Introduction

Osteoporosis is associated with increased morbidity and mortality and decreased quality of life. [1, 2] Osteoporosis care reduces risk of future fractures by about 50%. [3, 4] Regardless, fewer than 20% of adults, 50 years of age and older, are tested or treated for osteoporosis after a low-trauma fragility fracture [3, 4] generating a substantial and unwarranted “care gap.” Fracture liaison services (FLS) are an evidence-based and effective approach to secondary fracture prevention utilizing a 3i approach to secondary fracture prevention (i.e., Identify those at risk, Investigate using bone mineral density tests, and Initiate appropriate treatment when needed). [5,6,7]

The FLS model has been found effective for secondary fracture prevention in Canada and internationally [7, 8]. Despite promotion of FLS with a best practice framework by the International Osteoporosis Foundation [6, 9] and advocacy by Osteoporosis Canada [7], implementation of a coordinator-based post-fracture model of care is not without barriers. Implementing change can be difficult. Implementation outcomes serve as indicators of implementation success and, when implementation is successful, are the effects of purposeful and deliberate actions to implement new treatments, practices, and services [10]. When a newly implemented healthcare innovation fails to achieve the expected benefits, it is often attributable to ineffective implementation rather than issue with the innovation itself [11]. Challenges can emerge from individual and organizational factors and obstacles in the local environment [11,12,13]. Therefore, understanding the context in which implementation occurs can shed light on the implementation outcomes.

Rogers’ diffusion of innovations theory [14] proposed categories to describe the adoption of innovations. Innovators and early adopters lead the way, followed by the early and late majority, and finally the laggards take up the innovation. When implementing a new healthcare service, investigating the experience of the early adopters can help to identify the facilitators and barriers to implementation and provide valuable lessons learned ahead of the spread of the innovation through the rest of the system.

As part of an ongoing collaboration to improve secondary fracture prevention in Alberta, the Bone and Joint Health Strategic Clinical Network (BJH SCN), Alberta Health Services (AHS), and the Alberta Bone and Joint Health Institute (ABJHI) partnered with 2 hospital sites to implement a Type A [15] FLS. In brief, the FLS identified patients age 50 or older with a hip fracture within the hospital setting, commenced appropriate osteoporosis care, bridged the acute-to-post-acute period and the return to pre-fracture living environment, and, finally, transitioned care back to the family physician. The FLS utilized the expertise and continuity of clinical nurses and a physician at each site to serve as a common source of information and connection to the healthcare system, with the clinical nurses following patients for 1-year following the hip fracture. In advance of broader service rollout, we assessed the 2 early adopter sites to understand the context in which the FLS was implemented, including readiness to implement change as well as facilitators and barriers to implementation, to inform its potential spread provincially (Fig. 1).

Fig. 1
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Perspectives represented by participants when commenting on the context in which the H-FLS was implemented. (Note: Due to rounding error, percentages do not equal 100)

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Methods

This qualitative study was situated as part of a larger comprehensive, pragmatic mixed-methods evaluation of three secondary fracture prevention initiatives in Alberta, Canada. Focused on the implementation of FLS, in this study, we conducted a qualitative contextual assessment of the service as it unfolded naturally at two early adopter sites. The qualitative design allowed us to elicit and understand the experience and perceptions of individuals directly involved in FLS implementation and service delivery.

Data collection

We used purposeful and snowball sampling to identify key informants with knowledge of the implementation and/or a clinical role in the FLS at the provincial level and at the two sites. Potential key informants were identified in collaboration with the Fragility and Stability Program Manager and the Unit Managers at each site, who also sent an introductory email about the study. Interested participants contacted the research team by telephone or email with questions and to arrange participation. Participants were invited to participate in telephone interviews at 2 time points: at baseline during the initial implementation phase and at approximately 16 months post-implementation. In addition, participants were asked to identify other individuals with knowledge of the FLS; newly identified individuals were invited to participate in the study using the same strategy outlined above. Lastly, individuals at the site level who participated in baseline interviews were invited to complete the Organizational Readiness for Implementing Change (ORIC) tool [13]. ORIC is a 10-item tool which measures readiness for change on a 5-point Likert scale and includes the sub-domains of change commitment and change efficacy. Participants received the ORIC questionnaire by email following their baseline interview, with instructions to complete and return the questionnaire.

A trained researcher (LAW) conducted the telephone interviews using semi-structured interview guides at baseline and post-implementation (Online Resource). The interview guides were refined as data analysis progressed. Interviews lasted up to 90 min. Interviews were digitally recorded and transcribed for subsequent analysis and verified for accuracy. The study received Research Ethics Board approval from the Universities of Alberta and Calgary and all participants provided written informed consent.

Data analysis

We used thematic analysis [16, 17] to analyze the data. One researcher (LAW) identified emerging codes and concepts and discussed with the study lead (HMH). The research team held regular meetings to review code definitions, emerging concepts, and memos and discussed discrepancies to reach consensus. We conducted data collection and analysis until thematic (and role) saturation was achieved [18] as was appropriate based on the design and objective of the study [19]. Qualitative data were managed and analyzed using ATLAS.ti Version 7 [20]. Descriptive statistics were conducted for the ORIC questionnaire, with data entered and managed using SPSS Statistics for Windows Version 25 [21]. Total and sub-scale scores were calculated by the sum across items. Guided by the questionnaire response scale anchors, we categorized participant scores as low (10–29), neutral (30–39), or high (40–50), with higher scores representing more favorable Organizational Readiness for Implementing Change through the FLS. We implemented several strategies throughout the research process to ensure rigor including methodological coherence [22], peer debriefing [23], and maintaining an audit trail [23]. In addition, we synthesized and presented the findings using thematic statements, which is a strategy to make findings clear and actionable. [24]

Results

In total, we conducted 33 semi-structured telephone interviews with 21 key informants at the 2 time points. We conducted 20 baseline interviews between July 2015 and January 2016, and 13 post-implementation interviews between October 2016 and March 2017. Participants represented a variety of roles, including managers (24%), FLS team members (i.e., physicians and nurses) (19%), those in leadership or operational roles (19%), physicians or surgeons (14%), pharmacists (10%), nurse practitioners (10%), and social work (5%). Of those who participated in a baseline interview, 18 were invited to complete the ORIC, 17 of which returned the questionnaire. Two participants were not eligible to complete a questionnaire due to their role or because they did not participate at baseline and 1 participant was unresponsive. All 17 participants who completed the questionnaire scored their organization’s readiness to implement change as high or neutral. There was no difference in ORIC scores between the two sites (t (15) = − 0.62, p = 0.54). We provide a summary of the participant characteristics and ORIC scores in Tables 1 and 2.

Table 1 Organizational Readiness for Implementing Change (ORIC) scores
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Table 2 Examples of participant quotes in support of identified themes
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Three major themes emerged. First, the FLS was implemented using several strategies that were essential to implementation success, particularly in the context of change fatigue. Second, participants perceived the FLS as acceptable in meeting the needs of this patient population. Third, there was clear evidence of facilitated learning that went beyond monitoring implementation of the FLS as intended. We detail each thematic statement below. We provide a list of codes, sub-codes, and additional quotes for each statement in Table 2. For all quotes, we included the study ID number for each participant.

Theme 1—Use of strategies in the context of change fatigue

There was evidence that the FLS was implemented at the two sites through the use of strategies that were vital to successful implementation, particularly within the context of reported change fatigue. This included demonstrating the need or value of the service, providing the necessary resources to implement it, and selecting appropriate sites. Demonstrating the need for or value of the FLS involved communicating the benefits of the service for patients and/or healthcare providers. One participant commented on communicating the value of FLS,

I think if you are able to convey the need and provide the evidence and help people understand there a significant care gap. Even though this is an additional program and additional step…people are willing to come on board and be enthusiastic to support the program (Site 2, Participant 3).

In addition, many participants indicated at baseline that the target patient population (i.e., hip fracture patients and/or seniors) had become a priority (e.g., identified by the BJH SCN and ABJHI as a priority, identified by AHS as a care gap in osteoporosis, and the introduction of senior-friendly initiatives). Another important strategy was providing the resources (i.e., human and/or financial) needed to implement the FLS, thereby not increasing the existing workload of others. Participants commented on the need to be mindful of staff workloads with comments such as,

I don’t think that the FLS is adding on to anyone else’s workload. If anything I think it’s helping other people’s work load so I think that’s a key thing with this initiative, we’re not piling anything onto anyone else (Site 1, Participant 1).

It’s a fairly non-invasive program. It’s not one that demands a lot of buy in or extra work from the staff on the ground level (Site 2, Participant 8).

However, some participants reported some role confusion at baseline, such as concerns over duplication of services or territorial issues. In addition, there were some concerns regarding the workload and coverage for the FLS physician and clinical nurse. Finally, appropriate site selection appeared to have been another important strategy used in implementing the FLS. This included partnering with sites with high change commitment and change efficacy as demonstrated by their ORIC scores, where participants scored their sites’ readiness to implement change as high (71%) or neutral (29%) at baseline, and as reported by participants during interviews. For example, participants described the people or sites involved as “early adopters” or as having a culture open to change. In speaking of the culture of openness to new ideas, one participant described the site as follows,

It’s the people. The administration team at the [site] was all for it. Let’s go for it…. it’s just a group that’s open and willing to look at something or introduce something or participate in something when they know it could be of benefit to the patient (Site 2, Participant 7).

Commitment to the patient population or content area was also identified as a facilitator to successful implementation, as was the importance of having champions of the service to support communication and implementation, as well as having learned from previous experiences with change and applying those learnings to the implementation of the FLS. In the following quotation, a participant described the learning process,

It's been foundational to how FLS has been designed from the get go. We’ve borrowed very heavily from past experience on implementing the [care pathway] and implementing [2i model for secondary fracture prevention]. All of these programs have influenced how we designed and rolled out the FLS right from site selection to the fact that we’re doing a staged roll out, through to how we communicate, how we engage with our stakeholders, or how we even organized the content development and delivery of this program (Provincial Stakeholder, Participant 2).

Of note, several participants described change fatigue independent of the FLS, including the introduction of several pilot programs and/or new initiatives related to the hip fracture patient population over a relatively short period of time. Regardless of the amount of change experienced, participants did not believe that change fatigue was/would be a barrier to implementing the FLS, often citing the strategies outlined above as the rationale for this opinion. The following participant commented,

In AHS, we are used to change so I don’t think it would have much of an influence. I think people would be accepting of a new service like FLS (Site 2, Participant 4).

Theme 2—Perceived acceptability of the FLS

Participants involved in the implementation and delivery of the FLS perceived it to be acceptable. That is, they had a clear understanding of its intent, believed it was aligned with organizational values, and appreciated that it was evidence-based but tailored to their local context. Participants described a clear and consistent understanding of the intent of the FLS related to the 3i model of “Identify” eligible patients, “Investigate,” and “Initiate” treatment, mainly medication, with the purpose of secondary prevention of fractures or falls or to bridge a care gap. In addition, many participants identified the transition of patients back to primary care, including sharing clinical information, as a key part of the FLS. In describing the letter sent to the primary care physician of FLS patients, this participant identifies communication of the occurrence of a fracture and the tests and treatments initiated as being of potential benefit to the patient’s continuing care,

And then in respect to communications with transitions, the FLS does provide communications to the family physicians which I would think that they would appreciate it. I think sometimes they are surprised to hear that their patient has been in the hospital with a hip fracture, that they find out months later and then are kind of left wondering what to do. And here we are sending them a letter saying, “your patient has had a hip fracture and this is some of the things that we’ve done… we’ve started this medication, we’re doing these investigations”, to help them out because they may not often be comfortable with orthopedic care or osteoporosis management (Site 1, Participant 1).

Of note, several participants indicated that the scope of the FLS was either intended to move beyond or had expanded beyond the 3i model, with a focus on medication initiation, to include identification of geriatric syndromes or issues (e.g., fall risk, urinary incontinence, dementia, and swallowing dysfunctions) with referral (or triage or red flagging) to additional services (e.g., geriatric unit in hospital or community, fall prevention program in community, home care, or osteoporosis clinics). The following participant described the broader focus,

We decided to make ours a little bit broader in the sense that we didn’t want it just to be a medication type program. We also wanted to include some aspects of geriatric care because of the model that we developed and we were using care of the elderly physicians. So that was another piece to it. So we expanded the scope to include having physicians to start to identify those underlined geriatric syndromes that may be contributing to the fall initially. And then we also obviously deal with the osteoporosis medication and treatment piece of it but there is that added geriatric component (Provincial Stakeholder, Participant 1).

In addition, participants indicated that the FLS was aligned with organizational values including providing patient-centered care and using a collaborative or multi-disciplinary approach, as described by these patients,

It certainly helps to provide that greater education for patients so that then they can make informed decisions; patients and families and then their wants. We are also having to be patient centered, so giving them the options with the risks and benefits and then respecting whichever choice they choose to make (Site 1, Participant 4).

We are very collaborative multidisciplinary team including rehab, PT [Physical Therapy], OT [Occupational Therapy], the transition coordinator, pharmacy, the clinical associate/physician, and our FLS [clinical nurse]. We work together collaboratively to try to make sure that we are placing not just fractured hip patients but all of our patients on the right [path of care] (Site 1, Participant 9).

Lastly, participants appreciated that the FLS was evidence based and/or informed by Alberta-based experts,

The evidence base for this program is very strong. We are not testing an unproven method here. We’re actually applying strong evidence that we know works. So this is one of those few areas in health care where there’s not a lot of controversy and not a lot of dispute over the value of this program. That’s a very unique situation. Most of our programs, they’re far greyer in terms of the economic and quality of impact on health service delivery. Here we’ve got pretty cut and dried strong evidence based, a lot of that evidence also is made in Alberta. We’ve got lots of research history in this area here in Alberta (Provincial Stakeholder, Participant 2).

Further, participants appreciated that they were able to build from the evidence base for the service but that they were able to tailor implementation of the service to the site-level context, and recommended this approach to the spread of the FLS service to future sites within the province. The following participant quotation describes the approach taken to tailor implementation,

A little bit of negotiation, in terms of “here's what we're doing, how does it fit into your model?” Because, you know, each of the sites is different…I really relied on those site leads to tell me what makes sense at their hospital site (Provincial Stakeholder, Participant 1).

Theme 3—Evidence of facilitated learning, not merely monitoring implementation

There was clear evidence of facilitated learning in the implementation and delivery of the FLS at the 2 sites. This was demonstrated by a willingness to share and accept lessons learned during FLS implementation and the establishment of a provincial FLS steering committee. Participants reported a willingness of people to share, accept, and apply lessons learned about the FLS during its implementation, particularly from the first early adopter site to the second site that was afforded by the staggered implementation timing. One participant spoke of the value of being able to draw on the experience of the team at the first beta site,

She’s [the FLS Nurse at the first beta site] hugely supportive and had lots of really good tips for me for when I started. And when I started I could call her and say, “Ah, what do you do for this or that” and so lots of support that way (Site 2, Participant 5).

In addition, several participants offered or recommended that new sites, if the FLS is spread, should draw upon their experiences and expertise, including mentorship for FLS teams, promoting the program to interested sites, providing resources and tools (e.g., assessment format, medical algorithms), and offering opportunities for networking to share experiences. In addition, a few participants reported the establishment of a provincial steering committee to facilitate learning throughout the life of the service, beyond merely ensuring implementation unfolded as intended. One participant commented on the benefits of the steering committee as including peer sharing and the opportunity to discuss standardization,

There’s now been developed an FLS committee province-wide. So now we have other peers to run through decision-making with, and there are lots of decisions where we decide, okay, we’re going to make this standardized between the teams. So that helps, having colleagues. Also, some of the local resources for osteoporosis care, but it’s hard to program, like, the nuts and bolts (Site 1, Participant 3).

Other participants commented that activities of the steering committee could include the following: the development of an orientation and training program (e.g., trainers and materials developed/formalized); providing shadowing opportunities with an FLS clinical nurse, a toolkit for processes, and a list of physical/equipment requirements (e.g., office space, fax machine); and database training. Facilitated learning supported FLS implementation at the 2 early adopter sites.

Discussion

In this qualitative study examining the context in which a FLS was implemented at two early adopter sites, participants described a favorable implementation environment and had positive views of organizational readiness for implementing this change. An effective change management approach, including the use of effective strategies, the perceived acceptability of the service, and facilitated learning, neutralized change fatigue. Indeed, others can learn from this Alberta-based experience when implementing or spreading health interventions.

Participants demonstrated a clear understanding of the intent of the 3i model for post-fracture osteoporosis care. They perceived the FLS to be an acceptable approach for meeting the needs of hip fracture patients. Perceived acceptability of the FLS is an important facilitator for implementation, because modifications to the way in which care is organized has been identified as challenging in healthcare settings [25]. The attribute of acceptability is one of six identified dimensions of health service quality [26] and has been conceptualized as an implementation outcome [10]. Acceptability of the FLS contributed to the context of its successful implementation. Participants’ views of the acceptability of the FLS speak to the overall intent of the FLS as meeting the needs of older hip fracture patients.

Related to participants’ perceptions of acceptability of the FLS was their reported appreciation of the ability to tailor the service to their local site. Adaptation of the FLS to the local context was identified by Osteoporosis Canada as a strategy for the implementation of FLS [7]. The ability to fine-tune the FLS was facilitated by the learning orientation of the early adopter sites, which has been identified as an antecedent for implementation effectiveness [11]. The willingness to learn from the experience of others allowed sites to reflect on what had been done elsewhere and the potential suitability for their site. Teams actively participated in sharing their experiences and accepting suggestions from others. This transferability of learnings from elsewhere positively contributed to the context in which the FLS was implemented. The continued facilitation of a culture of learning will be essential to the successful spread of the FLS, and potentially other interventions for this patient population, provincially.

FLS implementation sponsors could consider using change readiness assessment tools, such as the ORIC, to inform the strategic selection of future sites to implement and spread the FLS, or any other intervention. For instance, an assessment tool could be used to identify and select sites with a culture of innovation or early adoption, similar to the sites in this study. The assessment tools could also assist in identifying committed individuals at the site level to act as champions of the innovation advocating for and assisting with the implementation process. As such, the implementation or spread of interventions, like the FLS, would be strategic by selecting early adopter sites until a “tipping point” of acceptance was reached, where late majority and laggards sites would be more likely to implement an intervention and succeed.

Participants were overwhelmingly positive in their perceptions of the implementation at their site. The interview guide did ask about barriers and challenges to implementation, and we used within interview discussion prompts to elicit feedback on the challenging aspects or obstacles to implementation to inform future roll-out. Despite explicitly asking for comments on such implementation barriers, we did not hear substantial criticism or negative feedback from participants. The predominantly positive orientation of participants reinforces the perspective that the initial selection these two sites as early adopters was correct. The organizational and team composition was ready and willing to implement the FLS at their site.

This study is not without limitations. First, we purposively invited participation from those with knowledge of and/or a clinical role in the FLS at the two early adopter sites. We also used a snowball recruitment strategy to identify any additional individuals whom participants felt would be appropriate for inclusion. This strategy provided us with a pool of individuals informed about the FLS and its implementation. It is possible, however, that our recruitment did not capture any detractors on the periphery of the service, people who might negatively view or influence implementation of the FLS. Second, we quantitatively assessed preparedness for implementing organizational change at baseline using the ORIC tool. We did not quantitatively assess perceptions of change at follow-up. Future studies might wish to investigate perceptions of change both before and following implementation to determine how the organizational context for the change may wax or wane with time.

Nonetheless, this study provides valuable insights into the context in which the FLS was implemented at two early adopter sites in Alberta. Participants in this study described how the strategies that helped to counteract change fatigue, the perceived acceptability of the service, and the incorporation of lessons learned aided in the successful implementation of the FLS. This study sheds light on the successful implementation context and readiness to implement change that unfolded at two early adopter sites and informs the subsequent wide-spread provincial implementation. The implementation approach bodes well for the potential spread of the FLS provincially if proven clinically and cost effective.