Table 2.

Detailed adaptations made in real-time by site and CFIR construct

Construct	Barrier	Facilitator or Adaptation
INTERVENTION CHARACTERISTICS
Intervention Source Definition: Perception of key stakeholders about whether the innovation is externally or internally developed.		1001: Internal
		1002: External
		1003: Internal
		1004: External
		1005: Internal
Evidence Strength & Quality Definition: Stakeholders’ perceptions of the quality and validity of evidence supporting the belief that the innovation will have desired outcomes.		1001:
		• Interviewees see benefit in social support that SMA and P2P programs would provide. This was also shown in their trial program.
		• See also, Trialability.
		• See also, Knowledge and Beliefs.
	1002:	1002:
	• Repeated throughout all the interviews, that the SMAs and P2P programs are seen as extra work and staff do not see any added value – overall negative mindset to this implementation.	• Our team presented evidence during the site visit and during a local primary care team meeting to help educate and influence the physicians.
	• Diabetes SMAs have been a hard sell with physicians; they are not on board – they do not see an added value.	1003:
		• “Buddy system” (similar to P2P) has been effective in other settings in the facility, which has in turn increased support for P2P program.
		• HBC believes evidence behind SMAs is good and they were already looking for opportunities to improve their diabetic population outcomes. Believes the SMA and P2P will be very “fruitful and helpful.”
		• Physicians involved believe they have seen evidence that having a peer or buddy for support will help the diabetic population.
		1004:
		• Leadership is on board and thinks there is good evidence for the positive effect of being part of a group for the SMAs and the P2P components.
		• See also, Knowledge and Beliefs.
		• See also, Leadership Support.
		1005:
		• The ACOS for Ambulatory Care believes strongly in the evidence for SMAs.
		• SMA PCP feels there is evidence that the SMA and P2P will engage the patients (participants); feels they are more motivated by hearing from peers than from a clinician- belief of local evidence that the group portion of the SMA and the P2P group will be beneficial.
		• See also, Knowledge and Beliefs.
		• See also, Leadership Support.
Relative advantage Definition: Stakeholders’ perception of the advantage of implementing the innovation versus an alternative solution.	1001:	1001:
	• According to some interviewees, staff were not encouraging their patients to attend the SMAs because they did not see an advantage of the SMAs compared to usual care.	• We had local staff present information about the SMA program and the value of it to the PCPs.
		• Our team presented evidence during the site visit and during a local primary care team meeting to help educate and influence the physicians.
	1002:
		• “Don’t see how it could hurt” attitude.
	• Physicians see the diabetes SMAs as extra work; do not see the added value. • See also, Evidence Strength & Quality.	1002: • Our team presented evidence during the site visit and during a local primary care team meeting to help educate and influence the physicians.
		• Nursing staff seems to be on board – believe in peer support aspect to improve diabetes care/outcomes for Vets. Believe Veterans listen to peers more than clinicians.
		1003:
		• Have had other diabetes studies at site, but group support was not formalized, “no mechanism for patients who have been-there-done-that providing support to others.”
		• Health psychologist and other staff saw SMAs as an advantage to their already mandated diabetes education classes because they had not translated into any action.
		1004: • Staff see a need for peer mentoring program in Veterans especially because they are deployed in a unit and relate to their Veteran peers.
		• A physician leader thinks that there may be a financial benefit to the SMA group and P2P component.
		• See also, Cost. 1005: • The Associate Chief of Staff sees the advantage of the diabetes SMAs because he thinks it will help with access, efficiency, and help Veterans to learn from each other. • Currently, the ACOS says there are 5–6 separate patients meeting with the clinical pharmacist specialist for 30 min each going over the same information with some tweaking for their condition. • Some PCPs talked about how they could see the relative advantage of doing group visits vs. one on one patient visits. • See also, Cost.
	1005: • Possible added work for clinicians due to number of patients needing clinical notes following SMAs; described as: “It is a little bit of extra work because I have to write you know, 8 to 12 notes rather than just the four that I would write in two hours, but it potentially helps, but, as a doc, that[‘s] the biggest detriment I see to it.” • While PCP SMA lead is excited about the prospect of group visits, there was only a 50/50 excitement from other PCPS at this site for expansions of SMAs. Levels of enthusiasm varied because some PCPs simply like the idea of group appointments and some do not.
Adaptability	1001:	1001:
Definition: The degree to which an innovation can be adapted, tailored, refined, or reinvented to meet local needs.	• Concern from staff if the program was not adaptable and patients may not want to work with their assigned partner and this may cause them to leave the study.	• We worked with the site to come up with an adapted plan whereby a patient who does not work well with his/her partner can be re-paired or put into a group of 3. We also worked with the nurses and PCPs for their recommendation on patients that will work well together. The site appreciated us working with them to make the peer pairing adaptable.
	• Several staff were concerned that the locally designed recruitment plan was too ambitious.
	• Nurses originally going to take charge of SMAs, varying levels of comfort and would need to train too many facilitators.
		• During a pre-implementation local site visit our project staff discussed recruitment; the site did change their recruitment strategy to be more realistic.
	1002:
	• Staff here were concerned with the standardization that they perceived was required of their local SMAs. This site did not feel the program was very adaptable initially.	• HBC or psychology fellow to fill role of nurses as leaders of SMAs.
		1002: • We were able to work with the local team through meetings and calls to ensure that the SMAs could be adapted as each site saw fit. Each sub-site was able to come up with its own SMA plan.
		1004: • Site has tailored current SMA visits according to Veteran feedback so they can get what they want out of sessions.
Trialability Definition: The ability to test the innovation on a small scale in the organization, and to be able to reverse course (undo implementation) if warranted.		1001: • Pilot SMA was conducted before our clinical program began. Local staff involved decided it was too difficult for patients to absorb all the information in a one-day SMA. Also, because they were making meta-adjustments/medication changes, they felt the sessions needed to be longitudinal to titrate. “We feel we can’t fix all of that in just one visit.” 1002: • Piloted SMAs locally prior to implementation. 1005: • Piloted SMAs locally prior to implementation.
Complexity = 4 Definition: Perceived difficulty of the innovation, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement.	1002: • Staff are “busy and stretched thin;” it is difficult to do anything additional. • Contrary to all our other sites we were told that the amount of training for the peer facilitator needed to be minimal. They had trouble finding a P2P facilitator because of their perception of the work required. • Originally staff felt this project was only supposed to be adding on the P2P component. “Yet, somehow it has ended up to be a lot more work for the SMA people.” Staff feel they had to make multiple changes to the SMAs that they were not anticipating. • Staff expressed annoyance about the work involved and administrative tasks: “very frustrating,” “just more stress.” The timeline getting pushed back “just became unnerving.” They did not anticipate that this project “would be so much work.” 1003: • Staff told us their largest barrier is always funding and finding time in staff schedules to devote to this project. 1004: • Very busy staff and many competing initiatives; not only diabetes, but overall information overload. 1005: • Although the ACOS is very supportive of the SMAs he did say that it cannot add extra work to his employees. • Clinical pharmacist notes are a large barrier. Generally, clinical pharmacist notes are very comprehensive and they are the SMA documenters for this site. ACOS is concerned about the amount of time the documentation of the diabetes SMAs will take for the clinical pharmacists. He wants someone to make sure that we build thoughtful templates that capture what is taking place, but for the most part are standard curriculum.	1001: • Interestingly, this is the only site where we did not hear about staff being overly busy, stretched thin. 1002, 1003, 1004, 1005: • Facilitation team worked with the sites through team meetings and phone meetings to streamline documentation, shared diabetes SMA clinical note templates across the sites, worked to better integrate into existing workflow with input from staff.
Design Quality and Packaging Definition: Perceived excellence in how the innovation is bundled, presented, and assembled.	All sites: We added this because of the comments from all sites that clinical staff was not always aware of what was happening and what the intervention actually was –many of the staff did not understand what P2P was and we spent a good portion of the interviews explaining P2P. This was not really the intention of the interviews going in, but we spent a lot of time on clarifications and answering questions.
Cost Definition: Costs of the innovation and costs associated with implementing the innovation including investment, supply, and opportunity costs.	1002: • Nursing leadership has suggested cost, in terms of staff time for the P2P facilitators, as a barrier to implementation of this program.	1004: • A physician leader thinks that there may be a financial benefit to the SMA group and P2P component.
		1005: • The ACOS feel that SMAs should improve efficiency of care and access.
Outer setting
Patient Needs & Resources Definition: The extent to which the needs of those served by the organization (e.g., patients), as well as barriers and facilitators to meet those needs, are accurately known and prioritized by the organization.	1001: • Patients have pre-paid phones, run out of minutes and are not able to make calls at the end of the month. • Patients are “guarded” and may not want to share phone numbers with their peer. • Clinicians stated top barrier would be “convincing the patients to show up.” • Patients not motivated in general to come to appointments or sessions unless compensated financially. • Lack of patient motivation or follow-though. • Low patient attendance to SMAs and P2P drop-ins. • Concern that copay could contribute to poor attendance. • Concern about early morning start – some Veterans come in without eating before, which leads to very low blood sugars. • Delays to the start of the diabetes SMAs; knowing when the patients arrive and where to take vitals (time). • Plan for post-SMA continuation of care. 1002: • Difficulties with patient recruitment for SMAs; believe they will experience the same problem for the P2P groups. Lack of motivation among patients to attend. • Local patients are elderly and very private. May not want to work with a peer; concern about potential mis-matches alienating patients from participating. • Concern about distance – many Veterans live far from this VA. • Concern Veterans may not want to stay after the SMA for P2P. 1003: • Patient attendance/compliance is low—particularly among patients with A1cs over 9. Elderly population with less financial means; many do not have phones or access to the internet. • Patients resistant to change. • Concerns from multiple staff about “passive patient population” through experience with SMAs patients tend to be passive and expect you to do something rather than making a change for themselves. • Some patients prefer not coming to clinic unless they will receive travel pay. • Concerns about attendance due to ongoing construction. 1004: • All interviewees mentioned that it is difficult to get buy-in from patients to participate in groups. • In their experience with recruiting for the diabetes SMAs you need to recruit 3 patients for every 1 who attends. • VA does not reimburse patients for travel to research visits. Sometimes patients would like to join the groups but cannot afford to travel without compensation. • Many patients at this site use disposable phones so their phone numbers frequently change. Nurses have this experience when they try to call patients for reminders. • Some Veterans work and take classes, making timing/attendance difficult.	1001: • The local RA facilitated patient attendance through reminder calls and letters. • We worked with the local nurses to determine how to ensure staff are better aware of when the patients arrive for SMAs to ensure a timely start. • Moved SMA start time to early in morning to resolve parking issue and in hopes to increase attendance. • Studied barriers to attendance – poor attendance correlated with adherence issues. • Adapted so that the SMA is no longer one full day. This was done to allow time for medication adjustments, which could not be done when the SMA as only 1 day. • We consulted with staff from the site to take into account their perspective on matching peers together and who would work best together allowing for adaptability and patient re-pairing. • We also worked with site to ensure whenever possible that these facilitators would be sustainable across time when the research team would no longer be involved (transference of some of these tasks in time to local clinical and administrative staff). • Worked to guarantee eligibility for travel pay for SMAs. 1002: • The local RA facilitated patient attendance through reminder calls and letters. • Presentations were given at staff meetings to increase patient attendance/ referrals. • We worked with staff from the site to consider their perspective on matching peers together and which would work best together (taking into account disease state, gender, age). • Worked to guarantee eligibility for travel pay for SMAs. • As above worked with site to ensure sustainability of facilitators. 1003: • The local RA facilitated patient attendance through reminder calls and letters. • Word of mouth support from Veterans who have participated in the diabetes SMAs to other Veterans has helped. This has been mostly serendipitous rather than organized. We discussed this with the local site PI and she presented information on P2P to a Veteran-run wellness group to help with the word-of-mouth support. • We instituted a way to distribute reminders for the P2P groups. • We worked to make sure the initial group script is very dynamic. • Worked to guarantee eligibility for travel pay for SMAs. • SMAs have been modified to better fit patient needs (number of sessions, etc.) • Veterans appreciate having an interdisciplinary team to guide them. • Social support will increase patient accountability/attendance. • As above worked with site to ensure sustainability of facilitators. 1004: • The local RA facilitated patient attendance through reminder calls and letters. • One facilitator staff has noticed is having 2 health psychologists participate in the SMAs to make sure that patients’ needs and wants are addressed in the class and moving the sessions to more of a conversation rather than a didactic session—has already been successful. • Vets will benefit from added social support and “hearing from ‘equals’ rather than somebody else.” • Worked to guarantee eligibility for travel pay for SMAs. • As above worked with site to ensure sustainability of facilitators. 1005: • The importance of goal setting, as a patient need, was discussed in regards to prior SMAs and how that was needed to improve outcomes – being held accountable helps to improve patient outcomes. • The local RA facilitated patient attendance through reminder calls and letters. • Social support is seen as a patient need and the SMA and P2P groups will fill a gap in patient needs. • PCPs here view the well-controlled patients attending the SMAs as a facilitator. • Worked to guarantee eligibility for travel pay for SMAs.
INNER SETTING
Structural Characteristics Definition: The social architecture, age, maturity, and size of an organization.		1005: • There is a new patient education room with the exam room attached. This site was getting ready to ramp up the SMA model. “We are well situated to make this work.”
Networks /Communications Definition: The nature and quality of webs of social networks, and the nature and quality of formal and informal communications within an organization.	1002: • Concern that there would be a communication gap between the SMA coordinator and the P2P facilitators. • Very large project and having 3 local sites makes it even more complicated because each site has some differing challenges. • Communication between main study site and 1002 cited as problematic. • Staff can be difficult to reach and get in contact with. • Concern word still needs to be spread about project. • The overall project site staff has ongoing difficulties in communicating with this site.	1001: • Nurse that managed previous SMAs has well established relationships with key stakeholders. • PharmD & health psychology fellow offered and gave more information to physicians at staff meetings. • Keeping project on MDs minds will help with referrals to program, so staff ensure this was done. • Champion is also chief – runs primary care meetings and encourages support from physicians. 1002: • We worked with this site and held team conference calls and developed a plan to address communication. • A staff member who knows the patient panels well is working to communicate with and enlist her providers.
Culture Definition: Norms, values, and basic assumptions of a given organization.	1001: • Multiple staff describe this site as a culture of Veterans not wanting to participate in group settings. • Veterans here are very “guarded” and have culture of not being very motivated to make their own changes, do not bring back homework, do not bring in things asked to bring. 1002: • Culturally have great difficulty getting staff to commit a few hours a week to any type of project, even though this site has more financial resources than others. The site is still very cautious to commit staff; they will not commit to having a pharmacist attend the SMAs unlike all other sites. There is also a reluctance to write down responsibilities because of a fear they will become an expectation.
Tension for change Definition: The degree to which stakeholders perceive the current situation as intolerable or needing change.	1003: • Diabetes education classes have been mandated, but have not “translated into action.”	1001: • This site has a lack of group appointments, interviewees see need for program that will provide extra social support. 1003: • SMAs seen as potential solution to lack of action/improvement in diabetes management. • Staff see need for innovation at their facility. 1004: • “Benefit to hearing from ‘equals’ rather than somebody else – someone lateral as opposed to top down…” • Always looking for new programs to help their “frequent flyers.”
Compatibility Definition: The degree of tangible fit between meaning and values attached to the innovation by involved individuals, how those align with individuals’ own norms, values, and perceived risks and needs, and how the innovation fits with existing workflows and systems.	1002: • Had mixed drop-in sessions which they now cannot do with diabetes SMAs. 1004: • According to the chief of primary care, it is very important that this process fit into the existing workflow for implementation to succeed. • It is very important that we foster buy-in from frontline providers and they need to see this [P2P] as integrated and not imposed or there will be pushback. We need to coordinate our work into the suite of already existing programs.	1001: • Local staff have confidence that research implementation will be smooth at facility because it will fit within existing programs. • This innovation is considered by staff to be good compliment to what is already going on in patient care. • Not a lot of diabetes programming, fits need. 1002: • SMAs were already in place at this site and P2P perceived as easy to add on. 1003: • Intervention fits within existing structure, some minor changes able to be made with information provided by innovation staff. 1004: • Chief of primary care presented information about P2P at a monthly staff meeting. • We spoke with several front-line staff about how to best integrate this with their already existing work. • The Director of primary care sent emails about the project. Coming from him will help elevate the status of the project. • The Director of primary care will present information at the bi-weekly meetings with team leaders. • Diabetes groups already running, innovation will be able to fit within context of ongoing groups.
Relative Priority Definition: Individuals’ shared perception of the importance of the implementation within the organization.	1002: • Intervention not on leadership radar – voluntary, so can be first of things to go. 1004: • The top barrier was stated to be infringement on their previous initiatives. During the interviews, we determined that if the staff already involved in diabetes management feel their work is being challenged or re-directed by P2P it will “put their backs up.” • Very busy staff and many competing initiatives; not only diabetes, but overall information overload.They	1001: • Leadership thinks the SMA expansion will easily fit in because already had SMAs ongoing. 1002: • Nurses want program to be success – trying to enlist more people/rally support. 1004: • The qualitative interviews with front line nurses and physicians helped determine how to integrate P2P with their existing workflow and programs. We also asked for their suggestions for modifications to enable local success and gain buy-in. • Chief of primary care circulated info to those involved in a strategic planning initiative to let them know what will be happening and how to incorporate it. • To overcome sense of infringement the chief of primary care suggested 3 people as potential champions and said it was very important for us to get them on board: 1) a diabetes management nurse, who is the “epicenter of things” and the “clearing point” for diabetes management, 2) the acting chief of pharmacy, who oversees the clinical pharmacists in primary care, and3) a highly-engaged dietician. We interviewed all three to get their perspective and pull them into the study. • We sent the Chief of primary care a summary to circulate to those involved in the strategic planning initiative so all can be on same page, let them know what’s coming and how to incorporate it. He pulled together a distribution list.
Readiness for implementation Definition: Tangible and immediate indicators of organizational commitment to its decision to implement an innovation.		1001: • This site is ready for implementation: the plan for when study related SMAs will begin is in place – recruitment strategies, SMAs already running and have been through trial and error period.
Leadership Engagement Definition: Commitment, involvement, and accountability of leaders and managers with the implementation of the innovation.	1002: • Leadership engagement is lacking compared to the other 4 sites. Physicians are not engaged or supportive of SMAs and the P2P groups. The leader who is the chief for one site and our local PI was mentioned as not being influential by several local staff. This could be complicated by the fact that there are 3 local sites. • Also, there was a barrier discussed confidentially by multiple staff about a high level leader being a barrier for this project, specifically, as well as other projects. This person is not supportive and has blocked nurses from being involved in this as well as other projects. Solving this issue was beyond the scope of our project.	1001: • We were impressed with Chief of primary care as are local staff. Helped to convince providers to enroll patients, blocked out time for clinicians to be at groups, guaranteed space, and made sure the project ran smoothly overall. • At this site we have support from leaders across disciplines. • General support for SMAs from staff. 1002: • Multiple interviewees said staff and clinicians are aware these programs. 1003: • Interviewees suggest leadership engagement is present and they have leadership support for the SMAs and P2P. This came from multiple staff including physicians. 1004: • Very impressive chief of primary care. Was very thoughtful in his remarks and what will need to be done on his behalf for this program to succeed. Several other staff also mentioned his as a very supportive leader who is engaged in this study. • Chief of primary care offered to help us to make sure staff see P2P as a benefit, leading from a high level, tell others why we are implementing P2P and that this is important work. • Director of primary care said data feedback is important for his staff to stand behind this and he offered to disseminate data to the strategic initiative quad and everyone involved in diabetes care. 1005: • We were very impressed with the ACOS for Ambulatory Care. He is extremely supportive of the diabetes SMAs and pushing them forward and making sure PharmDs are able to participate despite time constraints. He sees an advantage to having the SMAs in terms of efficiency. • See also, Relative Advantage and Knowledge and Beliefs.
Available resources Definition: The level of resources organizational dedicated for implementation and on-going operations including physical space and time.	1001: • Space constraints for group visits. • Rooms have been scheduled for SMAs, but when patients arrive that space is occupied. • Patient parking is often not available. • Psychologist who was the P2P facilitator and SMA facilitator was not renewed and now they must find someone new and re-train. • Not all resources are available for getting patients checked in and vitals taken prior to SMAs. For example, need their own scale. 1002: • Space is so limited that groups here are scheduled based on room availability rather than staff availability. • Facility covers a large geographic area; some Veterans live 200 miles away from their facility. • Cost concerns have meant that they use volunteers for the P2P facilitator position. This caused concern that they may not be here at the right time or not have the right skills to serve as the P2P facilitator. Indeed there was P2P facilitator turnover and re-training required. • The amount of training for the peer facilitator really needs to be minimal. We did not hear this from the other sites. • Staff are “busy and stretched thin;” it is difficult to do anything additional. 1003: • Patient parking is lacking and there are construction projects ongoing. • Group meeting space is constrained (SMAs and P2P drop-in). • Staff told us their largest barrier is always funding and finding time in staff schedules to devote to this project. 1004: • Time demands on staff are a major issue. We were told that if a lot of time would be required for patient recruitment and screening that implementation would be very difficult. • Busy staff, competing initiatives; overall information overload. • Space constraints for group meetings. • Concern there will not be enough resources to continue program after study period ends (SUSTAINABILITY). • Parking can be issue. 1005: • There is a big issue with lack of resources at this site. This was seen in terms of clinical pharmacist leaving and they were not able to replace her and the resulting lack of time for the remaining pharmDs. This may be related to the insistence that the SMAs be kept team specific. This issue came up at local team meetings with pharmacists and dieticians. • From the ACOS, “We are short-staffed right now and we are unable to hire people.”	All sites: • Worked to find a guaranteed room (applies to all except 1005). • Scheduled out all rooms for SMAs and P2P open group sessions in advance. • P2P phone access to peers is available and always a viable option for all. • We did write scripts for the P2P facilitators to ease their workload and make it easier to understand their role. We also hosted bi- monthly training and question and answer sessions for them to talk to the facilitators as well as all other site P2P facilitators. 1003: • Made sure the classroom was reserved early for next couple of years for P2P. • Likely patient parking/construction problems will be resolved by time funding comes through. 1004: • We worked with the local staff to ensure that the P2P process will fit into the existing workflow. Additionally, P2P was presented at a monthly staff meeting by study staff. • Director of primary care offered to help us to make sure staff see this as a benefit, leading from a high level, tell others why we’re doing P2P, ‘this is important work.’ • We will send ongoing data to the director of primary care and he will disseminate to the strategic initiative quad and everyone involved in diabetes care. • RA will help to relieve time demands of staff for implementing initiative 1005: • The ACOS is very on board (see also Leadership) and did help to overcome some of these barriers, such as securing time from the PharmDs despite their initial statements that they did not have enough time. However, see his caveat at left.
Access to knowledge &information Definition: Ease of access to digestible information and knowledge about the innovation and how to incorporate it into work tasks.	1001: • Chief of Primary Care aware of study. 1002: • Extended project delays (over a year) and the roll-out keeps getting pushed back with a lot of time to not know what is happening has made staff uncomfortable. Other key stakeholders may not be aware of project because of these delays – leadership has not pushed it due to delays. • Lack of awareness of project	1001: • PharmDs speak at primary care meetings to educate MDs about SMA groups. • In general, most staff aware of the way study will be conducted. 1004: • P2P facilitator engaged and knowledgeable of her role.
CHARACTERISTICS OF INDIVIDUALS
Knowledge & Beliefs about P2P and SMA Definition: Individuals’ attitudes toward and value placed on the innovation, as well as familiarity with facts, truths, and principles related to the innovation.	1001: • Staff mentioned that they are curious to see if this P2P has an added benefit to the SMAs. Kind of a wait and see how it goes approach more than already believing in the evidence. • Unclear how much clinicians know about P2P aspect of program. • Some confusion over how patients will be communicating. • Some concern about patients sharing incorrect medical information. 1002: • Some staff were worried about the P2P group and its purpose. They thought the patients would be giving incorrect clinical advice to each other. • Some staff generally confused about the way implementation/P2P would work. 1004: • Some staff questioned aspects of the P2P study evaluation such as the patients recalling and self-reporting the number of times they had spoken with their peer partner (for those not using the telephone system). They do not think patients will be able to accurately recall. 1005: • Concern was common at this site that the patient may give each other incorrect clinical information when paired up in peer-to-peer. • The dietician discussed a negative belief about the interaction of peers and how one could be over-bearing and change the tone. • PCP interviewee talked about his beliefs that it may be possible that the pairing might not be well thought out and patients may clash or disagree.	1001: • Champion (also chief) understands program well and can use his knowledge to gain more support from clinicians. • HBC PhD Psychologist sees a potential benefit to the P2P program in addition to the already ongoing SMAs. • Conference call to discuss concerns about P2P groups—the intention and the instructions that the P2P patients will be given; patients will be educated and should not be exchanging clinical advice—this will be covered in the do’s and don’ts’ s card and in the patient orientation. 1002: • We held a conference call with this site to go into detail about the P2P groups—the intention and the instructions that the P2P patients will be given; patients will be educated and should not be exchanging clinical advice—this will be covered in the do’s and don’ts’ s card and in the patient orientation. Team calls also clarified this. 1003: • Much more positive about the evidence behind P2P than the other sites. Absolutely see a need for the P2P program. Believe based on work with other Veteran groups that it will be very fruitful. Believe having a peer will help with attendance and motivate Veterans to attend. A previous local veteran-paired smoking group has been successful. 1005: • The ACOS is very supportive of SMAs. When introduced to PACT in 2009/2010, was introduced to concepts of SMAs – got education on SMAs and started reading about them and thought, “Hey this is a fantastic way to actually create some efficiency in the way we provide care.” He is a practicing PCP and has numerous diabetic patients—he has been using the clinical pharmacists and nursing staff to help manage his diabetes patients for years. • Leadership says that clinicians recognize that this will have a good impact on patients, they understand impacts on efficiency, and they understand the concepts of peer support. • Dieticians believe P2P will work because patients really enjoy having someone check up on them.
Self-efficacy Definition: Individual belief in their own capabilities to execute courses of action to achieve implementation goals.	1005: • Physician talking about engaging other providers: “Some Primary Care providers are better than others, and I think it’s all going to have to do with their personality basically. I think some docs would be very well-suited for this where they’re not preaching at them and uh, and is okay with, like I’m kind of okay with it going off-topic every now and then but I’ll steer it back, uh, but I don’t have to be the center of attention, do you know what I mean? I don’t know, so it’s more of a Socratic method.”	1002: • “Champion” confident he can organize the logistics for the startup of project. 1003: • P2P facilitator confident in ability to help Veterans make changes and reach goals.
PROCESS
Planning Definition: The degree to which a scheme or method of behavior and tasks for implementing an innovation are developed in advance, and the quality of those schemes or methods.	1002: • Staff unclear of roles in SMAs – not yet defined. • Lack of schedule for SMAs.	1001: • Curriculum for SMAs tested and set prior to implementation. • Roles of clinicians in SMAs well defined prior to implementation (had nurse following up with patients for lab work, appointments, health psychologist working on goals with Vets, etc.) • Educational materials are prepared for patient use. • Nurse involved in SMAs willing to help/seek help in pairing Vets for P2P – can have group of three if pairing doesn’t work well. • Recruitment strategies thought out in terms of available patient pools. 1002: • Did SMA trial period prior to implementation. • Ready for implementation due to planning – gotten buy in at sub-site A, have organized RA. 1003: • Self-initiated local planning. The Site PI thought about ways to get buy-in from providers and planned for ways to spread the word to patients by presenting information at other groups. • P2P facilitator in place and has been attending SMAs to plan/learn more. 1004: • A lot of local planning was done. The Chief of primary care was very involved in making sure this was presented to involved staff multiple times and that buy-in from providers was obtained. 1005: • MD SMA group 2, talks about how the month interval is a good plan to follow because of the timing for when changes in behavior occur. See also knowledge and beliefs.
Opinion Leaders Definition: Individuals in an organization that have formal or informal influence on the attitudes and beliefs of their colleagues with respect to implementing the innovation.	1002: • The opinion leader for primary care was named by several staff; however, he has not been formally pulled into our project – we tried, but have not been able to yet. The named opinion leader/champion does not have the necessary influence, i.e. is not really an opinion leader. 1004: • PI and the chief of primary care seem to be opinion leaders backing this project—however, as pointed out in champions, the PI has not been able to influence 1 of the 2 SMAs groups to be supportive of this project.	1001: • The Director of primary care was named as an opinion leader; he also happens to be the champion, and a good supporter of this project. 1003: • Health Behavior psychologist is more of champion, but is also somewhat of an opinion leader for the primary care staff.
Formally appointed implementation leaders Definition: Individuals from within the organization who have been formally appointed with responsibility for implementing an innovation as coordinator, project manager, team leader, or other similar role.	1001: • Need for P2P facilitator who can engage participants. 1002: • The appointed physician implementation leader has little influence over staff at 2 of the local sites and several staff mentioned this. Also, he seems to think that he has the necessary influence, which compounds the problem. • General concern over roles in project/who will be filling roles. • P2P facilitator role of concern because seen as a lot of work/time.	1001: • RA role will be huge help for implementation of program (dedicated person to perform study related tasks). 1003: • Have P2P leaders in mind prior to implementation – is extremely engaged and prioritizes innovation.
Champions Definition: “Individuals who dedicate themselves to supporting, marketing, and ‘driving through’ an [implementation]”, overcoming indifference or resistance that the innovation may provoke in an organization.	1002: • No overall physician champion. The physicians have not bought into the diabetes SMAs. • The physicians see the diabetes SMA as extra work. They do not see the added value. • The physicians will not participate in the diabetes SMAs. Whereas, the nurses want a physician to be there for medical questions. • The named physician champion for the SMA/P2P project, does not have the influence that he needs to have (wrong champion selected) according to multiple staff.	1001: • Great champion in the director of primary care firm A. Helps with presentations, helps convince providers to enroll patients, blocks out time for providers to be at the groups, secures space, oversees local running of the project. 1002: We worked with the chief of primary care to present the study and try to gain physician buy-in for the SMAs as well as P2P groups. • Given the named champion is thought to not have adequate influence, we tried to pull in and speak with a physician who was named as being influential. 1003: • The health psychologist is a great champion for this site. He has a great deal of expertise and ideas to help with the project. He is very communicative. He is very passionate about this project and staff listen to him. 1004: • The Chief of Primary Care is a good champion for the diabetes SMAs. • Chief of PC also offered to send any emails to staff that we need him to. He said the material coming from him, would help. See also construct – leadership support. 1005: • The NP lead facilitator of most of the new SMAs is a champion, she started the SMAs (see also innovation sources), but she is also a champion. • Diabetes SMA has a nurse who was a big champion and really helped with the success of these groups according to the dietician and the lead MD facilitator. • The MD of the 2nd SMA group is a good champion and his group was well run and had good outcomes. See also innovation participants about how the PCP champion strategically used well-controlled patients in his groups.
Key stakeholders Definition: Individuals from within the organization that are directly impacted by the innovation, e.g., staff responsible for making referrals to a new program or using a new work process.	1002: • Hard sell for physicians – do not see benefit, takes too much time.	1001: • PharmDs speak at primary care meetings to educate MDs about SMA groups – overall support from clinicians for SMAs. • Champion also chief – engages key stakeholders (clinicians). 1002: • One interviewee cited a possible solution to engage residents in innovation. • One provider cited as enlisting physicians on her panel. 1004: • Chief of primary care will work to engage key stakeholders. 1005: • The ACOS for Ambulatory Care is a good supporter and has been working to engage key stakeholders in the SMAs.
Innovation participants Definition: Individuals served by the organization that participate in the innovation, e.g., patients in a prevention program in a hospital.	1001: • Poor attendance at group meetings – Vets at this site may not be comfortable in groups. • Success dependent upon engagement of participants. • Concern over finding enough interested participants. 1002: Participants need to see added value in SMA to get engagement. 1003: • Site SMAs began with recruitment of those with A1c’s over 9, attendance/engagement was very low. 1004: • Patient engagement low, patient drop-off high.	1001: • Scheduling ahead and getting reminder calls may help Vet attendance/engagement. • Pairing aspect of P2P may increase engagement among participants – peer holding them accountable. 1002: • Voluntary program – participants more likely to be motivated/engaged. 1003: • Include Vets with A1c’s under 9, which has increased attendance and engagement in program. • Having formally appointed implementation leaders (RA & P2P leader) to engage innovation participants will help. • Social support will increase engagement in SMAs. • Group setting/P2P will help to engage “passive patient population.” • Because travel is an issue, one interviewee suggested a carpool setup. 1004: • To increase engagement in SMAs/P2P, pair up Veterans at first or second SMA (previous SMA was only one visit). • Psychologists have been asking Veterans what they would like to get out of sessions/for feedback to increase engagement. • Let Veterans know they can self-refer.