Table 2.

Providers' post-implementation perspectives about the transition to primary HPV cervical cancer screening for patients with a normal screening history, aged 30–65 years.

Themes: Feasibility & Acceptability of the Practice Change
Representative Quotes
Acceptability
“[The practice change] made complete sense both logically and scientifically.”—Ob-Gyn Physician
“Oh, it was just accepted.”- Ob-Gyn Physician
“I mean, I'm always excited. Whenever there is kind of new evidence that's showing one, that we can have to either less frequently screen or maybe do it in a more patient-friendly manner, not having to use, for instance, as many brushes…and doing a pap smear. The switchover to one brush vs. two was…a nice kind of patient-friendly kind of approach, too.”—Family Medicine Physician
Feasibility
“…for the most part, everything went really well. There was no hiccups as far as I can recall. It was a pretty smooth transition.”—Family Medicine Medical Assistant
“…most of all, [the transition] was pretty smooth.”—Ob-Gyn Physician
“I feel the transition went very well. All things considered.”—Family Medicine Physician
“Frankly, it's less because we only have to pull one where [we] were pulling two. We were touching that cervix twice with that sticky, pointy brush. So, it's probably better.”—Ob-Gyn Licensed Vocational Nurse
“…as far as myself there was no hiccups. It seemed to go okay, and I didn't hear anything more than that. I think it was an easy transition. It wasn't something that was crazy difficult…we were already doing it. We just went from doing two specimens to down to one. We're, awesome. [laughing] No more having to write…number one, number two on the label, which one was the pap, which one was the HPV, and we don't do that anymore.”—Family Medicine Medical Assistant
Ease of Practice Change
“I think, comparably, this was the easiest transition. I feel it was explained very well. We knew what we were doing. We were ready for the change before it happened. So, I think out of all of the [practice] changes we've had, this was the easiest one.”—Family Medicine Physician
“I think it went really well…I think it was the best explained implementation of a new policy that I've had in 11 years of being here.”—Family Medicine Physician
Themes: Initial Post-Implementation Barriers
Representative Quotes
Specimen Collection and Ordering
“Everybody is at one brush now. But in the beginning, some doctors didn't want to change..we were guessing and making sure we had the right brushes.”—Ob-Gyn Licensed Vocational Nurse
“The main learning curve was…for a few months…they didn't know which order to put in, abnormal or normal history. It was hard when they went in because they kept both orders in our system for some reason, and so the nurses, for the longest time, didn't know which order to put in, and I think they still kept both in there. And then…it was always do we do two or one..now our OB nurses obviously know, so it's been fine.”—Ob-Gyn Physician
“I don't know if it was just because of the way that the smart order set changed, and then included kind of separating out rather than just age based, but more age based and abnormal history. If that made more complicated for staff. But to be perfectly honest, looking at the smart set from a provider perspective, it doesn't seem to be too confusing.”—Family Medicine Physician
Lack of Standardization in Training for Nurses and Physicians
“…it always feels like doctors are told something else as opposed to [nurses]… and [when] we're trying to work together,…we're miscommunicating because we each got two different perspectives…on whatever we're supposed to be ordering…or the way we're supposed to put it in the system, stuff like that.”—Ob-Gyn Licensed Vocational Nurse
“But then once we started to kind of implement, I did notice that I think we were not on the same page in regards to nurses, which are the ones who pend our orders and us.”- Family Medicine Physician
“Even for us, it still took some to try to understand it…the doctors had to go into detail. So, maybe that would've been better, so that us nurses understand the reasoning behind it, as well, before trying to educate somebody if we're not educated fully on it. In the future, when we do have changes, if they can train us or give us the information to be able to have as a reference, so when those questions get asked, or anticipate questions that our patients might ask…That would probably help, super helpful, so we're not stuck like, ‘Well, we don't know. Because they said so.’”- Family Medicine Licensed Vocational Nurse
Themes: Persistent Post-Implementation Barriers
Representative Quotes
Delay Resulting Reflexive Cytology Labs
“…sometimes I don't know what to do when I get a certain result back. And then the Pap…many times, when the HPV is positive, it takes forever for the actual pap to come back, because they're not running the pap until the HPV comes back…That's the only, I guess, patient dissatisfier…on their side, they're able to see HPV positive, and they're, “Why didn't you call me? What are we supposed to do?” And it takes sometimes a couple weeks before the pap comes back for you then to say, “Hey, here is your next step.”—Ob-Gyn Physician
“But what we do notice is there's still a little bit of an education gap for the patients when they're looking for their result…even though we tell them in the encounters and will often give them like patient instructions like this. Is HPV testing and this is what it means. And this is what to expect…[but] there's still a little bit of a holdover where people are going on to kp.org [the patient portal], and they don't understand how they're seeing the results…”—Family Medicine Physician
“The only issue in the beginning was when the HPV came back positive. The co-testing took a very long time to come back. I think it was taking four to six weeks, and a few times it didn't come back. So, it was just extra work on my part and a lot of extra anxiety on the patients' part because they saw a positive test, but they weren't given a diagnosis right away.”—Internal Medicine Physician
Fear of Missed Cancer
“…we're always having practice changes. Things are always changing. My concern was because I heard that the Pap wasn't getting run anymore, and me as someone that has a history of abnormal pap smears, that was concerning for me. I'm well what do you mean it's not being ran? And then when the doctor really explained it…I had a better understanding of it.”—Family Medicine MA
“I would say the concern probably from the older docs is, in the older days, there were other things that had caused cervical dysplasia, so from their aspect, it was, how can we not also check the cells? But for the most part I think everybody was accepting of that as the new way moving forward.”—Ob-Gyn Physician
Patients Uninformed About the Practice Change
“I feel it's almost we're not highlighting the change…we're leaving it to the providers to say if a patient is surprised, then it's the provider that then has to explain everything, which takes time and we often don't have time. We're not really prepping the patient for this. And I don't know if that's intentional.”—Ob-Gyn Physician
“But I think that a patient that's just coming in for routine screening, they feel you get the Pap, and they don't really recognize the difference that we're only running HPV where before we were running HPV and cytology.”—Ob-Gyn Physician
“I feel like we're not highlighting the change. Like we're leaving it to the providers to say, you know, like if a patient is surprised, then it's the provider that then has to explain everything, which takes time and we often don't have time. So, we're not really prepping the patient for this. And I don't know if that's intentional. Because sometimes, that's a big task as well, and it may cause more—like patients that, you know, they might just get upset seeing this. But so maybe that was the decision to just not address it until it comes up…I have never seen any patient education about it.”—Ob-Gyn Physician
Theme: Fidelity to Interventions
Representative Quotes
“I think based on the rollout, it happened, it went well. It was well organized. Information was shared appropriately. All the equipment was made available quickly, and we had immediate feedback from our staff or the lab.”—Family Medicine Physician
“I didn't get any feedback as far as challenges. When I was speaking to the coworker that was helping me in that time, he was just saying it was a lot more simpler for him, as well. And he appreciated the change.”—Family Medicine Licensed Vocational Nurse
“I think partially because of the discussion I was involved with prior to this rollout. It was information that I already had recorded in my mind, knowing that it was going to happen…When the new information came out, I didn't pay as much closer attention to it. Having said that, I think I recall our DA and our quality team, I believe it was our quality team or our Pap team leader, who had rolled out that information via email.”—Ob-Gyn physician
“I have not heard anything. In fact, I think most of us said, “Oh, good, I don't have to do it twice, but just one”…I think everybody loved it. So, you cut down the, you cut a few seconds of our life down. it's almost like a no-brainer. It's a better, easier process, so I have never heard of anything about it…”—Family Medicine Physician
Theme: Use of Adaptations Across Sites
Representative Quotes
“We stayed very true to form.”—Ob-Gyn Medical Assistant
“According to the instructions is how we do it.”—Family Medicine Licensed Vocational Nurse
“No, I think we did it the way it was intended to be done.”—Family Medicine Physician
“I think we rolled it out just how they asked. I don't think we made any changes.”—Family Medicine Licensed Vocational Nurse
Theme: Recommended Refinement to the Practice Change Approach
Representative Quotes
Provider Training
“I mean, we obviously trust that there is a group that is on the frontline of this, and really know the ins and outs. And so, we were just like okay, if this what they looked into and validated and then, you know, this is what we're going to do. Like, we have that trust in that. Because I know how everything, you know, within Kaiser, like they don't just make changes overnight. It's like a huge process. And so, for it to pass through that process, there have, you know, dozens of eyes have been on this. And so, it's not something that you—we question. But of course, the curious, the—you know? Intellectual curiosity is there, and people are like, huh, you know? And I feel like if they provided an opportunity maybe for a webinar that focused on the data and the science behind it? That that would have been very beneficial, and a lot of people would have been interested in that… A separate webinar on the medicine and the, you know, evidence behind it.”—Ob-Gyn Physician
“I think, you know, it's with any change. I think just making sure it's communicated and, like you know, like I said, everyone's a different learner. So, if it means, you know, visually kind of going through or doing this step by step and kind of walking through it rather than just like handing a paper, that makes a big difference”.—Family Medicine Physician
“I believe standardizing not only the nurses but also the doctors. Because I feel like everyone, again, works differently. But we…should stick to the same way of practicing…it's just the whole, let's be a team. Like everyone work the same…”—Family Medicine Physician
Patient Education
“I think that in terms of—and I don't know. I think the providers like—I don't know what is being shared with patients. Like maybe if they sent this to the patient, and actually, you know, obviously patient friendly format. But like, hey, you know? This is how we're doing this now, and 99.7% is caused by HPV, and explained it in patient language. I think that would help the providers. I don't know if that was done. I feel like—I mean, and I could be wrong. I don't know that the patients knew we were rolling this out.”—Ob-Gyn Physician
“I think more basic, simpler terms. And then pictures. Pictures always help, it seems, you know, where patients understand. Even multiple pictures for them to just better understand the concept of what they're trying to tell them.”—Family Medicine Physician
“But even the change, I wish we could have notified our patients first. Because they want to know what we're testing for.”—Family Medicine Physician
“I mean, now, thinking about it, it would've been nice if we had some information to hand out to our patients to better explain it, ourselves. Even for us, it still took some to try to understand it. Like, oh, okay. And the doctors had to go into detail. So, maybe that would've been better, so that us nurses understand the reasoning behind it, as well, before trying to educate somebody if we're not educated fully on it.”—Family Medicine Licensed Vocational Nurse