Factors Influencing Implementation of Evidence-based Cancer Prevention and Control Practices in FQHCs: A Qualitative

1. Factors Influencing Implementation of Evidence-based Cancer Prevention and Control Practices in FQHCs: A Qualitative Study CPCRN FQHC Qualitative Inquiry Subgroup MaríaE. Fernández, Ph.D Associate Professor of Health Promotion and Behavioral Science University of Texas Health Science Center at Houston School of Public Health

2. Outline • Research Question • Methods • Data collection • Analysis approach • Preliminary results • Timeline

3. Research Questions • Primary question: What factors influence the implementation of evidence-based cancer prevention and control practices in FQHCs? • Secondary question: How useful is the CFIR in assisting the analysis and interpretation of qualitative empirical data on implementation?

4. Methods Used qualitative inquiry approaches (in-depth personal interviews and focus groups) to understand factors influencing the implementation of evidence-based cancer prevention and control programs and practices in FQHCs.

5. Instruments • Focus group and in-depth interview guides were developed broadly informed by the Consolidated Framework for Implementation Research (CFIR) • A modified Appreciative Inquiry (AI) approach was used to guide the discussions • Open-ended questions and prompts about successful practice changes were included as well as questions that tap intoa specific evidence-based cancer control practices (including tobacco cessation) • A brief survey asking about FQHC size, patient population, EHR integration and participation in the Health Disparity  Collaboratives was administered.

6. Focus Group Guide Overview Part I: Example of successful practice changes Part II: Explore evidence-based cancer prevention and control strategy (Tobacco Cessation: Ask-Advise-Refer) Part III: Inner setting—organizational characteristics and implementation climate and readiness for implementation Part IV: Other domains of CFIR—intervention characteristics and outer settings

7. Sampling & Recruitment • Sample: CEOs, CMOs (or Medical Directors), COOs (or Operation Managers), Quality Improvement managers, frontline project managers, etc. of FQHCs • Recruited through partnerships with:

8. Data Collection • Conducted focus groups and interviews at: • National conferences attended by FQHC leaders and staffs in San Diego, California; Albuquerque, New Mexico; and Washington, D.C. • Regional Primary Care Association (PCA) meetings in Denver, Colorado; Columbia, South Carolina; and Pine Mountain, Georgia. • Five focus groups and 21 in-depth personal interviews; all were digitally recorded • Data collection period: August, 2011—April, 2012

9. Data Analysis

10. Grounded Thematic Analytic Strategy

11. Phase 1: CFIR-based Coding • A list of pre- existing codes was developed based on the CFIR domains and constructs • Each transcript is coded by a research team member using pre-existing codes and reviewed by another, followed by group reviews • Additional codes were added as needed for responses that do not fit with the CFIR

12. Phase 1 (cont.): Frequency Distribution • Frequencies of coded quotations among each CFIR domain and subdomains were calculated and organized by the three groups of respondents: • CEOs or COOs (executives) • CMOs or Medical Directors (medical managers) • All others (other staff)

13. Phase 2: Data-driven Coding • Phase 2 has three separate but inter-related activities that proceed in an iterative fashion • Identify barriers and facilitators to implementation that most accurately reflect the experience of the respondents (i.e. data-driven) without regard to the meaning and content of the CFIR • Naming barriers and facilitators at second level of abstraction from the data • Renaming and merging codes as they emerge

14. Phase 3: Thematic Analysis • Clustering codes into a two-dimensional model for initial data reduction • Further data reduction and exploration within and between each cell of the matrix

15. A Two-dimension Model for Initial Data Reduction

16. Phase 3: Further Data Reduction and Exploration • Group themes and subthemes into a smaller number of categories • Explore possible linkages among themes and subthemes • Identify themes/subthemes that are most salient to each respondent group and compare them • Compare identified themes (emergent from the data) with CFIR constructs

17. Current Progress • We are currently engaged in Phase 3 • Finished coding 522 quotations (in Inner Setting and Individual Characteristics) • Came up with 147 barriers and facilitators

18. Preliminary Results

19. Participants’ Roles • 59 individuals (29 male & 30 female) • 29 Chief Medical Officers (CMO) or Medical Directors • 4Chief Executive Officers (CEO) & 1 Executive vice president • 9 Chief Operations Officers (COO)or Operations Manager • 4 Quality managers (in different titles) • 3 Director of nursingand 1 nursing supervisor • Others include nurse practitioner, physician’s assistants, director of health services, project managers, grant manager and medical interpreter

20. Participants’ Locations • Participants represent FQHCs in 14 states and Washington, D.C.

21. Coded Quotations • A total of 1, 213 coded quotations (meaning units) • 740 of them were coded to more than one CFIR code

22. Examples of Data-driven Barriers and Facilitators Barriers • Disinterest in prevention activities • Lack of resources to implement change • Staff lack of time to integrate change • Patients resistant to change • Limited functions of EMR • Lack of staff follow through with patients Facilitators • Change aligned with organization mission and values • Action and change oriented staff • Designated Quality Improvement (QI) personnel • Obtaining buy-in through feedback and recognition • “Pilot team” to test new changes (low risk and important information)

23. Preliminary Highlights • The use of EMRs is pivotal in cancer prevention practices and other quality improvement efforts in CHCs • Federal regulations and requirements (UDS & PCMH) and national visionary goals (Meaningful Use incentives) drive changes • Leadership engagement is essential for practice change • Connections and partnerships with academics and other healthcare organizations are very important for CHCs’ cancer prevention efforts • Providing sufficient training and resources for staff to implement change is very important • Programs aligning with the goal of improving quality of care are more likely to be implemented

24. Significance Findings will contribute to the understanding of the factors influencing the implementation of evidence-based cancer prevention and control programs in FQHCs serving disadvantaged populations and inform the design of interventions to increase the use of EBAs in FQHCs.

25. Proposed Timeline for Manuscript • Receive feedback on analysis (Oct,2012) • Complete analysis (Nov, 2012) • Manuscript outline (Nov, 2012) • Writing (Nov—Dec, 2012) • Manuscript review and feedback (Jan, 2012) • CDC approval (Jan 2012) • Submission (Feb, 2012)

26. Acknowledgement — QIS Members • UT Houston: Maria Fernandez (PI), Nick Woolf (Consultant), Lily Liang, Glenna Dawson, William Calo, Jenny Tektiridis, Barbara Kimmel, Glorili Alejandro, Patricia Mullen • Emory University : Michelle Kegler (PI), Michelle Carvalho, Gillian Schauer • University of South Carolina (SC): Vicki Young (Co-I), Dayna Campbell • University of Colorado (UC): Betsy Risendal (PI), Andrea Dwyer, Yvonne Kellar-Guenther • University of Washington (UW): Shin-Ping Tu (Co-I) • National Association of Community Health Centers (NACHC): Michelle Proser • National Center for Farmworker Health: Alicia Gonzales

27. Questions? Thank You!