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Evaluation of normalization after implementation of the digital Dutch Obstetric Telephone Triage System: Mixed methods design (questionnaire and focus group discussion) (Preprint)


 BACKGROUND
 The Dutch Obstetric Telephone Triage System (DOTTS) was developed to improve the quality of acute obstetric care. To achieve optimal effect, DOTTS should be adopted in the daily care process by triage staff. The outcome of implementation was evaluated in nine hospitals.
 
 
 OBJECTIVE
 The aim of this study was to gain insight into the degree of implementation (normalization) and to evaluate which lessons can be learned from the implementation of DOTTS that can help optimize current and new implementations.
 
 
 METHODS
 An evaluation study with a mixed methods design was performed. All triage staff in hospitals who implemented DOTTS before 1 September 2019 were invited to complete the Normalization MeAsure Development (NoMAD) questionnaire between December 2019 and July 2020. The questionnaire is based on the Normalization Process Theory. This self-report questionnaire gives insight into the work people do in order to integrate and embed new practice in routine care. Normalization Process Theory is based on four constructs: coherence, cognitive participation, collective action and reflexive monitoring. Within the questionnaire each construct is represented by 4-7 questions. Questions could be scored on a 5-point Likert scale. Descriptive statistics were used for analysis of questionnaire scores. Subsequently, analysis of questionnaires were discussed during a focus group. Template analysis following the four constructs of NPT was used for analyzing the results of the focus group.
 
 
 RESULTS
 In total 173 triage-staff members completed the NoMAD questionnaire. Ninety percent of the participants had used DOTTS for over six months. The digital application was used as much as possible or always by 79.1% of the participants (n=137). The overall Normalization Process Score was 3.77 (SD=0.36). The constructs Coherence and Cognitive Participation scored 4.01 (SD=0.47) and 4.05 (SD=0.45) respectively. Collective Action scored 3.5 (SD=0.45) and Reflexive Monitoring scored 3.72 (SD=0.47). Analysis of the focus group discussion showed that the added value of DOTTS was seen as a quality improvement for pregnant women. Dedication of the complete multidisciplinary implementation team, with specific support from the medical staff, as well as proper use by all disciplines involved in the triage is important for facilitating normalization. Participants appreciated training and evaluation and indicated a need for ongoing training and evaluation in relation to goal achievement.
 
 
 CONCLUSIONS
 The DOTTS has been integrated into normal care in daily practice. Evaluation by NoMAD-questionnaires gave a positive overall score. These results are in line or, in some aspects better, when compared to other evaluation studies. Key factors in the normalization process of the DOTTS in obstetric triage are the shared added value for stakeholders, the dedication of the complete multidisciplinary implementation team and implementation plans that are tailor made in the practical context of the hospital.
