MMHA 6475 Week 8 Fidelity Monitoring Plan Example

Four Things That Cannot Change: A Fidelity Monitoring Plan for Tamarack Hospital at Home

Student Name

Walden University

MMHA 6475: Program Planning, Implementation, and Evaluation

Instructor Name

Month Day, Year

Four Things That Cannot Change: A Fidelity Monitoring Plan for Tamarack Hospital at Home

Core Components

A program's core components are the elements it cannot change without becoming a different service. For Tamarack Health's hospital-at-home program, there are four: an in-person nurse visit twice a day; a daily physician round by video; a response to every escalation call within the window the clinical protocol sets, currently 30 minutes for a clinician call-back and two hours for an in-person visit when needed; and delivery of medications before the first scheduled dose at home. These four components are what make home care hospital-level care. A program that dropped to one nurse visit a day or let medication deliveries arrive late would be offering something closer to home health care, and the evidence from hospital-at-home studies would no longer apply (Levine et al., 2020).

Adaptable Elements

Other elements can and should be adapted to circumstances: the order in which nurses visit patients, courier routing, the time of day the video round occurs within the daily window, whether a caregiver or the patient handles the tablet, and the format of patient education materials. Distinguishing these from the core components tells staff where their judgment is expected and where the protocol must be followed. Implementation research has long noted that adherence to a program's essential elements, and how much of it patients actually receive, shape whether a program achieves its intended outcomes (Carroll et al., 2007).

Measures

The plan measures the program through four of the implementation outcomes defined by Proctor et al. (2011), chosen for an administrator's purposes: fidelity, penetration, acceptability and implementation cost. Table 1 lists each measure.

Table 1

Implementation Outcome Measures

Why These Four Outcomes

Proctor et al. (2011) distinguish implementation outcomes, such as fidelity and acceptability, from service and patient outcomes. That distinction matters because a program can fail for two reasons: the intervention does not work, or it was never delivered as designed. Without implementation measures, a disappointing result cannot be interpreted. Fidelity is measured component by component so that a lapse can be traced to the part of the operation responsible. Penetration tells leaders what share of eligible emergency patients actually end up in the program, which bears directly on whether it can free beds. Acceptability is measured among both patients and hospitalists, since hospitalist willingness to refer drives volume. Implementation cost per episode links the monitoring plan to the budget and its break-even line.

How the Data Are Used

The program manager compiles the weekly fidelity measures into a one-page report reviewed at the Monday program huddle, with any measure below threshold discussed and assigned an owner for follow-up. Monthly, the full table goes to the steering group with a short narrative. Quarterly, the medical director presents the results to the flagship campus's quality committee. A threshold breach does not mean the program has failed; it means someone looks at why, and the finding is recorded with the response so that patterns across weeks become visible. A week in which visits fell below 90% because of a snowstorm calls for a different response from one in which they fell because a nurse position was vacant.

Records and Their Limits

Visit timestamps depend on nurses documenting promptly; a late entry can make an on-time visit look late. The command center log records when calls are answered but not whether the response was clinically appropriate, which the weekly escalation review addresses case by case. Patient surveys tend to be returned by more satisfied patients. The hospitalist survey reflects stated willingness, not actual referrals, which the screening log captures. Cost per episode depends on how shared costs are allocated. The plan uses these records because they already exist, and supplements them with the reviews described above rather than creating new data collection.

One addition is planned. Every month, the medical director selects three completed episodes at random and reviews the full record against the protocol, checking whether visits, rounds, escalations and deliveries happened as the measures report. This audit tests the measures themselves. If the audit finds that the electronic records overstate on-time visits, for example because nurses document a planned time rather than the actual arrival, the measure is corrected before it is used to judge the program. A fidelity plan is only as trustworthy as the records it relies on, and a small regular audit is the cheapest way to keep them honest.

Adapting Without Drifting

Programs that succeed usually adapt, and Tamarack's will too. The rule is that adaptable elements may change at the program manager's discretion, while any change to a core component requires the medical director's written approval and a note in the program log explaining why. If monitoring shows that a core component is routinely missed, the response is first to fix the operation, for instance by adding a nurse on weekend evenings or rerouting courier runs; only if that proves impossible should the steering group consider whether the component itself should change, knowing that doing so may change what the program is and what its evaluation can show.

References

Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., & Balain, S. (2007). A conceptual framework for implementation fidelity. Implementation Science, 2, Article 40. https://doi.org/10.1186/1748-5908-2-40

Levine, D. M., Ouchi, K., Blanchfield, B., Saenz, A., Burke, K., Paz, M., Diamond, K., Pu, C. T., & Schnipper, J. L. (2020). Hospital-level care at home for acutely ill adults: A randomized controlled trial. Annals of Internal Medicine, 172(2), 77-85. https://doi.org/10.7326/M19-0600

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76. https://doi.org/10.1007/s10488-010-0319-7