Implementing a new clinical pathway in a non-receptive context: mixed methods evaluation of a new fracture pathway for older people in a hospital Trust in the West Midlands, UK

Gill Combes, Gareth Owen, Sarah Damery, Sarah Flanagan, Celia Brown, Graeme Currie

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This paper reports a mixed methods evaluation of a new pathway to improve clinical outcomes for older people with fractures treated at a hospital Trust in the West Midlands, UK. The paper focuses specifically on the context surrounding the translation of the new pathway into practice and the way that external and internal factors influenced its adaptation and implementation. Quantitative analysis used a controlled Interrupted Time Series (ITS) to estimate the effect of the new pathway on patient complication rate, median length of hospital stay and 30-day mortality by comparing the pre- and post-intervention periods. ITS data were extracted from the UK Trauma Audit and Research Network (TARN) database and a patient-level control group identified using propensity score matching. Parallel qualitative analysis aimed to examine the context surrounding the new pathway and how external and internal factors might influence its adaption and implementation into clinical practice. Data were collected via semi-structured interviews (n = 16) undertaken with staff and clinical stakeholders within the Trust and were analysed using the COM-B (Capability, Opportunity, Motivation) model of behaviour. No statistically significant effects were found for any of the patient outcomes studied in the controlled ITS analysis. Qualitative data suggest that the lack of effectiveness of the new initiative can be explained with reference to the capability, opportunity and motivation of internal Trust stakeholders to engage with the pathway, which created a non-receptive environment within the Trust. Successfully implementing new care pathways in environments that may be non-receptive to change requires efforts to be put into winning 'hearts and minds' within the organisation to ensure engagement from key stakeholders during intervention development. Evidence must be provided internally of the way that a given intervention will alleviate the problematic issues being experienced within the organisation, and external dissemination of results should be avoided until there is evidence of a positive effect within the organisation where the new care pathway is first implemented.
Original languageEnglish
Article numbere0247455
JournalPLOS One
Issue number2
Publication statusPublished - 22 Feb 2021

Bibliographical note

Funding Information:
A patient advisory group contributed to the initial design of the study and the data collection tools, alongside the patient and public involvement group of the long term conditions theme of CLAHRC-WM.

Publisher Copyright:
Copyright: © 2021 Combes et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


  • Quality improvement
  • secondary care
  • context
  • older people
  • service organisation
  • fracture

ASJC Scopus subject areas

  • Agricultural and Biological Sciences(all)
  • General
  • Biochemistry, Genetics and Molecular Biology(all)


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