| Staffing | Staff shortages High staff turnover Training of staff on bundle implementation Training of staff on inhaler technique and smoking cessation Staff not following the whole patient journey Capability to make COPD referral-A&E nurse/doctor not referring to appropriate ward Lack of staff engagement Low buy in from pharmacists Staff too busy
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| Process | Lack of prompt data capture Patient coding issues Lack of prompt feedback to staff on the progress of the project Poor quality of spirometry Completion status unsure because of community bundle end point
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| Infrastructure | Added workload of bundle Bed shortages Ward moves Lack of pulmonary rehab service Issues with government plans GP involvement Sustainability and costs of BLS booklet Lack of communication and collaboration across sites
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| Patient and Public Involvement | Patient involvement declined over time Patient ’s focused on own interest and not the projects’ Patient illness Patient engagement poor-amount or quality?
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| QI Methodology | Issues using PDSAs-not completed Sustainability tool-Too generic not context specific Unfamiliarity with tools
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