaboration amongst
communities of practice (academics, regional managers and support staff, and clinicians),
exercising, rather than delegating, this important aspect of their role.
Avoiding Discordance, the Need for a Process
The Sepsis Guideline Set implementation at Select Health suggests that, despite some
collaborative and connecting activity, the implementation’s success was challenged by an
unhelpful insularity or compartmentalization where: researchers researched, regional
managers and support staff made key decisions and managed, and clinicians learned and
adjusted based on their local, day-to-day context. The insularity resulted from differences in

197
the perspectives about CPG implementation within the constellation of practices critical to
implementation success. As predicted by practice theory (Wenger, 1998), without alignment
of the different community of practice perspectives, the CPG implementation process was
discordant and, ultimately, unsuccessful. Select Health might have benefitted from a process
designed explicitly to offset community of practice insularity and the discordance it creates.
Such a process would have supported the explicit recognition of differences in perspectives
among academics, regional managers and support staff, and clinicians, yielding purposeful
decisions and commitments about a particular undertaking such as a CPG implementation.
This is not to say that it is necessary for all participants to be involved at all times.
Academics, regional managers and support staff, and clinicians hold different roles and
accountabilities. However, discussion, decisions, and commitments for action could have
better aligned the perspectives and actions of the communities of practice, for each of the
dimensions of perspectives. Drawing from Table 8.1, dimensions of perspectives appear to
include:
1. The focus of, and rationale for implementation,
2. A vision of successful implementation,
3. The priority of a particular CPG implementation over potential uses of time and
resources,
4. The amount and mechanisms of motivating power (e.g., expert influence, authority,
and professionalism), and
5. The goals, strategies and actions required to implement the CPG successfully.
A process that enables discussion, decisions, and commitments for action across
communities of practice aligned on each of these dimensions would need to involve trustful
sharing and integration of perspectives about CPG implementation. Study findings presented

198
in Table 8.1 suggest that participants from all three communities of practice held a common
overarching interest in improving safety and better outcomes for patients. This common
interest could have been the foundation of a shared vision among the three communities of
practice. Researchers point to the importance of shared vision (Kislov et al., 2018) and a
strong patient focus (Nilsson et al., 2018). Given the limited degree to which most study
participants spoke of the views and needs of patients, Select Health might have achieved a
higher degree of alignment if they had spent more time focusing on this aspect of the CPG
implementation.
A shared vision based on a common interest – better patient care – might have helped
the three communities of practice to address and balance their respective power bases. Social
power is the potential for a person or group to exert influence, leading to a change in the
belief, attitude, or behaviour of someone who is the target of influence (Ravens, 1965). This
study describes three sources of power motivating action, and the processes through which
power was exerted by the different communities of practice toward CPG implementation:
• Academics influenced through expertise, mobilized through advocacy and
networking,
• Managers influenced through authority, mobilized through organizational position
and control of resources, and
• Clinicians influenced through professionalism, mobilized through learning and
competence, or competent practice.
Unfortunately, due to the degree of insularity of the three communities of practice,
their respective power bases were not aligned and struggles, expressed as conflict or
ambivalence among individuals from different communities of practice, resulted. In an EBP

199
implementation research study, Currie (2014) observed similar tensions. To avoid
discordance, a process is needed to support participants to explicitly recognize their different
power bases, and to engage through power-balanced structures and processes (Fitzgerald &
Harvey, 2015) toward to the productive, mutually beneficial, application of each.
To avoid discordance, it appears that the insularity of communities of practice needs
to be reduced. Individuals from all communities of practice must be willing to share and
resolve their differences in perspective. A systematic review conducted by Sarkies et al.
(2017) highlights the importance of trust and relationship for CPG implementation. This
research extends the concepts of trust and relationship by recognizing that trust and good
relationships stem from collective discourse and activity and, for CPG implementation, must
enable some specific decisions and commitments to be made. Avoiding discordance isn’t
simply about getting along, it enables participants to engage, imagine, and make aligned
commitments to act, and to coordinate their actions (Wenger, 1998).
A process designed to avoid discordance would incorporate, but extend well beyond,
the concept of coordination. Li et al. (2019) draw from systematic review findings to promote
coordination among stakeholders as a mechanism to “magnify the facilitators and overcome
the barriers.” Coordination is only likely to be successful, however, if all participants agree
on the actions to be coordinated, and the means of coordination. Agreement across
communities of practice, then, is a precursor to successful coordination.
Building from an assumption that, without some intervention, differences in
perspectives will prevail and discordance is the likely outcome of any modestly complex
CPG implementation, harmonization is proposed in the next chapter as a necessary process
underlying successful CPG implementation. Like its musical metaphor, harmonization
appears to be about sharing and understanding of perspectives across a constellation of

200
practices - within and across communities of practice - so that, together, they can determine
the best way to align their activities toward a shared goal. The six areas of activity
influencing the CPG implementation at Select Health discussed in this chapter will inform
the identification of key enablers – affordances (Wenger, 1998, p. 229) - for harmonization
within Regional Health Authorities.
Chapter Summary
While most study participants had some reason to describe the Select Health Sepsis
Guideline Set implementation as successful, the implementation process itself was
discordant. Academics, regional managers and support staff, and clinicians had different
perspectives about the implementation, and undertook actions that were not sufficiently
aligned to ultimately ensure adherence to the CPG. The differences in perspectives among
academics, regional managers and support staff, and clinicians were significant and appeared
to have been deeply rooted in the functions, experiences, and day-to-day realities of each of
these groups of participants. The discordance in the implementation appears to have been a
result of inadequate engagement among participants across a constellation of practices;
insufficient connections within and across communities of practice to support shared
understanding and alignment of action.
A relational process might have facilitated explicit recognition of differences in
perspectives across the constellation of practices most critical to CPG implementation
success. Greater and ongoing collaborative engagement of academics, regional managers and
support staff, and clinicians, is likely to have yielded more purposeful decisions and
commitments about the sepsis CPG implementation. Discussion, decisions, and commitments
for action among the three communities of practice could have better reflected alignment

201
across the five dimensions of perspectives: focus and rationale, vision, priority, power, and
goals, strategies and actions.
The next chapter presents a proposal for harmonization as a process of alignment of
perspectives within and among communities of practice, that can facilitate better CPG
implementation.

202
Chapter Nine: Conclusion and Implications
This concluding chapter proposes the concept of harmonization as a process that is
critical to successful CPG implementation in Regional Health Authorities. Harmonization is
a process that RHA decision-makers need to support explicitly, to address the discordant
actions that arise from differences in deeply rooted perspectives about CPG implementation
among three communities of practice: academics, regional managers and support staff, and
clinicians.
RHA decision-makers can enable harmonization by supporting the collaborative
planning and action, across the constellation of practices relevant to the CPG
implementation. Harmonization can be supported through ongoing collaborative activity,
facilitated by structures, processes, and people, that engage individuals from the three
communities of practice in meaningful discussion, decisions, and commitments for action.
While RHA decision-makers are best positioned to promote and enable harmonization
(Martin et al., 2013), academics, regional managers and support staff, and clinicians
(communities of practice) will need to make significant changes to avoid insularity that can
arise within their individual communities of practice and to engage fully in what must be an
ongoing, collaborative process.
Harmonization advances practice theory by strengthening its prospective focus;
helping decision-makers to use the theory to inform action. The study highlights that, while
communities of practice facilitate learning, identity, and normalize day-to-day practice, they
can also promote insularity, and differences in perspective that must be addressed if
collective action across a constellation of practices is to be successful. The study also offers
some implications for improving the Consolidated Framework for Implementation Research
while demonstrating the utility, for implementation researchers, of complementing CFIR

203
with the more processual, relational view of practice theory. The study’s findings offer
considerable potential for application and future research. Harmonization and its enablement
offers researchers and decision-makers a unique way to think of, approach, and improve CPG
implementation, with the potential for better implementation processes and corresponding
health outcomes.
Harmonization and Enabling, Harmonizing Activities
This research set out to understand how individuals and teams with various functions
and decision-making purviews come together to implement prioritized clinical guidelines in a
Regional Health Authority. The study findings bring a variety of insights in response to the
research question. The findings explicate the groups of individuals involved, and the
mechanisms through which they do, or do not, come together to bring about a successful
CPG implementation in a Regional Health Authority.
Three broad groups of individuals are highly relevant to CPG implementation:
academics, regional managers and support staff, and clinicians. These broad groups can only
be loosely defined as they are not comprised based on singular attributes. This study used
function as a starting point for establishing participant groupings. The initial functional
categories proved helpful but insufficient for explaining study findings. Instead, the groups
are better described as communities of practice: loose affiliations of participants in practice
who share sufficient mutual engagement, joint enterprise, and shared repertoire as to be
distinct from one-another (Wenger, 1998). For CPG implementation, this distinction
manifests as three very unique perspectives about the objectives of CPG implementation and
the things that are important to ensure successful implementation. The differences in
perspective among academics, regional managers and support staff, and clinicians are
significant and deeply rooted in the beliefs, functions, experiences, and day-to-day realities of

204
each of these groups of participants. Individuals within each group hold different
perspectives about CPG implementation along at least five dimensions: focus and rationale,
vision, priority, power, and goals, strategies and actions required. Without explicit action to
reconcile the perspectives within the constellation of practices essential to CPG
implementation, individuals from each group act based on their own interpretations and
definitions of success, and a discordant, and likely unsuccessful, CPG implementation
results.
This dissertation presents a proposal for harmonization as a process comprised of
many harmonizing activities that support engagement, relationship-building and explicit
reflection and reconciliation of key differences in perspective among three communities of
practice: academics, regional managers, and clinicians. Harmonization requires iterative
cycles of discussing, deciding, committing, and acting, with explicit focus on the dimensions
upon which perspectives can differ. Harmonization enables a higher degree of shared,
negotiated meaning – a characteristic of a community of practice – to a wide network, a
constellation of practices (Wenger, 1998). Harmonization is not about winning individuals
over to one of the perspectives. It is about working together in an ongoing and meaningful
way such that new norms, new practices, can be established across an important constellation
of practices. Harmonization is not just about “getting along.” Harmonization is targeted to
specific types of decisions and actions that support the adoption of evidence, such as a CPG,
into practice.
The Processes Underlying Harmonization
Harmonization is based on an assumption that the three communities of practice can
become insular and establish differences in perspectives that are sufficiently entrenched that,
without intentional intervention to better support engagement and alignment among the

205
communities of practice, discordance is likely in all but the simplest of implementations, and
the goals of the implementation are unlikely to be achieved. Discordance (noun) was seen
during the CPG implementation at Select Health. Harmony (noun) would have been the
result if perspectives and actions had been sufficiently aligned. Harmonization (noun) is
characterized as a process but is comprised of many, largely contextual (to a particular
implementation), activities that act, over time, to promote harmony through interpersonal and
inter-community-of-practice connection amongst academics, regional managers and support
staff, and clinicians. Activities that engage and align perspectives and actions of individuals
within and among communities of practice are harmonizing (verb).
Harmonization is underpinned by ongoing connection and interaction of many
individuals from all three communities of practice – academics, regional managers and
support staff, and clinicians. Discussing, deciding, committing, and acting appear to be
foundational to the iterative, interactive cycle of harmonization. The dimensions of
perspectives bring a focus for this cycle. Each dimension can be investigated using the
questions posed for each in Table 9.1. Further, each dimension relates to a set of processes3
that, when performed collaboratively, can facilitate harmonization across the constellation of
practices essential for success. Together academics, regional managers and support staff,
clinicians appear to need to work together, regularly, on the five sets of processes presented
in Table 9.1.

3

The term process set is used here to reflect the layered nature of process as described by Business Process
Management Jeston, J., & Nelis, J. (2014). Business process management: Practical guidelines to successful
implementations (3 ed.). Routledge. The process of harmonization is comprised of sets of processes or subprocesses reflected in subsequent process layer.

206
Table 9.1
Dimensions of Perspectives and Proposed Harmonizing Process Sets
Dimension of Perspectives

Processes/Process Sets Supporting Harmonization

Together, communities of practice (academics,
managers and support staff, and clinicians) need
to harmonize their perspectives about:

Together, communities of practice (academics, regional
managers and support staff, and clinicians) might learn
to:

1. Focus and Rationale: Why might the CPG be
implemented? How compelling are the
benefits based on assessment of the merits of
the evidence? What are the clear implications
for improved outcomes for specific local and
regional patient populations?

1. Review and assess evidence about improvement
interventions including CPGs, considering the
current performance and the potential for the
intervention to improve patient outcomes (or some
other explicit and shared objective) for the RHA
overall but also for specific sites.

2. Vision: How will successful implementation
be described and assessed? What are the
practical workflows, actions, and behaviours
required?

2. Envision and specify the operational requirements
prescribed by the evidence and agreed among
participants. Experiment with implementation to
learn and inform subsequent work, determining the
changes in process, structure, and people, including
workload and workflow, required to implement the
intervention.

3. Priority: What is the relationship of the
implementation to other priorities? Are there
potential synergies or conflicts with other
priorities? What is the relative advantage of
each?

3. Assess benefits and costs, prioritize, and
communicate priorities and rationale.

4. Power: What amount and mechanisms of
motivating power (e.g., expert influence,
authority, and professionalism) correspond to
the implementation strategies selected? How
will they be collectively managed to motivate
and ensure aligned accountability, while not
perpetuating differences?

4. Reflect explicitly on different perspectives including
their underlying forms and perceptions of power.
Negotiate approaches to mitigate negative impacts
and the enhance motivating aspects of power and
power differentials.

5. Goals, Strategies and Actions: What activities
are required of all participants to implement
the CPG successfully? Who must do what, by
when? What supporting implementation
strategies and resources are required to
promote and coordinate these activities?

5. Set goals, plan, resource, establish accountabilities,
coordinate, act, and evaluate.

Enabling Harmonization
Regional Health Authority decision-makers are responsible and accountable for
establishing the affordances that can enable harmonization over time. The six areas of
activity discussed in the previous chapter, with effort to address their potential for intra- and

207
inter-community of practice connections, incorporate structure, process, and roles to establish
an enabling context for harmonization within Regional Health Authorities. With the objective
of harmonization, RHA decision-makers need to facilitate co-development across the
communities of practice (with academics, regional managers and support staff, and
clinicians) of mechanisms for service improvement including consideration of CPGs:
1. Horizontal service-oriented improvement conversations and activities,
2. Interprofessional learning and development,
3. Quality improvement collaboratives and networks,
4. Evidence review and impact assessment,
5. Prioritization and resource decisions, and
6. Relationship management.
The six enablers of harmonization promote interdependent action toward
harmonization. Strong, widely engaging service-oriented improvement structures, processes,
and people, articulated with inclusive local interprofessional learning and development
activities for a strong, reliable foundation for harmonization. Integrated with this foundation,
robust engagement with academics and regional managers and support staff, and clinicians
from other health organizations through quality improvement collaboratives, has the potential
to stimulate interest and information sharing among all participants, potentially prompting
early CPG assessment and implementation activity amongst local clinical teams. Together
these structures, processes, and people can establish an enabling context within which a
broad range of participants across the three groups can be engage in reviewing evidence and
assessing impact, prioritizing and resourcing CPG implementation. RHA managers,
particularly clinical managers can support harmonization by encouraging open sharing of
perspectives and managing in a way that is responsive to the realistic ebbs and flows of a

208
dynamic, non-linear implementation process. Coordination and accountability management
can be enacted by management, but as a support to agreed activity rather than direction in
advance of necessary shared engagement, imagination, and alignment (Wenger, 1998, pp.
174-181).
Study Implications by Community of Practice
In this research, three communities of practice proved important to CPG
implementation: academics, regional managers and support staff, and clinicians. The next
sections present the implications of harmonization for individuals within each of the three
communities of practice.
Implications for Academics
By focusing on harmonization through increased and ongoing engagement with
regional managers and support staff, and clinicians, academics, including researchers and
educators, have an opportunity to support better patient outcomes while creating relationships
that can support: improved uptake of research, more practically relevant research questions
and research, and closer alignment of education and practice opportunities within the
Regional Health Authority. All of these benefits are consistent with a more practical, aligned
relationship between academia and industry that some researchers argue will be essential to
the survival of the academic institution in the future (Brown & Duguid, 2000, p. 222) and
others argue to be essential to improved research use by health providers (Bowen et al.,
2019).
Academic engagement with Regional Health Authorities to the degree required to
support harmonization will require academic policy and decision-makers to promote
significant change within the academic environment. Teaching, research, and administrative
schedules may need to be altered to ensure that academics have time available to engage in

209
collaborative activities. Incentives and advancement structures (e.g., promotion/tenure) must
be broadened to better recognize applied research, collaboration, and practical impact. With
these changes, academics will require more support to ensure clear, relevant communication
and, potentially, mediating roles that can strengthen connections across the boundaries
between academia and health management and clinical care (Kislov et al., 2018).
Academics will also need to learn to recognize, discuss, apply, and adapt the use of
their power of influence. This study demonstrates the discordance that can result when
academic, advocacy, and policy influence exerts such pressure on Regional Health Authority
decision-makers that normal learning, prioritizing, resourcing, and implementation activities
are usurped. Academics should consider quality improvement collaboratives as a sensible,
productive activity through which they could productively organize, focus and exert their
influence.
It is not clear from this study whether mandating CPG implementation by government
was an effective strategy. It appears reasonable to argue that if policy-makers wish to
mandate implementation of a CPG, they should be careful not to circumvent wide
engagement and rigorous organizational assessment and prioritization processes. Policymakers might also consider alignment of resources in support of identified improvement
priorities, to be allocated by regional managers and support staff in alignment with a
collaboratively designed CPG implementation process. As with regional managers and
support staff, policy-makers would need to consider and assess the evidence of potential
widespread improvement of outcomes prior to mandating implementation of a CPG.
Implications for Regional Managers and Support Staff
By focusing on harmonization through increased and ongoing engagement with
academics and clinicians, regional managers and support staff have an opportunity to support

210
better patient outcomes while realizing more successful CPG implementation, better culture
and relationships within the organization, and less wasted resources and effort.
Given the authority and accountability inherent in their control of resources, Regional
Health Authority decision-makers must be particularly cognizant of the different perspectives
held by different communities of practice. Regional Health Authority decision-makers must
establish the structures, roles, and processes – the affordances – that allow participants from
across the constellation of practices to work to harmonize their perspectives. Specifically,
Regional Health Authority decision-makers must invest in, and support the ongoing
development of harmonizing structures, processes, and people. Further, attention must be
given to how each of the process sets that support harmonization can be designed and
supported to facilitate collective discussion, decision, commitment, and action on each of the
dimensions of perspectives as presented in Table 9.1 (e.g., supports for evidence review, data
analysis, workload and workflow assessment, prioritization, coordination, etc.).
This study has described the foundational, harmonizing nature of horizontal serviceoriented improvement structures, processes, and people, articulated with local
interprofessional learning and development activities; an important iterative and horizontal
regional/local dynamic. Given the importance of this foundation, Regional Health Authority
decision-makers might place early focus, with academics and clinicians, on its collaborative
design and development. Care must be taken to ensure that key boundary roles (e.g.,
managers, clinical leads, educators and others who work across communities of practice) and
activities are woven into the service-oriented structures and processes, and that robust
engagement of clinicians is supported.
There are many obstacles to robust engagement in regular interprofessional learning
and development activity among all participants, but particularly, clinicians. With 24/7 shifts,

211
inconsistent staffing over time, unsupportive physician remuneration schemes, high service
demand, and ongoing cost pressures and workforce limitations, establishing consistent
mechanisms for improvement activity amongst clinicians is difficult. But the findings from
this case study indicate that robust engagement among communities of practice is essential to
establishing the harmonization required for successful CPG implementation and, so, must be
a focus for Regional Health Authority decision-makers.
Regional managers and support staff will also need to learn to recognize, discuss,
apply, and adapt the use of their power of authority. Within the ebbs and flows of a complex
CPG implementation, hierarchical authority and performance management will be essential
at times. At other times, however, regional, and particularly clinical, managers will need to
learn to take a more open and flexible stance to ensure that all participants are free to express
their perspectives and negotiate their interpretations and actions related to CPG
implementation. Regional Health Authority decision-makers need to support managers to
learn and practice these harmonizing skills.
Implications for Clinicians
By focusing on harmonization through increased and ongoing engagement with
academics and regional managers and support staff, clinicians have an opportunity to support
better patient outcomes while realizing more successful CPG implementation, better culture
and relationships within the organization, less wasted resources and effort, and greater input
and influence of the focus of academics (educators and researchers), and the priorities and
resources allocations of regional managers and support staff.
This study highlights that clinicians should engage and advocate for time to work and
develop in an interprofessional manner. Clinicians must have the time and inclination to
engage in challenging conversations about perspectives, and to overcome professional or

212
hierarchical assumptions that get in the way of productive relationships. Evidence presented
in this dissertation is supportive of establishment of a research culture which would be
enhanced by considerable interaction between academics and clinicians. To achieve this,
clinicians must be willing to take the time to engage in relationship-building activities and
quality collaboratives. Clinicians must also be willing to engage in, and with, research and
training, to test, redesign, and re-test clinical approaches. In recognition that barriers do exist
within and among professions for such time commitment and activity, clinicians might
advocate within their own professional and representational bodies for policies and resources
that can advance fuller interprofessional interaction related to development, rather than those
that can perpetuate professional divides.
Clinicians will also need to learn to recognize, discuss, apply, and adapt their use of
professional power. Interprofessional activity requires that all participants recognize and
respect the value brought by other professions and participants. While professionalism has
many positive and motivating qualities, it must not be applied in a way that devalues other
professions whether they be oriented toward clinical care, academia, or regional management
and support.
Harmonization and Practice Theory
The perspectives presented in this case study provide a striking example of how three
communities of practice established, over time, unique and rather different views of what it
means, and what it takes, to implement a Clinical Practice Guideline. Consistent with
practice theory, the perspectives held by participants within each community of practice
influenced the actions of those participants, and unresolved differences within and across the
constellation of practices led to critical limitations in the implementation process.

213
Besides offering a strong practical example of the applicability of practice theory, this
study offers several new considerations for practice theory-building. While some theorists
refer to perspectives within communities of practice, they do so in a relatively informal way,
often interchanged with other concepts such as beliefs and perceptions. Perspectives held
across communities of practice affect action of participants and can create barriers across
boundaries. While communities of practice facilitate learning, identity, and normalize day-today practice, they can also promote insularity, and differences in perspective that must be
addressed if collective action across a constellation of practices is to be successful. This study
offers five dimensions in which perspectives can be analyzed (focus and rationale; vision;
priority; power; and goals, strategies, and actions). These dimensions of perspectives can
help bring greater explanatory and practical power to practice theory. Care must be taken,
however, to keep discussion of community of practice perspectives within the fluid and
negotiated theoretical foundation of practice theory, lest they become reifications, or
stereotypes. Similarly, this study demonstrates the utility of Wenger’s concept of
constellations of practices (Wenger, 1998, pp. 126-133) as a fresh way of examining and,
perhaps, promoting networks of activity – connections - that do not necessarily conform
rigidly to organizational confines. The constellation of practices concept invites participants
from all communities of practice to look outside of their own organizational confines to
determine who really needs to be engaged and in alignment with some type of activity (e.g.,
the implementation of a CPG) and to ensure that ways of engaging meaningfully and over
time are established. By promoting outward reflection and engagement, harmonization
facilitates broader negotiation of meaning – extending the characteristics of a community of
practice to a broader constellation of practices.

214
Along with the concept and dimensions of perspectives, harmonization is a novel,
practical addition to practice theory, adding a needed degree of instrumentality (practical
applicability) to the theory. Harmonization recognizes the unique perspectives held within
communities of practice and offers a framework – the dimensions of perspectives and related
process sets - with which decision-makers can work forward toward better alignment and,
ultimately, more successful CPG implementation. Harmonization may prove helpful beyond
CPG implementation in Regional Health Authorities; to be used to conceptualize and enact
change within larger organizations in general.
This study adds value to Wenger’s communities of practice theory by demonstrating
the primary importance of engagement. Wenger identifies engagement, imagination, and
alignment as critical activities toward learning or change (Wenger, 1998). This study
indicates that without engagement, no imagination or alignment can occur and the likely
outcome to change initiatives will be discordance, severely limiting the potential for success.
This study affirms the importance of boundary spanning activity as established by
practice theorists. The findings are also suggestive of the breadth and depth of collaborative
boundary activity required for successful change within larger, geographically distributed
organizations. While discrete role-based boundary spanners are likely essential (e.g.,
educators, middle managers) these very thin “threads” of connectivity may prove insufficient
to avoid the discordance that arises from differences in perspective within and among
communities of practice. As Giddens notes with the concept of structuration, if not
addressed, differences in perspective among communities of practice can be reified - made
real - through the actions of participants, establishing structures that can then perpetuate the
differences in future (Giddens, 1984). A key objective of those roles spanning communities
of practice should be the promotion of widespread, inter-community of practice engagement

215
in the processes described in Table 9.1. Through this engagement, the participants themselves
can imagine solutions and facilitate alignment amongst themselves (Wenger, 1998).
Harmonization and the Consolidated Framework for Implementation Research
Having now conducted the study and discussed key findings and interpretations,
including the novel concept of harmonization, it is important to reflect on CFIR and its
application in advancing knowledge about CPG implementation. There is little in this study
of CPG implementation that did not align in some way with some construct within CFIR.
There are, however, some areas where opportunities might exist to adjust or build upon the
CFIR framework.
CFIR’s domain Characteristics of Individuals could better recognize that individuals
act within socially situated practices, or communities of practice. The practices of academics,
regional managers and support staff, and clinicians are social activities involving their
negotiated meaning; their perspectives about CPG implementation, their assumptions, and
resulting actions. Without reflecting this practice-oriented view on how individuals think and
act in communities of practice, CFIR’s inner setting appears too homogeneous, interaction
between inner and outer settings too bipartite, and efforts to apply the framework’s various
constructs can be seen as overly functional and mechanistic. While the CFIR inner setting
construct Networks and Communication offer some discussion of the complexity of social
relations among individuals and groups, the power of communities of practice not only to
facilitate learning and alignment of day-to-day activity, but also to promote unhelpful
insularity, is lost.
In addition to the above consideration, harmonization is offered, not as an
adjustment to the CFIR framework itself, but as a potential complement. Harmonization
provides a unique line of sight to CPG implementation and to CFIR. While the CFIR

216
framework offers domains and constructs that categorize implementation enablers,
harmonization provides a process for mobilizing those enablers through practical structures,
processes and people. CFIR might be seen as describing the “what” of CPG implementation,
while harmonization brings new insights to the “how.”
Harmonization and Implementation Strategies
The Expert Recommendations for Implementing Change (ERIC) project (Powell et
al., 2015) offers an extensive list of strategies that can be employed toward more effective
CPG implementation. Harmonization and its enablers, being processes targeted toward
enhancing CPG implementation success, can be considered to be implementation strategies.
Harmonization warrants consideration as a novel implementation strategy as it does not
appear to be captured, either by name or concept, within the current ERIC listing. The
concept of facilitation, listed in ERIC (Powell et al., 2015) and detailed by Harvey and
Kitson (2015) incorporates activities related to relationship and trust-building, but is not
specifically aimed at addressing differences in perspectives across a constellation of practices
involving academics, managers and support staff, and clinicians. The enablers of
harmonization – also reasonably considered implementation strategies – include three
activities, interprofessional learning and development, evidence review and impact
assessment, and quality improvement collaboratives and networks, that are clearly reflected
in ERIC. The remaining three, horizontal service-oriented improvement conversations and
activities, prioritization and resource decisions, and relationship management, are not directly
addressed in ERIC, though some overlaps may exist.
Harmonization and its six enablers warrant consideration as implementation
strategies and, together, they complement the ERIC (or any other) taxonomy by presenting a
layered, interdependent relationship amongst a set of strategies, tied to an objective. The

217
objective of harmonization is to promote engagement across communities of practice to
address differences in perspectives that can cause discordance. The strategies are layered and
interrelated – harmonization is a higher-order process, comprised of at least the six enabling
strategies. Harmonization, with its linked objective, can bring further practical value to the
ERIC listing as other documented strategies can be assessed for their potential, or tailored to
be, harmonizing.
Future Research Opportunities
Many opportunities for further research can be identified based on the findings and
conclusions of this Sepsis Guideline Set implementation research case study. Prospective
case study and quasi-experimental research would be helpful to further examine and build
upon the concepts of harmonization, testing and evaluating new approaches to engagement
across communities of practice and the five dimensions of perspectives. Prospective case
study or action research could be conducted to examine approaches to facilitating and
documenting agreements relative to each of the five dimensions of perspectives identified in
this study. Survey tools could be developed, tested, and used to identify and measure
differences in perspective along the five identified dimensions. Such tools could help to
identify the loose boundaries of communities of practice, and/or to assess the degree of
similarity or difference in perspective among them. Comparative case study research can
examine the impact of different approaches to supporting each of the six enablers of
harmonization, beginning with the foundation of strong, widely engaging service-oriented
improvement structures, processes, and people, inclusive local interprofessional learning and
development activities, and improvement collaboratives. The effect of cross-cutting
improvement collaboratives on community of practice perspectives could be assessed.
Comparative case study could also be conducted to examine whether similar or different

218
perspectives arise in different jurisdictions (e.g., other provinces, other countries) or contexts
(e.g., rural versus urban).
This dissertation presents the importance of engaging through service-oriented
structures, processes, and people/roles toward harmonization and, ultimately, success of CPG
implementation. Despite their apparent importance, very little is known about service
networks, service management, or program management generally, or in healthcare
specifically. Standard definitions for these structures do not exist (Humphries et al., 2014).
Beyond what is described in this dissertation and Greenhalgh’s emphasis on the importance
of their horizontal nature (Greenhalgh et al., 2004), the definitions, attributes, and indicators
of success of program/service management/networking largely remain to be explored.
Some researchers have highlighted the importance of middle management in
successful implementation (Boutcher et al., 2022), however much remains to be explored to
develop a full understanding of how front line and middle managers, including clinical
managers, can develop and work with organizational structures and processes to most
successfully affect CPG implementation. This study highlights the importance for managers
of open and changing stances. Further, research should focus on how successful managers
think about, and carry out, these stance changes, and how they constructively work through
challenges that arise from differences in perspective. Participants from across the three
communities of practice could come together to collaboratively create, implement, evaluate,
and research training programs aimed at enhancing managers’ competencies in managing
relationships, multiple perspectives, and necessary changes in stance.
This study identified the importance of harmonization of perspectives among many
participants in CPG implementation. Likely because of the retrospective and processual
nature of this study, few participants spoke of the role of patients and their families or

219
informal caregivers in the implementation. Research should be conducted to better
understand the potential and experienced role of patients in quality improvement
collaboratives, and in service-oriented and interprofessional improvement structures and
processes.
This study describes a central, enduring and supportive role for a regional office that
guides and supports CPG implementation. Such an office has an important but challenging
role in establishing regional standards toward evidence-based practice, while also promoting
local professional interest and engagement. As such this central office could be the focus for
a breadth of research activity designed to understand how that engaging and balancing role,
across the three communities of practice, can best be structured and supported. Specific
research into how a regional health organization’s Executive Team might best organize and
assign resources in support of both local learning and experimentation, and of regional
priorities, would be valuable for organizational decision-makers.
This research suggests that a stronger relationship between academia and the regional
health organization would be highly beneficial (Bowen et al., 2019; Bowen & Graham,
2013). Further research is needed to understand the best ways this collaboration can be
promoted and supported through quality collaboratives, and how collaboration can inform
and affect the commitments of harmonization. Case study and quasi-experimental research
could examine approaches to better meet the needs of the academic through closer
relationships with decision-makers and clinicians, and vice-versa.
Finally, further theoretical work and empirical testing should be undertaken to
incorporate the concepts of harmonization into practice theory. This dissertation describes a
meaningful relationship between community of practice perspectives and the actions their
respective participants most likely take toward CPG implementation. Communities of

220
practice facilitate learning and alignment of activity into practice, but insularity within
individual communities of practice can be detrimental to the achievement of an
organizational goal that requires collaboration among them. Theoretical work could be
conducted to assess this study’s five dimensions of perspectives toward further alignment
with concepts of psychology explicating individual behaviours. The relationship between
individual and community of practice perspectives and underlying concepts including beliefs,
values, and stances could prove instructive. Theorists are just beginning to explore the
relationship of adoptable stances to effectiveness of EBP adoption (McGivern et al., 2016).
Further exploration of these inter-related concepts of perspective, stance, and action would be
highly instructive to both theory and practice.
Reflections on Positionality
In Chapter 3, I provided a positionality statement describing my background and
likely influences and biases entering into this research study. At the time I initiated this
research, practice theory offered an intriguing way to approach the organizational, relational
focus to CPG implementation that was not well established in the CPG implementation
literature. As the study progressed, practice theory not only proved helpful in ensuring that I
remained open to what study participants were telling me, but, with Wenger’s communities
of practice, it offered me a way of making sense of what I was hearing.
While making sense intellectually, I admit to experiencing internal conflict as my
hard-earned perspectives as a senior manager were challenged. This is not to say those
perspectives are (were?) wrong – they are as correct as any other. Where I struggled was in
abandoning the belief that managers could unilaterally conceive and enact a correct
implementation solution. I came to realize through this study that managers need to let go of
assumptions that people across the organization see an implementation problem, let alone a

221
potential implementation solution, in the same way we do. Alignment across communities of
practice isn’t inherent. Alignment comes from tackling the problem together. To the extent
that managers continue to hold some legitimate role as stewards of the organization’s
resources, I am convinced that more of our focus must be placed on supporting rather than
directing – supporting engagement and working toward alignment of perspectives and actions
across communities of practice. The notion that managers can “drive out” (a term I hear all
too often in my RHA executive role) our decisions now seems incredibly naïve to me.
Further, I have come to believe that practice theory, with its focus on situated learning,
negotiated meaning, and affordances, can philosophically underpin a new way of
understanding and managing health organizations.
Study Limitations
This dissertation is written in compliance with published standards for reporting
qualitative research (O'Brien et al., 2014). This Sepsis Guideline Set implementation case
study offers much toward an understanding of guideline implementation in regional health
organizations, though some limitations must be recognized. First, the study faces the
limitations that are inherent in all retrospective case study research. Retrospective study is
reliant on the clarity and accuracy of memories of its participants and availability of relevant
documents and documentation. Retrospective study must assume that interview participants
are able to provide a reasonable account of practice – the actions that actually took place.
Direct observation is a useful source of research data that is not available in retrospective
study. To address this limitation, the study involved triangulation of concepts among multiple
participants and documents.
The transferability of the findings to other settings or situations is a decision to be
made by the reader within her/his own context (Merriam, 2009). Other jurisdictions, for

222
instance, may not have the same structures or attributes (e.g., modest automation, publicly
funded RHA with physicians operating as private businesses) that affect CPG
implementation behaviours of different communities of practice. This dissertation provides
rich description of the case study findings and explication of conclusions in an effort to assist
readers in determining the degree to which it may be useful or meaningful to them.
For this study, a single student researcher undertook all data collection and analysis.
While concerns about inter-researcher consistency do not apply, a single researcher can
introduce bias that additional researchers might have identified and addressed. To reduce the
potential for consistency issues, my supervisor conducted a review of my interview technique
and coding at an early stage of analysis. Further, the dissertation contains rich description
including extensive use of participant quotes so the reader is able to make their own
judgement as to the consistency of study findings with the empirical data.
Finally, while interview participation enabled good coverage of the organization and
the communities of practice referenced throughout, the study was not designed to enable
definitive differentiation of viewpoints among professions. The study certainly identifies
issues that appeared to be related to profession, particularly the unique perspective of
physicians. While suggestive, further research would need to be focused more specifically on
those matters.
Conclusion
This dissertation presents the results of a case study of a CPG implementation within
a Regional Health Authority – the Sepsis Guideline Set at Select Health. The CPG
implementation process was highly dynamic and non-linear, involving different activities and
intensities of involvement of individuals from three communities of practice: academics,
management and support staff, and clinicians. Individuals from each of the three groups had

223
different perspectives about the implementation along five dimensions (focus and rationale,
vision, priority, appropriate balance and application of power, and goals, strategies and
actions to be taken). As a result, the different communities of practice undertook actions that
were not sufficiently aligned to ensure adherence to the CPG. The result was a discordant,
and unsuccessful implementation. CPG adherence was not achieved. The differences in
perspectives among academics, regional managers and support staff, and clinicians were
substantial and appeared to have been deeply rooted in the beliefs, functions, experiences,
and day-to-day realities of each of these groups of participants. The discordance in the
implementation resulted from an insularity of each community of practice from the others,
brought about by inadequate engagement among participants; insufficient connections across
communities of practice to support shared understanding and alignment of action.
Without some intervention, differences in perspectives will prevail and discordance is
the likely outcome of any complex CPG implementation. This dissertation proposes the novel
concept of harmonization as a means of achieving more successful CPG implementation; a
process intended to reduce insularity of individual communities of practice within and
beyond a Regional Health Authority. Harmonization is conceptualized as a process
comprised of many harmonizing activities that support engagement, relationship-building
and explicit reflection and reconciliation of key differences in perspective among academics,
regional managers, and clinicians. Perspectives can differ along at least five dimensions and,
therefore, five harmonizing sets of processes can be collaboratively (amongst the three
communities of practice) planned and implemented to support harmonization.
Collaboration through a well-designed CPG implementation process can certainly
improve harmonization and can help to mitigate discordance. However, as a relationshipbased phenomenon, harmonization is rooted in context; aspects of day-to-day activity that

224
extend well beyond the particular CPG implementation. Harmonization must be supported as
part of the Regional Health Authority’s ongoing operations.
This study identifies six inter-related enablers of harmonization. The six enablers can
be supported by the organization’s decision-makers and managers, to facilitate better
harmonization of perspectives and actions within and between communities of practice.
Strong, widely engaging service-oriented improvement structures, processes, and people,
articulated with inclusive local interprofessional learning and development activities and
quality improvement collaboratives, provide a strong foundation for engagement, alignment,
and CPG implementation activity. Together these structures, processes, and people can
establish an enabling context within which a broad range of participants across the three
groups can engage in reviewing evidence and assessing impact, and in prioritizing and
resourcing CPG implementation. RHA managers, particularly clinical managers can support
harmonization by encouraging open sharing of perspectives and managing in a way that is
responsive to the realistic ebbs and flows of a dynamic, non-linear implementation process.
The findings of this study advance knowledge about Clinical Practice Guideline
(CPG) implementation in several ways. Harmonization of perspectives of participants within
and across academic, regional management and support staff, and clinician communities of
practice is a unique contribution to CPG implementation knowledge, merging organizational
context and focused CPG implementation process, as a necessary process to enable CPG
implementation success. By proposing harmonization as alignment across dimensions of
perspectives and offering related process sets and enablers, this dissertation offers regional
decision-makers a unique and promising way to practically support CPG implementation,
and opens promising new opportunities for research.

225
The study also brings added empirical evidence to inform the growing body of
practice theory, adding harmonization as a unique contribution to theory and offering an
intriguing relationship between community of practice perspectives and harmonization and
CPG implementation for future theoretical focus and empirical testing.

226
References
Aarons, G. A., Ehrhart, M. G., & Farahnak, L. R. (2014). The implementation leadership
scale (ILS): Development of a brief measure of unit level implementation leadership.
Implementation Science, 9(45).
Aarons, G. A., Ehrhart, M. G., Farahnak, L. R., & Hurlburt, M. S. (2015). Leadership and
organizational change for implementation (LOCI): A randomized mixed method pilot
study of a leadership and organization development intervention for evidence-based
practice implementation. Implementation Science, 10, 11.
https://doi.org/10.1186/s13012-014-0192-y
Argyris, C., & Schön , D. A. (1974). Theory in practice: Increasing professional
effectiveness. Jossey-Bass.
Argyris, C., & Schön , D. A. (1996). Organizational Learning 2. Addison-Wesley Publishing
Company.
Armson, H., Roder, S., Elmslie, T., Khan, S., & Straus, S. (2018). How do clinicians use
implementation tools to apply breast cancer screening guidelines to practice?
Implementation Science, 13(79).
Ashok, M., Hung, D., Rojas-Smith, L., Halpern, M., & Harrison, M. (2018). Framework for
research on implementation of process redesigns. Quality Management in Health
Care, 27(1).
Baker, G. R., Norton, P. G., Flintoft, V., Blais, R., Brown, A., Cox, J., . . . Tamblyn, R.
(2004). The Canadian Adverse Events Study: the incidence of adverse events among
hospital patients in Canada. CMAJ: Canadian Medical Association Journal = Journal
De L'association Medicale Canadienne, 170(11), 1678-1686.
Balestracci, D., & Barlow, J. (1996). Quality improvement: practical applications for
medical group practice (2 ed.). Quality Press.
Bamford, D. R., & Forrester, P. L. (2003). Managing planned and emergent change within an
operations management environment. International Journal of Operations and
Production Management, 23(5), 546-564.
https://doi.org/10.1108/01443570310471857

227
Baumann, A. A., Li, C., & Stirman, S. W. (2019). Adaptation in dissemination and
implementation science. In R. C. Brownson, G. A. Colditz, & E. K. Proctor (Eds.),
Dissemination and implementation research in health (pp. 285-300). Oxford
University Press.
Best, A., Berland, A., Herbert, C., Bitz, J., van Dijk, M. W., Krause, C., . . . Millar, J. (2016).
Using systems thinking to support clinical system transformation. Journal Of Health
Organization And Management, 30(3), 302-323. https://doi.org/10.1108/JHOM-122014-0206
Birken, S., Clary, A., Tabriz, A. A., Turner, K., Meza, R., Zizzi, A., . . . Charns, M. (2018).
Middle managers' role in implementing evidence-based practices in healthcare: A
systematic review. Implementation Science, 13(149). https://doi.org/10.1186/s13012018-0843-5
Birken, S. A., Daniel Lee, S.-Y., Weiner, B. J., Chin, M., H., & Schaefer, C. T. (2013).
Improving the effectiveness of health care innovation implementation: Middle
managers as change agents. Medical Care Research and Review, 70(1), 29-45.
Bonawitz, K., Wetmore, M., Heisler, M., Dalton, V. K., Damschroder, L., Forman, J., . . .
Moniz, M. H. (2020). Champions in context: Which attributes matter in change
efforts in healthcare? Implementation Science 15(62).
Bone, R., Balk, R., Cerra, F., Dellinger, R., Fein, A., Knaus, W., . . . Sibbald, W. (1992).
Definitions for sepsis and organ failure and guidelines for the use of innovative
therapies in sepsis. Chest, 101(6), 1644-1655.
Bourdieu, P. (1977). Outline of a theory of practice (R. Nice, Trans.). Cambridge University
Press.
Boutcher, F., Berta, W., Urquhart, R., & Gagliardi, A. (2022). The roles, activities and
impacts of middle managers who function as knowledge brokers to improve care
delivery and outcomes in healthcare organizations: A critical interpretive analysis.
BMC Health Services Research, 22(11). https://doi.org/10.1186/s12913-021-07387-z
Bowen, S., Botting, I., Graham, I. D., MacLeod, M., de Moissac, D., Harlos, K., . . . Knox, J.
(2019). Experience of health leadership in partnering with university-based
researchers in Canada: A call to "re-imagine" research. International Journal of
Health Policy and Management, 8(12), 684-699.

228
Bowen, S. J., & Graham, I. D. (2013). From knowledge translation to engaged scholarship:
promoting research relevance and utilization. Archives Of Physical Medicine And
Rehabilitation, 94(1 Suppl), S3-S8. https://doi.org/10.1016/j.apmr.2012.04.037
Boyatzis, R. E. (1998). Transforming qualitative information: Thematic analysis and code
development. Sage Publications.
Braithwaite, J., Glasziou, P., & Westbrook, J. (2020). The three numbers you need to know
about healthcare: The 60-30-10 Challenge. BMC Medicine, 18(102).
https://doi.org/10.1186/s1216-020-01563-4
British Columbia Ministry of Health. (2011). Ministry Correspondence to Select Health
Chief Executive Officer dated April 1, 2011. In C. E. O. Select Health (Ed.), (Letter
from MoH Assistant Deputy Minister to Select Health Chief Executive Officer ed.).
British Columbia, Canada: British Columbia Ministry of Health.
British Columbia Ministry of Health. (2012). Innovation and Change Agenda. British
Columbia Ministry of Health. Retrieved July 7 from
http://docs.openinfo.gov.bc.ca/d30170613a_response_package_hth-2012-00165.pdf
British Columbia Patient Safety and Quality Council. (2011). BC Sepsis Guidelines.
Retrieved 8 January from https://bcpsqc.ca/clinical-improvement/sepsis/guidelines/
British Columbia Patient Safety and Quality Council. (2012). Sepsis guide: Improving care
for sepsis. www.bcpsqc.ca
British Columbia Patient Safety and Quality Council. (2018). About the Council. Retrieved
July 1 from https://bcpsqc.ca/about-the-council/
Brown, J. S., & Duguid, P. (2000). The social life of information. Harvard Business School
Press.
Bunger, A., Birken, S., Hoffman, J., MacDowell, H., Choy-Brown, M., & Magier, E. (2019).
Elucidating the influence of supervisors' roles on implementation climate.
Implementation Science, 14(93).
Bunger, A., Powell, B., Robertson, H., MacDowell, H., Birken, S., & Shea, C. (2017).
Tracking implementation strategies: a description of a practical approach and early
findings. Health Research Policy and Systems, 15(15).
Cammer, A., Morgan, D., Stewart, N., McGilton, K., Rycroft-Malone, J., Dopson, S., &
Estabrooks, C. (2014). The hidden complexity of long-term care: how context

229
mediates knowledge translation and use of best practices. The Gerontologist, 54(6),
1013-1023.
Canadian Institute for Health Information. (2009). In focus: A national look at sepsis.
Ottawa: Canadian Institute for Health Information
Cassidy, C., Harrison, M., Godfrey, C., Vincic, V., Khan, P., Oakley, P., . . . Graham, I.
(2021). Use and effects of implementation strategies for practice guidelines in
nursing: A systematic review. Implementation Science, 16(102).
https://doi.org/10.1186/s13012-021-01165-5
Charmaz, K. (2003). Grounded theory: Objectivist and constructivist methods. In N. K.
Denzin & Y. S. Lincoln (Eds.), Strategies for qualitative inquiry (2 ed., pp. 249-291).
Sage.
Ciro Correa, V., Lugo-Agudelo, L. H., Aguirre-Acevedo, D. C., Plata Contreras, J. A.,
Posada Borrero, A. M., Patino-Lugo, D. F., & Castano Valencia, D. A. (2020).
Individual, health system, and contextual barriers and facilitators for the
implementation of clinical practice guidelines: a systematic metareview. Health
Research Policy and Systems, 18(74).
Cochrane Effective Practice and Organization of Care. (2015). EPOC Taxonomy. Retrieved
April 8 from https://epoc.cochrane.org/epoc-taxonomy
Consolidated Framework for Implementation Research. (2020). CFIR Constructs. Retrieved
November 21 from https://cfirguide.org/constructs/
Corbin, J. M., & Strauss, A. L. (2008). Basics of qualitative research :techniques and
procedures for developing grounded theory (Vol. 3). Sage Publications, Inc.
Cunningham Goedken, C., Livorsi, D., Sauder, M., Vander Weg, M., Chasco, E., Chang, N.C., . . . Schacht Reisinger, H. (2019). "The role as a champion is to not only monitor
but to speak out and to educate": the contradictory roles of hand hygiene champions.
Implementation Science, 14(110).
Currie, G., Burgess, N., White, L., Lockett, A., Gladman, J., & Waring, J. (2014). A
qualitative study of the knowledge-brokering role of middle-level managers in service
innovation: managing the translation gap in patient safety for older persons’ care.
https://doi.org/10.3310/hsdr02320 (Health Services and Delivery Research)

230
Currie, G., El Enany, N., & Lockett, A. (2014). Intra-professional dynamics in translational
health research: The perspective of social scientists. Social Science and Medicine,
114(81-88). https://doi.org/10.1016/j.socscimed.2014.05.045
Currie, G., Finn, R., & Martin, G. (2007). Spanning boundaries in pursuit of effective
knowledge sharing within networks in the NHS. Journal of health organization and
management, 21(4-5), 406-417.
Currie, G., Lockett, A., & El Enany, N. (2013). From what we know to what we do: lessons
learned from the translational CLAHRC initiative in England. Journal Of Health
Services Research & Policy, 18(3 Suppl), 27-39.
https://doi.org/10.1177/1355819613500484
D'Andreta, D., Scarbrough, H., & Evans, S. (2013). The enactment of knowledge translation:
a study of the Collaborations for Leadership in Applied Health Research and Care
initiative within the English National Health Service. Journal of health services
research & policy, 18(3), 40-52. https://doi.org/10.1177/1355819613499902
Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C.
(2009). Fostering implementation of health services research findings into practice: a
consolidated framework for advancing implementation science. Implementation
Science: IS, 4, 50-50. https://doi.org/10.1186/1748-5908-4-50
Dellinger, R. P., Schorr, C. A., & Levy, M. M. (2017). A Users' Guide to the 2016 Surviving
Sepsis Guidelines. Critical Care Medicine, 45(3), 381-385.
https://doi.org/10.1097/CCM.0000000000002257
Donabedian, A. (1988). The quality of care. How can it be assessed? Journal of the American
Medical Association, 260(12), 1743-1748.
Dopson, S., & Fitzgerald, L. (2006). The role of the middle manager in the implementation of
evidence-based health care. Journal of nursing management, 14(1), 43-51.
Ebben, R. H., Siqeca, F., Riis Madsen, U., Vloet, L. C. M., & van Achterbeg, T. (2018).
Effectiveness of implementation strategies for the improvement of guideline and
protocol adherence in emergency care: A systematic review. BMJ Open, 2018(8).
https://doi.org/10.1136/bmjopen-2018-017572
Eddy, D. M., Adler, J., Patterson, B., Lucas, D., Smith, K. A., & Morris, M. (2011).
Individualized guidelines: the potential for increasing quality and reducing costs.

231
Annals Of Internal Medicine, 154(9), 627-634. https://doi.org/10.7326/0003-4819154-9-201105030-00008
Ellen, M., Leon, G., Bouchard, G., Lavis, J., Ouimet, M., & Grimshaw, J. (2013). What
supports do health system organizations have in place to facilitate evidence-informed
decision-making? A qualitative study. Implementation Science, 8(84).
Ellen, M., Leon, G., Bouchard, G., Ouimet, M., Grimshaw, J., & Lavis, J. (2014). Barriers,
facilitators and views about next steps to implementing supports for evidenceinformed decision-making in health systems: a qualitative study. Implementation
Science, 9(179). https://doi.org/10.1186/s13012-014-0179-8
Esmail, R., Hanson, H., Holroyd-Leduc, J., Brown, S., Strifler, L., Straus, S., . . . Clement, F.
(2020). A scoping review of full-spectrum knowledge translation theories, models,
and frameworks. Implementation Science, 15(11).
Evenblij, K., Verbon, A., & van Leth, F. (2016). Intention of physicians to implement
guidelines for screening and treatment of latent tuberculosis infection in HIV-infected
patients in the Netherlands: a mixed-method design. BMC Public Health, 16(915).
Fischer, F., Lange, K., Klose, K., Greiner, W., & Kraemer, A. (2016). Barriers and strategies
in guideline implementation - A scoping review. Healthcare, 4(36).
Fischler, I., Riahi, S., Stuckey, M., & Klassen, P. (2016). Implementation of a clinical
practice guideline for schizophrenia in a specialist mental health center: an
observational study. BMC Health Services Research, 16(372).
Fitzgerald, L., & Harvey, G. (2015). Translational networks in healthcare? Evidence on the
design and initiation of organizational networks for knowledge mobilization. Social
Science and Medicine, 138, 192-200. https://doi.org/10.1016/j.socscimed.2015.06.015
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005).
Implementation research: A synthesis of the literature.
Fonarow, G. C., Yancy, C. W., Hernandez, A. F., Peterson, E. D., Spertus, J. A., &
Heidenreich, P. A. (2011). Potential impact of optimal implementation of evidencebased heart failure therapies on mortality. American Heart Journal, 161(6).
https://doi.org/10.1016/j.ahj.2011.01.027
Gagliardi, A., & Alhabib, S. (2015). Trends in guideline implementation: a scoping
systematic review. Implementation Science, 10(54).

232
Gherardi, S., & Nicolini, D. (2002). Learning in a constellation of interconnected practices:
Canon or dissonance? Journal of Management Studies, 39(4), 419-436.
https://doi.org/10.1111/1467-6486.t01-1-00298
Giddens, A. (1984). The constitution of society. University of California Press.
Gifford, W., Graham, I., Ehrhart, M., Davies, B., & Aarons, G. (2017). Ottawa Model of
Implementation Leadership and Implementation Leadership Scale: Mapping concepts
for developing and evaluating theory-based leadership interventions. Journal of
Healthcare Leadership, 9, 15-23.
Gifford, W. A., Davies, B., Edwards, N., & Graham, I. D. (2006). Leadership strategies to
influence the use of clinical practice guidelines. Nursing Research, 19(4).
Gorley, C., Lindstrom, R. R., McKeown, S., Krause, C., Pamplin, C., Sweet, D., . . .
Kennedy, C. (2016). Exploring distributed leadership in the BC Sepsis Network.
Healthcare Management Forum, 29(2), 63-66.
https://doi.org/10.1177/0840470415606451
Gotts, J. E., & Matthay, M. A. (2016). Sepsis: pathophysiology and clinical management.
BMJ (Clinical Research Ed.), 353, i1585-i1585. https://doi.org/10.1136/bmj.i1585
Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of
innovations in service organizations: systematic review and recommendations. The
Milbank quarterly, 82(4), 581-629.
Grimshaw, J., Eccles, M., Thomas, R., MacLennan, G., Ramsay, C., Fraser, C., & Vale, L.
(2006). Toward evidence-based quality improvement: Evidence (and its limitations)
of the effectiveness of guideline dissemination and implementation strategies 19661998. Journal of General Internal Medicine, 21(S), 14-20.
Grimshaw, J., & Russell, I. (1993). Effect of clinical guidelines on medical practice: A
systematic review of rigorous evaluations. Lancet, 342, 1317-1322.
Guerrero, E. G., Frimpong, J., Kong, Y., Fenwick, K., & Aarons, G. (2020). Advancing
theory on the multilevel role of leadership in the implementation of evidence-based
health care practices. Health Care Management Review 45(2), 151-161.
https://doi.org/10.1097/HMR.0000000000000213
Harrison, M. B., & Graham, I. D. (2021). Knowledge translation in nursing and healthcare:
A roadmap to evidence-informed practice. Wiley Blackwell.

233
Harvey, G., & Kitson, A. (2015). Implementing evidence-based practice in healthcare: A
facilitation guide. Routledge.
Havers, S. M., Martin, E., Wilson, A., & Hall, L. (2019). Implementation of governmentdirected policy in the hospital setting: a modified Delphi study. Health Research
Policy and Systems, 17(91).
Helfrich, C. D., Damschroder, L. J., Hagedorn, H. J., Daggett, G. S., Sahay, A., Ritchie, M., .
. . Stetler, C. B. (2010). A critical synthesis of literature on the promoting action on
research implementation in health services (PARIHS) framework. Implementation
Science: IS, 5, 82-82. https://doi.org/10.1186/1748-5908-5-82
Hendy, J., & Barlow, J. (2012). The role of the organizational champion in achieving health
system change. Social Science & Medicine (1982), 74(3), 348-355.
https://doi.org/10.1016/j.socscimed.2011.02.009
Hermens, M., Oud, M., Sinnema, H., Nauta, M., Stikkelbroek, Y., van Duin, D., & Wensing,
M. (2015). The multidisciplinary depression guideline for children and adolescents:
an implementation study. European Child & Adolescent Psychiatry, 24, 1207-1218.
Higuchi, K., Davies, B., & Ploeg, J. (2017). Sustaining guideline implementation: A multisite
perspective on activities, challenges and supports. Journal of Clinical Nursing, 26,
4413-4424.
Humphries, S., Stafinski, T., Mumtaz, Z., & Menon, D. (2014). Barriers and facilitators to
evidence-use in program management: a systematic review of the literature. BMC
Health Services Research, 14, 171-171. https://doi.org/10.1186/1472-6963-14-171
Institute of Medicine. (2011). Clinical Practice Guidelines We Can Trust. N. A. P. (US).
Jeffs, L., Beswick, S., Lo, J., Campbell, H., Ferris, E., & Sidani, S. (2013). Defining what
evidence is, linking it to patient outcomes, and making it relevant to practice: insight
from clinical nurses. Applied Nursing Research, 26, 105-109.
Jeston, J., & Nelis, J. (2014). Business process management: Practical guidelines to
successful implementations (3 ed.). Routledge.
Kislov, R., Wilson, P. M., Knowles, S., & Boaden, R. (2018). Learning from the emergence
of NIHR Collaborations for Leadership in Applied Health Research and Care
(CLAHRCs): A systematic review of evaluations. Implementation Science, 13(111).

234
Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence
based practice: a conceptual framework. Quality In Health Care: QHC, 7(3), 149158.
Knudsen, S., Laursen, H., Johnsen, S., Bartels, P., Ehlers, L., & Mainz, J. (2019). Can quality
improvement improve the quality of care? A systematic review of reported effects
and methodological rigor in plan-do-study-act projects. BMC Health Services
Research, 19(683).
Koch, T., & Harrington, A. (1998). Reconceptualizing rigour: the case for reflexivity.
Journal of advanced nursing, 28(4), 882-890.
Kouzes, J. M., & Mico, P. R. (1979). Journal of Applied Behavioral Science, 15(4), 449-469.
https://doi.org/10.1177/002188637901500402
Langley, A. (1999). STRATEGIES FOR THEORIZING FROM PROCESS DATA [Article].
Academy of Management Review, 24(4), 691-710.
https://doi.org/10.5465/AMR.1999.2553248
Latour, B. (2005). Reassembling the social. Oxford University Press.
Lave, J., & Wenger, E. (1991). Situated learning: legitimate peripheral participation.
University Press.
Lengnick-Hall, R., Stadnick, N., Dicskson, K., Moullin, J., & Aarons, G. (2021). Forms and
functions of bridging factors: Specifying the dynamic links between outer and inner
contexts during implementation and sustainment. Implementation Science, 16(34).
https://doi.org/10.1186.s13012-021-01099-y
Lengnick-Hall, R., Willging, C., Hurlburt, M., & Aarons, G. (2020). Incorporators, early
investors, and learners: A longitudinal study of organizational adaptation during EBP
implementation and sustainment. Implementation Science, 15(74).
https://doi.org/10.1186/s13012-020-01031-w
Leonard-Barton, D. (1990). A DUAL METHODOLOGY FOR CASE STUDIES:
SYNERGISTIC USE OF A LONGITUDINAL SINGLE SITE WITH REPLICATED
MULTIPLE SITES [Article]. Organization Science, 1(3), 248-266.
Levy, M. M., Dellinger, R. P., Townsend, S. R., Linde-Zwirble, W. T., Marshall, J. C., Bion,
J., . . . Angus, D. C. (2010). The Surviving Sepsis Campaign: results of an
international guideline-based performance improvement program targeting severe

235
sepsis. Intensive Care Medicine, 36(2), 222-231. https://doi.org/10.1007/s00134-0091738-3
Levy, M. M., Fink, M. P., Marshall, J. C., Abraham, E., Angus, D., Cook, D., . . . Ramsay, G.
(2003). 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions
Conference. Intensive Care Medicine, 29(4), 530-538.
Li, S., Cao, M., & Zhu, X. (2019). Evidence-based practice: Knowledge, attitudes,
implementation, facilitators, and barriers among community nurses - systematic
review. Medicine, 98(39). https://doi.org/10.1097/MD.0000000000017209
Li, S.-A., Jeffs, L., Barwick, M., & Stevens, B. (2018). Organizational contextual features
that influence the implementation of evidence-based practices across healthcare
settings: A systematic integrative review. Systematic Reviews, 7(72).
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Sage.
Martin, G., McNicol, S., & Chew, S. (2013). Towards a new paradigm in health research and
practice? Collaborations for Leadership in Applied Health Research and Care.
Journal of Health Organization and Management, 27(2), 193-208.
https://doi.org/10.1108/14777261311321770
Martin, G. P., Kocman, D., Stephens, T., Peden, C. J., & Pearse, R. M. (2017). Pathways to
professionalism? Quality improvement, care pathways, and the interplay of
standardisation and clinical autonomy. Sociology of Health and Wellness, 39(8), 1-16.
McGivern, G., Dopson, S., Ferlie, E., Bennett, C., Fischer, M., Fitzgerald, L., & Ledger, J.
(2016). "Epistemic fit" and the mobilization of management knowledge in healthcare.
In J. Swan, S. Newell, & D. Nicolini (Eds.), Mobilizing knowledge in healthcare:
Challenges for management and organization (pp. 23-40). Oxford University Press.
McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., & Kerr, E.
A. (2003). The quality of health care delivered to adults in the United States. The New
England journal of medicine, 348(26), 2635-2645.
McKeown, S., Krause, C., Shergill, M., Siu, A., & Sweet, D. (2016). Gamification as a
strategy to engage and motivate clinicians to improve care. Healthcare Management
Forum, 29(2), 67-73. https://doi.org/10.1177/0840470415626528
Merriam, S. B. (2009). Qualitative research: A guide to design and implementation. JosseyBass.

236
Meza, R., Triplett, N., Woodard, G., Martin, P., Khairuzzaman, A., Jamora, G., & Dorsey, S.
(2021). The relationship between first-level leadership and inner-context and
implementation outcomes in behavioral health: A scoping review. Implementation
Science, 16(69). https://doi.org/10.1186/s13012-021-01104-4
Miake-Lye, I., Delevan, D., Ganz, D., Mittman, B., & Finley, E. (2020). Unpacking
organizational readiness for change: An updated systematic review and content
analysis of assessments. BMC Health Services Research, 20(106).
Miles, M. B., & Huberman, M. A. (1994). Qualitative data analysis (2 ed.). Sage.
Moore, J., Uka, S., Vogel, J., Rashid, S., Gulmezoglu, A. M., & Straus, S. (2016). Navigating
barriers: two-year follow up on recommendations to improve the use of maternal
health guidelines in Kosovo. BMC Public Health, 16(987).
Nadalin Penno, L., Davies, B., Graham, I., Backman, C., MacDonald, I., Bain, J., . . .
Squires, J. (2019). Identifying relevant concepts and factors for the sustainability of
evidence-based practices within acute care contexts: a systematic review and theory
analysis of selected sustainability frameworks. Implementation Science, 14(108).
Nembhard, I. M., & Edmondson, A. C. (2006). Making it safe: The effects of leaders
inclusiveness and professional status on psychological safety and improvement efforts
in health care teams. Journal of Organizational Behaviour, 27, 941-966.
https://doi.org/10.1002/job.413
Nicolini, D. (2011). Practice as the Site of Knowing: Insights from the Field of Telemedicine.
Organization Science, 22(3), 602-620. https://doi.org/10.1287/orsc.1100.0556
Nicolini, D. (2012). Practice theory: Work and organization. An introduction. Oxford
University Press.
Nicolini, D. (2017). Practice theory as a package of theory, method and vocabulary:
Affordances and limitations. In M. Jonas, B. Littig, & A. Wroblewski (Eds.),
Methodological reflections on practice oriented theories (pp. 19-34). Springer.
Nilsson, K., Baathe, F., Erichsen Andersson, A., & Sandoff, M. (2018). The need to succeed
- learning experiences resulting from the implementation of value-based healthcare.
Leadership in Healthcare, 31(1).

237
O'Brien, B. C., Harris, I. B., Beckman, T. J., Reed, D. A., & Cook, D. A. (2014). Standards
for reporting qualitative research: A synthesis of recommendations. Academic
Medicine, 89(9). https://doi.org/10.1097/ACM.0000000000000388
Ortner, S. (2006). Anthropology and social theory: culture, power and the acting subject.
Duke University Press.
Pettigrew, A. M. (1990). Longitudinal Field Research on Change: Theory and Practice.
Organization Science, 1(3), 267-292.
Powell, B. J., Beidas, R. S., Lewis, C. C., Aarons, G. A., McMillen, J. C., Proctor, E. K., . . .
Mandell, D. S. (2017). Methods to improve the selection and tailoring of
implementation strategies. Journal of Behavioral Health Service and Research, 44(2),
177-194. https://doi.org/10.1007/s11414-015-9475-6
Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, M. M., Proctor, E. K.,
& Kirchner, J. E. (2015). A refined compilation of implementation strategies: Results
from the Expert Recommendations for Implementation Change (ERIC) project.
Implementation Science, 10(21). https://doi.org/10.1186/s13012-015-0209-1
Prior, M., Guerin, M., & Grimmer-Somers, K. (2008). The effectiveness of clinical guideline
implementation strategies - A synthesis of systematic review findings. Journal of
Evaluation in Clinical Practice, 14, 888-897. https://doi.org/10.1111/j.13652753.2008.01014.x
Proctor, E. K., Powell, B. J., & McMillen, C. J. (2013). Implementation strategies:
Recommendations for specifying and reporting. Implementation Science, 8(139).
https://doi.org/10.1186/1748-5908-8-139
Provvidenza, C., Townley, A., Wincentak, J., Peacocke, S., & Kingsnorth, S. (2020).
Building knowledge translation competency in a community-based hospital: a
practice-informed curriculum for healthcare providers, researchers, and leadership.
Implementation Science, 15(54).
Racko, G. (2018). Knowledge exchange in the UK CLAHRCs: The enabling role of
academics and clinicians' social position. Journal of Health Organization and
Management, 32(2 ), 246-262.
Rapport, F., Clay-Williams, R., Churruca, K., Shih, P., Hogden, A., & Braithwaite, J. (2018).
The struggle of translating science into action: Foundational concepts of

238
implementation science. Journal of Evaluation in Clinical Practice, 24, 117-126.
https://doi.org/10.1111/jep.12741
Raveis, V., Conway, L., Uchida, M., Pogorzelska-Maziarz, M., Larson, E., & Stone, P.
(2014). Translating infection control guidelines into practice: Implementation process
within a health care institution. Qualitative Health Research, 24(4), 551-560.
Ravens, B. (1965). Social influence and power. In I. D. Steiner & M. Fishbein (Eds.),
Current studies in social psychology (pp. 371-382). Holt, Rinehart, Winston.
Reade, M. C. Variability in management of early severe sepsis. Emergency Medicine
Journal, 27(2), 110-115.
Reade, M. C. (2010). Variability in management of early severe sepsis. Emergency Medicine
Journal, 27(2), 110-115.
Rivers, E., Nguyen, B., Havstad, S., Ressler, J., Muzzin, A., Knoblich, B., . . . Tomlanovich,
M. (2001). Early goal-directed therapy in the treatment of severe sepsis and septic
shock. The New England Journal Of Medicine, 345(19), 1368-1377.
Rivers, E. P. (2010). Point: Adherence to early goal-directed therapy: Does it really matter?
Yes, after a decade the scientific proof speaks for itself. Chest, 138, 476-480.
Rogers, E. M. (2003). Diffusion of innovations (Vol. 5th). Free Press.
Rogers, L., De Brun, A., & McAuliffe, E. (2020). Defining and assessing context in
healthcare implementation studies: A systematic review. BMC Health Services
Research, 20, 591. https://doi.org/10.1186/s12913-020-05212-7
Rowan, K. M., Angus, D. C., Bailey, M., Barnato, A. E., Bellomo, R., Canter, R. R., . . .
Yealy, D. M. (2017). Early, Goal-Directed Therapy for Septic Shock - A PatientLevel Meta-Analysis. The New England Journal Of Medicine, 376(23), 2223-2234.
https://doi.org/10.1056/NEJMoa1701380
Rowley, E., Morriss, R., Currie, G., & Schneider, J. (2012). Research into practice:
Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for
Nottinghamshire, Derbyshire, Lincolnshire (NDL). Implementation Science, 7(40).
Runciman, W. B., Hunt, T. D., Hannaford, N. A., Hibbert, P. D., Westbrook, J. I., & Coiera,
E. W. (2012). CareTrack: Assessing the appropriateness of health care delivery in
Australia. Medical Journal of Australia, 197(2), 100-105.

239
Rycroft-Malone, J. (2004). The PARIHS framework--a framework for guiding the
implementation of evidence-based practice. Journal of nursing care quality, 19(4),
297-304.
Rycroft-Malone, J., Burton, C., Wilkinson, J., Harvey, G., McCormack, B., Baker, R., . . .
Williams, L. (2016). Collective action for implementation: a realist evaluation of
organizational collaboration in healthcare. Implementation Science, 11(17).
https://doi.org/10.1186/s13012-016-0380-z
Rycroft-Malone, J., Wilkinson, J., Burton, C. R., Harvey, G., McCormack, B., Graham, I., &
Staniszewska, S. (2013). Collaborative action around implementation in
Collaborations for Leadership in Applied Health Research and Care: Towards a
programme theory. Journal of Health Services Research and Policy, 18, 13-26.
Sackett, D. L., & Rosenberg, W. M. C. (1995). The need for evidence-based medicine.
Journal of the Royal Society of Medicine, 88, 620-624.
Santos, W., Graham, I., Lalonde, M., Varin, M., & Squires, J. (2022). The effectiveness of
champions in implementing innovations in health care: A systematic review.
Implementation Science Communications, 3(80). https://doi.org/10.1186/s43058-02200315-0
Sarkies, M. N., Bowles, K.-A., Skinner, E. H., Haas, R., Lane, H., & Haines, T. P. (2017).
The effectiveness of research implementation strategies for promoting evidenceinformed policy and management decisions in healthcare: A systematic review.
Implementation Science, 12(132). https://doi.org/10.1186/s13012-017-0662-0
Schatzki, T. (2016). Practice theory as flat ontology. In G. Spaargaren, D. Weenink, & M.
Lamers (Eds.), Practice theory and research: Exploring the dynamics of social life
(pp. 28-42). Routledge.
Schatzki, T. R. (1997). Practices and actions: A Wittgensteinian critique of Bourdieu and
Giddens. Philosophy of the Social Sciences, 27(3), 283-308.
Schmidt, R. (2016). The methodological challenges of practising praxeology. In G.
Spaargaren, D. Weenink, & M. Lamers (Eds.), Practice theory and research:
Exploring the dynamics of social life (pp. 43-59). Routledge.

240
Schouten, L., Hulscher, M., Everdingen, J., Huijsman, R., & Grol, R. (2008). Evidence for
the impact of quality improvement collaboratives: systematic review. BMJ,
336(7659). https://doi.org/10.1136/bmj.39570.749884.BE
Senge, P. M. (1990). The fifth discipline: The art and practice of the learning organization.
Doubleday.
Seymour, C. W., Liu, V. X., Iwashyna, T. J., Brunkhorst, F. M., Rea, T. D., Scherag, A., . . .
Angus, D. C. (2016). Assessment of Clinical Criteria for Sepsis: For the Third
International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA,
315(8), 762-774. https://doi.org/10.1001/jama.2016.0288
Shankar-Hari, M., Phillips, G. S., Levy, M. L., Seymour, C. W., Liu, V. X., Deutschman, C.
S., . . . Singer, M. (2016). Developing a New Definition and Assessing New Clinical
Criteria for Septic Shock: For the Third International Consensus Definitions for
Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 775-787.
https://doi.org/10.1001/jama.2016.0289
Sinfield, P., Donoghue, K., Horobin, A., & Anderson, E. S. (2012). Placing interprofessional
learning at the heart of improving practice: the activities and achievements of
CLAHRC in Leicestershire, Northamptonshire and Rutland. Quality In Primary Care,
20(3), 191-198.
Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., .
. . Angus, D. C. (2016). The third international consensus definitions for sepsis and
septic shock (Sepsis-3). Journal of the American Medical Society, 315(8), 801-810.
Slote Morris, Z., Wooding, S., & Grant, J. (2011). The answer is 17 years, what is the
question: Understanding time lags in translation research. Journal of the Royal
Society of Medicine, 104(12). https://doi.org/10.1258/jrsm.2011.110180
Smith, L. M. (1978). An evolving logic of participant observation, educational ethnography
and other case studies. In L. Shulman (Ed.), Review of research in education.
Peacock.
Society of Critical Care Medicine. (2018). Surviving Sepsis Campaign. Society of Critical
Care Medicine. Retrieved June 30 from http://www.survivingsepsis.org/AboutSSC/Pages/History.aspx

241
Soper, B., Hinrichs, S., Drabble, S., Yaqub, O., Marjanovic, S., Hanney, S., & Nolte, E.
(2015). Delivering the aims of the Collaborations for Leadership in Applied Health
Research and Care: Understanding their strategies and contributions. Health Services
and Delivery Research, 3(25). https://doi.org/10.3310/hsdr03250
Soper, B., Yaqub, O., Hinrichs, S., Marjanovich, S., Drabble, S., Hanney, S., & Nolte, E.
(2013). CLAHRCs in practice: combined knowledge transfer and exchange strategies,
cultural change, and experimentation. Journal Of Health Services Research & Policy,
18(3 Suppl), 53-64. https://doi.org/10.1177/1355819613499903
Spaargaren, G., Weenink, D., & Lamers, M. (Eds.). (2016). Practice theory and research:
Exploring the dynamics of social life. Routledge.
Spoon, D., Rietbergen, T., Huis, A., Heinen, M., van Dijk, M., van Bodegom-Vos, L., & Ista,
E. (2020). Implementation strategies used to implement nursing guidelines in daily
practice: A systematic review. International Journal of Nursing Studies, 111.
https://doi.org/10.1016/j.ijnurstu.2020.103748
Squires, J., Aloisio, L., Grimshaw, J., Bashir, K., Dorrance, K., Coughlin, M., . . . Graham, I.
(2019). Attributes of context relevant to healthcare professionals' use of research
evidence in clinical practice: a multi-study analysis. Implementation Science, 14(52).
Stake, R. E. (2008). Qualitative case studies. In N. K. Denzin & Y. S. Lincoln (Eds.),
Strategies of qualitative inquiry (3 ed., pp. 119-150). Sage Publications.
Stannard, D. (2019). A practical definition of evidence-based practice for nursing. Journal of
PeriAnesthesia Nursing, 34(5), 1080-1084.
Star, S. L., & Griesemer, J. R. (1989). Institutional ecology, "translations" and boundary
objects: Amateurs and professionals in Berkeley's Museum of Vertebrate Zoology,
1907-39. Social Studies of Science, 19(1989), 387-420.
Streubert, H. J., & Carpenter, D. R. (2011). Qualitative research in nursing: advancing the
humanistic imperative (Vol. 5). Lippincott, Williams & Wilkins.
Suman, A., Schaafsma, F., Buchbinder, R., van Tulder, M., & Anema, J. (2017).
Implementation of a multidisciplinary guideline for low back pain: Process-evaluation
among health care professionals. Journal of Occupational Rehabilitation, 27, 422433.

242
Sungkar, Y., Considine, J., & Hutchinson, A. (2018). Implementation of guidelines for sepsis
management in emergency departments: A systematic review. Australasian
Emergency Care, 21, 111-120.
Sweet, D., Marsden, J., Ho, K., Krause, C., & Russell, J. (2012). Emergency management of
sepsis: The simple stuff saves lives. BC Medical Journal, 54(4).
Tashakkori, A., & Teddlie, C. (2010). SAGE handbook of mixed methods in social &
behavioral research (Vol. 2). SAGE Publications.
Tri-Council. (2014). Ethical conduct for research involving human subjects.
www.pre.ethics.gc.ca/eng/policy-politique/initiatives/tcps2-eptc2/Default/
University of British Columbia Department of Emergency Medicine. (2018). Evidence to
Excellence. Department of Emergency Medicine, University of British Columbia.
Retrieved July 1 from http://emergency.med.ubc.ca/professionaldevelopment/evidence-2-excellence/
Urquhart, R., Porter, G., Sargeant, J., Jackson, L., & Grunfeld, E. (2014). Multi-level factors
influence the implementation and use of complex innovations in cancer care: a
multiple case study of synoptic reporting. Implementation Science, 9(121).
Vaughan, J., Jeffery, H., Raynes-Greenow, C., Gordon, A., Hirst, J., Hill, D., & Arbuckle, S.
(2012). A method for developing standardised interactive education for complex
clinical guidelines. BMC Medical Education, 12(108).
Vincent, J.-L., Martin, G. S., & Levy, M. M. (2016). qSOFA does not replace SIRS in the
definition of sepsis. Critical Care, 20.
Votova, K., Laberge, A.-M., Grimshaw, J., & Wilson, B. (2019). Implementation science as a
leadership capability to improve patient outcomes and value in healthcare. Healthcare
Management Forum, 32(6), 307-312.
Waltz, T. J., Powell, B. J., Fernandez, M. E., Abadie, B., & Damschroder, L. J. (2019).
Choosing implementation strategies to address contextual barriers: Diversity in
recommendations and future directions. Implementation Science, 14(42).
https://doi.org/10.1186/s13012-019-0892-4
Watkins, K., Wood, H., Schneider, C., & Clifford, R. (2015). Effectiveness of
implementation strategies for clinical guidelines to community pharmacy: A

243
systematic review. Implementation Science, 10(151). https://doi.org/10.1186/s13012015-0337-7
Wenger, E. (1998). Communities of practice: learning, meaning and identity. University
Press.
Wensing, M. (2017). The tailored implementation in chronic diseases (TCID) project:
Introduction and main findings. Implementation Science, 12(5).
https://doi.org/10.1186/s13012-016-0536-x
Yin, R. K. (2014). Case study research: Design and methods (5 ed.). Sage Publications.
Zamboni, K., Baker, U., Tyagi, M., Schellenberg, J., Hill, Z., & Hanson, C. (2020). How and
under what circumstances do quality improvement collaboratives lead to better
outcomes? A systematic review. Implementation Science, 15(27).
Zhang, Z., Hong, Y., Smischney, N. J., Kuo, H.-P., Tsirigotis, P., Rello, J., . . . Caironi, P.
(2017). Early management of sepsis with emphasis on early goal directed therapy:
AME evidence series 002. Journal Of Thoracic Disease, 9(2), 392-405.
https://doi.org/10.21037/jtd.2017.02.10
Zhou, F., Chandra, K., Sohi, D., Robertson, C., Fraser, J., Scoville, J., . . . Atkinson, P.
(2018). Do guidelines influence emergency department staff behaviours and improve
patient outcomes? Evaluation of a multifaceted intervention for the implementation of
local acute exacerbations of chronic obstructive pulmonary disease guidelines.
Cureus.
Østerlund, C., & Carlile, P. (2005). Relations in Practice: Sorting Through Practice Theories
on Knowledge Sharing in Complex Organizations. Information Society, 21(2), 91107. https://doi.org/10.1080/01972240590925294

244
Appendices

245
Appendix A: Effective Practice and Organization of Care Strategies
The Effective Practice and Organization of Care (EPOC) taxonomy (Cochrane Effective
Practice and Organization of Care, 2015) provides a catalogue of evidence-based
implementation strategies organized into three categories and 22 subcategories/strategies.
The categories are summarized in the table below and can be accessed using the following
link https://epoc.cochrane.org/epoc-taxonomy.

Category: Interventions targeted at healthcare organizations:
•

Organizational culture

Category: Interventions targeted at healthcare workers:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Audit and feedback
Clinical incident reporting
Monitoring the performance of the delivery of healthcare
Communities of practice
Continuous quality improvement
Educational games
Educational materials
Educational meetings
Educational outreach visits, or academic detailing
Clinical practice guidelines
Inter-professional education
Local consensus processes
Local opinion leaders
Managerial supervision
Patient-mediated interventions
Public release of performance data
Reminders
Routine patient-reported outcome measures
Tailored interventions

Interventions targeted at specific types of practice, conditions, or settings
•
•

Health conditions
Practice and setting

246
Appendix B: BC Sepsis Guidelines
The British Columbia Clinical Care Management (CCM) guideline set for sepsis is copied
below from the British Columbia Patient Safety and Quality Council (BCPSQC) website at:
https://bcpsqc.ca/clinical-improvement/sepsis/guidelines (British Columbia Patient Safety
and Quality Council, 2011).
All patients with 2/4 SIRS (HR>90, RR>20, temperature ≥38 ⁰ C or <36⁰ C, altered LOC)
and suspected infection and one of the following will be triaged as a CTAS =2
• Looks unwell
• Age > 65
• Recent surgery
Immunocompromised (AIDS, Chemotherapy, neutropenia,
asplenia, transplant, chronic steroids)
• Chronic illness (diabetes, renal failure, hepatic failure, cancer,
alcoholism, IV drug use)
All patients with 2/4 SIRS and suspected infection (with above risk factor)
• ABG venous lactate measurement within 30 minutes of
presentation to triage should be taken with initial blood
draw and this will require access to a ABG machine with rapid
turnaround time (approximately 30 minutes)
• If initial lactate is elevated have a repeat venous lactate
measurement drawn in next 2-4 hrs
If systolic blood pressure is < 90 mmHg at presentation CTAS =1
• Antibiotics within 1 hr
• Culture before antibiotics
• Second liter of crystalloid started with 1 hr
If initial lactate result is ≥4 mmol/L
• Antibiotics within 1 hr of measurement of elevated lactate
• Culture before antibiotics
• Second liter of crystalloid started with 1 hr of measurement
of elevated lactate
If systolic blood pressure > 90 at presentation and initial lactate is < 4 mmol/L but
patient is admitted to the hospital and received IV antibiotics
• Antibiotics within 3 hrs
• Culture before antibiotics
Note: During the study recent (2016) changes to international sepsis guidelines were
recognized. Given the retrospective nature of the study the 2011 guidelines were used.

247
Appendix C: Participant Data Collection Tool and Interview Guide

248
Participant Personal and Professional Data Collection Tool

Participant name: _____________________

Title: _______________________________

Years in current role: _________

Professional designation(s):_____________________ Since: ______________ (year)
_____________________ Since: ______________ (year)
_____________________ Since: ______________ (year)

Current role description:

Roles since 2011:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Years with organization: _____________

Thank you. I would like to move on now to speak with you about your experience with
implementing the Sepsis Guidelines.

249
Interview Guide

Pre-Interview Reflection: The following interview guide provides a frame for discussion
during individual interviews. Questions are organized to reflect key components of
investigation. Questions phrasing, order and priority may be changed by the researcher to
reflect the participant and situation. Given the study’s focus on implementation inquiry is to
take a largely processual posture drawing out what happened, how it happened, when it
happened and who was involved. Issues identified as attributes or characteristics may be
probed to better understand how these characteristics/attributes arose or became relevant
through the implementation process.
Introduction
•

Describe the purpose of the study with the participant

•

Review principles of confidentiality and confirm consent; signing of consent forms

•

Discuss and seek permission to audio record interview

•

Pause for opportunity for participant to ask questions about process or principles of
participation

Discussion
1. When did the Sepsis Guidelines come to your attention? When would you say
implementation started?
2. Tell me what you thought of the guideline in the first place? What concerns did you have
about them? Did you feel they were shared by others? How were your concerns
resolved?
3. Can you tell me what helped move the implementation forward? What got in the way?
How were challenges addressed?
4. Can you describe how the process of implementation was managed? (Important people?
Important meetings or structures (e.g., committees, team structures, departments)?
Important documents? Other important things?)
5. Can you describe how your team worked to bring about the change? How did people
know their roles in the implementation? Can you describe any challenges that arose?
How were they resolved?

250
6. What other teams did you or others interact with during the implementation process?
Can you tell me when and describe that interaction? (Board? Executive? Support Teams?
Management? BCPSQC or Ministry?)
7. What was it about the involvement with these other teams that you found helpful (and/or
not)?
8. Are there other things you can add regarding the Sepsis Guideline Set implementation
process that would help me better understand what enables or impedes success?
9. How successful has the implementation been? Review process performance and outcome
measures with the participant (RHA and/or site as applicable) and seek
interpretation/comment.
Thank you for participating in the study!
•

•
•
•

Review next steps including:
o Study process steps
o Process re: protection, transcription, retention and destruction of interview
recording
Reinforce willingness to hear and respond if any other input into the study or
concerns about what was discussed today
Turn off tape recording
Thank participant.

251
Appendix D: Interview Consent Form
Interview consent form attached. Select Health pseudonym and obscuring of personal
contact details has been incorporated.

252

INTERVIEW CONSENT FORM
Understanding Knowledge Translation Processes in a Regional Health
Organization
Principal Investigator: Martha MacLeod, Professor, School of Health Sciences, University
of Northern British Columbia
3333 University Way, Prince George, B.C., V2N 4Z9
Contact: Martha.Macleod@unbc.ca and/or (XXX) XXX-XXXX
Co-Investigator:

Fraser Bell, PhD Candidate, School of Health Sciences University
of Northern British Columbia 3333 University Way, Prince George,
B.C., V2N 4Z9
Contact: bellf@unbc.ca and/or (XXX) XXX-XXXX

This study is being conducted toward fulfilment of Fraser Bell’s PhD requirements.
INTRODUCTION
You are being invited to participate in an interview regarding your experience with Sepsis
Guideline implementation at Select Health. You are being invited to take part in this research
study based on your role and/or your experience with the implementation of the Sepsis
Guidelines from 2011 to 2017.
YOUR PARTICIPATION IS VOLUNTARY
Your participation is entirely voluntary, so it is up to you to decide whether or not to take part
in the study. Before you decide it is important for you to understand what the research
involves. This consent form will tell you about the study, why the research is being done,
what will happen if you participate and possible benefits and risks.
If you wish to participate, you will be asked to sign this form. If you do decide to take part in
the study, you are still free to withdraw at any time and without giving any reasons for your
decision. Also, if you do agree to participate you are free not to answer any questions with
which you do not feel comfortable.
If you do not wish to participate, you do not have to provide any reason for your decision.
Your decision will have no negative consequences.
Please take time to read the following information before you decide.

253
STUDY BACKGROUND
In spite of much effort, the health industry continues to face challenges in moving new
clinical knowledge into practice at a substantial scale and pace. All but the simplest of
guidelines require action from many people working in various departments and teams, and
at many levels throughout the organization. Yet there is very limited knowledge about
guideline implementation that recognizes this multi-team, multi-level reality.
WHAT IS THE PURPOSE OF THE STUDY?
The purpose of this research is to gain a better understanding of how regional health
authorities successfully implement clinical guidelines using Sepsis Guidelines as a case
study. The focus of the study is on how various individuals and teams across the organization
work together to bring about a successful implementation. If a better understanding of these
interactive processes can be gained, health organizations may be able to develop better, more
practical implementation supports. The question guiding the research is:
How do individuals and teams with various functions and decision-making levels come
together to implement prioritized clinical guidelines in a Regional Health Organization?
WHO CAN PARTICIPATE IN THE STUDY?
Participants will include individuals who may offer a perspective on the implementation of
the Sepsis Guidelines within Select Health between 2011-2017. Individuals have been
invited to participate based on involvement and/or current or past roles. Participants also
include individuals involved with implementation of the Sepsis Guidelines through the
British Columbia Patient Safety and Quality Council (BCPSQC).
WHO SHOULD NOT PARTICIPATE IN THE STUDY?
As this study looks at implementation of the Sepsis Guidelines between 2011-2017,
individuals who are very new to Select Health would not have the needed historical
perspective.
WHAT DOES THE STUDY INVOLVE?
You are being invited to participate in a research interview based on your role and/or your
experience with the implementation of the Sepsis Guidelines at Select Health. It will take up
to 60 minutes. The interview will be scheduled at a time and location (Select Health office or
meeting room) that is convenient for you. If applicable, arrangements will be made through
Select Health Administration and your manager to obtain permission to participate during
work hours. Select Health has agreed to this as part of the organization’s support of this
research study.

254
If you agree to participate, the Co-Investigator (Fraser Bell) will engage you in conversation
to understand your perspective about how the Sepsis Guidelines were implemented between
2011 and 2017. He will seek to understand the process as you have seen it from the time the
guidelines were published by the British Columbia Patient Safety & Quality Council
(BCPSQC) to today. Because of the study’s focus on team interaction, he will look for your
view on the individuals and teams involved; the roles they played and how and when they
played them. He will also seek to understand how any structures (e.g., committees, tools,
systems, etc.) might have played a role in the implementation from your perspective.
WHAT ARE THE POSSIBLE RISKS OF PARTICIPATING?
Risk of participating is negligible. Social risk such as potential strained relationships or loss
of reputation is unlikely but could arise for participants when addressing aspects of Sepsis
Guideline implementation that were unsuccessful (e.g., failed processes, poor relationships).
This risk will be mitigated by ensuring confidentiality, anonymity and documentation
security. Additionally, the Co-Investigator will discuss with the participant any information
provided that may involve risk. Discussion may involve:
• further probing to understand system aspects of the identified issue (moving away
from personal attributions and/or blame-laying), and/or
• subsequent member-checking to confirm observations, interpretations and to ensure
phrasing mitigates risk.
WHAT ARE THE BENEFITS OF PARTICIPATING IN THIS STUDY?
Participants may not benefit from being in the study, however, many of the participants
involved will have a personal and professional interest in change management and will find
the research discussion useful to their own understanding. Near the end of the study all
participants will receive a summary of key findings. The summary may prove useful in future
implementation efforts.

255
WHAT HAPPENS IF I DECIDE TO WITHDRAW CONSENT TO PARTICIPATE?
Your participation in this research is entirely voluntary. You may withdraw from the study at
any time. If you decide to enter the study and to withdraw at any time in the future, there will
be no penalty or negative consequences for you personally or professionally.
If you choose to enter the study and then decide to withdraw, all data collected during your
participation will be destroyed.
WHAT WILL THE STUDY COST ME?
No costs should be incurred by you through participation in this study. You will not be paid
for participating though where appropriate arrangements will be made with your manager to
obtain permission to participate during work hours.
WILL MY TAKING PART IN THIS STUDY BE KEPT CONFIDENTIAL?
Your confidentiality will be respected. However, research records identifying you may be
inspected in the presence of the Principal Investigator or her designate by representatives of
the Select Health Research Ethics Board for the purpose of monitoring the research. No
information or records that disclose your identity will be published without your consent, nor
will any information or records that disclose your identity be removed or released without
your consent unless required by law.
You will be assigned a unique study number as a participant in this study. Only this number
will be used on any research-related information collected about you during the study, so that
your identity (i.e., your name or any other information that could identify you) as a
participant in this study will be kept confidential. Information that contains your identity will
remain only with the Principal Investigator and/or the Co-Investigator (Fraser Bell). The list
that matches your name to the unique study number that is used on your research-related
information will not be removed or released without your consent unless required by law.
If you consent, the Co-Investigator (Fraser Bell) will audio-record the interview. The
resulting digital file will be uploaded onto a secure server at the University of Northern
British Columbia and accessed through a secure password protected laptop using secure
VMware. The recording will be transferred securely using data encryption for transcription.
The transcription service provider used for this study will be required to sign an agreement of
confidentiality and non-disclosure which includes arrangements for the destruction of study
information once services have been rendered. The recording will be accessible only to
Martha MacLeod, Principal Investigator and Co-Investigator, Fraser Bell. The recording will
be stored as described for a period of 5 years after which time the recording will be
destroyed.

256
WHO CAN I CONTACT WITH ANY QUESTIONS OR CONCERNS?
If you have any questions or desire further information about this part of the study before or
during participation, you can contact Martha MacLeod, Principal Investigator or Fraser Bell,
Co-Investigator using the contact information provided on the first page of this form.
WHO DO I CONTACT IF I HAVE ANY QUESTIONS OR CONCERNS ABOUT MY
RIGHTS AS A PARTICIPANT DURING THIS STUDY?
If you have any concerns or complaints about your rights as a research participant and/or
your experiences while participating in this study, contact the Select Health Research Ethics
Board (REB) Co-Chairs by calling XXX-XXX-XXXX. You may discuss these rights with
one of the Co-Chairs of the Select Health REB.

257
CONSENT TO PARTICIPATE
Your signature below indicates that you have received a copy of this consent form for your
own records. Your signature indicates that you consent to participate in this study.
I have read and understood the participant information and consent form and I am freely
consenting to participate in the study Understanding Knowledge Translation Processes in a
Regional Health Organization.
YES NO
I have had sufficient time to consider the information provided and to ask for advice if
necessary.
YES NO
I have had the opportunity to ask questions and have had satisfactory responses to my
questions.
YES NO
I understand that all the information collected will be kept confidential and that the result will
only be used for scientific objectives.
YES NO
I understand that my participation in this study is voluntary and that I am completely free to
refuse to participate or to withdraw from this study at any time without negative
consequences.
YES NO
I understand that I am not waiving any of my legal rights by signing this consent form.
YES NO
I have been told that I will receive a dated and signed copy of this form.
YES NO

258
I agree to be recorded.
YES NO
The study summary or follow-up information (e.g. transcription) can be sent to me at the
following e-mail or mailing address:
YES NO
Address:

Printed name of Participant:

Signature of Participant:

Printed name of Principal Investigator/CoInvestigator:
Signature of Principal Investigator/CoInvestigator:

Date:

Code (quotes drawn from raw transcribed interview
data – lightly edited for reporting)
“For a lot of us who are Emerg-trained, I feel like it’s
almost automatic. Like, you’ve got your patient, you’ve got
their history and everything like that. You look at it and it’s
just, kind-of, there. I don’t know how else to say it. ‘They
look septic, I think they might be septic, we should start a
protocol.” (ED Nurse)

“The form might not necessarily get put on the chart at
triage, and we don’t necessarily always print the paperwork
out anymore because we all kind-of, like the majority of us
and especially the docs know, like it’s just, ‘cause it’s an old
guideline, you know you get a lot of the experienced docs, a
lot of the experienced nurses and it’s just “this guy sounds
septic, I’ve started the two-litre bolus on him.” We’ve
started it without printing off the paperwork because we just
know, it’s just ingrained. I don’t know how to explain it, it’s
just there.” (ED Nurse)

Raw Data (with code section highlighted)

R: Okay, as far as kind of ongoing, we’ve talked about the in-service so you
now understand how to do it, are there other prompts or other refreshers
or things?
I: Um, for a lot of us, who are like Emerg trained, I almost feel like it’s
almost automatic. Like you’ve got your patient, you’ve got their history
and everything like that and you kind of look at it and it’s just kind of
there. I don’t know how else to say it, like oh, they look septic, or oh I
think they might be septic, we should start a protocol and there’s a lot of
nurses that’ll be like oh hey that guy he doesn’t look very well, what are
his vital signs? Oh, they’re this, oh he looks septic, maybe we should
start the protocol, you know what I mean? There’s just, it’s very, and if
we sometimes as nurses miss it, the doctors will catch it. Like it’s a big
thing. Like that, asthma, DKA, massive transfusion, there’s protocols
that are very much like right there. You just do, for lack of a better
word.

R: Does the form get put on the chart?
I: The form might not necessarily get put on the chart at triage, and we
don’t necessarily always print the paperwork out anymore because we
all kind of, like the majority of us and especially the docs know, like it’s
just, cause it’s an old guideline, you know you get a lot of the
experienced docs, a lot of the experienced nurses and it’s just, ya, this
guy sounds septic, I’ve started the two litre bolus on him, you know,
like we’ve started it without printing off the paperwork because we just
know, it’s just engrained.
R: It’s just the way it happens?
I: I don’t know how to explain it, it’s just there.

Becoming
ingrained

It’s just what
we do

Category

Now it’s
just what we
do

Category

Building
competence

Theme

Appendix E: Examples of Coding Method and Flow
This appendix provides examples of the study coding method and flow stemming from raw data extracted from interview transcripts
and documents. All categories attached to codes in this example relate, with other codes and categories, to a theme Building
Competence within the overarching theme: Learning, Becoming Competent conveying the Sepsis Clinical Practice Guideline from the
perspective of the Academic, Advocacy and Policy group/community of practice (excerpt from Chapter 7).

259

“I wouldn’t say the in-services. I guess it’s just nursing
theory as well. I’m sure that we learned this in the
emergency course as well. Maybe that’s something I
should have mentioned before. It’s a big focus when we
do in our emergency training.” (ED Nurse)

“It came to my attention probably, like, 2009, 2010,
during my residency.” (ED Physician)

It depends where you are. And if I’m at triage, then they’ll get a CTAS 2,
they need to be seen quite quickly. You communicate to the next staff to
implement fluids, early antibiotics, those are probably the two mainstays.
And then if I’m in an acute bed and I receive a patient that meets that
criteria then implementing the same thing, communication with a doctor
quite quickly. I’d say here we treat it very urgently which is what we
should be doing. Sepsis kills.
R: So how do you know that? You know that all because of one 15 minute,
I’m trying to understand how does this?
I: So not, I wouldn’t say the in-services, I mean I guess it’s just nursing
theory as well. I’m sure that we learned this in the emergency course as
well. Maybe that’s something I should’ve mentioned before, it’s a big
focus when we do our Emergency training. So maybe that was one of the
differences too when I’m thinking back. When I mentioned that my first
year and a half, two years were, it seems foggy and then I remembered
sort of an increase in my knowledge around Sepsis so it was probably
my Emergency training. And then when I did the ICU training, once
again it was constantly revisited quite a bit.

R: Can you describe the Surviving Sepsis campaign, what are you referring
to then and what timeframe was that and what were you seeing then?
I: So you know, it’s hard to, I don’t know when it originally started. It
came to my attention probably like 2009, 2010 during my residency. The
Surviving Sepsis campaign I think it’s an American campaign, uh, so I
believe it’s part of Society of Critical Care Medicine and they came out
with things like Sepsis bundles with the idea that Sepsis care is
something that could be improved upon.

I:

Coming to my
attention

Part of
emergency
training

From when
I was a
student

Building
competence

260

261
Appendix F: Missing Guideline Set Implementation Process Activities
Missing Activity
Review of research
evidence and regional
and local implications

“Research culture” at
Select Health

Case Study Examples
Regional management and support, and clinical participants largely relied on the
leads of the E2E network for their assessment of the rigour and clinical
implications of the research evidence. Participants noted that prioritization of the
Sepsis Guideline Set for regional implementation was not based on an assessment
of the RHA or any site’s potential for significant improvement in outcome. This
process is named “evidence to outcome assessment in this dissertation.”
Clinical participants noted that the Emergency Department team seldom engaged
in research. Participants believed that engagement with research predisposes
clinicians to experiment with changes in practice to see if outcomes can be
improved. Lack of such involvement was believed to have led to a low tolerance
for change – including the use of new tools such as pre-printed orders.

Interprofessional
forums to enable
academic, regional
management and
support, and clinical
participants to engage
with the evidence and
implementation process

Clinical participants recognized that their learning and professional development
activities during the Sepsis Guideline Set implementation were divided along
professional (nurse, physician) lines that seldom intersected. Participants noted
that this led to a lack of knowledge of each others’ thoughts or concerns about the
guidelines or how to implement them. Similarly, regional management and support
participants tended to engage with clinical participants along professional lines and
only sporadically. Academic participants engaged primarily with designated Select
Health leads.

Analysis and practical
resolution of workflow
issues related to Sepsis
Guideline Set
implementation

Clinical participants noted that limited patient time with the triage nurse, and
inability to attend to all potentially septic patients in the most appropriate
Emergency Department space due to Department congestion challenged stringent
adherence to the guidelines. Most strikingly, a workflow was not established
within the Department to ensure that the pre-printed order sheet was placed
prominently in the chart of all suspected septic patients. Some participants also
noted challenges and a lack of clarity regarding expectations and process for
handing over potential sepsis patients between clinicians at when work shifts
changed.

Bundling of guidelines
or parts of guidelines
by regional
management and
support or clinical
participants to improve
use or effectiveness of
implementation
Automation of
diagnostic or care tools

Staffing adjustments to
reflect changes in
workload indicated by
the guidelines

Some clinical participants argued that three conditions – stroke, STEMI (heart
attack) and sepsis might have been considered for implementation together, as
conditions most requiring rapid response in the Emergency Department. Bundling
of these conditions for implementation might have led to greater efficiency, and
awareness of each, and reduced the impression amongst clinical participants that
the three were in competition for implementation resources. Public awareness was
high for stroke and heart attack, leaving clinical participants to feel that sepsis was
of lower priority than these two conditions.
Streamlining and support of workflow can be accomplished through the use of
digital and other technologies. In this case, while some early experimental
automation enabled Sepsis case identification, further maturation of automation
did not follow this early work-around effort.
The Sepsis Guideline Set specified intensive clinical monitoring for patients
suspected to have sepsis. Many study participants noted that the pre-Sepsis-3
definitions led to high volumes of suspected cases, with many false positives.
Review and change of Emergency Departments resourcing was not conducted by
management to ensure adequate staff/physician time to effectively achieve the
aggregate work of the department, taking into consideration the requirements of
practice expectations set out in standards and guidelines. Without this review and
change, clinical participants deemed the practice expectations to be impractical.