IM Task 1: Needs and assets assessment
A comprehensive needs assessment of the existing Co-LEC service was developed using the RE-AIM framework. A full description of the assessment and its results are described in detail [13]. Briefly, four key stakeholder groups were identified as critical to understanding barriers and facilitators related to utilisation: GenesisCare cancer patients (including both Co-LEC participants and non-participants), GenesisCare oncologists, GenesisCare nurses and EMRI-ECU Accredited Exercise Physiologists (AEPs). Clinic records were also collected to provide perspective on overall utilization and financing of the Co-LEC service. One-hundred nineteen GenesisCare cancer patients completed a survey describing their experience with the Co-LEC, questionnaires and workout summary sheets were completed by 237 Co-LEC participants, and semi-structured interviews were conducted with 7 GenesisCare oncologists, 8 GenesisCare nurses, and 3 AEPs. The needs assessment suggested the Co-LEC concept offered a good organizational fit but had several behavioral and environmental barriers to overcome. Notably, patients who attended the service reported high levels of satisfaction but expressed frustration with logistics (e.g. inadequate hours of operation). Those who did not attend expressed a strong interest, but the majority (45%) reported not knowing it was available whilst they were undergoing treatment. Oncologists reported wanting to refer patients to the service, but not feeling confident with the referral process or satisfied with the availability of the program. Two oncologists were responsible for most of the referrals. Additionally, inefficient systems created a referral process that discouraged use, which was made worse by poor communication between the exercise and clinical oncology staff. Finally, a lack of funding resulted in service cutbacks making the service inaccessible for many patients.
The assessment clarified who needed to be targeted for the various stages of implementation. While the Co-LEC had already been adopted by GenesisCare, the general manager (GM) was defined as the person responsible to adopt the proposed implementation changes and to make resources available for the program. Multiple people were identified as responsible for implementing different components of the program: oncologists, patient services officers (PSO), AEPs, billing officers, and center leaders. The operations manager was deemed responsible for ensuring the program was maintained for as long as needed.
IM task 2: Performance and change objectives
The target adoption, implementation, and maintenance outcomes for each group (adopters, implementers, and maintainers) were defined and the specific steps required to meet them (i.e., performance objectives) were outlined (Table 2). Twenty performance objectives were identified across all groups. This work was guided by results of the RE-AIM assessment [13], which helped the SAG identify who needed to be involved in the program’s implementation plan and what actions were necessary to enhance implementation effectiveness. For example, the evaluation elucidated the critical role of oncologist referrals, the absence of effective communication strategies, and the need for a billing structure. The GenesisCare GM, a member of the SAG, identified people within the organization who would be best suited to work through those issues. Those people were contacted to contribute to the development of performance objectives. Next, the SAG consulted the literature to understand the changeable determinants within healthcare implementation that could help explain why the adopters, implementers, and maintainers would perform a particular behavior. The salient constructs of the TDF framework identified by the SAG were knowledge (program goals and procedures), group norms, environmental facilitators, and outcome expectations [24,22,25]. These were linked to each performance objective, creating a “change matrix” that defined what needed to change in order to achieve the performance objective and served as a blueprint for the selection of implementation strategies. Table 3 represents a portion of the change matrix developed for program implementers.
Table 2. Target adoption, implementation, and maintenance outcomes and performance objectives by role
Target: Role
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Adoption, Implementation, and Maintenance Outcomes
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Performance Objectives
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General manager (GM):
Adopter
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The GM decides to adopt the Co-LEC implementation program as indicated by completing a memorandum of understanding (MOU).
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1. Agree to re-implement the Co-LEC
2. Agree to expand exercise services
3. Approve updates to systems (e.g. electronic medical records, EMR), internal workflows, and policies necessary to support the exercise service
4. Approve allocation of appropriate staff to support the initiative
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|
|
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Oncologist:
Implementer
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The oncologist will tell patients about the Co-LEC and complete a referral for all eligible patients.
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1. Discuss Co-LEC service with new patients
2. Tell the patient about the chronic disease management plan payment option
3. Tick box to refer eligible patients to service
4. Check-in with patients during ongoing appointments to ask about exercise progress.
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Accredited exercise physiologist (AEP):
Implementer
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The AEP will integrate the service utilizing standard operating protocols for other clinicians at GenesisCare.
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1. Record all Co-LEC information into the electronic medical record system
2. Request ongoing appointments using electronic quick orders
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Patient services officers (PSO):
Implementer
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The PSO will include Co-LEC information in all new patient packets, call eligible patients to book an initial appointment at the Co-LEC, and schedule all ongoing appointments as directed by the AEP.
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1. Add the Co-LEC brochure to all new patient packets
2. Call to schedule an initial appointment at the Co-LEC for all oncologist referrals
3. Book in ongoing Co-LEC appointments based on all AEP quick orders
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Billing officer:
Implementer
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The billing officer will match all CDMPs against patient appointments at the Co-LEC and bill accordingly.
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1. Update billing protocol to include exercise claims
2. Train staff regarding new procedures
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Center leader:
Implementer
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The center leader will ensure all resources are available for the oncologists and PSOs.
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1. Institute systems changes to EMRs and work with technology staff to make changes
2. Ensure Co-LEC is properly resourced to perform optimally
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|
|
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Operations manager:
Maintainer
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The operations manager will ensure the general manager maintains the Co-LEC as part of standard practice.
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1. Monitor implementation barriers
2. Report key program metrics and needs to GM
3. Advocate for program changes required to sustain program
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|
|
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GM, general manager; Co-LEC, co-located exercise clinic; EMR, electronic medical records; PSO, patient services officers, AEP, accredited exercise physiologist.
Table 3
Partial matrices of change objectives for co-located exercise clinic (Co-LEC) implementers
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Behavioral outcome: Oncologist tells patients about the Co-LEC and completes a referral for all eligible patients
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Performance objectives
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Determinants
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Knowledge
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Group Norms
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Environmental Facilitators
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Outcome Expectancies
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PO.1. Oncologist discusses service with new patients
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Understand the service and how it can benefit patients
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Believe that other oncologists are discussing the service with their patients; it is an expectation of practice
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Materials are available to remind oncologist to discuss Co-LEC service and provide talking points for discussion.
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Expectation that a discussion with patient will result in patient attendance at the Co-LEC, which will positively impact their treatment experience.
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PO.2. Oncologist tells patients about Medicare payment option
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Be aware that Medicare is an option for payment
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Believe that other oncologists are discussing Medicare payment options with their patients; it is an expectation of practice.
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Materials are available to remind oncologist to discuss Medicare payment and provide talking points for discussion.
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Expectation that a discussion with patient will result in utilization of Medicare payment plan.
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PO.3. Oncologist ticks boxes to refer eligible patients to service
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Describe the role of exercise during cancer treatment. Identify potential safety concerns for each patient.
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Believe that other oncologists are referring all eligible patients to the service; it is an expectation of practice
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Tick box for service is embedded into a currently existing workflow and does not require an extra step.
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Expectation that ticking the box will result in patient attendance at the Co-LEC, which will positively impact their treatment experience.
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PO.4. Oncologist checks in with patients during follow-up appointments to ask about exercise progress
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Describe how the Co-LEC referral process works
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Believe that other oncologists are checking in with patients about exercise progress; it is an expectation of practice
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Information regarding patient progress at the Co-LEC is located in an area of the patient information that the oncologist regularly accesses.
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Expectation that patient check-ins will provide meaningful feedback about their experience with the Co-LEC which can result in an improved treatment experience.
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PO = performance objective; Co-LEC = co-located exercise clinic
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IM Task 3: Implementation plan design
SAG members consulted the literature to identify theory-based methods to influence the determinants identified in task 2 [26]. A mix of individual- and organizational-level methods were chosen to strengthen the intervention by influencing multiple layers of the ecological framework simultaneously. Based on these determinants, implementation strategies were derived from the Expert Recommendations for Implementing Change (ERIC) strategy list [27] using the following criteria: contextual feasibility, ability to address identified determinants, and potential impact. A final list was compiled and presented to the group for consensus; the group agreed on the inclusion of eight strategies in the overall implementation plan design (Table 4).
Table 4
Implementation strategy overview
ERIC category Implementation strategy | Contextual application | Determinant | Learning objective/Change objective |
Use evaluative and iterative strategies | | | |
Audit and provide feedback | Identify key measures to describe Co-LEC success (for individual stakeholders and for organization). Create weekly reports to share with operations manager, who will use the information to modify the implementation as necessary and report key findings to individuals (e.g. general manager) and groups (e.g. oncologists) based on results. | Knowledge | Enhanced stakeholder awareness of program success and areas that need improvement to encourage program refinement. |
Develop stakeholder interrelationships | | | |
Identify and prepare champions | Identify and prepare an oncologist who will take the lead in promoting the Co-LEC implementation amongst the medical staff, overcoming indifference or resistance and liaising with the management/implementation teams to communicate the needs of the oncologists to ensure they are being met. | Group Norms | Recognition that the Co-LEC service is a part of normal operating procedures within GenesisCare. |
Use an implementation advisor | Appoint a person with implementation experience and programming expertise to guide the project. | Knowledge | Understanding of implementation best practices across stakeholders. |
Train and educate stakeholders | | | |
Conduct educational meetings | Schedule sessions with oncologists during regularly scheduled meetings to provide training and updates regarding the Co-LEC. Organize sessions to teach each administrative group about the Co-LEC and their role in it. | Knowledge | Understanding of Co-LEC vision and overarching implementation plan. |
Develop educational materials | Develop and format “how-to” information sheets to outline the steps of how the Co-LEC operates and the associated workflows. | Knowledge | Understanding of roles and responsibilities for the service. |
Utilize financial strategies | | | |
Access new funding/use other payment schemes | Utilize the Medicare chronic disease management plan to support the service. Update billing system to capture these payments. | Environmental facilitators | Facilitate financial sustainability of the service. |
Change infrastructure | | | |
Change record systems | Update EMR to include the Co-LEC, so appointments can be captured and all relevant participation information recorded. | Environmental facilitators | Facilitate the recognition that exercise is a standard component of treatment at GenesisCare. |
Support clinicians | | | |
Revise professional roles | Employ the AEP within GenesisCare; appoint lead PSO to schedule for the Co-LEC; include the Co-LEC tasks in job descriptions for all relevant roles. | Environmental facilitators | Facilitate better intra-organization communication regarding Co-LEC. |
ERIC = expert recommendations for implementing change; Co-LEC = co-located exercise clinic; EMR = electronic medical record; PSO = patient services officer |
IM Task 4: Protocol and material production
In this task we designed, produced and pre-tested materials based on the methods and implementation strategies chosen in task 3 (Table 4). Since the “adopter” was a part of the SAG and participated in the decisions to re-implement the program, no materials were necessary for the adoption phase.
Implementation
Using information gathered through the RE-AIM evaluation, follow-up conversations with key members of each group of “implementers” (as identified by the GM), and consultation with an oncologist “program champion”, the SAG outlined proposed systems changes to integrate the Co-LEC into standard organizational workflows. Specifically, a Co-LEC tick box was added to the oncologists’ initial patient visit form that, when ticked, generated an alert for a PSO to call the patient to schedule an appointment at the Co-LEC. Additionally, a dedicated section was defined for exercise information to be entered into the patient’s electronic medical record (EMR). A presentation was prepared for the oncologists to describe and demonstrate the updates; it was included in the agenda of a regular monthly meeting prior to the re-launch of the Co-LEC. Finally, a “how-to” guide, with an introduction to the new Co-LEC operations, detailed workflows, and key contact details was created for each implementer group and given to the team leads for each implementer group for training and distribution. An official re-launch date was distributed.
Maintenance
Throughout the implementation design process, the GM expressed clear categories for success: patient participation, oncologist engagement, and financial stability. Using these as a guide, a monthly reporting template was created to provide feedback about each category. The operations manager was appointed as a lead for the service (by the GM) and given authority to make changes as necessary to support the vision.
IM Task 5: Evaluation plan
In the final task, an evaluation plan was created to allow for ongoing refinement and improvement of the service and overall effectiveness of implementation. The RE-AIM framework was used to develop a comprehensive evaluation plan, with the aim to complete one-year after implementation. A mixed-methods approach was designed to ensure qualitative data could elucidate information generated through quantitative methods. As this project was still in its early stages, this was especially important to ensure barriers and facilitators were fully understood [28]. Data sources included audit and feedback reports, clinic records, surveys, and semi-structured interviews with the target implementers and maintainers (Table 5).
Table 5
Outcome measures for evaluation plan
Framework Category | What will be measured? | How will it be measured? | Why is it being measured? |
Reach -patient level | Number of patients who received a call to book an appointment at the Co-LEC compared to number of patients eligible for the service | Clinic records | To demonstrate the integration of oncologist referral within the clinics |
Effectiveness -patient level | Patient enrollment in exercise program Patient attendance for initial consult | Clinic records | To demonstrate the effectiveness of the implementation strategy in engaging patients in the Co-LEC |
Adoption -organizational level | Number of oncologists per site that participate in exercise referral compared to those able to refer Number of exercise referrals completed per oncologist PSO engagement in booking process | Clinic records Surveys | To determine the absolute number, proportion, and representativeness of utilization of referral the program at both a site and individual provider and staff member level. |
Implementation (Fidelity) -organizational level | Fidelity to proposed workflow Program costs Patient experience | Surveys Clinic records | To demonstrate adherence to the proposed workflow and highlight any deviations and/or intentional adaptations To compare the patient experience to the protocol to understand what components of the intervention are actually being delivered by the oncologists. |
Maintenance -organizational level | Degree to which the practice has become integrated into standard practices for the organization and individual oncologists Financial sustainability for service | Semi-structured interviews Policy/workflow audit Clinic records | To understand to how much a part of the routine the referral practice has become and highlight areas that may threaten its ability to be sustained |
Co-LEC = co-located exercise clinic; PSO = patient service officer |