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Table 1 Intervention characteristics that influence implementation success (according to CFIR)

From: Implementation of the uterine fibroids Option Grid patient decision aids across five organizational settings: a randomized stepped-wedge study protocol

Construct Short description
I. Intervention characteristics
A. Intervention source: quality assurance. EBSCO Systematic Literature Surveillance System (source of evidence for DynaMed Plus product) is best in class.
B. Relative advantage: comparison opportunity Very few clinicians have used patient decision aids designed to facilitate shared decision making. Our evidence so far indicates that clinical teams are positive about their utility.
C. Adaptability: the degree to which an intervention can be adapted to local needs. The availability of multiple formats: online and two printed versions (text and Picture Option Grid) allows maximum adaptability to local workflow variations. The online tool can be sent to patients ahead of visits, as well as after visits. The printed versions allow clinicians to tailor the content to local practice variation and to fit the tool into their style of communication with patients of varying literacy and computer literacy levels. We know that clinicians value the ability to add, edit, and make notes on these tools before they give them to patients to take home. The use of pictures maximizes the usability and accessibility of this approach across socioeconomic strata.
D. Trialability: local test The cost or complexity of using Option Grid is low, and so, we anticipate low resistance to trialability by the participating clinical teams. In other clinical contexts, we have experienced zero resistance to trialability.
E. Complexity: as the number of steps, or the number of people or processes increases, so does the difficulty of implementation. The Option Grid has been designed to be fast, frugal, and outwardly simple, so that it can fit into decision discussions that will benefit from accurate, accessible information.
F. Design quality and packaging: instills confidence in the intervention. The EBSCO Option Grid has achieved high quality design with professional user centered graphic design.
G. Cost: investment, supply, and opportunity costs. Investment will be related to the time taken to learn how to integrate the tool into the clinical workflow, a learning curve that has been observed to take a few interactions. The project will ensure adequate supply; future use will need to ensure online access for sustainability. We anticipate minimal disruption on opportunity costs—clinicians typically cover the type of information in Option Grids. The tool makes the exchange more efficient according to our evaluations. Evidence suggests that Option Grid decision aids do not typically increase consultation time as the content of the tool is information clinicians already provide to patients routinely.
II. Inner setting
B. Networks and communication: The nature and quality of webs of social networks and the nature and quality of formal and informal communications within an organization. Eligible patients will be identified using the site’s outpatient scheduling system in advance of their visit. Where possible, the eligible patients will be sent an Option Grid in advance of their appointment and will be instructed to bring the Option Grid to their appointment.
C. Culture: Norms, values, and basic assumptions of a given organization. We want to help implement a process where patients are engaged in their treatment decisions “upfront” by receiving an intervention that can facilitate a discussion with their clinician regarding their treatment options.
D. Implementation climate: The absorptive capacity for change, shared receptivity of involved individuals to an intervention, and the extent to which use of that intervention will be rewarded, supported, and expected within their organization. We will assess implementation climate by calculating the expected use of the intervention which is based on the volume of patients visiting each site who have been diagnosed with symptomatic uterine fibroids.
E. Readiness for implementation: Tangible and immediate indicators of organizational commitment to its decision to implement an intervention. We will determine readiness for implementation from the Measuring Organizational Readiness for patient Engagement (MORE) survey which will be administered prior to the commencement of the pre-implementation phase to 10 stakeholders at various levels of the service delivery team (i.e., clinicians, administrators, managers).
III. Characteristics of individuals
A. Knowledge and beliefs about the intervention: Individuals’ attitudes toward and value placed on the intervention as well as familiarity with facts, truths, and principles related to the intervention. ADOPT is a measure of patient attitudes to patient decision aids. Clinicians will be asked to select one or more words that best describes their attitudes to the potential use of patient decision aids from a pool of ten words.
B. Self-efficacy: Individual belief in their own capabilities to execute courses of action to achieve implementation goals. The words selected by the participating clinicians who complete the ADOPT measure will be indicative of their self-efficacy or the belief in their ability to execute the course of action and achieve implementation goals.
C. Individual stage of change: Characterization of the phase an individual is in, as he or she progresses toward skilled, enthusiastic, and sustained use of the intervention. We will compare collaboRATE scores (three-item patient-reported outcome measure) before and after the initiation phase to determine individual stage of change.
D. Individual identification with organization: A broad construct related to how individuals perceive the organization, and their relationship and degree of commitment with that organization. Ten stakeholders at various levels of the service delivery team (i.e., clinicians, administrators, managers) at each site will complete the Measuring Organizational Readiness for patient Engagement (MORE) survey.
E. Other personal attributes: A broad construct to include other personal traits such as tolerance of ambiguity, intellectual ability, motivation, values, competence, capacity, and learning style. Personal attributes will be determined via the ADOPT survey. Clinicians will circle up to 10 words that will be indicative of their personal traits.
IV. Process
A. Planning: The degree to which a scheme or method of behavior and tasks for implementing an intervention are developed in advance and the quality of those schemes or methods. We will be visiting each site multiple times throughout the study to provide support and assess the degree to which each site is willing to adopt our processes.
B. Engaging: Attracting and involving appropriate individuals in the implementation and use of the intervention through a combined strategy of social marketing, education, role modeling, training, and other similar activities. Our second site visit will aim to attract and involve appropriate individuals in the implementation and use of the intervention. In addition, we will be providing initiation to clinicians to teach them how to use the tools in practice. Each site will also have a “clinical champion”/site principal investigator that will support the implementation of the intervention. The strategy will also include feedback on study processes from the members of the Community Advisory Board.
C. Executing: Carrying out or accomplishing the implementation according to plan. The primary outcome measure is the number of eligible patients who receive the uterine fibroid Option Grid.
D. Reflecting and evaluating: Quantitative and qualitative feedback about the progress and quality of implementation accompanied with regular personal and team debriefing about progress and experience. A 23-item instrument—NoMAD Normalization Process Theory (NPT) survey—will be used to capture the perspective of professionals directly involved in the work of implementing the intervention. We will also conduct semi-structured interviews with a convenience sample of clinicians and staff at each of the five clinical sites to identify, monitor, and assess the progression and integration of the intervention and to determine the utility of the Option Grid patient decision aid and the barriers and facilitators to their integration in the clinic workflow.
We will also be receiving feedback at our annual site visit to determine the process each site is using to facilitate implementation of the intervention. The outcomes we will be measuring include the extent to which tools are delivered, the extent to which patients are reporting use of Option Grid in appointments, and the collection of collaboRATE scores.