The results of this study are described in terms of each CFIR domain (intervention characteristics, process, characteristics of individuals, inner setting, and outer setting). These findings highlight both relevant constructs and changes from baseline to follow-up. Discussions of sub-constructs are included in discussions of the main constructs under which they fall (i.e. engaging, implementation climate, and readiness for implementation).
Overall, there was little discussion of intervention characteristics in either the baseline or follow-up surveys. Four CFIR constructs did not have any text coded to them: design quality and packaging, intervention source, relative advantage, and trialability. Those constructs that were discussed saw a general trend of improved rating (from negative or neutral to positive rankings) over time, as well as an increase in specific positive examples at follow-up.
Evidence strength and quality
Overtime, survey participants’ view of evidence supporting the COE changed in a positive way. At baseline, participants were largely aware of other COEs; however, they were unaware of the details or benefits of them and found it difficult to justify implementing their own COE. At follow-up, survey participants had more fully engaged in implementation of the COE and had seen first-hand evidence demonstrating the value of COEs, particularly in their own setting.
Intervention complexity was a significant focus of participants during both the baseline and follow-up interviews. The tone in which participants discussed intervention complexity changed dramatically between the two surveys. At the time of the baseline survey, participants discussed the many moving parts of the COE (i.e. the five focus areas described in Fig. 1, with numerous action items to achieve each part) as barriers to implementing the COE. At follow-up, these complexities were reframed as challenges, and participants indicated their success in overcoming most of them.
Though complex with some rigidity built into the strategic plan and six-pronged approach to implementing the COE, survey participants felt that the COE model could be adequately adapted to the current setting at baseline and demonstrated this adaptability in the examples provided during follow-up. Specific adaptations included those embracing the rural setting compared to urban settings that are traditionally home to COEs.
Concerns over the cost of maintaining the COE and the GWC within the larger healthcare network were discussed at both the baseline and follow-up. At baseline, several participants expressed concern about costs, and indicated that the team needed more evidence to demonstrate financial sustainability. In the follow-up survey, this concern persisted; however, participants had begun thinking about funding options for continuing the GWC and COE, particularly in terms of competitive grants to establish and maintain relevant services.
Similar to intervention characteristics, there was limited discussion related to process measures, particularly in the baseline surveys. Those discussions that did take place were more positive at follow-up than at the baseline.
The CFIR construct of engaging can relate to a number of individuals. In this study, the primary focus of discussions related to engaging clinical and administrative champions; specifically, those who could serve as a bridge between the GWC and larger healthcare network. At baseline and follow-up, the discussions primarily focused on the fact that such champions were needed in order to make progress and establish sustainability within the network. Despite success in garnering support from many members of the healthcare network, including local administrators, there was a consistent concern over the difficulty of engaging key administrators in the network executive leadership team to actively support the COE and GWC. Both at baseline and follow-up, participants also recognized the importance of engaging members of the transgender population. Participants described their development of a community advisory board comprised of transgender individuals to address this gap.
Survey participants primarily discussed the planning construct in the baseline survey, which took place soon after the strategic plan for implementing the COE was developed and initiated. In these discussions, participants described the benefits of including transgender patients in the planning process as well as the importance of developing a cohesive plan for project implementation. At follow-up, this discussion transitioned to appreciation of the strategic plan as a valuable tool for implementation and evaluation of progress toward achieving stated goals.
Discussion of how the COE implementation would be executed did not occur at baseline. However, at follow-up, several participants discussed both challenges and facilitators of execution. Participants described challenges around involving non-clinical staff with the COE, particularly those who were not engaged in the process early on or who did not share similar values. Additionally, participants discussed the development of a marketing plan for the GWC, with conflicting feedback regarding how well this strategy was carried out.
Reflecting and Evaluating
The benefits of strategic planning were demonstrated further at follow-up when participants reflected back on their planned processes and goals. Participants described a process of repeatedly evaluating progress toward implementation goals and revising the strategic plan based on challenges or new opportunities. Reflection and evaluation took place in the form of gathering patient, community, and healthcare network feedback through GWC advisory boards as well as team discussions regarding progress.
Characteristics of Individuals
Particularly when discussing the GWC team, participants reported positive views of constructs within the characteristics of individuals domain which remained largely unchanged from baseline to follow-up. Much of this discussion took place during the baseline survey, with relatively little discussion of the various characteristics of individuals at follow-up.
Individual identification with the organization
Participants largely indicated that they themselves had beliefs that closely aligned with the mission of the GWC. Participants also indicated that some non-clinical or supervisory staff did not share similar values or passion for the work. Those individuals were reportedly more likely to hold personal biases about the gender affirming care conducted at the GWC, creating challenges in implementation of the COE.
Individual stage of change
At baseline, four of the five participants reported being in the implementation stage, with one reporting being in the confirmation stage (Fig. 4). At follow-up, most participants (four out of six) reported being in the confirmation stage, with one participant each in the implementation and persuasion stages (Fig. 4).
Figure 4: Stage of change at baseline and follow-up for participants to both surveys (n = 4). One individual responded to the baseline survey only, while two responded to the follow-up survey only.
Knowledge and beliefs about the intervention
Similar to individual identification with the organization, most participants indicated (at baseline and follow-up) positive opinions about the COE and implementation within the GWC. In rare instances, participants indicated that they were unsure of the overall success of the COE but still believed in the importance of the overall mission. There was also discussion about external individuals and the groups who were critical of the COE and concern that these opinions could damage team efforts.
Discussions of self-efficacy were notably limited. At baseline, participants indicated that they believed in their abilities to implement the COE.
Other personal attributes
Similar to other constructs captured in the characteristics of individuals domain, the codes categorized within the other personal attributes construct related primarily to individual’s intrinsic desires to succeed with the COE implementation. These discussions did not change significantly from baseline to follow-up.
Throughout this study, constructs considered under the inner setting domain were among the most highly discussed. The relative positivity of the constructs was fairly static from baseline to follow-up.
Culture: In terms of this implementation study, organizational culture needed to be examined on multiple levels: from within the GWC, as well as within the outer layers of the healthcare network. As survey participants described at both baseline and follow-up, the organizational culture within each layer of the healthcare network was complex with differences between and within each layer. As the layers of the healthcare network interacted around COE implementation, these complexities and differences become more apparent. Overall, this became one of the most heavily discussed constructs among participants, with two primary components of culture discussed: the GWC culture (and resulting interactions) and culture surrounding the acceptance of trans-identified people.
One of the most direct survey questions related to culture asked participants, “to what extent (%) would you characterize your culture as” each of four types, with the end result totaling 100%. These types included:
Team: A friendly workplace where leaders act like mentors, facilitators, and team-builders. There is value placed on long-term development and doing things together.
Hierarchical: A structured and formalized workplace where leaders act like coordinators, monitors, and organizes. There is value placed on incremental change and doing things right.
Entrepreneurial: A dynamic workplace with leaders that stimulate COE. There is value placed on breakthroughs and doing things first.
Rational: A competitive workplace with leaders like hard drivers, producers, or competitors. There is value placed on short-term performance and doing things fast.
Within the GWC itself, measures of the type of workplace culture most actively present changed over time, with the primary culture shifting from a mixture of team and entrepreneurial at the baseline to hierarchical at follow-up (Fig. 5). In addition, at both baseline and follow-up, participants described relatively high amounts of conflict and negativity within the GWC but outside of the core implementation team. At baseline, there was a great deal of discussion about GWC and family practice staff feeling out of touch with the COE implementation, and therefore without support. At follow-up, these concerns had improved.
Figure 5: Average distribution of perceived team culture at baseline and follow-up.
In addition to these challenges, struggles related to support for the transgender population and the work of the GWC were present at both baseline and follow-up. At baseline, participants indicated that members of the GWC team were highly supportive of and provided affirming care to the transgender population. However, participants also indicated that outside of the GWC, individuals, including support staff in their own family practice, were sometimes less tolerant or supportive.
At follow-up, several participants indicated that as the GWC became better known and integrated into the larger healthcare network, there was a positive shift in network culture, with outside clinicians and non-clinical staff becoming more tolerant and affirming of the transgender population. Despite verbal support, a lack of follow-through with supportive actions often occurred, indicating that a full culture shift towards support of the GWC COE, and transgender people had not yet been achieved.
Much of the discussion on implementation climate focused on the inner-most implementation setting, the GWC itself. In this setting, participants generally were quite positive, describing an organizational incentive of improving patient care through the COE implementation. They described a positive learning climate with opportunities for education and the discussion and implementation of new ideas, as well as an appreciation for the strategic plan as a means of monitoring of goals and reviewing feedback.
Though most indicators of implementation climate were positive, there were mixed opinions of the compatibility of the COE with the existing environment at the time of the baseline survey. In addition, at both baseline and follow-up, participants described numerous competing priorities, particularly when it came to the responsibilities of the larger healthcare network. Finally, tension for change was shown to be variable in different parts of the healthcare network. The highest levels of tension for change were present in the immediate GWC; lower levels of tension for change existed in the more outer settings of the healthcare network.
Networks and communication
Communication issues in particular have been a challenge within the GWC over the course of the COE implementation. At both baseline and follow-up, participants indicated that communication within the GWC could be both tense and inconsistent. In terms of consistency, this related to both a lack of a standardized process for sharing new information, as well as challenges caused by the fact that several GWC mental health providers were not employed by the healthcare network and therefore unable to access patient records. At follow-up, participants expressed that communications about the GWC with other members of the larger healthcare network had improved over the course of the COE implementation.
Readiness for implementation
Due to the fact that the follow-up survey was conducted at the end of the grant cycle, much of the discussion related to readiness for implementation took place in the baseline survey. These constructs (leadership engagement, available resources, and access to knowledge and education) were described to a lesser extent in the follow-up survey.
Over the course of the study, participants indicated that network leadership engagement and support generally varied from person to person; however, at follow-up participants indicated that there was overall more and better engagement by and support from leadership than at the baseline. At follow-up, several participants focused heavily on the resources that were lacking, specifically ancillary staff (mental health providers, administrative support, etc.), physical space, and time and energy of members of the GWC team. This lack of resources created barriers to smooth implementation of the COE. In addition, participants consistently described the educational opportunities that were available to them; noting, however, at baseline that individual’s ability to participate was somewhat limited due to time and funding constraints related to the consuming nature of project implementation.
From baseline to follow-up, responses did not change with regard to structural characteristics that could impact implementation. At both times, participants indicated that the relative newness of the GWC could be seen as a benefit to implementation, as there was ample opportunity to mold the GWC and COE to fit within the mission and vision of the larger healthcare network. While this was seen as a positive, COE implementation occurred during the restructuring of the healthcare network. Because this restructuring led to incorporation of the GWC into a new system, views were mixed with regard to the advantages and disadvantages of being included in a much larger network. This restructuring resulted in challenges adapting to a new organizational structure.
Discussion of the outer setting constructs was limited in this analysis. Overall, the interactions between the GWC team, implementation of the COE, and the outer setting remained positive from the baseline through follow-up.
At both the baseline and follow-up surveys, participants discussed the benefits of collaborating with transgender healthcare providers outside of the healthcare network. Study participants indicated that making these connections through engagement in events and conferences was encouraged by GWC leadership.
External policy and incentives
Survey participants described the benefits of being the only organization in the region that provided interdisciplinary gender-affirming health care across the lifespan, with a commitment to the GWC’s six prongs for care (discussed previously). In addition, the implementation of the COE to improve these services was seen as positive compared to other regional services for transgender people.
Patient needs and resources
Throughout the study, survey participants consistently indicated that recognition of patient needs and the ability to meet those needs were a high priority for the GWC. At baseline, participants expressed concern that non-clinical GWC staff were less sensitive to the unique needs of transgender patients. This led efforts to improve cultural competency through training and education. At follow-up, better patient transportation and health insurance were also identified as sources of gaps in care.
At the baseline evaluations, participants described examples of peer pressure. This included the pressure to fit into the wider healthcare network, as well as the pressure to train other clinical departments within the healthcare network who also provide care for transgender patients. At follow-up, discussion around peer pressure focused on whether or not the GWC could continue to meet the healthcare network’s standards in terms of productivity and patient care metrics.