Explicating the work of regional leads in implementing at scale: a qualitative study of the perinatal optimisation care pathway

Background Spread and scale-up of evidence-based interventions in healthcare is complex, given the challenges of different contexts, networks of interactions and collaborative processes in healthcare delivery. Quality Improvement Collaboratives (QICs) provide a multi-organisational structured approach to improvement. However, the current evidence base underpinning QICs effectiveness is still limited and effectiveness appears strongly bound to context. Seeing scale-up and spread as a social practice, this paper explores the work of Patient Safety Collaboratives (PSC) in England that support implementation of a nationally mandated perinatal optimisation care bundle. Methods The PremPath study explored implementation of perinatal optimisation at scale across different regions within England. We report from the first work package, comprising scoping interviews with 40 strategic leads from across Patient Safety Collaboratives (PSCs) in England who support implementation and quality improvement of perinatal optimisation. Analysis drew on the constant comparison method and Normalisation Process Theory (NPT) to explore implementation activities and contextual challenges. Results Findings demonstrate cognitive participation as a key feature of the improvement work undertaken at regional level. This entailed bringing healthcare staff together into a multi-disciplinary community of practice focused on the pathway. Data work underpinned efforts to identify priorities for improvement and track progress. However, fluctuations in performance contrasted with the ideal of continuous improvement. Regional leaders identified turbulence in the context of maternity and neonatal care as contributory factors to fluctuations. Our work highlights, for regional leads, the hidden emotional work and micropolitics of engaging clinical staff in communities of practice and shifts attention from individual implementation efforts to the broader context of maternity and neonatal care, which presented as dynamic, unstable and already crowded with other improvement priorities. Conclusions Our findings provide an overview of the landscape of perinatal optimisation at regional level in England, helping to open up the ‘black box’ of collaborative efforts managed via national PSCs. Our work highlights the significance of the micropolitical dimensions of regional leads’ improvement work, and raises questions around how best to ensure sustainability of change given the current inelasticity of the implementation environment of maternity and neonatal care.