Structural characteristics
This construct comprises many of the traditional quantitative measures of context, including age and size of the organization. There was no mention of these aspects influencing implementation of MOVE!, perhaps because these measures are often proxies of more proximal factors. This construct also includes potential influences of the social architecture (e.g., how people are organized into separate service lines or clinics to deliver health care). We found that the quality and nature of networks and communications within and across organizational units were the more proximal influence, as described in the next section.
Networks and communication
This construct strongly distinguished between low and high implementation facilities. We identified three sub-themes that clearly distinguished low from high implementation facilities. First, the high quality of working relationships across service (e.g., nutrition, primary care) and professional (e.g., health psychologist, dietitian) boundaries was apparent in the high implementation facilities:
‘If I need something, I just contact either the primary care supervisor or the mental health RN supervisor and request a meeting and they’ve been cooperative.’ [MOVE!Coord; 300]
In the other high implementation site, the coordinator (a Nurse Practitioner in primary care) had strong working relationships with other primary care providers, which helped in coordinating care for a patient who was working hard to lose weight and stay off of medication:
‘[The patient] looks dejected [today], extremely depressed and […] he goes, ‘I’m trying so hard to lose weight and I just saw my primary doctor and my primary doctor put me on diabetic medication and I’m like trying to do all of this and I still have to start taking medication?’ so I said, ‘You know what? Let me go and take a look at your chart […] and see what […] is actually needed’ so I go and review the chart, I call this patient’s primary care provider and I said, ‘He’s under my supervision and I’m trying to get him to lose weight. Do you agree that we can give him three-month trial to fix this with diet?’ […] So he agreed!’ [MOVE! Coord; 400]
In contrast, at one low implementation facility, a former MOVE! coordinator was not even told that a new coordinator had been hired to replace her.
The second sub-theme was related to team formation. The MOVE! teams at the two high implementation and transition facilities met regularly, for example:
‘Every two weeks we meet after the MOVE sessions […] with all the members of our group to discuss successes and other things […] we do this through our […] supposedly lunch time […] we carve out like 20 minutes to 30 minutes maximum […] to discuss obstacles, to discuss problems.’ [MOVE!Coord; 400]
These regular meetings helped the team coalesce. Multiple members of the interdisciplinary teams confirmed the collaborative nature of their team:
‘From what I’ve seen out in the world […] there’s a huge friendliness attitude here […] We have a huge staff retention […] so we all know each other and have worked together […], So that’s a huge benefit for us […] nobody was real pushy or bossy or anything. We all kind of collaboratively worked together so that definitely helped.’ [Physical Therapist; 300]
In the low implementation facilities, communications were poor between staff involved with MOVE! and they did much of their communication through email, if at all:
‘[If we have any MOVE! team meetings] we haven’t been invited. I don’t think we do, though.’ [Librarian; 200]
The third sub-theme was related to communications about MOVE! to other staff and patients. Multi-pronged and on-going communications helped to ensure primary care providers continued to refer patients to MOVE! in the high implementation facilities:
‘Every now and then we’ll send them a blanket message to all providers reminding them about the MOVE! program and how they need to make the referrals to the MOVE! program. I’ve met several times with the LPNs at their monthly meetings, encouraging them as front line people that they need to sell the program and […] a lot of them have attended the class to see what it’s like.’ [MOVE!Coord; 300]
In the low implementation facilities, some patients presented themselves to MOVE! staff, confused about what MOVE! was; a movie, a dance class, or bariatric surgery were some of the assumptions:
‘Sometimes they come without that little hard copy consult and they think that they need to see a movie […] they’re kind of confused sometimes about what they’re coming for […] [Librarian; 200]
Thus, the two high implementation sites were rated a strong positive, and the two low implementation sites were rated a strong negative.
Culture
We did not ask explicitly about perceptions of overarching culture.
Implementation climate
This construct comprises six sub-constructs. Conceptually, the aggregate of these six constructs may provide an overall measure of implementation climate, but we rated the individual sub-constructs, which are more useful for generating actionable recommendations.
Tension for change
This construct strongly distinguished between high and low implementation facilities. There was no expressed need for the program—or expressed concern that the program was not needed—in either of the low implementation facilities (neutral rating). Staff at high implementation facilities expressed some dissatisfaction with their current weight management options and welcomed MOVE! as a way to fill some of the gaps in their programming:
‘We had nothing else to offer and so they’d attend the class and when you could tell they were newly motivated or wanted additional information, at that point, we had nothing more to offer.’ [MOVE!Coord; 300]
Tension for change was strongest at the transition facility after expectations were raised in the first year but the program failed to materialize:
‘For a year, it was […] stagnant […] they had put up the […] [MOVE!] posters, […] and they didn’t have anything set up so people were consulting to the MOVE program when there wasn’t even a program set up.’ [MOVE!Coord; 100]
Compatibility
This was not a distinguishing construct. Despite one low implementation site having a strong negative rating and one high implementation facility having a strong positive rating, two of the facilities (one high and one low implementation) had a weak positive rating based on general statements like, ‘[…] everybody believes in the program.’
Compatibility has two major themes: compatibility with stakeholder values and compatibility with existing processes. Related to the first sub-theme, one low implementation facility felt that programming for a community-based program was better aligned with their desire to provide a wider array of options that focused on wellness, versus MOVE!, which at that time was marketed to “obese Veterans.” Related to the second theme, MOVE! was perceived as being highly compatible in one of the high implementation sites with a pre-existing metabolic clinic which focused on weight management.
Relative priority
This construct strongly distinguished between high and low implementation facilities. At one high implementation facility, the high priority of getting a bariatric surgery program in place worked against MOVE! implementation efforts at first. However, the MOVE! coordinator successfully linked the success of the bariatric surgery program to success of MOVE!, which increased priority for MOVE!
In contrast, it was clear that the low implementation facilities were struggling to respond to other higher priority initiatives, such as setting up new traumatic brain injury and poly-trauma screening programs and an urgent push to reduce clinic backlogs:
‘We had such a backlog […] It just depends on where you are on the totem pole […].We are absolutely, pardon the expression, under the gun to take care of these returning Iraq Veterans and so it’s a matter of, the MOVE program’s important, but these people are on fire over here.’ [MOVE!Coord; 500]
Organizational incentives and rewards
This was not a distinguishing construct. There was little or no evidence of any monetary rewards or of less tangible incentives like positive evaluations at any of the study facilities. The absence of incentive was rated as a weak negative influence at one low implementation facility because an interviewee acknowledged that she could not expect to get a raise, a bonus, or a pat on the back for successfully implementing MOVE!. All other sites were rated as neutral.
Goals and feedback
This construct strongly distinguished between high and low facilities. All of the facilities struggled with collecting program data and translating it into useable information. Organizational leaders generally did not ask for program data. One supervisor in a low implementation facility tried to collect tracking data but was burdened by the lack of tools:
‘I haven’t pushed it [compiling data] because our clinical responsibilities are so high and pulling it together, we’ve worked on it every spare minute for the past two days […] just compiling the data on a hard copy.’ [MOVE!Coord; 500]
In contrast, at the high implementation facilities, coordinators regularly tracked program data and reported it to organizational leaders who reviewed progress of the program:
‘I know how they’re doing during my MOVE! level two classes because I keep track of their weight from week to week […]. We do every quarter look at all the surveys and my clerk kind of comes up with a report of all the questions, comments, outcomes and I send that to [the Physician Champion] quarterly.’ [MOVE!Coord; 300]
In addition, coordinators in both of the regions associated with the high implementation facilities used program data to keep the program visible with key regional-level leaders. One regional coordinator used program data to win funding for additional dedicated staff at all of the medical centers in the region, and the other regional coordinator coached local coordinators about how to use program data to argue for needed resources.
Learning climate
This construct strongly distinguished between high and low facilities. We did not assess all dimensions of learning climate, but an important theme that clearly arose out of the data was the difference in the degree to which interviewees felt psychologically safe to take initiative in implementing MOVE!. Both of the high implementation facilities exhibited multiple dimensions of a learning climate: MOVE! coordinators were not afraid to experiment; they shared ideas with peers and superiors; and they had regular forums for learning from others. For example, one regional coordinator rotated meetings between sites in the regions so people could get to know and learn from one another. Facility coordinators kept in touch with one another through email and phone as well:
‘[These connections] give me an idea of what they’re doing and how we can modify here and I can give them a few suggestions that we have […] we kind of share, exchange information and it really benefits both sides because people do things differently and we learn from each other.’ [MOVE!Coord; 400]
There were indications of a potentially toxic climate at one low implementation facility:
‘I contacted the next likely person […] he just seemed to be so enthused about our goals […] [so I] Focused him in my binoculars […] I sent him an email. I didn’t want any arrows in my back so […] the safest thing to do here is in the little email (laughing) and then if that gets positive response, then you actually meet someone.’ [MOVE!Coord; 500]
Readiness for implementation
This construct comprises three sub-constructs. Conceptually, the aggregate of the three constructs may provide an overall measure of readiness for implementation; but like our approach for implementation climate, we rated the individual sub-constructs instead, which are more useful for generating actionable recommendations.
Leadership engagement
This construct strongly distinguished between high and low implementation facilities. Service chiefs at the high implementation facilities allocated time for their respective staff to be a part of the interdisciplinary team and the coordinators had supervisors who were actively supporting the program.
Leaders helped to solve problems, get the resources needed, and ensure MOVE! was visible in the organization:
’If we have any equipment issues or you know, space issues, although space, you know, is hard but you know, they continue to look for us and help and it’s kept up there on […] radar, so they haven’t forgot about it […] if you say, ‘Can you bring it up at this meeting’ and that, they certainly will […] I would say leadership here is supportive and interested in it and then by them agreeing to hire, to hire a two positions for this MOVE program I think says a lot. It’s saying yes we will support you, we have value into the program.’ [Supervisor; 300]
Leaders at one low implementation facility seemed to work against implementing MOVE!, in part because MOVE! was low priority and in part because they were so focused on developing a bariatric surgery program and failed to acknowledge MOVE!’s role in preparing candidate patients for the surgery. At the other low implementation facility, the MOVE! coordinator had difficulty assembling the required interdisciplinary team, because service chiefs did not allow staff who willingly volunteered to participate on the MOVE! team:
At the transition facility, we heard about how a key clinical leader succeeded in getting approval for more staff to implement and then expand program:
‘I told them that we wouldn’t play if they didn’t give me the FTE [staff time] […] it came down to, ‘Are we going to do this or not’ and I said, ‘You know, we are more than happy to do this but if you don’t give me the FTE, then you can get dietician involvement by paying somebody from the outside to come in because I won’t do it. I don’t have the staff to support the program’ so I did play a little bit of hardball and put my foot down.’ [Supervisor; 100]
Leadership engagement was often double-coded along with relative priority and available resources. It is sometimes difficult to disentangle these influences. Engagement of leaders is often demonstrated by their actions in reinforcing priority and helping get needed resources in place, as the above illustrations show.
Available resources
This construct weakly distinguished between high and low implementation facilities with strong negative ratings in both of the low implementation facilities and a mix of weak ratings in the other facilities. Resources were constrained at all of the study facilities. The most common constraints were lack of dedicated staff time and shortage of physical space. At one of the low sites:
‘There was a lot of conflict with scheduling. The room was only available certain times of the day and it conflicted with other group classes in the room […] we basically moved into a room that was full of storage and we offered to go in there and try to make it conducive to a classroom and once we showed that there was going to be some attendance and it was going to be an ongoing and successful project we were able to get a more permanent location.’ [MOVE!Coord; 500]
At this facility MOVE! was just one more under-funded initiative:
‘Well there’s nothing like an unfunded mandate […] to get […] their blood boiling around here where workloads are so high everywhere else.’ [Clinical Psychologist; 500]
The MOVE! coordinator here purchased supplies out of her own pocket as incentives for Veterans who completed the MOVE! classes until she finally won approval for funding:
‘Our coordinator’s extremely distressed over facility issues and begging […] management has not put money forth for things.’ [Dietitian; 500]
However, staff at the high implementation and transition facilities viewed these constraints as challenges that could be overcome, rather than feeling defeated by them. In fact, one high implementation facility, despite tight budgets, won approval for dedicated staff time and was in the process of hiring an additional staff position that was approved by regional leaders.
Access to knowledge and information
This was not a distinguishing construct. NCP published program materials online, including an implementation guide. We coded this construct as ‘missing’ at two facilities because there was no explicit mention of the helpfulness of these materials as an information source and we failed to probe more on this topic. This construct should be distinguished from design quality and packaging, in that it focuses more on access to information about the intervention and how to incorporate it into work tasks; where design quality and packaging focuses more on how components of the intervention itself (such as patient materials) are packaged and presented.
Training is also an important potential source of information and knowledge. No staff at any facility had access to training or training materials to help guide how to implement or administer the program. One high implementation site was rated a weak positive because they had plans to provide training to new staff:
‘Now that I have all the staff hired, we need to set up a face to face training meeting and I myself have never planned a [region-]wide training conference and so they’re helping me get in touch with the education coordinator and helping me with funding to schedule that […] for new MOVE! coordinators and staff.’ [regional Coord; 300]