Background Though the knowledge base on implementation strategies is growing, much remains unknown about how to most effectively operationalize these strategies in diverse contexts. For example, while evidence shows that champions can effectively support implementation efforts in some circumstances, little has been reported on how to operationalize this role optimally in different settings, or on the specific pathways through which champions enact change. Methods This is a secondary analysis of data from a pragmatic trial comparing implementation strategies supporting the adoption of guideline-concordant cardioprotective prescribing in community health centers in the USA. Quantitative data came from the community health centers’ shared electronic health record; qualitative data sources included community health center staff interviews over 3 years. Using a convergent mixed-methods design, data were collected concurrently and merged for interpretation to identify factors associated with improved outcomes. Qualitative analysis was guided by the constant comparative method. As results from the quantitative and initial qualitative analyses indicated the essential role that champions played in promoting guideline-concordant prescribing, we conducted multiple immersion-crystallization cycles to better understand this finding. Results Five community health centers demonstrated statistically significant increases in guideline-concordant cardioprotective prescribing. A combination of factors appeared key to their successful practice change: (1) A clinician champion who demonstrated a sustained commitment to implementation activities and exhibited engagement, influence, credibility, and capacity; and (2) organizational support for the intervention. In contrast, the seven community health centers that did not show improved outcomes lacked a champion with the necessary characteristics, and/or organizational support. Case studies illustrate the diverse, context-specific pathways that enabled or prevented study implementers from advancing practice change. Conclusion This analysis confirms the important role of champions in implementation efforts and offers insight into the context-specific mechanisms through which champions enact practice change. The results also highlight the potential impact of misaligned implementation support and key modifiable barriers and facilitators on implementation outcomes. Here, unexamined assumptions and a lack of evidence-based guidance on how best to identify and prepare effective champions led to implementation support that failed to address important barriers to intervention success. Trial registration ClinicalTrials.gov, NCT02325531. Registered 15 December 2014.
Successfully incorporating social determinants of health (SDH) screening into clinic workflows can help care teams provide targeted care, appropriate referrals, and other interventions to address patients' social risk factors. However, integrating SDH screening into clinical routines is known to be challenging. To achieve widespread adoption of SDH screening, we need to better understand the factors that can facilitate or hinder implementation of effective, sustainable SDH processes. The authors interviewed 43 health care staff and professionals at 8 safety net community health center (CHC) organizations in 5 states across the United States; these CHCs had adopted electronic health record (EHR)-based SDH screening without any external implementation support. Interviewees included staff in administrative, quality improvement, informatics, front desk, and clinical roles (providers, nurses, behavioral health staff), and community health workers. Interviews focused on how each organization integrated EHR-based SDH screening into clinic workflows, and factors that affected adoption of this practice change. Factors that facilitated effective integration of EHR-based SDH screening were: (1) external incentives and motivators that prompted introduction of this screening (eg, grant requirements, encouragement from professional associations);(2) presence of an SDH screening advocate; and (3) maintaining flexibility with regard to workflow approaches to optimally align them with clinic needs, interests, and resources. Results suggest that it is possible to purposefully create an environment conducive to successfully implementing EHR-based SDH screening. Approaching the task of implementing SDH screening into clinic workflows as understanding the interplay of context-dependent factors, rather than following a step-by-step process, may be critical to success in primary care settings.
BackgroundNational leaders recommend documenting social determinants of health and actions taken to address social determinants of health in electronic health records, and a growing body of evidence suggests the health benefits of doing so. However, little evidence exists to guide implementation of social determinants of health documentation/action.MethodsThis paper describes a 5-year, mixed-methods, stepped-wedge trial with realist evaluation, designed to test the impact of providing 30 community health centers with step-by-step guidance on implementing electronic health record-based social determinants of health documentation. This guidance will entail 6 months of tailored support from an interdisciplinary team, including training and technical assistance. We will report on tailored support provided at each of five implementation steps; impact of tailored implementation support; a method for tracking such tailoring; and context-specific pathways through which these tailored strategies effect change. We will track the competencies and resources needed to support the study clinics’ implementation efforts.DiscussionResults will inform how to tailor implementation strategies to meet local needs in real-world practice settings. Secondary analyses will assess impacts of social determinants of health documentation and referral-making on diabetes outcomes. By learning whether and how scalable, tailored implementation strategies help community health centers adopt social determinants of health documentation and action, this study will yield timely guidance to primary care providers. We are not aware of previous studies exploring implementation strategies that support adoption of social determinants of action using electronic health and interventions, despite the pressing need for such guidance.Trial registrationclinicaltrials.gov, NCT03607617, registration date: 7/31/2018—retrospectively registeredElectronic supplementary materialThe online version of this article (10.1186/s13012-019-0855-9) contains supplementary material, which is available to authorized users.
Objective Previous research has demonstrated the importance of eliciting patients' goals and values during shared decision‐making (SDM), but this does not occur in most SDM conversations. Understanding challenges to eliciting patients' goals and values is crucial. This study assessed how clinicians balanced sharing medical information and considering patients' goals and values during breast cancer surgery consultation in an integrated health care system. Methods We conducted interviews with clinicians (n = 6) and patients (n = 11) and conducted naturalistic, ethnographic observations of eight surgical consultations in a multidisciplinary breast cancer clinic. We analyzed the data following the template method using the qualitative software NVivo 10. Results Clinicians prioritized sharing medical information. We identified four patient factors necessary to integrate patients' values and goals into the conversation in addition to sharing medical information: ability to process large quantities of information quickly, willingness to embrace swift decision‐making, ability to quickly formulate one's values, and prioritization of surgical choice as the goal of the conversation. Conclusions We found that SDM implementation results in practices that emphasize information and choice, with less focus on patient goals and values. More research is needed to explore factors that may encourage the elicitation of patients' goals and values.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.