Table 2 Summary of findings by the Consolidated Framework for Implementation Research (CFIR) domains and constructs

Provider (MD, NP, PA) (n = 10)

1. Relative Advantage

Facilitator:

“When we get this data, right, you’re rejuvenated and you’re like, ‘Oh! We’ve really got to work on this.’ And, the hope is then it, we can incorporate it more and that it turns into more of a workflow type, I guess, moving forward that it fits back in workflow.”

Barrier:

“It (EMR reminder) didn’t rock anyone’s world either way. I don’t think. But it quickly fatigued people…I’d be like going into a chart at the end of the day, and I’d like, ‘Oh, yeah, I did see that,’ but I didn’t address it.”

“I don’t know that it (EMR reminder) fit into our workflow specifically. I mean, we would see it popup. I don’t think it was overly effective…oftentimes we click through, we skim through that. But again, when the EMR reminders weren’t updated, even if the patient had the FIT test done, they become really unreliable and useless.”

2. Adaptability

Facilitator:

“Provider feedback is usually done in the provider meeting. I think that we listen to people, we hear what’s going on, respond to it, try to come up with solutions. Frequently there is the leader or the EMR expert user who’s leading the discussion, but others within round table come up with their own – you know, who have confronted similar challenges – suggest workaround solutions.”

Barrier:

“Some of the other, some clinics I think are able to roll this out more easily than others, just based on their structures or their staffing or other things that can be more cumbersome in other places.”

3. Complexity

Facilitator:

“So this one (EMR reminder), I think it’s fairly straightforward, in that we need to have this conversation and that the benefits are pretty clear. The patients get screened, and we know about their health. So, and there’s been, I would say a medium amount of reminders about it. So not too overwhelming, but also not, like, out of sight completely.”

1. External Policy & Incentives

“We are an FQHC, so we are HRSA-funded. And part of HRSA baseline grant is based on quality measures.”

2. Peer Pressure

Facilitator:

“The other thing is if you, we look at our UDS measures in different ways. But one of the ways we look at it is quartile where we rank nationally amongst everyone else. And we’re in the first for everything except one that we’re in the second [quartile], and the only one we’re below [the second quartile] is colorectal cancer screening.”

3. needs & Resources of Those Served by the Organization

Barrier:

“There’re challenges. We have, you know, we have language and culture. We have patients from 50 different countries in our clinic.”

“It seems that people in the community are very, first of all, women are very aware of breast cancer screening, and they come in asking for breast cancer screening…cervical cancer screening is also very well, has been, people know about it and request it. And colon cancer seems to not be as well understood as a condition that needs to be screened.”

“Most of my patients are adults. And so we have, it’s hard to keep up because I’m generally not talking about colon cancer screening on the first visit. And then, you know, there may or may not be a second visit for a while.”

1. Available Resources

Facilitator:

“I think this grant helped to fund our ICS (Integrated Care Specialist), two of our positions…as we grew, we built up and made more of that, those folks.”

Barrier:

“If I have a positive FIT, it’s probably a year before they can get a colonoscopy.”

“Sometimes things don’t get disseminated as well as we think that they do…we don’t have any, like, easily available for this program specifically.”

“A lot of stuff ends up into the providers’ hand, so like I have to see, I have to, like, touch everything…which is sometimes good, but mostly just draining.”

“One of the providers work 80 hours a week. The other one is part-time at 20 hours but puts in probably 60 hours.”

“The providers here want to do a good job…sometimes you see stuff like that and you go, ‘it’s hopeless’…there are just so many barriers.”

2. Leadership Engagement

Facilitator:

“The organization as a whole is kind of backing that (CRC screening program) and putting the effort toward it, and putting the time toward it – we had everyone blocked out schedules to get this training.”

3. Culture

“Our clinic culture is patient-centered and also we want to work together…it’s very teamwork-orientated.”

“Everybody is very committed to our mission and doing the right thing and doing things that are going to improve the lives of our patients and people in our community.”

“Our staff here takes great pride in accomplishing goals and having high achievement levels.”

4. Organizational Incentives & Rewards

“Right now, there are no incentives. I think incentives would be nice. I don’t know how much they would help, but I think they would be nice.”

“I remember getting a gift card because I had the highest screening rate or something at, or like the most FIT. So, to get that recognition that all the work, I’m doing something that all work, I’m doing something good, that’s nice.”

5. Goals & Feedback

Facilitator:

“Some of our staff were surprised at some of the data…didn’t know that they were as low as they were…that was incorporated into some of that educational, like, slide show that we did with staff…that’s motivating…as we’re trying more to this team-based approach, it helps having everyone on the same page.”

“The data has helped drive some of these other implementation strategies.

Barrier:

“There have been goals for colon cancer screening kind of globally. I can’t think of what they are offhand. There’s usually a bar that we’re below.”

6. Tension for Change

“We want to and need to increase our goals. We understand that we need to increase it.”

7. Access to Knowledge & Information

“The grand rounds, we’ve had a few on colon cancer, just basic information. And then on the motivational interviewing…and other stuff, print material. I don’t think there really was all that much print material that was all that helpful.”

1. Knowledge & Beliefs about the Innovation

Facilitator:

“I think making sure your patients are healthy…and they’re up to date on these screenings that are advantageous, and encouraging your patients to be an advocate for their own health, or educating patients on this…that’s the incentive for myself to help patients become better advocates of their own health care.”

“We want our patients to be as healthy as possible, and getting their necessary screenings is always a goal.”

“We also have a really, really strong team here. Everyone’s really positive, and so I think if we do set a goal and somethings we could, I think that people would be on-board to do that.”

2. Other Personal Attributes

“Well, what motivates me would be wanting to do my job well for my patients. I guess a certain amount of self-respect. I’d like to think that I’m a leader amongst providers, so I really do want to see that my numbers are better.”

1. Engaging

“You guys were great…The grand rounds, we’ve had a few on colon cancer, just basic information. And then on the motivational interviewing…and other stuff, print material. I don’t think there really was all that much print material that was all that helpful.”

2. Executing

“We have an integrated care specialist, who is doing outreach and identifying people that are likely to need colorectal cancer screening, and them it’s a conversation that comes up.”

3. Reflecting & Evaluating

“I think the site-specific rates, provider-specific rates, and the order rates and completion rates, those are all good data.”

Integrated Care Specialist (n = 4)

1. Relative Advantage

Facilitator:

“Now they really gave us, like a FIT list that they want us to work from, a FIT list and process. So, we’re working with patients that already given the FIT test. So, we’re just reminding them.”

“We’re actually following up and we’re really looking into those charts to make sure that patient completed. And we also create care management, and we see that the colonoscopy has been completed, we just put ‘completed’.”

Barrier:

“When we were creating the popup alerts, that was working back then. At the beginning it was working so great because providers would see the notification and they would do the test, the ordering the FIT test. But then eventually, I feel like when they saw that popup alert, like, showing up all the time, they kind of got used to that, so that’s why we decided to change the workflow.”

2. Adaptability

Facilitator:

“So we didn’t change the workflow. Yes, we kind of, we changed it just a little bit just to add colorectal cancer, because we were doing hepatitis B. And then we started doing both.”

1. Needs & Resources of Those Served by the Organization

“I think it is really…meets the needs because once patients actually do decide to do the screening, and they’re happier if they know they’re healthy.”

1. Available Resources

Barrier:

“The only thing that we were using was kind of like leaflet of information from CDC…and information that we were given through the program as well. It was just a pamphlet informing about the different types of screening.”

2. Culture

“Our goal is taking care of our patients first…getting them to take charge of their health…for patients to get tested if they need to get tested and treated and we’re always there for them.”

3. Goals & Feedback

Barrier:

“it would be great to get more communication about where we stand. Because usually, when we hear about our program through our supervisor, it is pretty much to let us know that we didn’t hit a certain number. But we are not aware of what number to hit.”

“We didn’t have a number set, but we just want to see, to get better, to get higher.

4. Organizational Incentives & Rewards

“Nothing…They have not given s anything or said anything to us.”

1. Self-efficacy

“Well, some people say nobody reads what you get in the mail. Yeah, perhaps actually read…so we have all our patients that we’re giving a FIT test, and if they don’t return, we’re calling them, remind them…So a lot of them are actually bringing their FITs back, or they’re calling to schedule an appointment.”

“Very confident, you know? We do have several places where we check for our patients’ screenings, and we check to make sure they are needed, and we, like I said, we send our flags to the doctor. I feel very confident. I think we’re doing well.”

2. Other Personal Attributes

Facilitator:

“Well, I speak Spanish, so that sometimes, that helps a lot. I try to really promote, like preventive care visits for our patients, where a lot of that can, that conversation takes place. Because a lot of our patients sometimes don’t understand the need to come in for things when they’re not unwell.”

1. Reflecting & Evaluating

“So we have all our patients that we’re giving FIT test, and if they don’t return, we’re calling them, reminding them…So a lot of them are actually bringing their FITs back or they’re calling to schedule appointment.”

Administrator (n = 2)

1. Complexity

Facilitator:

“I think the language in the EMR reminder was straightforward. We knew what it meant – that they were, the patient’s due for colon cancer screening. The provider assessment and feedback, I think it’s, the data is pretty much straightforward.”

2. Relative Advantage

“Trying to highlight that and making sure that people are aware of it, as well as talking with the MAs. And you know, it’s like, yes, this orders and alerts and those kinds of things. So I think we’ve done something.”

1. Needs & Resources of Those Served by the Organization

Barrier:

“I guess I just think about we have a lot of things that are required…there’s like 15 minutes that each provider has with a patient. And, we’ve got, like, 16 different preventive care kinds of screenings that they need to be aware of.”

1. Available Resources

Facilitator:

“We did implement another system that does population health management…that helped us kind of identify patients who are missing colon cancer screening.”

2. Tension for Change

“We really have wanted to do, make a more concerted effort and now looking at some different strategies and whatever we can do to improve it (CRC screening rate).”

3. Goal & Feedback

Facilitator:

“I just started the last two months talking with our CMO, and we also have a new provider that we’ve hired that’s very focused on outcome and quality. And looking at having some dashboards. And having information that’s communicated regularly.”

4. Networks & Communication

“We’ve got to push more information out to our providers. And not even just the providers. And that’s where I think the dashboard’s good because it’s going to the team.

5. Organizational Incentives & Rewards

“As an FQHC, we really can’t be providing incentives.”

1. Reflecting & Evaluating

“I mean we have increased from like 26, 7% compliance rate to almost like 37, 38% compliance rate over the course of, like, two to three years.”