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Table 5 Factors that influenced the implementation and/or the perceived impact of the interdisciplinary case conferences (ICCs)

From: Process evaluation of a complex intervention to optimize quality of prescribing in nursing homes (COME-ON study)

 Factors*ImplementationPerceived impactQuotes
InterventionFace-to-face approach
[Nature and characteristics + implementability]
Barrier PH-W1: “On the other hand, in relation to timing and planning, it wasn’t easy…/…/ we met several general practitioners, one after another, we didn’t know how long that would take. So sometimes we had to wait half an hour or an hour and sometimes we hadn’t finished and the GP had to wait a quarter of an hour. So, timing wasn’t easy… /…/ because we all have our own very busy schedules.”
  FacilitatorPH-W2: “The fact that we took the time, we were all around the table, it was much more convivial too and there was real sharing… Just sending e-mails is less effective.”
Interdisciplinary approach with three different HCPs
[Nature and characteristics + implementability]
Barrier HN-W1: “[About the organization] It is necessary to be quite conscious that to gather everyone around the table, it’s a complex balancing act. And that it’s not always easy.”
 FacilitatorCP-F1: “I found it worked well with those three [GP, pharmacist, and nurse]. You shouldn’t do it with fewer – then you’re lacking one of the keys.”
Preparation of the ICCs
[Nature and characteristics]
 FacilitatorCP-W2: “/…/ I think one secret [for an effective interdisciplinary case conference] was to prepare the meeting properly. I think that when she [the pharmacist] came, she had done her homework in a way I hadn’t. So that was very helpful.”
Material (i.e., summary of the evidence) provided by the research team
[Nature and characteristics]
 FacilitatorPH-W2: “I worked a lot with the summary sheets [the research team provided some summary sheets about various topics: e.g., a short list of STOPP-START criteria, a list of medications with anticholinergic activity, etc.], which were quite well done. I shared those with my colleagues, because they are very interesting tools on which I relied during the discussion.”
ProfessionalsGPs’ motivation to participate
[Attitudes to change]
Facilitator HN-W1: [About identification of facilitators for success] “We have about 90 generalists who attend our institution and I actually chose them [GPs who participated in the COME-ON study].../…/ I think, in terms of the choice in the first place and the motivation, they have already agreed to be part of the project ...halfway convinced.”
 Barrier HN-W2: “I mean that the GPs who were not interested or not motivated, well, they refused to participate. We’ve had quite a few refusals to participate.”
Interprofessional relationships and clarity of role and responsibility
[Professional role]
 FacilitatorGP-F2: “I think that, because you have sat around the table with each other more – and that always works in my opinion – you feel more part of a team. If you go to a NH for the first time and you don’t know anyone there. But if you have been able to discuss things with those people a few times, then you know who you are dealing with and who you are working with. But that’s not only due to this project. There are many things that contribute. If you collaborate in relation to a very difficult resident or a very difficult situation, then you also learn to work together and you get to know the people you work with a bit.”
  BarrierCP-W3 : “But I think in your job as a pharmacist, you have to be aware of ‘what doesn’t go with what [drug-drug interactions]’… /…/ I think it is necessary for everyone to bring his/her expertise but everyone must still be in his/her own job. So the physicians choose the treatments according to the indications...and the pharmacist...makes sure that everything is in...that’s how I see it! It doesn’t bother me that she [the pharmacist] has access to diagnoses. That’s not the problem but...but I think that if she [the pharmacist] wants to have an expert opinion on medications, it is not the diagnoses that are going to help her.”
GPs open to suggestions from other HCPs FacilitatorGP W1 :“I think that the atmosphere was positive. In the discussion ([ICC], the GP did not insist on always being right; so there was a real collaboration, with all three (GP, pharmacist, and nurse] working together with a shared goal.”
  BarrierDIR-F5: “And I think that, nothing to do with the individuals as such, but it has to do with, how should I say this, the overall perception of physicians and pharmacists. That there still is a bit of a tension between physicians and pharmacists… It has to do with the therapeutic freedom of physicians, who still participate all the time but don’t really like it when a pharmacist interferes with prescribing. Although I think the input from the pharmacist is really great, I think physicians don’t like it.”
Lack of skills, knowledge, and experience of pharmacists to conduct a medication review
[Competency]
 BarrierPH-W1: “It was new. And besides asking [basic] questions [on medication regimens] like ‘Why is it like that?’ […]...unlike the clinical pharmacist, it's still a minimum of three more years of study, after all, it's different...to start discussing things with the physicians...so, between theory and practice..."
OrganizationThose of the nursing staff not involved in ICCs
[Involvement]
 BarrierDIR-F5: “At a certain moment, we sat down together here and we said we are operating on two different wavelengths. One the one hand, we have the COME-ON team that goes on step by step. And we haven’t done enough to involve the people in charge here, who are involved in the daily care for these people and who therefore also see possible side effects of medication and who should actually implement what has been discussed at the ICC. They haven’t had enough opportunities, and it’s all our fault, to thoroughly apply all the information that was available.”
Lack of nursing staff resources
[Resources]
Barrier HN-W4: “It was really [difficult/complicated] to release someone [a nurse], at times that, moreover, were difficult here in the nursing home, when there was a pretty well record rate of absenteeism. And it was hard for me to tell my management. Well, I'm taking four nurses .../…/ to spend half a day reviewing the treatments. It's really complicated.”
Availability of the delivering pharmacist
[Resources]
Barrier HN-W1: “In contrast, it was X [pharmacist] and her timetable that got hit, rather than the general practitioners.”
Previous experience of interdisciplinary collaboration/pre-existing relationship between HCPs
[Relationship]
Facilitator CP-W3: “…and so we had a team that knew each other well, who already met often...and I wonder about the implementation in practice of something like that with the other general practitioners come to the nursing home.”
One person responsible for the planning, who motivated the team
[involvement]
Facilitator HN-F2: “Dr XX (coordinating physician of the NH) first asked which days suited them best. We took that into account. But then we drew up a schedule for the year, with all the ICCs planned from the start. And yes, send a reminder a week beforehand, before we started the next series, and sometimes a reminder to the physicians two days in advance as well. So that’s everything sorted out [laughs]. But I do understand that it’s important.”
Logistical resources: e.g., a quiet room, access to the resident’s records and medication schedule during ICC, computer, Wi-Fi connection
[Resources]
 FacilitatorCP-W2: “…and at a practical level, but which was in the specifications [required in the protocol], is to have a specific room with a computer and a Wi-Fi connection. That was really very useful, because if it had to be done in the nurses’ station while other nurses are preparing drugs or when you have patients coming in all the time and so on, it would have been... So having the adequate infrastructure was necessary.”
External contextFinancial incentiveFacilitator PH-F4: “The payment: for sure, in a study context, that’s nice to have. I think for implementation on a wider scale, now we’re only speaking of 30 patients, but there will be more patients, it will be more frequent, there will be more work to do too, and there has to be something in return, otherwise it’s not feasible.”
Clinical trial contextFacilitator CP-W1: “We’re doing it this time because this time we're in a... [study]; we've accepted a contract and we respect it.”
  1. CP: coordinating physician, DIR: directory board, F: Flanders, GP: general practitioner, HCPs: healthcare professionals, HN: head nurse, ICCs interdisciplinary case conferences, PH: pharmacist, W: Wallonia
  2. * According to the framework defined by Lau et al. [27]