Theory-informed refinement and tailored implementation of a quality improvement program in maternity care to reduce unwarranted clinical variation across a health service network.

Background: Unwarranted clinical variation presents a major challenge in contemporary healthcare, indicating potential inequalities and inefficiencies, and unrealised potential for better outcomes. Despite an increasing focus on unwarranted clinical variation, and consideration of efforts to address this challenge, evidence-based strategies which achieve this are limited. Audit and feedback of healthcare processes (process auditing) and clinician engagement are important tools which may help to reduce unwarranted clinical variation, however their application in maternity care is yet to be thoroughly explored. We describe the development and implementation of a program to address unwarranted clinical variation across a multi-site maternity network termed Practice Improvement with Clinicians eNgaged in Improving Care (PICNIC). The goals of the program were to engage clinicians to identify and reduce unwarranted clinical variation and enhance the delivery of evidence-based care, with the intention of improving care quality, clinical outcomes, and efficiency of the health service.

Methods: A theory-informed approach was used to design and implement the four-phase program, underpinned by implementation science and quality improvement methodologies. It utilised clinician-performed process auditing, built upon existing evidence for audit and feedback, and employed evidence-based implementation strategies to promote clinician behaviour change.

Results: The intervention was implemented across the five maternity network sites in 2020 with around 300 clinicians participating in 18 audit topics over four years (2020-2023). A diverse array of evidence-based strategies were utilised to support implementation over this period and are mapped to the Behaviour Change Taxonomy and Expert Recommendation for Implementing Change (ERIC) compilation. Observed benefits of the program include the development and implementation of clinician co-designed system-level improvements that are tailored to context, to improve the delivery of best-practice healthcare and improve outcomes.

Conclusions: Implementation science theory and quality improvement processes can be integrated pragmatically to engage clinicians to address unwarranted clinical variation, with the objective of creating meaningful behaviour change, and system-level improvements for better healthcare outcomes. The replicability of this approach in other disciplines and hospital networks should be explored.

Trial Registration: Not applicable to this report.