The initial search yielded 4072 records with 4042 records retrieved from database searches and 30 records retrieved from other methods (figure 1). Two hundred and thirty reports were sought for full-text review as they fulfilled the criteria or a decision could not be made based on title and abstract alone. Despite extensive efforts, including contacting the authors and the publishing journals, six records could not be retrieved. Following full-text screening, 37 papers were deemed eligible for inclusion in the meta-summary synthesis. The main reasons for excluding studies were: research did not examine health and/or social care standards; not pertaining to implementation of standards; wrong type of study, for example, study protocols. Three papers were identified as being part of one study.37–39 These were crosschecked by a second reviewer (NO’R) to confirm identical setting and population and were counted as one study thereafter.

Of the 35 studies included, 9 originated from the USA,40–48 8 from Australia,49–56 5 from the UK,28 30 57–59 4 from the Netherlands,60–63 2 from Iran64 65 and 1 from each of Bangladesh,66 Brazil,67 Croatia,68 Ethiopia,69 Jordan,70 Republic of South Africa37–39 and WHO regions (including 180 countries).71 The majority of studies used quantitative methods (n=21)28 40–43 46 48 50 51 55–59 61 62 64 65 67 68 71 with questionnaires, followed by qualitative methods using mainly focus groups and interviews as data collection approaches (n=9).30 37–39 45 47 52–54 60 70 There were five mixed methods studies that used focus groups, interviews, observations and surveys for data collection.44 49 63 66 69 One mixed methods study adopted a three-step process using an assessment of causality, rapid review and case study design.66 As such, only the qualitative component (case study) was included in the synthesis and quality appraisal.66 Studies examined healthcare standards (n=30),28 30 37–44 46 47 50–53 56–71 social care standards (n=2),45 48 health and mental healthcare standards (n=2),49 55 and health and social care standards (n=1).54 The standards ranged from cross-system standards (n=1),71 ‘WHO Child Growth Standards’ to whole system standards (n=8 of which 2 were examined in more than one paper),37–39 42 49 53–55 65 69 72 for example ‘National Safety and Quality Health Service Standards’ to standards for specific conditions (n=26),28 30 41 43–48 50–52 54 56–64 66–68 70 for example ‘Delirium Clinical Care Standard’. The included studies represented the analysis of 847 documents, for example, patient charts and notes and, 13 679 participants. Of this 13 679 sample, 308 represented individuals at system level, for example, government representatives and academic professionals, 1920 were service-users and the remainder consisted of individuals working at service management and front-line level (online supplemental appendix 4).

Nineteen included studies were assessed as having no methodological limitations,28 30 43 46 49 50 53–56 60 61 63–68 71 14 had minor37–42 44 45 48 52 57 58 62 70 and 4 had moderate methodological limitations47 51 59 69 (online supplemental appendix 5). Quantitative studies with cohort and descriptive cross-sectional designs were mainly assessed as having no methodological limitations. The main reasons for minor to moderate methodological limitations across studies included: poor reporting of sampling and outcome measures in quantitative studies; poor reporting on reflexivity, ethical considerations and rigour of analysis in qualitative studies; poor reporting on the integration of findings, divergences between study designs and unclear rationale for using a mixed methods approach in mixed methods studies.

We had high confidence in 16 enablers, moderate confidence in 4 and low confidence in 2 enablers (table 1). We had high confidence in 16 barriers, moderate confidence in 6 and low confidence in 2 barriers (table 2). Our concerns were mainly with methodological limitations and adequacy of data as reported in studies (online supplemental appendix 6). Reasons for downgrading adequacy of data were concerns relating to a low number of studies reporting the finding and studies with low numbers of participants. Downgrading for relevance occurred where a study took place in a jail or prison setting, as this was deemed only partially relevant to our research question. Coherence did not feature as a concern throughout the assessments.

Themes, thematic statements and descriptions of enablers to implementing (inter)nationally endorsed health and social care standards with level of confidence in the evidence* reporting the enablers

Themes, thematic statements and descriptions of barriers to implementing (inter)nationally endorsed health and social care standards with level of confidence in the evidence* reporting the barriers

For enablers to implementing standards, six themes with 22 thematic statements were generated from 322 findings extracted from 31 studies (table 1). For barriers, six themes with 24 thematic statements were generated from 376 findings extracted from 35 studies (table 2).

The FES for thematic statements describing enablers ranged from 10% to 55% (online supplemental table 3). Themes containing thematic statements with the highest FES were: services have key staff who will lead and share knowledge of the standards (theme 2); services have accessible training, support tools and monitoring practices (theme 6). The FES for thematic statements describing barriers ranged from 6% to 63% (online supplemental table 4). Themes containing thematic statements with the highest FES were: services work in silos, have limitations with staffing and knowledge of standards (theme 2); services have poor access to resources and funding (theme 4). One study contributed a large proportion of findings for both enablers (IES=77%) and barriers (IES=75%).49 The majority of studies (n=25) had an IES between 21% and 46%.

Thematic statements and their associated themes are discussed below.

Enabler: Standards are adaptable and relevant in day-to-day practice.

Barrier: Standards have limited adaptability.

Theme 1 described the adaptability of standards and relevance in practice. Studies reported that standards were adaptable when they were simplified and tailored for implementation (FES 16%, high confidence) and relevant for application in practice (FES 12%, high confidence).

Standards had limited adaptability when there was heterogeneity across healthcare services and their geographical locations (FES 20%, high confidence). Language used in standards was described as medical oriented, which made standards difficult to embed in practice (FES<10%, moderate confidence). Standards did not always fit neatly with legislation, accreditation or regulatory frameworks and this did not support effective implementation (FES<10%, moderate confidence).

Enabler: Services have key staff who will lead and share knowledge of the standards.

Barrier: Services work in silos, have limitations with staffing and knowledge of standards.

Theme 2 focused on knowledge and staff. Studies reported that shared knowledge and interprofessional collaborations enabled collective efforts with implementation of standards (FES 45%, high confidence) and knowledge of the standards were fundamental to implementation (FES 26%, high confidence). Active involvement from managers by providing leadership and commitment was reported as assisting with implementation (FES 26%, high confidence). The availability of staff was identified as a key enabler and studies referred to key staff as champions, role models, designated personnel or care coordinators (FES 52%, moderate confidence).

A lack of knowledge, awareness and understanding of the standards was the most frequently reported barrier (FES 63%, high confidence). The gap in knowledge related to the rationale for standards, their content, expectations and knowledge of available support tools. Staffing constraints were reported as a barrier, which resulted in issues such as an increase in transient staff (FES 46%, high confidence). Other barriers reported were: managers who do not support staff with consistent processes or onsite presence (FES 23%, moderate confidence); services taking a monodisciplinary approach resulting in a lack of shared knowledge (FES 20%, moderate confidence); staff not consistently involved in implementation (FES 11%, moderate confidence).

Enabler: Services collaborate with people using services.

Barrier: Services and service-users have misconceptions about healthcare and support.

Theme 3 described the role of the service-user in implementation of standards. Collaborations and partnerships with patients, family and carers were reported as improving care delivery (FES=16%, high confidence). The availability of appropriate supports for service-users assisted with implementing standards (FES=13%, high confidence).

Barriers included service-users having misconceptions about healthcare due to a lack of knowledge on service delivery and healthcare needs (FES 23%, high confidence). Care and support that was patient-focused resulted in families and carers experiencing challenges accessing supports for themselves (FES 23%, high confidence). Healthcare professionals reported concerns that they would harm relationships with patients if they raised sensitive issues as recommended in some standards (FES 11%, high confidence).

Enabler: Services have access to resources.

Barrier: Services have poor access to resources and funding.

Theme 4 described the availability of adequate resources such as supplies, equipment and screening systems which were required to incorporate the standards into practice (FES 39%, high confidence). The allocation of sufficient budgets to services (FES 10%, low confidence) and maintenance of infrastructures were reported as facilitating implementation (FES 10%, low confidence).

Conversely, limited supply of equipment, medical supplies and materials impeded implementation (FES 40%, high confidence). Reasons for limited supply were described as a lack of availability or, distribution and allocation issues. Other barriers such as insufficient funds resulted in shortages in supplies, poor maintenance of equipment and infrastructure. Standards had cost implications that led to competing tenders for safety and quality projects (FES 43%, high confidence). Infrastructural issues were described as limited physical space, old structures and service size (FES 26%, moderate confidence).

Enabler: Services promote quality improvements and value staff in doing so.

Barrier: Services experience resistance to change due to cultural practices.

Theme 5 set out organisational cultures and practices that influenced implementation of standards. Enabling factors comprised a culture of quality improvement such as: capacity building and staff engagement (FES 32%, high confidence); recognising staff for their efforts (FES 19%, high confidence); credibility that standards were an impetus to safety and quality improvements (FES 19%, high confidence).

Barriers related to entrenched cultures that resisted change because standards were perceived as a burden (FES 40%, high confidence). Studies reported that there was insufficient time to implement standards (FES 40%, high confidence) as time spent on standards meant time away from other competing projects, resulting in variation in implementing standards (FES 20%, high confidence). Unclear accountability systems resulted in a misunderstanding of roles and responsibilities with standards (FES 17%, high confidence). A culture where staff did not perceive the standards as the norm for high quality care was also reported as hindering implementation (FES <10%, low confidence).

Enabler: Services have accessible training, support tools and monitoring practices.

Barrier: Services have a lack of training, support tools and consistent monitoring processes.

Theme 6 described strategies that facilitated implementation of standards. The availability of support tools (FES 55%, high confidence), training courses (FES 52%, high confidence) and accessible educational materials (FES 32%, high confidence) helped to implement standards. Studies referred to support tools as standardised assessment tools, checklists, policies and guidelines. Descriptions of training courses across studies included targeted training, prequalification education, workshops and role-play sessions. Effective communication strategies such as newsletters, internal websites and academic journals promoted information about the standards (FES 10%, moderate confidence). Internal and external monitoring were motivating factors to implementation. Internal monitoring such as audit and feedback guided quality improvements (FES 32%, high confidence). External monitoring such as benchmarking, accreditation or regulation were motivators (FES 10%, high confidence).

Conversely, an absence of clear policies, guidelines, protocols and pathways (FES 29%, high confidence), and challenges with education and training (FES 31%, high confidence) acted as barriers to implementing standards. Challenges with education related to cost, time and backup capacity to replace staff, causing staff to become unreceptive to training. A lack of internal monitoring resulted in an inability to determine if implementation was effective (FES 20%, high confidence). Inconsistent external assessments resulted in low reliability and thus effected stakeholders’ perceptions of the credibility of the standards (FES <10%, low confidence).