Professional Early-Adopter Experiences of Implementing a Novel Rehabilitation Model of Care across Alberta, Canada: A Focused Ethnography

Background In 2017, a provincial health-system released a Rehabilitation Model of Care (RMoC) to promote patient-centred care, provincial standardization, and data-driven innovation. Eighteen early-adopter community-rehabilitation teams implemented the RMoC using a 1.5-year long Innovation Learning Collaborative (in-person learning sessions; balanced scorecards). More research is required on developing, implementing and evaluating models of care. Understanding RMoC implementation will expand implementation science knowledge, particularly around factors influencing model-of-care outcomes and sustainability in, and between, jurisdictions. We aimed to explore experiences of early-adopter providers and provincial consultants involved in the community-rehabilitation RMoC implementation in Alberta, Canada.Methods Via focused ethnography, we used focus groups (or interviews for feasibility/confidentiality) and aggregate, site-level data analysis of RMoC standardized metrics. Purposive sampling ensured representation across geography, service types and patient populations. Team-specific focus groups were onsite, at participants’ convenience, and led by a researcher-moderator and co-facilitator. A semi-structured question guide promoted discussions on interesting/challenging occurrences; perceptions of RMoC impact; and, suggested definitions of successful implementation. Focus groups and interviews were audio-recorded and transcribed alongside field notes. Data collection and analysis were concurrent to saturation. Transcripts were coded for implementation-related phrases. Similar ideas were collapsed forming themes, with inter-theme relationships identified. Tactics for rigour included negative case analysis, use of thick description, and an audit trail.Results We completed 11 focus groups and seven interviews (03/2018 to 01/2019) (n=45). Participants were 89.6% female, mostly-Canadian trained and represented diverse rehabilitation professions. Teams varied on their focal health service and patient step-wise

population. The implementation experience involved navigating emotions, operating amongst dynamics, and integrating the RMoC details. Confident, satisfied early-adopter teams demonstrated traits including strong coping strategies; management support; and, being opportunistic and candid about failure. Teams faced common challenges (e.g. emotions of change; delayed data access; and lack of efficient, memorable communication across team and site). Implementation success targeted patient-, team-and system levels.Conclusions We recommend specific training priorities for future teams including evaluation training for novice teams; timelines for step-wise implementation; on-site, inperson time with a facilitator and full-team present; and prolonged facilitated introductions between similar teams for long-term mentorship.

Contributions to the Literature
We studied diverse early-adopter experiences in the implementation of a new Rehabilitation Model of Care in community rehabilitation across a large provincial health system.
Cross-jurisdictional factors critical to Model spread were informed by studying diverse demographic profiles varying by geographical area (including rural and regional), patient population (e.g. musculoskeletal vs. neurological rehabilitation), and service programming (e.g. group vs. individual programming).
As models of care continue to emerge as policy innovations to promote equity and patient-centredness across systems, this study contributes clarity on common challenges, facets of success, and strategies to support model spread and scale.

Models of Care and Their Implementation
Understanding the implementation of policy innovations, like the RMoC, is critical to understanding change within complex health systems. Such understanding will build new knowledge in implementation science, particularly on why models of care work in a particular jurisdiction and factors that influence model outcomes between jurisdictions [13,14]. There is a call for more research on developing, implementing and evaluating models of care [15]. Model-of-care evaluation must consider practices and outcomes before and after a model is introduced.
A model of care is an "… evidence-informed policy or framework that outlines the optimal manner in which condition-specific care should be made available and delivered to consumers at a system level" [15]. It is not a clinical guideline, but a vehicle for moving best evidence into practice using appropriate teams, timing and resources [15,16]. In Australia, Canada, the US and the UK, models of care are increasingly developed for diverse settings including chronic conditions [17,18], e-health strategies [19,20], mental health [20,21], musculoskeletal issues [15,22,23], pregnancy [24], and primary and community care [25].
Implementation science theory supports understandings around why models of care work in a particular jurisdiction and clarify factors to consider when transferring the model between jurisdictions [13,14]. The Consolidated Framework for Implementation Research (CFIR) represents a framework and "over-arching typology" to understand implementation developed from combining common constructs from published theories [14,28]. CFIR aims to promote theory development and verification around "… what works where and why across multiple contexts" [28]. Implementation is viewed as "… the transition period during which targeted stakeholders become increasingly skillful, consistent, and committed in their use of an intervention" [28].
The CFIR describes five domains, with a total of 37 constructs across the domains, that influence implementation effectiveness in multiple, complex ways individually, interactionally and collectively [29]. The five domains relate to characteristics of the intervention (e.g. 'core components' vs. 'adaptable periphery' of the intervention; the intervention's complexity, costs, course, and evidential base); the outer setting (e.g. network with external organizations, peer pressure, patient needs and resources, and external policies or incentives); the inner setting (e.g. internal structural characteristics, communication, climate, and culture); characteristics of individuals (e.g. self-efficacy, knowledge/attitudes/beliefs, personal attributes; individual state of change); and the implementation process (e.g. the activities of planning, engaging, executing, and reflecting and evaluating) [29]. This framework supports strategic assessments of potential barriers and facilitators to the implementation of a novel innovation, including a model of care [13].

Organizational Context
The RMoC has five competency domains: access and wayfinding; service options, client and community outcomes, transitions, and professional practice ( Figure 1) [4]. The RMoC mandates standardized tools to capture collaborative goal-setting and patient-reported outcomes, including quality of life (EQ-5D-5L) and care experience (WatLX TM ) [30,31].
These metrics map onto recognized quality dimensions of effectiveness (% clients reporting clinical improvement in EQ-5D-5L), acceptability (% clients reporting a positive experience on WatLX TM ) and appropriateness (% clients setting a collaborative, functional goal) [32]. This will inform implementation, policy development, quality improvement, accountability, comparisons and research.
RMoC adoption began May 2017: 18 community rehabilitation teams volunteered as Early Adopters. Early Adopters then implemented the RMoC while being stewarded through the 1.5-year Innovation Learning Collaborative change-management process. Based on the Institute for Healthcare Improvement's Collaborative Model for Achieving Breakthrough Improvement, the Innovation Learning Collaboratives gave structure and process that engaged local teams to make changes towards health system advancement [33][34][35][36][37][38]. The Innovation-Learning-Collaborative process involved several learning strategies including independent study, team-based learning, face-to-face learning sessions, and team-driven balanced scorecards for progress measurement [33].
Separate from the RMoC, the provincial health system broadly introduced HealthChange® Methodology [39]. HealthChange® focuses on educating providers to help patients make behavior changes for health promotion [40]. HealthChange® training discusses personcentred approaches to patient engagement that may influence shared decision-making or collaborative goal-setting [40]. The 18 Early-Adopter teams implementing the RMoC had priority to participate in the training.

Gaps in Understanding
There has been no formal evaluation of the Innovation-Learning-Collaborative process or the RMoC in the Early-Adopter teams. The literature around the development, implementation and evaluation of models of care is quite nascent, particularly in community rehabilitation. We aimed to contribute clarity on the implementation of novel models of care, which in this context would also support the provincial spread and scale of the RMoC. This study is part of a broader research program examining the implementation and impact of the RMoC; this manuscripts focuses' on provider experiences of implementation, while other under-review manuscripts describe patient and provider perspectives on shared decision-making both pre-, [41], and post-, [42], RMoC.

Methods
In this study, we aimed to explore the experience of implementing the RMoC. We asked: how do providers and professionals involved in the early adoption of the RMoC in Alberta describe the experience of implementation?
We used focused ethnography in this research program [43]. Ethnography involves making cultural inferences from peoples' communications, actions and artifacts [44]. The culture of interest included patients and professionals composing diverse community rehabilitation sites across Alberta. Focused ethnography uniquely focuses on specific problems and contexts; on discrete social phenomena; on a single researcher's conceptual orientation; on small samples; on limited to no participant observation; and on academic and healthcare settings [45,46].

Study Population & Recruitment
Study sites or teams included those involved in enacting, directing, or supporting the early adoption of the new RMoC between April 2017 and June 2018. Purposive sampling ensured site sampling across geographically-and patient-population-wise-diverse settings provincially, including rural (<10000 population), regional-urban (population between 10000 and 100000); and metropolitan-urban (>100000 population) geographical settings, while accommodating feasibility and managerial considerations.
Inclusion criteria for participants whether providers, leadership or consultants, was either recognized membership on an Early-Adopter community rehabilitation team or a professional role facilitating RMoC implementation. Rehabilitation providers must have held a professional license, as appropriate, during implementation. No exclusion criteria were set.
Site leadership informed provider recruitment strategies. Tactics included email introductions followed by study presentations (by webinar, in-person, or one-on-one) overviewing aims, methods and implications. After discussions with the previouslyunknown researcher, informed consent was procured.

Data Collection
We used focus group methodology [47,48]. Each focus group was limited to members of that team. Participants were offered the alternative of individual interview participation if preferred for confidentiality or scheduling. We also examined aggregate standardizedmetric data (i.e. EQ-5D-5L and WatLX TM ) collected by Early Adopter team during the Innovation-Learning-Collaborative period (July 2017 to November 2018), and located on the provincial health-system's cloud-based data-visualization program.
Site managers worked with staff to organize focus group timing and location. In-person focus groups (or interviews) were in private rooms at rehabilitation sites. The provincialconsultant focus group used video discussions due to geography. The research team traveled to teams. Prior to the focus group, all participants received the written consent form, focus group guidelines and outline document, study backgrounder, and a confidentiality agreement. The experienced, PhD-trained lead researcher (KPM) moderated all focus groups to facilitate discussion; a second research personnel assisted her as cofacilitator to log non-verbal behaviours and group dynamics in field notes [48]. Due to geography and cost, the co-facilitator varied and included either a hired clerical staff, therapy assistant, patient-researcher, or research trainee. Focus groups were guided by a semi-structured question guide. Discussion centred on participants' (a) experience of RMoC implementation; (b) experiences that they found interesting or challenging during implementation; (c) perceptions of the RMoC in practice; and, (d) criteria for defining successful RMoC adoption.
Prior to data collection, previous Phase 1 provider-participants gave feedback on the question guide. The moderator convened the focus group, beginning with an ice-breaker and introduction. The moderator used verbal and non-verbal approaches (e.g. calling on quieter participants, using head nodding and eye contact) to encourage participation [48].
All focus groups and interviews were audio-recorded and confidentially transcribed.
Interviews followed same question guide.
The moderator and co-facilitator debriefed after each session to ensure complete field notes; co-facilitators shared detailed field notes and their impressions of key-takeaways from the conversation.
Both the process of collection and the outcomes in the three standardized-metrics provided important insight into the issues related to success and sustainability of RMoC adoption for each team. Primary data collection was a new experience for teams. We gained secondary access to the aggregate data on the provincial health-system's datavisualization platform specifically on the three standardized metrics (EQ-5D-5L, WatLX TM , and Collaborative Goal Setting) for the period of the Early-Adopters' Innovation-Learning-Collaborative (April 2017 and November 2018).

Data Analysis
Data collection and analysis of field notes, transcripts, and any participant notes, was concurrent [43,44]. Analysis began by uploading cleaned transcripts into NVivo, with coding of transcripts for words and phrases related to implementation, including experiences, successes and challenges. Recruitment, data collection, and data analysis continued until no new information about the dimensions of implementation were obtained. The research-trainee co-facilitator examined three coded transcripts to ensure appropriateness and no missing codes. Similar ideas were grouped together to form themes, with tentative relationships among the themes identified. This qualitativelyderived description of the implementation experience of Early-Adopter teams and leadership was contextualized by descriptive analyses of site-level data including standardized RMoC metrics. An audit trail of decisions was kept to ensure rigour [49].
Data analysis also considered the unique attributes of focus group research, particularly participant interaction [50][51][52]. Coding was informed by the nuances of focus group interactions, including an examination of the sequence of responses to determine the process of evolving consensus and debate; an appreciation of individual contributions along the group discussion; and, an exploration of the impact made by types of questions (e.g. general vs. specific; particular topics) [52]. Any perceptions of consensus amongst a group was tempered by recognition of the influence of group dynamics, discussion and conformity [50]. We examined group adherence to issues posed by the moderator; sequence of discussion; context of group debate or conflict; presence of alliances among group members; resolution of disagreements; interests represented amongst group; emotionality of discussion or members; and, common experiences expressed [50].
We used the provincial health-system's data visualization platform to analyze Early-Adopters' aggregate data, and SPSS 25 for the provider sociodemographic data collected in focus groups. For each site, we analyzed the quantitative data to consider the collection process and outcomes related to the standardized metrics: EQ-5D-5L, WatLX TM , and collaborative-goal-setting and site characteristics (e.g. disciplines, number of patients per month). We statistically described these data using means, standard deviations and ranges for continuous variables (e.g. number of patients) and proportions for categorical data (e.g. types of disciplines). Process-wise, we determined how many months after the April-2017 start of the Innovation-Learning-Collaborative process did the team begin data collection generally, and for each of the three standardized metrics specifically. We used

Participant Information
Ten of the 18 Early Adopter teams took part, as well as a provincial team of community rehabilitation senior practice consultants. In total, 47 professionals participated in focus groups or interviews (30-to-120-minutes duration). The researchers conducted 11 teamspecific focus groups (n = 2-7 participants per group) and seven one-on-one interviews.
Save the provincial consultant-team, all focus groups were in-person at locations specified by the team. Interviews were by phone (2) or in-person (5). Saturation was achieved.
Five teams represented metropolitan-urban settings, one team represented regional-urban settings, and four represented rural settings. While the Innovation-Learning-Collaborative process began in May 2017, teams varied on when they initiated the novel, RMoC-required data collection processes. For the available data from eight teams, three teams began collecting the standardized metrics data in July 2017, two in August 2017, one in September 2017, one in October 2017 and one in November 2017. The data collection start time was not associated with geographic setting or survey delivery format (i.e. paper vs. iPad vs. both). We found that mean completion rates were 87.25% at sites using paper-copies only, and 95% at sites using both iPad and paper copies together.
We examined the WatLX TM completion rates and actual measures at the available eight sites. Across July 2017 to November 2018, on average 85% of patients responded entirely agree or mostly agree on the ten individual WatLX TM items. Individual items that had a higher response rate for not applicable related to inclusion of chosen family and friends (32%), control of physical pain (15%), and no delay on information availability (13%).
We examined the EQ-5D-5L completion rates and actual measures at nine available sites between July 2017 and November 2018. Sites collected 1376 intake EQ-5D-5L surveys and 753 end-of-episode-of-care EQ-5D-5L surveys. In July 2017, the ratio of intake EQ-5D-5L surveys completed to end-of-care EQ-5D-5L surveys was 86.61% to 13.39%. In November 2018, this ratio was 64.36% intake and 36.54% end-of-care surveys. Across the nine sites, the mean change in EQ-5D-5L Index Score was 0.11 in July 2017 and 0.09 in November 2018. The largest monthly mean change in EQ-5D-5L Index Score was 0.14 and the lowest monthly mean change was 0.04: these are all above the minimally-important difference of 0.037. [53] The mean number of patients who indicated that they had no problem across the five EQ-5D-5L dimensions was 31.80% at intake, and 41.27% at the end of care.

Professionals' Experience of RMoC Implementation
The experience of implementing the RMoC called upon teams to navigate emotions, operate amongst myriad dynamics, and integrate novel RMoC processes ( Figure 2). Professionals described implementation success as multi-faceted, relating to patient metrics, team processes, and system efficiency ( Figure 3). The frameworks reveal the traits of confident, satisfied teams, and challenges common to most RMoC-implementation experiences.

Navigate Emotions
The emotional fall-out of RMoC implementation was prominent to Early Adopter professionals. Emotions and connections were intertwined for providers. Many providers spoke of developing a common, shared language during implementation, which was facilitated through training (e.g. HealthChange®) and transdisciplinary approaches. All teams experienced feelings of frustration, anxiety and being overwhelmed, especially at the start of implementation. Failure, or when things did not go as planned, often causes stress, challenges and other negative emotions at the individual-and team-level. Teams varied in their approach to failure. Some teams were open and candid about failure and took an opportunistic "fail fast, fail forward" approach. This mitigated stress and negativity, and it pre-empted failure-related delays. Other teams were more hesitant to change their plans when things did not go as expected. Exemplar quotes from professionals substantiate the emotional navigation in RMoC implementation (Table 1). Intext, we provide one quote for the three key aspects of navigating emotions: shared language, feelings and approach to failure, respectively.

Operating amongst Dynamics
Early-Adopter teams faced challenges and made adaptions for micro-, meso-and macro-  Table 2 provides transcript quotes demonstrating these dynamics.
In-text, we provide one quote for the three key aspects of these dynamics: the patients, the team, and the resources, respectively.

Integrating the Model
The implementation experience hinged on three aspects related to the integration of RMoC polices and processes. First, some teams questioned the introduction of data collection using RMoC standardized and non-standardized metrics. It was difficult to see the value in the data. Some metrics were problematic due to ceiling effects or inapplicability to unique populations. Prolonged delays in access limited data utility.
Second, RMoC implementation was accompanied by either novel service programming or an opportunity to highlight provincially-unique, long-standing site services. Some teams then inappropriately conflated the RMoC and service programming. Some teams struggled to understand the rationale and aspects of the RMoC despite implementation activities.
These struggles and misunderstandings often led to lower prioritization of the RMoC, and thus limited its full integration.
Third, RMoC integration tied to information availability. Some team members avoided extraneous information in their daily tasks, which sometimes included RMoC-related information. Team leads in the ILC process consistently had the greatest connection and understanding of the RMoC, which was accompanied by disparities in understanding across the rest of the team. Training and learning opportunities were most memorable and impactful when in-person, practice-relevant and resource-efficient. In-person interactions that were perceived as inefficient or irrelevant were both unmemorable for content, and associated with negative attributes. Table 3 contains quotes supporting these features. Intext, we provide one quote for the three key aspects of these dynamics: the metrics, model vs. program, and available information, respectively.

"I think the issue with some of the mandatory indicators is there's not a lot of play in it.
So if you're already scoring a nine or a ten from day one, where is the challenge? And

Practical Implications
Understanding the professional-participants' experience as Early  We developed recommendations for RMoC spread (Table 4). These recommendations highlight educational priorities for staff (e.g. evaluation training); areas to emphasize more frequently (e.g. the RMoC aim); inevitable experiences to prepare for (e.g. supporting the natural feelings of being overwhelmed and anxiety related to changing processes); examples and strategies to share (e.g. a timeline to adopt the RMoC in sequential parts); and the optimal format for educational endeavors (e.g. efficient, inperson sessions with the full team present when decisions are required to plan implementation). These recommendations target leadership, consultants and future teams. Prepare teams for likely initial feelings of confusion, frustration and being overwhelmed. This was not un previous teams, and they do pass. Perhaps with subsequent implementations, an Early Adopter team come and speak to providers about what to expect. Break down the RMoC and its implementation into step-by-step parts with an accompanying timeline. Pro teams early in the process. Regularly reinforce that patience is often needed for large-scale change and that evidence of impact ma readily or immediately visible. There should be an emphasis on the import of measurement in large ch showing small and early gains. Shared Language Inform teams that a recognized value of the RMoC and related training (e.g. HealthChange®) is a shared language amongst teams and patients. Multidisciplinary teams must be steadfast in their planning, approach and criteria to garner the shared la needed to become transdisciplinary. Management and provincial consultants could directly empower teams to deal with resistance to change within and outside the team) using group discussions and shared resources on conflict negotiation and RMoC's vision and aims.

Approach to Failures
Facilitate transparent, constructive discussions on approaches to failure, and the benefit of viewing failur candid and opportunistic mind-set.
Incorporate the mantra "Failing fast, and failing forward" into RMoC implementation discussions so that f not viewed as a flaw to hide. Clarify where there is flexibility in RMoC adoption, so teams can customize to their site-specific workflow populations.

Operating Amongst The Resources
Teams may benefit from both one-on-one, in-person time with consultants, facilitators as well as the full membership for decision-making on action plans and scorecards. This could occur in advance or follow province-wide in-person sessions. Learning sessions may be modified for more virtual participation (with facilitators and consultants going to ensure efficient time management and value. Management and team support is consistently required to ensure team members (especially in smaller o teams) understand sufficient time is available for RMoC-related activities separate from clinical respon Ensure external, expert facilitators at Learning Sessions or related events have experience directly linked team's practice or population. The Patient Teams must be coached to sustain learnings related to a shared patient-first language (often built from R learnings and HealthChange®). Tactics include keeping such language learnings on team meeting age discussion and possibly small incentive-based activities. The Team Management and leadership must consistently demonstrate collaborative support for RMoC implementat not just at start, not sporadically). Avoid top-down decision-making with teams, especially around the logistics of RMoC implementation to e local customization of provincial standards where relevant and meaningful. Collaborate with teams on decisions and timelines; empower teams to complete detail-related decisions. Tailor team education and communication to that team's experience with quality improvement, research systemic change. Novice teams will need more in-depth education and long-term support, especially o evaluation and data collection. Teach team members how to keep track of and communicate priorities in progress to navigate staff chan management and team level. Teach teams and provide standardized tools to support communication regarding implementation ration activities to colleagues (on team and at facility) who are not part of implementation process but are (o impacted by RMoC implementation process or outcomes.

Integrating the RMoC The Metrics
Clarify the pros and cons of iPad use for data collection (e.g. for some seniors and homecare patients, iPa to lost privacy and fewer open-text responses in the WatLX TM ). Permit flexibility in data collection (e.g. iPad or paper copies with team data entry). Give earlier, more-frequent team access to mandatory metrics' data (at aggregate level) to facilitate pra changes, improvement of implementation flaws, and team engagement. Training and messaging mus this access. Support teams in better customization of approaching the non-mandatory metrics (especially safety met either re-considering their value and necessity; clarifying their necessity to teams more often; or maki optional (e.g. if no relevant safety metric, do two efficiency metrics). Allow teams to implement the RMoC through a staged-gate approach to avoid teams implementing ever "falsely" and "going through the motions". Available Information Support and create opportunities for team leads to share RMoC-related information with other team mem memorable, valuable and efficient way (e.g. a regular, brief overview of summary statistics at team m Ensure that in-person learning (when providers must travel and lose clinical time) are directly applicable memorable, useful and efficient (e.g. HealthChange®). Provide operational details to save team time and frustration (e.g. early-adopter examples of logistical p clerical staff involvement). Facilitate mentorship between early-adopter teams and new teams, ideally when there is commonality b patient populations, geography and service options.

RMoC vs. Program
Clarify amongst leadership what takeaways from the RMoC are essential and what are nice to have. Con messaging prioritizes essential RMoC takeaways and how the RMoC is distinguishable from service op Highlight that uniqueness and commonality are not mutually exclusive. Clarify and initiate connections ( regular follow-up meetings) between teams across service types, Zones and geographies to foster inte support and learning. Support teams with efficient, appropriate advertising examples and strategies to enhance their referrals programming.

Contextualizing Findings within Broader Literature
These findings corroborate many empirically-recognized facilitators and barriers to the implementation success of models of care. Facilitators-wise, we saw that individual acceptance, supportive leadership, distribution of decision-making roles, and the power of systematic measurement and sustainability were critical [21,24,25,27]. Barriers-wise, limited resources, lack of buy-in, communication, and overwhelmed or unsupported staff were present in Alberta as in other jurisdictions that struggled with model-of-care implementation [18,20,21,24,27]. We move beyond this extent literature in several ways.
First, previous research emphasized organizational structures that work to impede or facilitate model-of-care implementation [18,20,21,24,25,27]. Our findings focus less on organizational or policy factors and rather emphasize the importance of the interpersonal factors, particularly emotional and communicative factors. In the language of the Consolidated Framework for Implementation Research (CFIR) [28], the intervention and individuals involved with the intervention were more determinative of the implementation experience, while the inner and outer settings as well as the process of implementation were influential but less prominent.
Individual connection to, and clarity about, the RMoC was important. The navigation of emotions was a conspicuous process in the implementation experience. Teams that struggled in implementation generally got "stuck" and could not steer the emotional fallout of large-scale change, novel transdisciplinary approaches, and dynamic team membership. Team motivation resulted from the emotional connection between the individual team members and the RMoC vision. Lack of connection meant lack of motivation, and successful RMoC implementation was distant. Teams could get behind neither increased data collection nor data-driven innovation. This was further compounded by teams noting that the standardized metrics lacked sensitivity in many rehabilitation populations, had ceiling effects, and likely suffered from strong acquiensence and social desirability bias.
The RMoC -the intervention itself -had adaptable and requisite components [28]. The adaptable components sometimes exaggerated confusion around RMoC vision and aims. In particular, Early Adopters could select the patient population and type of service programming upon which to apply the RMoC components. This selection was informed by local needs, interests and available resources. Where teams introduced novel service programming and were somewhat unsure about the RMoC, that insecurity exacerbated as the new program (e.g. a new group program for balance) and the RMoC (i.e. a patientcentred framework to promote shared decision-making, standardized quality of care, and data-driven innovation) became conflated. Meanwhile, the requisite components such as the collection of standardized metrics faced a great deal of resistance from many teams.
These concerns targeted the nature and content of the measurement tools. In implementing models of care such as the RMoC, the challenges consequent to the adaptable and requisite interventional components must be made explicit so that they can be addressed.
Second, this study addresses the call to understand why models of care work in a particular jurisdiction and the factors that influence outcomes when transferring between jurisdictions [13,14]. Through the common challenges and the characteristics of confident teams, we see jurisdictional lynchpins. The size, dynamism, resources, and attitudes of all rehabilitation staff at a particular site informed the subset, Early-Adopter team success in realizing the RMoC facets and aims. Rural teams struggled more often with fewer resources, smaller teams, and thus less sustained reprieve from clinical duties to spend the time required to understand the RMoC and implement its component parts. Second, not all focus groups occurred at the same time of the day or at the same time in the Innovation-Learning-Collaborative process. The latter may lead to different levels of recall or acceptance around the implementation experience. The former seemed influential as afternoon focus-group participants seemed quieter and less-forthcoming.
Whether due to fatigue or post-prandial issues, we may not have fully captured the all participants' experience.
Third, due to feasibility and efficiency, the co-facilitator for the focus groups was not constant; had different levels of research training, experience and interest; varied in the level of detail in note-taking; and varied in focus-group involvement. Two focus groups involved the patient co-investigators as co-facilitators, which may have influenced the level of candor of the focus-group participants. We aimed to minimize this limitation by having the same moderator for each focus group, and trying to have debriefing conversations with all co-facilitators immediately after the focus group to ascertain cofacilitator perceptions while fresh.
Fourth, we collected both focus-group and interview data; there was greater variability of information shared by participants in these two data-collection modalities. Participants typically chose interviews for scheduling and convenience. Some interviews lacked the elaboration of focus groups. Ethically and feasibly, interview opportunities were necessary. Given there was little dissent and infrequent disagreement amongst focus group participants, it suggested general consensus. The interview-based results were similar to the focus group discussions; but of course, the interview-participants did not benefit from the discussion with colleagues.
Finally, we did not have access to full peer review of all interview and focus group transcripts for both studies. For the Early Adopter study, the research-trainee cofacilitator gave feedback on the lead-researcher coding on three transcripts. Availability and costs prohibited more in-depth and independent second assessments on coding. Many other tactics were used to promote rigour including audit trail, thick description, and negative case analysis.

Conclusion
This study has organizational relevance to health-systems aiming to use models of care as frameworks that can advance patient-centred care in allied-health-dominant domains. We clarify the professional experience of Early Adopters of the RMoC, and found that experience centres on three major themes: the navigation of emotions, the operation amongst myriad dynamics, and the integration of model details. More importantly, this experience provides a foundational information resource to expose the seminal differences between jurisdictional success or failure in RMoC implementation. We offer future adopters information on common challenges to support preparedness, and strategies to overcome them. Possible future research directions include (a) rigorous development, testing and implementation of the training strategies identified, and (b) evaluating the RMoC itself using research designs that acknowledge and measure fidelity.   Common Challenges in the RMoC Early Adoption Process  bmc impl COREQ checklist Manhas EA impl 083019.pdf