Abstract
Background: Literature indicates that patient-centered goal-setting is a crucial component of integrated care for people after a stroke. Despite this evidence, it is not routinely implemented in practice.
There is a need for an improvement program on goal setting to implement the process of goal-setting in the care of people after a stroke. Such an improvement program should contain the process of goal setting and different strategies to overcome possible barriers of its implementation.
Objectives: To develop an improvement program for the implementation of patient-centered goal-setting in the care of people after a stroke.
Method: We used a realist paradigm-inspired design science methodology to develop an improvement program. The design team consisted of ten transdisciplinary (from acute care to first line care) experts: physician (N=1), nurse specialist (N=1), healthcare manager (N=1) physiotherapists (N=2), speech therapist (N=1), researchers (N=3) and occupational therapist (N=1), from four different Belgian stroke care facilities (CUSL, UZLeuven, Noorderhart en Jessa hospital) and one academic institute (UHasselt). First, the goal-setting process was designed by systematically screening the literature and experts' opinions. Feasibility of the preliminary process was evaluated in a multidisciplinary team (N=83), followed by a final selection of the different items to be included in the goal-setting process. Second, based on the COM-B model, a program theory was developed following the identification of possible barriers and facilitators to implementation. Context-Mechanism-Outcome (CMO) configurations were suggested based on the barriers and facilitators. These CMO configurations were aggregated in an overarching program theory. In the final step, implementation strategies (based on the Expert Recommendations for Implementing Change strategies framework) were selected and developed.
Results: The selected improvement program consisted of six domains: patient evaluation, informed patient, collective decision, goal-oriented therapy, (re)-evaluation of goals, and inter-and transmural care. Based on barriers and facilitators of those domains, nine CMO configurations and its corresponding implementation strategies were further developed. Barriers include among others limitation of knowledge, no systematic registration, lack of motivation and willingness to change daily practice and constriction of patients characteristics. Implementation strategies consisted of 1) education and training of professionals and patients, 2) development of tools by establishing a care path and standardized evaluation process, 3) organizational (re)design using quality monitoring systems, and 4) social (re)design consisting of environmental restructuring and building a coalition.
In the next phase of this project, the improvement program and program theory will be evaluated and refined using a realist evaluation approach.