Table 7 Exemplar quotes for qualitative results

Compelling leadership communication

11 (standard/increasing)

Just communicating [was important for implementation experience at this clinic]. Just when [leadership] rolls something out, them communicating with us, giving us education, so we know how to use and how we're supposed to use it and know what the purpose is.

12 (tailored/increasing)

Systemic operational environment I think is very important. It has a big effect on how successful this is because I think logistical things are a big barrier or help. I think my viewpoint as a team lead is, I see and have hope that the organization is trying to move to not just pure productivity numbers, but also some measurement based care… they do encourage the PHQ-9. [The message is that] it's important, because it's good for the patient.

4 (standard/decreasing)

If they would just explain to us how this could be useful for us and useful for our consumers I think we would have been more receptive to it, but a lot of times that's not what happens. They tell us what it is that they want us to do and we're standing around like a three year old. "But why?" We never get the answer.

10 (tailored/decreasing)

Clinician 1: It’s always, “Here’s something new, you gotta do this now.” But it’s not, “this is going to replace that.”

Clinician 2: And it’s not why! There’s no why

Clinician 1: Yeah, there’s hardly ever a why and it’s…

Clinician 3: In addition to

Clinician 4: And you’ll get penalized if you don’t do it!

Supportive supervision

11 (standard/increasing)

When your clinic manager -and I’m thinking also maybe like the regional manager- if they support what you’re doing and they’re helping to facilitate what’s being asked, I see that as a plus. And it’s more likely then that, whether it’s measurement-based care of some other, it’s gonna be implemented and implemented well. Without that support, if you’re being asked to do something, and you feel like you don’t have that support, that can be a little discouraging.

12 (tailored/increasing)

Clinician 1: Our direct supervisor really helps facilitate PHQ-9. I know she's really good about reminding us to do them, so she's been a huge help. She even brought us all copies of the paper forms so we'd have them to use, so I think she's probably the biggest support we have for it.

Clinician 2: Which encourages us to use it. Frankly, if anyone above her mentioned it, it wouldn't have any effect on my behavior. I don't know any of them personally above her…. I've met [the Vice President], but apart from that, I don't know who runs this place, and I don't care.

4 (standard/decreasing)

Clinician 1: We had confused supervision a little bit. Especially early on, I think we were being told different things

Clinician 2: My clinical supervisor didn't know what it was. I had to explain it to her and showed it to her. She was like, "oh, okay." She travels between offices, so … She doesn't see patients, I don't think, so I don't know.

Facilitator: Okay, so your supervision didn't really include that element. Anyone else have supervision where it helped, hurt, wasn't present?

Clinician 3: Yeah, I have supervision. Of course I vented about it, about us having to implement this and then it went from doing it voluntarily now it's mandated to continue to do it. She just like, "Well I really don't have anybody to do this." Is what she said.

10 (tailored/decreasing)

[My clinical supervisor], she has staffing and she has so much administrative stuff she has to get done because her higher ups are telling her to get it done. We [clinicians] come in as clinical people thinking we don't want to do that, we want to talk about our patients [in supervision], we want to understand how to help them better. You can't do both when you have such a large group. So, does she get her part done, the admin stuff? Or do we get our part done, to get support? Neither get done satisfactorily. In my opinion

Clinical consultation opportunities

11 (standard/increasing)

With the organization, with Centerstone, to have that support, that goes a long way, and again, knowing that your colleagues are kinda doing the same thing. It's been helpful, you know, the tri-weekly meetings that we've had over the telephone, I've enjoyed those. That's supportive because you're getting feedback and things like that about a different concept.

12 (tailored/increasing)

I feel like, especially in the children's department, right now we have five clinicians total, and then a lot of family support specialists, and so my group is much smaller, more cohesive, and I think that there's a lot more of the trust. We support each other and talk. I don't think anybody in my department would have a feeling of isolation, and so that's good for the children [patients].

4 (standard/decreasing)

Clinician 1: From a clinic perspective I don't know if there is an actual norm. We're sort of left to our own implementation devices.

Facilitator: What do you see happening? Are you seeing your colleagues using measurement based care, or not so much?

Clinician 1: I don't know if I'd had the opportunity to see yay or nay on that.

Facilitator: Okay. You don't have a window into each other's work to know.

Clinician 1: We ain't got time for that.

Clinician 2: We wave at each other as we pass in the hall.

10 (tailored/decreasing)

Facilitator: Do you feel like you have chances to discuss new things that you're using?

Clinician 1: With our staff? With each other?

Facilitator: Yeah, with each other, to support each other?

Clinician 1: I don't. We kind of, like, live in our office

Clinician 2: We work in different buildings! So the only reason I have even gotten to talk to [another clinician in the focus group] is the fact that we're doing video conferencing once every three weeks for this [study] meeting. Otherwise, you and I would never talk

Clinician 3: I come to your staffings, that's the only reason I see you

Clinician 1: I never talk to [another clinician]

Strong support staff

4 (standard/decreasing)

Going back to implementation measurement based care, in this particular clinic, another big barrier is, has been honestly, our support staff. We've had a lot of turnover in the past year. I might not be supposed to know this, but I go up to [different clinic] every Friday and so I get to see how they implement measurement-based care compared to us. I'm seeing their support staff giving out the surveys every time a patient checks in. I'm going, "oooh, that looks helpful." I don't know if our current front desk could handle something else on top of them right now. They're barely checking our patients in as it is