Table 1 Implementation outcomes—summary of qualitative results
Strategy | Themes (in bold) and Exemplary Quotes (in italics) |
|---|---|
Change the record system (Template) | Encouraged Risk Stratification and Guideline-concordant Surveillance Recommendations "I think familiarizing ourselves with the criteria and the surveillance schedule, you know, reinforcing that has been good. Using the template helps. I think—and it’s particularly good because…the same doctor doesn’t always see the patient. So, it helps to put that in perspective and, you know, where the patient is in the treatment schedule” [ID01] Reduced Documentation Time "The provider enters the stage, grade, and the size of the tumor, and the focality and the recurrence, and then they can immediately see which risk category this specific patient they have falls into. And then the appropriate surveillance will then pop out, pop up, and then they can follow that" [ID03] Guided Residents in Risk-aligned Surveillance “I think it’ll like immediately be part of their workload” [ID09] “I think that any academic VA center where the residents are doing a lot of independent work in clinic is going to be really reliant on these residents coming through, some of whom may not know oncology super well yet. And maybe they’ve never treated any bladder cancer patients before this. And so previous to having the schedule and the CPRS [EMR] templates they would have to go to a website or to our share drive and look up the guidelines document and like to go page 37 of the guidelines document to find the follow-up protocols for these patients. And that’s a lot of manual work that they’re unlikely to do for every patient. And so being able to easily pull it in through a template I think is an effective strategy” [ID11] Required Support from Local IT “We are as good as the support we have locally, and that sometimes can be quite challenging with all the demands. We have only one person that does that, and I imagine they are working with the entire surgery and subspecialties, to do all the templates. So that can be a little bit of a challenge, to say the least” [ID03] Impact “I believe all had an impact. I would say that the most impactful was…CPRS templates” [ID03] “I think especially with this, with it being like resident run and we, you know, see these patients who had maybe high-risk bladder cancer with multiple recurrences, and it's managed over the last six years it's just nice having this template that, for the most part, gives you some organization on how to…put all the info together. Gives you, at the top, kind of like the rundown of…what's their risk category, how often should they be followed, when was the last, it asks, you know, the important questions…like when was the last recurrence, last imaging, things like that that can sort of prompt someone to look for the important pieces of information to put their, their story together. So, I think, I think that that's quite nice” [ID08] |
Surveillance Grid (Prepare patients to be active participants) | Effective Clinician and Patient Tool “That was helpful for them to appreciate how often they should come in. I obviously explained it in detail using those cue cards and then at the end I would utilize those sheets that we would hand out to them” [ID05] “I think appreciated by patients but also on the provider side…I have personally found it helpful to grab one of those and go over it with the patient. And it just helps to clarify the schedule in your mind. I love the sheets I use them for all the patients because I really like using them and I feel like the patients like seeing what their schedule is and where they are in the process.” [ID11] “I think they like it because they can see, especially the high-risk guys they get…three-month cystoscopy and then…when you give them the grid you can show them how long they stay disease free how…the frequency decreased and they’re a little bit encouraged by that. And feel like they, they like it a little bit more to have it in a graphic representation [ID08] Time Intensive for Clinicians to Complete “Filling out that grid often was pretty time-consuming when I was looking retroactively to see like when they got their previous cystoscopies because I wanted to make sure that they had done all of their appropriate and necessary follow ups. However, after talking with my chairman, he essentially said that, you know, it's okay that I don't fill out all the stuff in their, in their surveillance history on to those grids. Focus more is on what needs to be done next. So just looking like prospectively instead of like retrospectively. The only things that I would write down that were retrospective were the dates of their most recent diagnosis. And if it was readily available, which it is…it fit into the six months, nine months, or 12-month marker, I would, I'd write it down” [ID05] Patients did not Return to Office with Surveillance Grid “I think the patients just lose them. We haven't seen anyone bring it back” [ID06] |
Remind Clinicians: Cheat Sheet | Aided in Risk Stratification “They made it really clear which patients fall into what category” [ID11] Facilitate Surveillance Schedule Concordance between Providers “Looking at the sheet and, you know, figuring out where the patient fits into, you know, which category, that’s helpful. So yeah, I think- and it’s particularly good because not-the same doctor doesn’t always see the patient” [ID01] Aided Patient Education “I utilize the cheat sheets with the patients frequently as I review their particular diagnosis. So I felt that i was very helpful to have a visual aid for them” [ID05] Helpful “The provider one was very helpful, and I honestly took that around with me. I refer to it frequently” [ID04] |
Remind Clinicians: Poster | Effective Visual Cue “…the provider not only has the grids to give to the patients, but also they can look in every cystoscopy room, we have three of them, and in the hallways, and the cystoscopy office, and in case they want to double-check, they can always just literally turn their head on the wall and they see the poster and they can say: Yes, it is this way" [ID03] “The posters and reminders also, similarly, it’s a complicated topic, so having like we have the poster up in our key workroom. And that’s actually really nice because it just provides a reminder of like how one does this, because it has all these facets to it that are hard to remember” [ID06] |
Educational Meetings | Critical to Implementation "I think they were, they were necessary at least to, to review risk stratification for all the different providers. And those are things folks should, should generally know but I, it wouldn’t have made sense to not have those sessions. I think they were helpful" [ID10] “The educational sessions help provide awareness to the group of why this is important, and what the ideal output should be” [ID06] Overcoming Implementation Barriers “We are going to provide you with tools that will make it easier on you. I think they get very happy, and the final, most important part, is to show them the tools and get buy-in" [ID03] Suggestions “Use more clinical scenarios or try to make them more interactive” [ID11] “If there were more education on the front end I think that that is a good idea” [ID09] Too Frequent “I’m not sure we needed all those meetings but didn’t hurt” [ID07] |
Champion | Leadership Role “Our champion has basically coordinated it so that our bladder cancer surveillance now is grouped individually. So we have clinics specifically devoted to that with providers that are well-versed on the process. So that’s been helpful” [ID02] Critical to Addressing Learning Curve “I just think there’s a learning curve wit this, and that’s where a repetitive nature, the assistance of the champion, I think until the providers get comfortable if very helpful” [ID02] Essential to Implementation and Coordination “I think it is important if not critical to have somebody locally as a champion when you launch the project. Someone has to explain it to everyone of like, hey guys we’re doing this and upload the templates and print everything out. And it you didn’t have a local person at all then I don’t think you’d probably be able to run it, to get it started. But once we started it I don’t feel like we ever really had a problem with it where we then had to reach out to our champion again for any problem solving or issues or encouragement. I feel like once we got rolling everyone, it makes sense to people, and for the most part we had pretty good adherence” [ID11] Unfamiliar with Role “I don’t know who those people are” [ID09] |
Tailored Strategies | Visual Alignment “We aligned the cheat sheet, poster, and grid to have the same streamlined way, the same horizontal-like, timeline, and the same font, the same kind of stuff so that kind of really helped” [ID03] Template “We modified the templates to include SWOG protocol, BCG schedules and put all the dates in” [ID09] “The residents started to modify them a little to add features that they thought were even more helpful that would tell them like when the next cysto was due or when the next BCG was due…I think those things have had a big impact and are continuing to be utilized” [ID11] |
Facilitation | Important to Implementation "Support from the research team was key to just kind of bring this up in the first place and show us importance of like what we're doing and then also like provide some helpful feedback on how to implement this at our site" [ID06] |
Blueprint | Unrecognized “So I assume that's what the blueprint is alluding to. And so I don't recall like this very specific moment that a blueprint was unveiled to us” [ID06] |
Audit & Feedback | Risk-aligned Surveillance Data not Conveyed by Champion to Broader Team “I don’t think I’ve heard any recent data, not from our VA, or from any VA, to tell you the truth” [ID01] Group-level Data Would be Helpful to Guide Local Improvement Processes "Yeah…I’m a big fan of audit and feedback style approaches. And I think that as long as it’s not, as long as it’s de-personalized and no one feels attacked and it’s across the whole group then I think it can be a good reminder to everyone" [ID11] |