Table 1.
Anticipated and experienced challenges to implementing the STOP CRC direct-mail fecal testing program
| Consolidated Framework for Implementation Research Construct/Theme | Challenges | Representative quote | |
|---|---|---|---|
| Anticipated | Experienced | ||
| Health centers (N = 8) | Health centers (N = 8) | ||
| External setting (outer environment) | |||
| Impact on colonoscopy access for higher number of positive FITsa | 7 | – | “The initial concern about follow up colonoscopy access … went away with the ACA because we went from having over 20% of our patients under sliding fee scales to now around 7%...[The] increase in coverage … has made a big, big difference.” |
| Cumbersome process of EMR vendor to activate EMR tools creating time delays for execution of worka | – | 6 | “We had to do multiple [work requests] to get it up and running, to get all the EMR network and semantics set up for it… And not getting the timely response that we needed from [EMR Vendor] just bogged down the process quite a bit.” |
| Burdensome interface with outside labs processing kits created delays/extra work | – | 2 | “The other challenge was in getting the kits to us from lab vendor. There was [sic] some delays... there would be weeks … where they [staff mailing kits] weren’t able to do anything.” |
| Low patient awareness about CRC in general / confusion with a mailed programa | 5 | 3 | “I think it’s difficult for people to figure out how to do those kits at home without having somebody having instructed them in advance at the clinic. They get the kit and … don’t know what to do with it, or else they complete it but then it’s not correct.” |
| Internal setting (organizational environment) | |||
| Time burden on staff to implement program components competing with other work demandsa | 8 | 8 | “It was time consuming because sometimes we’d get like 40 of them back in a week. One staff person would … make each person an appointment and ‘check’ them in [when FIT was returned]. And it would take her quite a while to get that done… then I would … go into their chart and document everything and result the test. So if I had 30 tests, it would take me a good couple of hours to get it all done at once.” |
| Staff roles unclearly defined, staff not fully in place or trained in new work | 3 | 3 | “One of the biggest, early challenges that we had was identifying a workforce that can actually do the work. Because the workflow was in process, I wasn’t ready to hand it over to the clinical teams where I wanted it eventually. And the front office team that ended up doing it, they were, of course, always really busy. So I had some part-time staff that worked on it.” |
| High leadership/staff turnover or restructuring | 2 | 5 | Our organization has changed a lot with role changes and turnover. We have also grown so much that we’ve had to kind of put the brakes a little bit on some of the more innovative work that we’re doing like STOP in order to build our foundation a little stronger, and create more solid workflows and ensure that we’re more standardized across the whole organization. |
| Inadequate EMR staffing resources/ technology challenges within electronic health record | – | 6 | “Another issue is that our EMR staff are really stretched beyond their FTE. There is 1.5 EMR staff available to the whole organization of 300+ people. And one of them… is not only in transition to her job, but she is in training still. And so having access for problems that might come up [for STOP] in … issues that need to be addressed from [EMR vendor], those were really problematic to resolve.” |
| Batch printing of materials was a new workflow creating time consuming challenges for execution | – | 5 | “We also had a lot of work that we had to do with [EMR vendor], to determine which of our printers could handle the capacity of printing batch letters. We hadn’t done that before, so this was our first experiment with batch letter printing… it was just a lot of time consuming work to figure out.” |
| Limited coordination between participating clinic sites, undefined process for resolving issues as they arise | – | 2 | “…one of the issues that I’ve been having is the communication with all the clinics… our own internal communication and, what that workflow is when there is retesting [of a FIT kit] that is required—does that become the work of their clinical team or does that become the work of the person who’s doing the central approach and sending out those kits centrally?” |
| Intervention characteristics | |||
| Cannot accurately identify target population because screening history inconsistently documented in health record | 5 | – | “One of the things that has come up as a concern is about patients who receive the kits unnecessarily. And it’s because the health maintenance alert in Epic hasn’t been updated because we’ve struggled with that. So there may be a patient who’s had a colonoscopy, [but s/he is] … on the list to receive a kit.” |
| Direct-mail approach may be incompatible with patient population (i.e. homelessness, low literacy) | 6 | 2 | A direct mail approach may not end up being the best approach for some of the population you serve if they are homeless or have sort of transitional housing and don’t have a stable address. |
| Direct-mail approach is incongruous with how organization likes to work | 5 | 1 | “Our new CMO is not fully supportive of mailed screening kits. He prefers face-to-face conversations and directly handing kits to patients.” |
| Direct-mail approach may be too impersonal/ inferior to face-to-face encounters | 4 | - | “I think the thing that is lacking… is the provider discussion with the patient and getting the patient to really understand that this is something that they want them to do, it keeps them healthy… I think it impersonalizes everything when you just get this kit in the mail and it’s a letter from your doctor.” |
| Process | |||
| Lack of timely or accessible data to show benefit worth the efforta | – | 8 | “I’ve struggled … to determine whether or not this particular type of intervention was really making a difference. And the data I’ve received from the project so far, though helpful, I don’t think really captures that piece very well…. Are we doing a better job at screening for and preventing CRC? And it’s been hard for me as the project manager to gather the data that I need in order to make that determination.” |
| Incorrect postage on kits | – | 3 | “The postage for mailing the kit was a hurdle, because we are putting it on the envelopes to go to the lab as well—we had figured out the cost and the weight for each one and then mailed a bunch, and I guess the postage cost increased so half came back. So now we are going to go back and add more postage for the next batch.” |
| Wasted samples / no collection date | – | 1 | “We had discovered that we had a very large percentage of returned samples coming back without the collection date on the label… We want to make sure that doesn’t happen anymore than we absolutely have to because it’s hard to do that kit… so wasted samples is something we need to resolve.” |
aAlso cited as a possible barrier to sustaining the STOP CRC program