Focus groupsParticipants

A total of 197 HIT members from 95 unique sites (73%) and 18 regions (100%) participated in 18 focus groups (range 3–16 participants) and seven individual interviews. Participants were 75% female and included nurses (37%), APPs (22%), pharmacists (17%), physicians (14%), and system redesign or other frontline roles (10%), working in gastroenterology, infectious disease, pharmacy, and operations to improve liver disease care in VHA. Focus groups identified barriers to and facilitators of cirrhosis quality improvement efforts across the five CFIR domains during the first year of a national learning collaborative pivoting from HCV to cirrhosis care improvement.

Implementation barriers

Barriers were primarily from the CFIR inner setting, intervention characteristics, and outer setting domains.

Intervention characteristicsComplexity

Participants universally emphasized the complexity of cirrhosis care, particularly in contrast to HCV treatment (e.g., cirrhosis “is a complete different animal, much more complex, and not that easy to implement”). Where HCV can be identified using lab data, identifying patients with cirrhosis requires more clinical training and involves more provider discretion. Thus, many sites faced ongoing challenges with accurately identifying the true cohort of patients with cirrhosis.

Logistically, the complexity of managing recurring imaging studies for HCC surveillance was a central concern for participants and raised the issues of staff distribution, including the “need [for] admin support” to handle the complexity of “post-discharge scheduling, pulling patients in, linking to clinics, HCC screening, and ultrasound every six months [with] patient no-shows and a difficult patient population.”

Adaptability

In part because of the complexity of cirrhosis care, individual sites were perceived to have different needs, requiring adaptations to address the fact that, “each site will look different.” This was particularly true for sites without specialty care: “rural facilities don’t have hepatologists…[specialists] aren’t geographically located where patients need the care.” Participants thus recommended a focus on adapting and tailoring care processes for sites relying on community providers for cirrhosis care.

Outer settingPolicies, incentives, and metrics

Participants described the need for clear performance metrics, goals, and national policies and directives promoting cirrhosis care. One clinician said few sites “are routinely engaged because no one knows exactly what the metrics are or how to use them—no agreed upon standard.” Another clinician explained, “until there is a national metric they are held to; it is hard to get it done—clear-cut direction will be helpful.”

Patient needs and resources

Engaging Veterans was noted as challenging because cirrhosis is often a silent disease. One participant lamented, “linkage to care is hard and many patients [are] asymptomatic, treated by primary care, and are under impression that no treatment is available.” Securing patient buy-in and commitment to surveillance efforts was viewed as a “herculean task…[and] a huge amount of time,” requiring largescale patient outreach and education.

Inner settingRelative priority and readiness

Even within the gastroenterology division where cirrhosis care takes place, focus group participants discussed the challenges of competing priorities: “even trying to engage [our] local GI department is a nightmare…colorectal screening priority is being measured, monitored, pushed and scrutinized so that’s their priority.” Participants explained that the catalyst for practice and process change would require making cirrhosis “a credible issue” and for it “to be a priority on everyone’s agenda.” Participants conveyed that readiness for implementation may not be uniform across all sites. There was an expectation that site size may affect organizational readiness, as one provider indicated “[we’re] not getting anything from our big sites, we were leaning on them to help us. [They] can’t expect the small sites to do it…they have to sail the ship.”

Leadership engagement and resources

Focus group participants identified that efforts should “come from top-down instead of us scrambling to the top.” Another participant cautioned that, “Patients need to buy in, but without leadership support, there will not be anything for the patients to buy in to.” Participants frequently reported needing increased resources to track patients, coordinate care, and conduct surveillances. One clinician hesitated that there was “more to do, [but] no one above us giving us time or resources to do it.” Participants spoke of demonstrating the need for HCC surveillance and increasing tension for change in leadership via building a compelling business case, “people [need to] understand the long-term complications and potential ways to save the hospital money with repeat hospitalizations if we have the support to manage the patients closely to try and prevent the re-hospitalizations.”

Structural characteristics and compatibility

Providers reported the structural characteristics of their sites impeded a multidisciplinary approach to cirrhosis care: “Structurally, if [we’re] going to screen more patients, each [site] will need to do more endoscopy, need more radiology availability, anesthesia support for endoscopy, ultrasound…[a] potential explosion of liver patients that is going to tax our system.” Many insisted the need to change clinic structure and existing workflows and systems to account for cirrhosis care because this “huge transformation” would require sites “dealing with totally different people and reestablishing relationships.”

Implementation facilitators

Facilitators participants described generally were in the domains of implementation process and characteristic of individuals.

Implementation process Infrastructure and communication

Most participants reported positive experiences with the HIT collaborative for HCV which they believed would transfer to wider cirrhosis care improvement. They specifically commented on the collaborative structure and expanded network allowing for communication through more channels and elevating the priority of the clinical area. There was a universal appreciation for cross-region networking and team development as it made teams “not to operate inside your own little bubble, to get out and talk to people and share ideas.” Participants expected continued opportunities for collaboration (including peer-to-peer and expert-to-peer) via HIT virtual and in-person meetings, and training opportunities.

Data tools for reflecting and evaluating

Participants generally felt that having centralized and reliable data tools would facilitate quality improvement and help to “work smarter” and streamline care. The HIT had an established structure for monitoring and feeding back progress reports to regions for HCV, which was expected to continue. However, participants tempered their appreciation of the tools because they “don’t really have anybody dedicated to go through the dashboard or reach out to people.”

Characteristics of individuals High self-efficacy due to prior success

Many participants underscored how their prior HIT experience prepared them for taking on new initiatives: “we have an idea of how to implement changes on a larger scale.” Gains from HCV work and the knowledge and skills fostered by the HIT contributed to heightened levels of confidence and self-efficacy that acted as facilitators for future cirrhosis care improvement: “It's been really exciting to see what VA has been able to accomplish when they put their minds to it.” Participants reported perseverance and comfort with change, and this served as a facilitator: “we lay the framework, we make sure everything is ready to roll and we do what we can until we get that support and then we go full throttle. We didn’t wait for the gate to be opened to start preparing to run.”

Recommended strategies

The 10 barriers from the focus groups detailed above (i.e., adaptability, available resources, compatibility, complexity, external policy and incentives, leadership engagement, patient needs and resources, relative priority, readiness, and structural characteristics) were all entered into the CFIR-ERIC Matching Tool to generate a list of strategy recommendations. The left column of Table 1 lists the top 20 strategies recommended by the CFIR-ERIC Matching Tool based on those 10 barriers from the focus groups (order unimportant). For example, the barrier of relative priority was a focus group-identified barrier and is linked to two recommended ERIC strategies: “conduct local consensus discussions” and “conduct cyclical small tests of change.”

Table 1 Recommended strategies based on CFIR-ERIC mapping of top barriersComparing recommended vs actual strategies

In Table 1, the percentages listed are the actual strategy use frequency in the first two years of implementation. The “top” column denotes in which year the strategy was a top-used strategy. Among the top 20 most recommended strategies (per the matching tool), six (30%) were actually used in FY18 and four (20%) were actually used in FY19. These included “build a coalition,” “capture and share local knowledge,” “conduct local consensus discussions,” “identify and prepare champions,” “involve patients and family members,” “promote adaptability,” and “tailor strategies.” On average, the remaining 53 strategies (i.e., 73 overall strategies minus 20 recommended) were not more or less frequently used in either year (FY18: 26% vs 25%; FY19: 19% vs 20%).

The “strategy significance” column in Table 1 indicates in which year the strategy was significantly positively associated with HCC surveillance. Overall, 35 of 73 (48%) of the actual strategies were effective in improving HCC performance in either FY18 and FY19 alone or in both years, compared to 14 of 20 (70%) of the top 20 recommended strategies. In the year after barriers were assessed (FY19), six strategies were associated with HCC surveillance including the five highest recommended strategies. This confirms the temporal sequence of barriers reported in FY18 being addressed in FY19.

In the first pivot year FY18, the recommended and effective strategies were: “inform local opinion leaders,” “participate in a collaborative,” “fund local efforts,” “capture and share local knowledge,” and “obtain and use patient feedback.” Strategies unique to the first year were related to barriers of opinion leaders, access to knowledge and information, and resources.

More planning and active implementation strategies were unique to the second year: “identify and prepare champions,” “build a coalition,” “conduct local needs assessments,” “assess for readiness,” “conduct local consensus discussions,” and “involve patients and family members.” Second-year strategies corresponded to barriers of champions, cosmopolitanism, readiness for implementation, relative priority, and patient needs and resources.

Of the recommended strategies, three were dynamic strategies used to optimize fit with context and improve outcomes and were effective in both years: “promote adaptability,” “tailor strategies,” and “conduct small tests of change.” Strategies effective in both years corresponded to barriers related to intervention characteristics of adaptability, trialability, and compatibility (from the inner setting but intervention-oriented).

Actual strategies and expected barriers (reverse mapping)

The most popular actual strategies in each year were similar, with several notable differences. Five strategies were unique to FY18, six to FY19, and 14 overlapped between years totaling 25 strategies. Expected barriers were derived from these actual strategies using the CFIR-ERIC Matching Tool in reverse. Several strategies addressed the same barrier resulting in 15 unique expected barriers. Of these, seven (47%) had been previously identified through focus groups as an actual barrier (i.e., adaptability, available resources, compatibility, leadership engagement, patient needs and resources, relative priority, and structural characteristics).

Table 2 displays the most common strategies and their corresponding expected barriers and whether each was an actual barrier. Barriers addressed by the most popular strategies, but not explicitly identified during focus groups and included in the reverse matching tool query include access to knowledge and information, champions, cosmopolitanism, evidence strength and quality, executing, networks and communications, patient engagement, reflecting and evaluating, and self-efficacy. Note: Table 1 has original ERIC labels while Table 2 has cirrhosis-tailored ERIC labels and the FY18 strategy frequencies guide the order of strategies for FY19.

Table 2 Reverse mapping ERIC strategies to CFIR barriers

The three most used strategies were consistently “use data warehousing techniques,” “change physical infrastructure,” and “change the record systems.” In turn, reverse mapping revealed these strategies were linked to expected CFIR barriers of reflecting and evaluating and available resources.

In the first year, sites did more “building on existing relationships,” “building a local coalition/team to address challenges,” “conducting local consensus discussions,” “sharing knowledge across sites,” and “intervening with patients to promote uptake of and adherence to cirrhosis care.” Unique first-year strategies corresponded to addressing expected barriers of networks and communication, cosmopolitanism, adaptability, relative priority, and patient engagement.

In the second year, sites did more “revising professional roles,” “creating new clinical teams,” “having cirrhosis care experts educate providers,” “providing ongoing training,” “involving patients and family members,” and “engaging in efforts to prepare patients to be active participants in cirrhosis care.” These strategies referred to barriers of evidence strength and quality, structural characteristics, networks and communication, patient needs and resources, and patient engagement.