Table 3 Key SCORE implementation strategies, definitions, and outcomes used during the Preparation phase

1. Use advisory boards and workgroups

Create and engage a formal group of multiple kinds of stakeholders to provide input and advice on implementation efforts and to elicit recommendations for improvements

Research team and CHC administrators, providers, and staff

Establish workgroups corresponding to CRC screening steps and comprising relevant stakeholders

Workgroups at CHC1 and CHC2

Throughout Preparation

• Established three workgroups to carry out three core functions: (1) Registry (research staff with EHR expertise, CHC data programmers); (2) Mailed FIT (research staff with community-building and implementation expertise, CHC practice managers, medical officers, referral staff); (3) FIT + to Colonoscopy (research staff project manager, patient navigator, internal medicine physician, gastroenterologists, CHC medical director)

• Developed workgroup charters to guide workgroup purpose and activities

2. Obtain formal commitments

Obtain written commitments from key partners that state what they will do to implement the innovation

Research team

Obtain (1) commitments from working group members; (2) regulatory and legal agreements to conduct screening outreach and follow-up on behalf of the clinics

Workgroup members of CHC1 and CHC2; CHC1 and CHC2 administration; cancer center leadership; university regulatory, legal, and financial entites; lab results processesing facilities

Workgoup member agreements obtained at the beginning of Preparation. Remaining commitments obtained throughout Preparation, completed before (and required as part of) Implementation

• Workgroup charters detailing workgroup expectations and commitment

• Business Associate Agreements to send FITs and conduct follow-up on behalf of the clinics and enable EHR access

• DUA entailing data sharing plans for the transfer of data between centralized outreach center and each CHC

• EHR access for centralized patient navigator

3. Assess for readiness and identify barriers and facilitators

Assess various aspects of an organization to determine its degree of readiness to implement, barriers that may impede implementation, and strengths that can be used in the implementation effort

Research team and CHC workgroups

Conduct site visits to CHCs and endoscopy centers to understand available resources and capacity; engage CHCs in process mapping and intervention planning discussions; conduct clinic-level chart reviews to inform understanding of referral practices

CHC1 and CHC2

Throughout Preparation

• Multiple visits to CHCs and endoscopy practices, discussing referral protocols and workflows

• Process maps of current processes and planned implementation processes

•Chart review outcomes

• Intervention protocols reflecting involved organizations’ readiness, barriers, and facilitators

4. Conduct cyclical small tests of change

Implement changes in a cyclical fashion using small tests of change before taking changes system-wide. Tests of change benefit from systematic measurement, and results of the tests of change are studied for insights on how to do better. This process continues serially over time, and refinement is added with each cycle

Research team and workgroup members

Within each workgroup, pilot intervention components and test them using PDSA cycles, to iteratively improve SCORE components; incorporate patient feedback

Research team, workgroup members at CHC1 and CHC 2

During Preparation after process mapping

• EHR query validated against manual patient-level chart review

• Lab order requisition form tailored to SCORE and each CHC

• MailedFIT packaging materials revised following return response

• Patient primer letter alerting to expect FIT kit in mail revised following patient input

• 4-call navigation protocol adapted from 6-call protocol

• Patient-facing navigation materials tailored to patient needs

5. Use data warehousing techniques

Integrate clinical records across facilities and organizations to facilitate implementation across systems

Research team and workgroup members with EHR expertise, including CHC data management staff

Gain CHC EHR access for centralized outreach staff; develop screening registry to accurately and efficiently conduct and track screening activities and support monitoring and reporting, using input from each workgroup’s PDSA cycles

Research team and data management staff at CHC1 and CHC2

Early in Preparation, and before initiating pilot mailedFIT and navigation cycles

• Secure, integrated CRC registry database of patient-level data from different sources (CHCs, endoscopy centers, and navigator calls)

6. Develop educational materials

Develop and format manuals, toolkits, and other supporting materials in ways that make it easier for stakeholders to learn about the innovation and for clinicians to learn how to deliver the clinical innovation

Research team and workgroup members

Develop SOP and supporting materials for implementers and patients within the Registry, MailedFIT, and FIT + to Colonoscopy workgroups to raise awareness, educate, and guide implementation communications (inform using stakeholder feedback and patient interviews); develop process maps to depict intervention workflows

SOP target is research team;

Process maps target is research team and workgroup members at CHC1 and CHC2

Throughout Preparation, completed prior to Implementation

• Functional, detailed SOP with supporting materials and process maps for each workgroup/implementer, including site-specific query and intervention tracking protocols (Registry workgroup); protocols for assembling FIT kits; patient-facing materials including primer letter, FIT instructions, and results notification (MailedFIT Workgroup); navigator protocols for patient navigation and questions, and patient-facing materials including welcome to navigation letter, bowel prep instructions, unable to reach and declined navigation letters (FIT + to Colonoscopy Workgroup)

7. Fund and contract for the clinical innovation

Governments and other payers of services issue requests for proposals to deliver the innovation, use contracting processes to motivate providers to deliver the clinical innovation, and develop new funding formulas that make it more likely that providers will deliver the innovation

Research team

Subcontract for specific services to fund laboratory testing of FIT samples and FIT + to colonoscopy activities (transportation, bowel prep, colonoscopy, interpreter services)

Transportation programs and pharmacy services at CHC1 and CHC2;  gastroenterology providers at referral clinics; interpreter service providers serving each CHC

Early in Preparation, for completion prior to Implementation

• Contract for flat, reduced-fee colonoscopies for uninsured patients at CHC1, as an extension of an existing program

• Contract with CHC2 to fund transportation services as part of an existing CHC transportation program

• Payment systems to fund colonoscopies and related services

8. Develop a formal implementation blueprint

Develop a formal implementation blueprint that includes all goals and strategies. The blueprint should include the following: (1) aim/purpose of the implementation; (2) scope of the change (e.g., what organizational units are affected); (3) timeframe and milestones; and (4) appropriate performance/progress measures. Use and update this plan to guide the implementation effort over time

Research team and workgroup members

Develop SOPs and process maps corresponding to each CRC screening step and update as needed

Research team and CHC1 and CHC2 leadership and workgroup members

Throughout Preparation, for completion prior to Implementation

• Written SOP outlining processes to guide implementation

• Process maps to formalize blueprint for who would do what and when during the Implementation phase