1. This presentation was supported by Cooperative Agreement Numbers U48-DP001909, U48-DP001946, U48-DP001924, U48-DP001934, U48-DP001938(03), U48-DP001944, U48-DP001936, U48-DP001949-02, U48–DP001911, & U48-DP001903 from the Centers for Disease Control and Prevention. The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Maria Fernandez, PhD on behalf of the CPCRN FQHC QIS Investigators University of ColoradoUniversity of South Carolina University of Texas HoustonUniversity of Washington Emory University CPCRN Fall Meeting October 3, 2013 The CPCRN FQHC Workgroup Qualitative Inquiry Subgroup (QIS)

2. QIS Research Questions Primary Research Question: What factors influence the implementation of evidence- based interventions (EBIs) for cancer prevention and control in FQHCs?

3. QIS Research Questions (Cont.) How useful is the Consolidated Framework for Implementation Research (CFIR) in assisting the analysis and interpretation of qualitative empirical data on implementation? What are the perceptions of Electronic Medical Records (EMR) use related to the implementation of EBIs?

4. Approach In-depth personal interviews and focus groups An adapted Appreciative Inquiry approach Open-ended questions broadly informed by the Consolidated Framework for Implementation Research (CFIR)

5. Data Collection—Interview Guide Part I: Example of successful practice changes Part II: Explore implementation of a specific evidence- based cancer prevention and control strategy (Example: Tobacco Cessation: Ask-Advise-Refer) Part III: Inner setting—organizational characteristics and readiness for implementation Part IV: Other domains of CFIR—intervention characteristics and outer settings

6. Data Collection—Partnerships & Recruitment Recruited and collected data with help of the Partnership Committee led by Dr. Vicky Young and partnerships with

7. Data Collection—Sample Sample: Chief Executive Officers, Medical Directors, Chief Operation Officers, Quality Improvement managers, frontline project managers, etc. of FQHCs Recruited from email invites and in-person invitations

8. Participants Profile 59 FQHC leaders: 29 CMOs, 4 CEOs, 9 COOs, 4 QI managers, other including nursing directors, vice presidents, etc. Participants represent FQHCs in 14 states and Washington, D.C.

9. Analytic Strategy CFIR-based Coding Segmented data into “meaning units” Code all data using pre-existing codes developed based on the CFIR Calculate frequency distribution of coded quotations Data-driven Coding Identified barriers and facilitators to implementation based on respondents’ descriptions of successful and unsuccessful efforts at implementation Thematic Analysis Barriers and facilitators were conceptually clustered to identify a small set of sub-themes Sub-themes are clustered to identify a smaller set of themes that comprise the main factors that influence implementation

10. Manuscripts-QIS ManuscriptsAims Paper 1: Factors influencing implementation of evidence-based practices for cancer prevention and control in FQHCs (Working Title) 1)Describe in depth factors influencing implementation of evidence-based cancer control practices in FQHCs 2)Draw implications for practice and future D&I interventions which aim to increase or improve the use of EBPs in FQHCs Paper 2: Evaluating the Consolidated Framework for Implementation Research (CFIR) Using Empirical Data: the Implementation of Evidence-Based Practices in Federal Qualified Health Centers(Working Title) 1)Evaluate the CFIR using empirical data collected in this study 2)Make recommendations for expanding the CFIR Paper 3: Implementation of Evidence-based Practices for Cancer Control in FQHCs: The Use of EMR & Implications for Practice (Working Title) 1)To describe the perceptions of EMR use related to the implementation of EBPs among FQHCs. 2)Draw implications for EMR-based interventions Paper 4: Exploring Leadership as a Factor Influencing Implementation of Evidence-based Cancer Prevention Services in Community Health Centers 1)To explore the role of leadership as a factor influencing implementation of evidence-based cancer prevention and screening services in community health centers.

11. Overview of Findings Levers of Change for Implementation of EBIs Individual Level Under- standing key roles Harnessing motivation for change Addressing resistance & disinterests Enhancing competencies Organization/ System Level Implemen- tation Strategies General Management External Relations Mandatory Requirements

12. Understanding Key Roles Leaders Champions Designated implementers (front-line) “QI person” (Quality Improvement managers/coordinators) Identifying and mobilizing a team of leaders as change agents (including CEOs, physician champions, nurse champions, front line staff, navigators, QI person) is very important

13. Understanding Key Roles—Leaders “The fish rocks from the head down. So if you do not have leadership at the top, no matter what you try to do from the bottom up, you’re going to hit a wall, and you’re either going to have to have perseverance or you’re going to go away……” Leaders as change agents Leader initiates, authorizes or mandates change Leader buy-in critical for supportive roles Leadership team must be on the same page Leadership’s personal networks facilitate change

14. Understanding Key Roles— Designated Implementers Designated implementers for EBIs may include: providers, nurses, patient navigators, etc. Even though implementation is carried out be a team, it is the desire and determination of the individual members that is responsible for success. “I really think it has to be a desire of the person who implements it……somebody has to be assigned the task of actually carrying out……of course it’s a team but……I think really success lies in how determined somebody is to carry their task to completion……”

15. Enhancing Competencies Increasing competencies (knowledge, skills, etc.) of key implementers Successful implementation requires that staff be completely oriented to the new standard practices and having their buy-in helps re-assure them that they are not just taking on additional work

16. Enhancing Competencies “Front-lines” are most important for implementation; enhancing their knowledge in the EBIs and their skills necessary to carry out implementation tasks are very important “There has to be…a small group of people who actually do the job that you’re talking about...don’t just go to the doctors; go to the front desk, medical assistants, community health workers, and ask them, “How can we get this assessment done? Who can do it? Who can do what?” Then once you have that done, set up your training using that work model or those ideas. You set up the training, and then the training has to be repeated….”

17. Implementation Strategies--Prioritization Prioritization involves: Strategic planning Partnerships building, which enables the health centers to reach more patients and refer patients to services that health centers cannot provide Focus on one change at a time; do not move onto the next one until one is fully incorporated in the routine and become the “bread and butter ” What is required or mandated by the funding agencies usually become the first priority.

18. Implementation Strategies--Prioritization “Too much change……This month, people get excited about smoking and next month they get excited about breast cancer and next month they get excited about colon cancer, and the clinicians just get barraged, you know.” “I think there's got to be some responsibility at high levels in the organization to pick a few things and stick with them ….stay with them until they become bread and butter…”

19. Implementation Strategies—Integrating EBAs into Quality Improvement Process Organic, dynamic, complex and various Quality Improvement (QI) processes exist in FQHCs QI plays a significant role in the organization’s overall functioning QI committees are often in charge of decision making and the overall workflow Any new practice (including EBAs for cancer control) need to be integrated into the QI process

20. “I think we’re going to be at 100% successful in the implementation of the tobacco cessation program, because I believe that the multidisciplinary component of QI brings all involved in terms of implementation……once the decision has been agreed upon to implement, …..and….begin to evaluate that process in terms of “how does it look?” and bring it back to QI.” Implementation Strategies—Integrating EBAs into Quality Improvement Process (Cont.)

21. How do FQHCs Integrate New Practices?  Get help from research institution to do “process mapping”  Put preventives (cancer control ) and all UDS requirements into EMR  When EMR doesn’t fit their needs, create a paper form that must be touched by every part of the center for each patient visit  When transitioning to EMR, add check boxes in current paper forms to remind providers and staff to do the “ask” and follow-ups.

22. Implementation Strategies: Cultivating Change-Supportive Structure Change-supportive structure requires: 1) Availability of time for staff 2) Internal resources leveraged for a particular change, 3) Top-down support from the administrative, 4) Process for initiating, testing, implementing and evaluating changes

23. “I think it's because of the history and experience the organization has with quality improvement……it's the kind of thing when I say, "Gee, I'd like to see us do this," and there were folks who said, "Great! Let's mock it up. Let's do it. Let's PDSA (Plan, Do, Study Act) it." And there was a structure to do that in. Implementation Strategies: Cultivating Change-Supportive Structure (Cont.)

24. Summary of Findings Obtaining buy-in from all key players and enhancing their competencies for implementation are pre- requisites for successful implementation of any EBIs that require practice changes Successful implementation strategies involve prioritizing efforts related to EBIs, integrating EBIs into routine Quality Improvement process and cultivating a change-supportive structure.

25. An In-depth look at Leadership: Exploring Leadership as a Factor Influencing Implementation of Evidence-based Cancer Prevention Services in Community Health Centers Leadership

26. Many factors operating at multiple levels influence closing the gap between what we know and health service delivery What is the role of leadership as a factor influencing implementation of evidence-based cancer prevention and screening services in community health centers? An In-depth look at Leadership: Exploring Leadership as a Factor Influencing Implementation of Evidence-based Cancer Prevention Services in Community Health Centers

27. Conceptual Model: Exploring Leadership as a Factor Influencing Implementation of Evidence-based Practices in CHCs - informed by Implementation Science (CFIR) and Leadership Theory (FRLT) Full Range Leadership Theory 2 Transactional Transformational: appeals to followers’ sense of logic, confident, ethical, sense of mission, etc. Transactional: clarifies role and task requirements, vigilant to insure standards are met, etc. Nontransactional: avoids making decisions, abdicates responsibility, etc. Laissez-Faire Consolidated Framework for Implementation Research 1 A.Structural Characteristics B.Networks and Communication C.Culture D.Implementation Climate E.Readiness for Implementation Constructs I.Intervention Characteristics II.Outer Setting III.Inner Setting IV.Characteristics of Individuals V.Process Typologies and Attributes DomainsSub-Constructs E1 Leadership Engagement 1 Damschroder, 2009 2 Bass & Avolio, 1994 Cancer Prev. & Control Res. Network Federally Qualified Health Center Qualitative Inquiry Study (CPCRN FQHC QIS) Exploring Leadership as a Factor Influencing Implementation of Evidence- based Cancer Prevention and Screening Services in Community Health Centers Focus groups and in-depth interviews to assess ideas, opinions and perceptions of CHC leaders about factors influencing the implementation of evidence-based cancer prevention and screening practices in CHCs

28. Full Range Leadership Theory Constellation of leadership attributes organized into three typologies: –Transformational –Transactional –Laissez-faire Typologies are a “toolbox” for leaders to select the style and behavior most appropriate for the situation to accomplish a goal (e.g., implementation of evidence-based practice) Well validated measurement instrument, the Multifactor Leadership Questionnaire (MLQ) FRLT used in health services implementation research leadership studies in other settings, e.g., mental health (Aarons 2011) and referred to by others (Emmons, 2012)

29. Preliminary findings from EMR analysis Documentation on EMR is time-consuming for physicians and hinders effective patient-provider communication. The busy provider is less likely to document on EMR Entering data to EMR is more laborious and takes more time than writing on paper* Physician’s attention is on the screen; documenting on EMR takes the visual contact away from patients Lack of supporting staff to enter data to EMR places too much burden on physicians “It’s rewarding though when you can sit down with a patient and just connect with them and you feel competent and they know you’re there for their care, you know, and that you can, at some point, put all these buttons and alerts aside and just take care of what they need.”

30. Technical challenges EMR does not connect automatically to the quitline. EMR sends willing-to-quit smokers to the quitline, but there is no automated way of feeding data back to the practice from the quitline, making it hard to follow up with patients. Difficulties in getting screening data from outside providers and documenting referrals for those services. Lack of a flagging system for cancer screening limits the opportunity to improve compliance with Pap smear guidelines. Difficulties in setting up the EMR to document cancer screening adherence in a real-world context; this forces physicians to recommend repeat Pap smear sooner than necessary.

31. Technical challenges “it’s hard to set up your electronic health record reporting system to give you good data about who really has missed… the measurement is to have a Pap every three years, so that means you either have to choose between doing it early or being out of compliance with the measure, so we’re dealing with that by saying OK, we’re going to start doing Paps two and a half years cause if you wait till three years and a day, then, you know, you’re late and you don’t count.”

32. Dissemination Efforts to Date Presentations at: 2012 CDC Cancer Conference, Washington D.C. 2012 Intercultural Cancer Council Biennial Conference, Houston, TX 2013 Seattle Implementation Research Conference IRDW, Seattle, WA 2013 National Association of Community Health Centers (NACHC) Community Health Institute (CHI), Chicago, IL Upcoming: 2013 APHA Annual Conference, an invited session at the Medical Care Section (Nov 4 th, Monday, 10:30AM-12:00PM) “Advancing the Dissemination and Implementation of Evidence-based Interventions in Community Health Centers: Research of the CPCRN”

33. Major Accomplishments of FQHC WG Developed partnerships with FQHCs at the national, state and local level Implemented two large-scale studies with almost no funds (other than the CPCRN grant funding) First multi-state effort that focuses on the dissemination and implementation of EBIs in FQHCs

34. Next Steps Provide reports back to FQHC partners to inform practices and gauge continued support Publish findings to inform the D&I field Pursue grant opportunities for Implementation Interventions