Implementation of the national Getting it Right First Time orthopaedic programme in England: a qualitative case study analysis.

Objective: To describe the implementation and impact of the Getting it Right First Time (GIRFT) national orthopaedic improvement programme at the level of individual National Health Service (NHS) Trusts.

Design: Qualitative case studies conducted at six NHS Trusts, as part of a mixed-methods evaluation of GIRFT.

Setting: NHS elective orthopaedic surgery in England.

Participants: 59 NHS staff.

Intervention: Improvement bundle, including bespoke routine performance data and improvement recommendations for each organisation, delivered via 'deep-dive' visits to NHS Trusts by a senior orthopaedic clinician.

Results: Although all case study sites had made improvements to care, very few of these were reportedly a direct consequence of GIRFT. A range of factors, operating at three different levels, influenced their ability to implement GIRFT recommendations: at the level of the orthopaedic team (micro-eg, how individuals perceived the intervention); the wider Trust (meso-eg, competition for theatre/bed space) and the health economy more broadly (macro-eg, requirements to form local networks). Some sites used GIRFT evidence to support arguments for change which helped cement and formalise existing plans. However, where GIRFT measures were not a Trust priority because of more immediate demands-for example, financial and bed pressures-it was less likely to influence change.

Conclusion: Dynamic relationships between the different contextual factors, within and between the three levels, can impact the effectiveness of a large-scale improvement intervention and may account for variations in implementation outcomes in different settings. When designing an intervention, those leading future improvement programmes should consider how it sits in relation to these three contextual levels and the interactions that may occur between them.