Background: Implementation of new diabetes clinical practice protocols in multiple rural and remote (R&R) hospitals continue to challenge health professionals and managers. Difficulties associated with coordinating nursing, midwifery, medical and allied health orientation and training to ensure consistency and continuity across multiple sites are wide and varied.

Aim: To investigate and recommend an appropriate model for successful implementation and ongoing maintenance of new clinical protocols in multiple R&R hospitals.

Method: Retrospective analysis of two separate protocol implementation projects was undertaken. A qualitative research methodology, using interpretive review of data and themeing of key ideas. A total of seven R&R hospitals participated in the two projects. Project methodology and outcomes were reviewed and analysed based on their contribution to;

~ staff education models and attendance

~ staff compliance with new protocols

~ impact on patient clinical outcomes

~ ongoing use of clinical protocol use.

Case note audits were conducted to determine compliance with protocols and clinical outcomes.

Results: Both projects used an action research methodology. Project one was implemented with four hospitals and project two was implemented with three hospitals. Six hospitals received their medical services via contracted general practitioners and one hospital was predominantly staffed by salaried medical practitioners. There were differences in senior staff clinical leadership models. Similarly, there were nursing and midwifery, pharmacy and diabetes specialist nurse leadership variables. Where staff leadership was displayed, attendance to training and compliance with protocols was higher. Patient clinical outcomes were clearly linked to compliance with protocol. Other contributing factors included management support for staff resource allocation and ongoing resources to provide maintenance training.

Conclusion: Implementation of new diabetes clinical practice protocols in multiple R&R hospitals had the best outcomes when there was commitment to local clinical leadership. Where local leadership was identified, a progressive cascade of activities followed including a mandatory and standardised training program, a commitment to ward based clinical support, clinical audits as a means to monitoring safety and quality, and ongoing training updates. A combination of these activities lead to improved clinical outcomes.