Table 1 Examples of resource-climate interactions at group 1 clinical sites

Champions (training, technological and social/emotional support)

Staff’s receptivity and trust in the new intervention

Champion (↑) → trust (↑)

A champion (the intervention developer) has helped the intervention users understand the reasoning behind the design of the intervention, and develop trust in the new tool

Implementation

“After all this time of using it, I have to say I know what the rules are in and out, and I talked to [a developer of the intervention] a lot, so I feel like I understand his reasoning behind a lot of the codes, so I definitely, I trust it.”

Site 1, Study ID 5

Support (↑) → receptivity (↑)

It is important to have a champion available for people to express their frustrations to and who can empathize with them and understand their pain points

“it’s really important to have one person I think as kind of the key person maybe or just get somebody onboard who can show the benefit of it, and then just keep discussing it and have open conversations… If people are really mad, just let them vent a little bit and how can we work through that…”

Site 45, Study ID 173

Learning climate

Education resources (↑) → learning (↑)

The interviewee helped create training materials for co-workers who volunteered to learn the dashboard and use it when the interviewee was unavailable. Because of the training materials, the staff can “fumble through” the dashboard

“I think most of them used that PowerPoint that I put together when they have to cover, and then they just go through that, like, ‘Okay, first I do this, and then I do that,’ and yeah, just go about it that way…they can fumble through it using like my how-tos.”

Site 30, Study ID 175

Trialability (the ability to experiment with the new tool)

Staff’s receptivity and trust in the new intervention

Time (↑) → trust (↑)

The staff were initially uncomfortable with relying on the dashboard, so they created a hybrid system in which they ran the dashboard but also did periodic patient reviews. They realized the dashboard was catching issues before their reviews were scheduled, as well as issues they would not have been prompted to check at all. Through this hybrid process, they realized that the dashboard is a beneficial tool and they established trust in the new tool

Implementation

“… we had kind of a hybrid model for probably about six months after going to the dashboard and I think by that point the pharmacists who weren’t really fully on board with it, they realized that there were alerts being generated in between the time they had, you know planned to follow-up with the patient, and they noticed that there were things that clinically really needed to be addressed before that six month mark or that 12 month mark but there wouldn’t have been any other reason for them to get into that veteran’s chart prior to then to review for any issues. So, I think that proved to them that the dashboard really was picking up on very critical things that needed to be addressed in a timely manner that our previous system would’ve missed… So, probably I would say at least a year after we started, everybody was fully onboard just doing the dashboard.”

Site 30, Study ID 175

Time, staffing, and supportive leadership

The extent to which the use of the intervention was supported within their organization

Staffing (↑) → barriers (↓)

The initial time investment in cleaning up the backlog of alerts made the dashboard more usable for them in the sustainment phase. The staff were able to overcome the initial challenge by recruiting more helps, which also required the leader’s support

Implementation

“So that initial review for a lot of the flags was very difficult just because we had to go through so many of them. That was probably the most difficult part of implementation, and we actually recruited some help from our pharmacy residents, we recruited some help from our Primary Care pharmacists, from our Cardiology pharmacists. We had a lot of our pharmacists taking a look at this dashboard all at the same time just to get the initial review done to the point where… let’s say if you have 500 flags for you know critical drug interactions, you’re not going to be able to catch a meaningful flag that pops overnight. So, we really needed to get it down to the point where it would actually be meaningful to be looking at this on a day-to-day basis, which it is now at this point.”

Site 44, Study ID 172

Time, staffing, and supportive leadership

Goals and feedback

Feedback (↑) → resources (↑)

Staff did not want to admit that sometimes they were struggling to keep up with the dashboard. Eventually, they realized that the dashboard required more dedicated time to be successfully managed so they provided feedback to their leaders and hired new staff to resolve the issue

Sustainment

“…when we transitioned to the DOAC dashboard as it is now, and as it continued to evolve and become more comprehensive, it just flagged more patients and it just took more time… maybe that lag in us figuring out okay wait we need to spend more time on this. So, I mean to our management’s credit, I think that they really listened, and they tried to fix it.”

“At first, people would kind of make excuses like, ‘Oh no, I can get it done, I just didn’t get it done this time because of this, this, this,’ and it was kind of like a self-protection thing, like, “I’ll get my job done, I’ll get it done’… I think as more people realized nobody is getting it done, then people felt more comfortable saying, ‘Yeah, it’s not me, it’s like the process, we need to have more time dedicated.’ So, I think there was that gap in there too, but then once people really started to be vocal about not being able to get it done, I would say probably 6 months to a year, you know by the time we hired that extra person and restructured the anti-coag clinic grid.”

Site 13, Study ID 108

Consistent support from implementation partners

The extent to which the use of the intervention was supported within their organization

Support (↓) → climate (↓)

The use of the intervention has been supported within their organization most of the time, but the staff wished that more of their recommendations about the medications would be taken by physicians (implementation partners)

Sustainment

“I would like to see a greater change in you know, I wish that our interventions that we recommend, that more of those recommendations were taken.”

Site 25, Study ID 112

“[Responding to what needs to happen to make the physicians more willing to take pharmacists’ recommendations] I think maybe more provider education. It would have to be probably a change in kind of I guess perspective. Maybe if the providers understood the training that we had as far as the anti-coag clinic pharmacists are supposed to be the expert in anti-coagulation but a lot of times we’ll get pushback and say, ‘Well Cardiology recommended this.’ Well okay, but Cardiology is recommending a dose that’s not recommended. So maybe education to the providers about the qualifications of the staff or just discussing with the staff that to make recommendations that are appropriate for the patient and not necessarily what was recommended by an outside provider or a cardiologist and just taking that as the gold standard.”

Site 25, Study ID 112