As displayed in Figure 3, the dimensions that participants had a most positive perception were change content (72,6%), organizational climate for change (70,8%), leadership (69,2%) and organizational contextual factors (67,7%).
On the item level [see in Additional file 1], the most frequently rated 4 and 5 in organizational climate for change were that staffs work together as a team (12/13), and help one another when needed (13/13). Organization contextual factors regarding professionals want to improve patient care (3 items with 13/13), which indicate that staffs are willing to cooperate and experiment to improve clinical procedures. The content of change seems important for participants, when they noted that changes should be effective and based on current scientific knowledge (12/13). About leadership in their organization, managers ask for results (13/13), clinicians and managers are involved in change processes (12/13 and 13/13), which highlight the fact that diverse stakeholders participated in changes. Related to the organizational support, majority of the participants (12/13) felt that staff members make pressures to change, which could be beneficial to maintain their engagement in the change process.
Results from FG
This section presents the results from the two FG held with the service providers. We linked F&B for implementation mentioned by participants to the domains of the CFIR. We selected verbatim quotations, we present below the main points of the analysis and we put in parentheses the number of times each F&B was mentioned by participants. French quotations have been translated into English.
The first CFIR domain is associated with the characteristics of the innovation we wish to implement into clinical rehabilitation programs. The adaptability of the tool was reported to be a major facilitator for implementation, mostly regarding the flexibility of the tool to adapt to local prioritization practice (9): “we could try to improve it […], just small details that could make it more user-friendly for users”. Participants also noticed that the tool would be easy to use, to adapt to the population and to the patient’s condition (3): “if the person just had a new diagnosis [...], you'll be able to add it, update it”.
The relative advantage of the innovation was also highlighted by participants, beginning with the insight that the PPT will reduce workload for the clinical coordinators or clinicians (5): “I imagine that for the coordinator, it removes workload at her level”. Some participants perceived that PPT could improve the reliability and the sensitivity of patient prioritization processes (4): “I think the right patients are going to have the right garments in the right time, more than currently”.
In contrast, the complexity of the tool appears to bring some potential barriers to implementation. One is related to the difficulty to find information about the patients in order to score and prioritize them (9): “I will not necessarily search for information about the 100 clients placed on the waiting list”. Another barrier mentioned by the participants was related to the intervention source, where some participants expressed their concerns from the fact that the tool is developed by an external organization: “that's the risk of research projects, you do that and at some point, there is no longer one to rely on”.
Globally, service providers discussed about this domain less than other ones, but they were able to point out a few F&B related to the outer setting. Facilitators exposed by participants are related to the patient needs & resources, because patients make pressures to receive services faster (3) and participants thought the tool would inform patients about waiting list management (3): “patients call and I have to explain to them [...], so when we have tools like that it's easier, I'm able to tell them”. Also, cosmopolitanism was indicated to be a facilitator, as participants presented that their organization is developing networks with other organizations to improve access to rehabilitation service (3): “at the last trauma symposium, we met with all the regional committee chairs in our territory, and we talked to them”. This can contribute in helping the program receive support by other organizations when they face a patient increase or other access challenges related to the prioritization process.
Other organizational determinants that could influence the implementation of PPTs on a smaller level were reported. In the studied organization, there was a tension for change, which could facilitate the implementation of a new prioritization practice, because clinicians perceived that actual prioritization process was less suitable than the one proposed (4): “I am not comfortable with Excel, so with [PPT], we would really be in business”. The compatibility was also a determinant often mentioned, sometimes as a facilitator but by others as a barrier. Indeed, participants considered that the tool would fit with actual practices and processes in their local contexts (3): “people are used to already using tools, […] we set things, it should be easy”.
Contrarily, some providers saw a barrier from the compatibility, as they suggested that the tool proposed may not fit with actual practices and processes (3): “I can do the analysis of patient’s file four months later, so if we have a system like that, we want to have the information right away”. Issues of confidentiality of the system were also brought up a few times (3), which can impede the implementation of the tool: “my question, before applying it, we must make sure we meet the confidentiality rules”.
Characteristics of individuals
Service providers are potential users of the tool, and their individual characteristics could influence implementation as well. Participants expressed thoughts on their knowledge & beliefs about the intervention. They expressed that it will facilitate and be easier to prioritize with the PPT (3): “it seems to work all by itself, this is the goal, right? That there is less analysis to be done necessarily”. Another characteristic of individuals that could have an impact on the tool implementation is the self-efficacy related to the potential use of the tool, and some participants already perceived that they would be able to use the tool (3): “I think it's our task, it's already rooted in what we are already doing, it's like improving”.
Barriers are also noted in terms of knowledge & beliefs about the intervention, as other participants specified that they encountered some difficulties understanding the functions/characteristics of the tool (7): “you presented us the tool, there may be some elements that we obviously do not have in hand and that we do not understand 100% yet”. There are even some individuals that said that the tool would not significantly change waiting list management as far as they were concerned (3): “what it will do in real life for these people? They will be seen just a few weeks before, not a major difference”. Other barriers were stated by participants, one about self-efficacy, as they considered that they did not have the abilities yet to use the tool (3). They expressed the lack of indication related to the scoring and management of prioritization criteria: “There are criteria that I find very easy [...] there are others that I do not know how we will be able to evaluate”. The other barrier was about individual stages of change, which specifies that some participants may not be ready yet to use the tool, as they expressed some resistance to change (3): “what would stop us from calculating as we do there, we calculate [the score], without filling each time and using the software”.
There are other concepts from the CFIR framework that did not emerge during FG. For example, service providers did not mention F&B related to the implementation process, as they were questioned about determinants prior the implementation of the tool. They also did not mention determinants about relative priority, organizational incentives & rewards, goals and feedback, access to knowledge, individual identification with organization, and other personal attributes.