Encouraging Best Practice in Residential Aged Care Program: Final Evaluation Report

3.2 - Implementation delays

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In any project there will always be changes to the sequence and scale of what takes place, when compared against initial plans, some of which may constitute a ‘delay’. Some project activities (e.g. obtaining approval from an ethics committee) may take longer than anticipated but not delay implementation. Some delays will be minor with an impact that is difficult to gauge.

Delays in implementation tended to occur during the initial ‘establishment’ phase because of under-estimating how long it would take to recruit staff, prepare materials, conduct audits, obtain ethics approvals or similar activities:
Things took longer at the beginning to really get rolling in terms of identifying the issues and then waiting for the base line reports to be finished so you could see what the data was saying. So it really slowed down. (P)
There was a lot more work in translating the guidelines than I think people thought there would be. (P)
Projects that involved environmental modifications experienced delays either in deciding what changes to make or actually making the changes, sometimes due to the need to identify a source of funding for the modifications. With some projects it was more a case of delays throughout the project cycle or delays with what was taking place in the facilities:
Every step of the project is taking more time than expected as we think of better ways to do things and we consult more professionals than originally planned. (T2)
Almost all facilities have taken longer than anticipated to identify, plan and implement their interventions. (T3)
Two projects experience significant delays due to the need to work with state-based health services: in one case to ensure compatibility of medical record numbers, in another case to obtain permission to use a particular audit tool. Table 5 summaries the more substantial delays that affected implementation.

Table 5 Delays in implementation

Project	Delays in implementation and reasons for those delays
1	One facility withdrew early on, which required considerable time and effort to replace (the project had the minimum number of facilities allowable). Difficulty recruiting nurse educators slowed progress in delivering the education program, although not to any great extent. Gaining ethics approval was time consuming due to the complex process of obtaining multiple ethics committee approvals across three states, resulting in a delay of 1-2 months in commencing data collection. Active involvement of one facility delayed by accreditation visit and outbreak of gastroenteritis.
2	Various issues in one facility resulted in temporary withdrawal of that facility from the project, rejoining later on and undertaking activities as originally planned. Almost all facilities took longer to identify, plan and implement interventions than anticipated. Some delays in ordering and obtaining equipment. Delay in commencing implementation in pilot facility due to delay in obtaining ethics approval.
3	Ethics approval and completion of baseline audits (to inform the action plans of each facility) took longer than anticipated. Resulted in one month delay in commencing action research meetings. Environmental modifications took longer than anticipated due to difficulty deciding which modifications to implement and the time taken to obtain quotes for the modifications.
4	Every step of the project took longer than anticipated due to constant refinement and greater consultation than originally planned. Delays in purchasing products resulted in reduced period of implementation in two facilities.
5	The project accumulated a delay of about one month in the first nine months due to various project establishment issues, including delays in obtaining ethics approval, baseline data collection being more time consuming than expected and the need to re-schedule education of staff to avoid accreditation visits. By the time the delivery of the final (of three) education modules commenced the project was back on schedule.
6	Unpredictable issues in some facilities (e.g. illness outbreaks, media attention) resulted in implementation activities being shortened and postponed, with fewer staff available to participate.
7	A web portal maintained by the project team took about six months longer to develop than originally anticipated and when it did become operational staff found it difficult to use. This meant that for over half the project there was a reliance on paper-based systems for collecting data, rather than using the web portal.
8	Delayed implementation of an end-of-life care pathway in one state due to issues around compatibility of medical record numbers with state health services. This delay meant that an evaluation of the acceptability of the pathway did not take place. Delay also occurred due to the need to negotiate a reasonable price for using the Respecting Patient Choices approach to advance care planning.
9	Departure of project manager and general practitioner resulted in some delays in project establishment phase. Delay in developing the educational resources for 1:1 education, with the result that delivery of the education did not commence until early 2010, several months later than initially planned.
10	It took longer than anticipated to translate the clinical guidelines into a form that could be used during the project. Recruitment of residents and families took longer than anticipated because of additional assistance required for staff to identify eligible residents and competing priorities e.g. accreditation and ACFI audits. Period of implementation in each facility reduced from 12 months to 9 months.
11	Delays due to Christmas holiday period soon after project commenced. Finalisation (with DoHA) of project plan, evaluation plan and communication and marketing plan took longer than anticipated. Changes in facility staffing and accreditation visits delayed initial engagement of some facilities.
12	Took longer than anticipated to prepare for staff training, assessments and mentoring, resulting in delay in preparing materials for family support groups, hence such groups started late. Environmental modifications took longer than anticipated. Data collection and analysis took longer than anticipated, resulting in delays feeding back audit results to staff.
13	Originally planned to use environmental assessment tool developed in Victoria but there was a delay in getting approval to use the tool from the Victorian Department of Human Services. Decision made to use another tool (the Environmental Audit Tool) but this resulted in a delay in conducting the initial audits, putting back the time period for environmental modifications by six months. When the environmental modifications did start it took longer than anticipated due to the time taken to make decisions about what modifications to make. Use of policy audit delayed due to time taken to develop suitable tool.

In summary, the delays in implementation experienced by projects would not be considered unusual in a program of this scale and complexity.
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