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. Shin-Ping Tu, MD, MPH; Maria Fernandez, PhD, Vicki Young, PhD on behalf of the CPCRN FQHC Workgroup Investigators Emory UniversityUniversity of California Los Angeles University of ColoradoUniversity of South Carolina University of Texas HoustonUniversity of Washington Washington University at St. Louis CDC September 24, 2013 The Cancer Prevention and Control Research Network: Federally Qualified Health Centers Workgroup

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

3. 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)

4. Data Collection—Instruments Part I: Example of successful practice changes Part II: Explore 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

5. Data Collection—Sample & Recruitment Sample: Chief Executive Officers, Medical Directors, Chief Operation Officers, Quality Improvement managers, frontline project managers, etc. of FQHCs Recruited and collected data through partnerships with:

6. 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.

7. Analytic Strategy CFIR-based Coding Segment 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 Identify 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

8. Overview of Findings Levers of Changes for Implementati on of EBIs Individual Level Understa nding key roles Harnessing motivation for change Addressing resistance & disinterests Enhancing competencies Organization/ System Level Implemen- tation Strategies General Management External Relations Mandatory Requirements

9. Understanding Key Roles Leaders as change agents Champions Designated implementers (front-line) “QI person” (Quality Improvement managers/coordinators)

10. 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 changes

11. Understanding Key Roles— Designated Implementers Designated implementers for EBIs may include: providers, nurses, patient navigators, etc. “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……”

12. Enhancing Competencies Increasing competencies (knowledge, skills, etc.) of key implementers “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…. “

13. 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…”

14. Implementation Strategies (Cont.) Integrating EBIs into Quality Improvement (QI) process “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.”

15. Implementation Strategies (Cont.) Cultivating change-supportive structure “I think it's because of the history and experience the organization has with quality improvement……In the years past that we have an infrastructure, folks really have done this so many different times that- you know-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.

16. Summary of Findings Obtaining buy-in from all key roles and enhancing their competencies for implementation are the 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.

17. 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

18. 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”

19. 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

20. 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