Table 2.

Examples of participant quotes in support of identified themes

Codes	Sub-codes	Supporting quotes
Theme 1—Use of strategies in context of change fatigue
Demonstrating the need for or value of the H-FLS	Communicating the benefits for patients and/or providers	I think if you are able to convey the need and provide the evidence and help people understand there a significant care gap. Even though this is an additional program and additional step…people are willing to come on board and be enthusiastic to support the program (Site 2, Participant 3). It’s important that people see how this actually supports the patient and I think they do (Site 1, Participant 6). People need to know why something is being done in order to have buy in. They need to be able to have something that you can latch on to. To say, “Ok, this thing - an extra step, extra employee, and extra set of paperwork is worth it because of this benefit” and I think with implementation as it is, we have seen that (Site 2, Participant 1). Good education, information of what’s in it for them, why it’s good for the patient, why it’s a necessity to move forward, and change. Those are all primary things for effective change management (Site 2, Participant 7).
	Target patient population had become a priority	The FLS is part of the Bone and Joint Health Strategic Clinical Network and it’s also the Bone and Joint Network signature project and the FLS falls under that. So we have had good support from a leadership perspective across the province and I think that will continue because it has been made a priority (Provincial Stakeholder, Participant 1). I think across the board everyone realized that osteoporosis is a big and costly issue for both patients and the system (Site 2, Participant 8). I think even from a higher level it’s having the FLS and osteoporosis care identified as a care gap by the AHS was what really started all of this. And having them focus on osteoporosis care and providing their funding to run the program like this and continue to fund it in the future if there is benefit to the program is more important than the local factors at the PLC (Site 2, Participant 3). The Bone and Joint SCN have gone to them [beta hospital] and asked them to become the center of excellence in orthopedic care in this area so that in itself, you know, when somebody sets it as a priority area, it becomes a facilitator (Site 1, Participant 8).
Providing resources so as not to increase workload of others		I do not think that the FLS is adding on to anyone else’s workload. If anything I think it’s helping other people’s work load so I think that’s a key thing with this initiative, we are not piling anything onto anyone else (Site 1, Participant 1). It’s someone else’s job and it’s not being added to the plate to the current staff (Site 1, Participant 4). It’s when changes occur that creates more work for them that they do not see value in it (Site 1, Participant 9). I think the one thing is that it does not add work load to other people and so it in fact does not impact other people at all. So that’s helpful in that it’s not yet one more thing someone has to do or learn or whatever (Site 2, Participant 5). It’s a fairly non-invasive program. It’s not one that demands a lot of buy in or extra work from the staff on the ground level (Site 2, Participant 8). We’ve been very mindful of anything that we have put in cannot add additional workloads to them (Provincial Stakeholder, Participant 1).
Appropriate site selection	Early adopters or culture open to change	Well, I’ve been told that [name of site] is a popular site for trying pilot projects, which shows that they are open to change or new initiatives (Site 1, Participant 3). I think we are one hospital that is really keen on trying out new projects initiated… I think it’s just that culture and the staff of course willing to participate in and initiate its own programs to improve the overall patient care (Site 2, Participant 6). It’s the people. The administration team at the [site name] was all for it. Let us go for it…. it’s just a group that’s open and willing to look at something or introduce something or participate in something when they know it could be of benefit to the patient (Site 2, Participant 7). We volunteered. We said, “Let us try it”, right? And having somebody say, “You guys need to do this now. It’s your turn”. That’s not always attractive (Site 1, Participant 2).
	Being committed to the patient population or content area	You really do have to find someone [referring to FLS clinical nurse role] who has a passion, not only for osteoporosis therapy and management but for kind of the overall care of patients. You have to recognize that it’s not just a prescription or it’s not just an order, that these are people (Site 1, Participant 1). I often think it’s people, not positions because if you have somebody who’s, you know, just like our FLS team, it’s going to fly. You could have somebody with the same position and not have any drive or passion and it would just flop. So I always believe it’s people and what they believe in and what they want to bring. It’s their passion and their commitment to what they want to do for the patients (Site 1, Participant 2). There’s a bunch of different stake holders. There’s the SCN, there’s the physician, there’s the orthopedic service, there’s the hospital admin. And they just generally have an understanding or a will to want to do it (Site 1, Participant 3). I’ve said this in the past that I’m not so sure why everyone worries about the bird flu. We’ve already had a pandemic. It’s called osteoporosis (Site 1, Participant 9). I have a great team. Most of them are just so passionate about hip fractures that they are open to all of these changes (Site 2, Participant 1). When they recruited the nurse clinician of the [name of 2nd site], she was just so passionate about the program. So you are passionate, you just get things going (Site 2, Participant 6).
	Importance of champions of the service	We had champions at those sites that were willing to stand up and say I want to lead this. We when we do program planning [we] recognize the barriers for making clinical change and lack of a champion is probably the biggest risk to any implementation project. So the fact that we had champions at those two sites really to stand up and take ownership of the program and to run the program, it raised those two sites to the top of the list (Provincial Stakeholder, Participant 2). Well you need champions… I think that particularly that physician champion is essential (Site 1, Participant 1). I’ve been helping with identifying stakeholders, communicating how the plans will work, how to implement it on site and providing support to the FLS nurse and whatever issues that pop up with trying to identify patients. Or communication with staff in acute care. But then also meeting with the primary care physicians to try and help with that transition or communication between our team and primary care (Site 1, Participant 3). We had a champion on board… having that engaged physician, elder-friendly care physician, willing to participate and the FLS nurse (Site 2, Participant 7). We have a physician and we have a nurse and they were the main primary drivers of getting this thing up and rolling… I’m involved in the provincial working groups and the [name of city] zone working groups and [the FLS clinical nurse] always there at the table with us. So to be able to have her to speak to the program as well, she was like a promoter (Site 1, Participant 2). The nurse practitioner herself was a champion (Site 2, Participant 6).
	Learned from past experiences with change and applied learnings to H-FLS implementation	It’s been foundational to how FLS has been designed from the get go. We’ve borrowed very heavily from past experience on implementing the Hip and Knee Care Pathway and implementing Catch a Break. All of these programs have influenced how we designed and rolled out the FLS right from site selection to the fact that we are doing a staged roll out through to how we communicate, how we engage with our stakeholders or how we even organized the content development and delivery of this program (Provincial Stakeholder, Participant 2). As long as things are as simple as possible for everyone else that really helps with implementation; we have learned that in other change as well (Site 2, Participant 1). But basic learnings from regular change management in terms of good communication, good education or information of what’s in it for them, why it’s good for the patient, why it’s a necessity to move forward, and change. Those are all primary things for effective change management (Site 2, Participant 7).
Context of change fatigue; however, it was not perceived as a barrier to implementing the H-FLS	Current context of change fatigue independent of the H-FLS	There’s a certain fatigue of having these pilots come in and once the funding runs out, having them canceled (Site 1, Participant 3). I think its health care in general. There has been so much change even in the last two years and it just never stops coming…So there is a sense among staff I think throughout healthcare that, you know, we are burned out, we cannot do anymore (Site 1, Participant 4). There’s a lot going on. A lot of different initiatives (Site 1, Participant 6). The ortho world has had so many different things implemented in it over the last couple of years in terms, you know, we have implemented pathways, we have implemented forms and check lists and all kinds of things and I think we can learn a lot from that (Site 2, Participant 1).
	Change fatigue was not perceived as a barrier to H-FLS implementation	I have not witnessed any change fatigue in this area...It wasn’t that they were fatigued with change. They were fatigued with change that did not go anywhere (Provincial Stakeholder, Participant 2). We’ve had some changes recently that I’m bucking hard against. But this is one [referring to the FLS], that I’m most certainly not opposing at all (Site 1, Participant 7). In AHS, we are used to change so I do not think it would have much of an influence. I think people would be accepting of a new service like FLS (Site 2, Participant 4).
Theme 2—The FLS was perceived as acceptable
Clear and consistent understanding of the intent of the H-FLS	3i model	The 3i’s are to identify the case, to investigate through them, and then to help implement some of the treatments (Site 1, Participant 3). The FLS nurse [is] doing the assessment to identify the patients who qualify for the FLS program and she is essentially doing all the work up to determine whether osteoporosis therapy is required (Site 2, Participant 4). So the FLS is really designed to identify these patients while they are still in hospital and really get them on the care pathway for osteoporosis treatments and make sure they are getting the right diagnostics, make sure they are getting the right drug therapy and the proper imagining and the necessary tests are being ordered (Provincial Stakeholder, Participant 2).
	Secondary prevention of falls or fractures	That they could try to prevent a new fracture from re-occurring (Site 1, Participant 2). Generally the intent is to improve post fracture osteoporotic treatment as well as overall reduce future falls or risk (Site 1, Participant 3). Hopefully preventing further fractures (Site 1, Participant 10). If we are just focusing on osteoporosis therapy we are missing kind of a bit of a bigger picture and so you know we are also looking at fall prevention…we certainly want to prevent fractures which not only includes osteoporosis therapy but also fall prevention (Site 2, Participant 5).
	To bridge a care gap	It’s not that they [primary care providers] do not want to provide osteoporosis therapy or teach. But sometimes they do not have the time or the ability to recognize the need or the ability to provide that education. So I think that having the FLS there is helping the providers (Site 1, Participant 1). I suspect there was a big gap there from when patients were discharged as far as flagging that for primary care physicians. Then to initiate treatment. And even then, there are some assessments there that just did not happen (Site 1, Participant 3). My understanding of the FLS is to bridge a gap in terms of ensuring those patients have osteoporosis or fragility fractures that they are started on the appropriate treatments when they present to hospital and before they leave the hospital. Because we know that a significant majority of these patients whether they have been diagnosed, they have not been treated with the appreciate medications (Site 2, Participant 3). There’s been a huge care gap with patients. The population that we are dealing with is the hip fracture patients. So the orthopedic surgeons are terrific at fixing the fracture but then they do not do any follow up as far as cause of fracture i.e. osteoporosis. So that’s a huge care gap as patients who have fractured and especially hip fracture are at high risk or re-fracturing again (Site 2, Participant 5). There are these monumental gaps in communication, coordination in services, as a hip fracture patient recovers from their hip fracture and they transition out of an acute care environment (Provincial Stakeholder, Participant 2).
	Transition patients to primary care	And then in respect to communications with transitions, the FLS does provide communications to the family physicians which I would think that they would appreciate it. I think sometimes they are surprised to hear that their patient has been in the hospital with a hip fracture, that they find out months later and then are kind of left wondering what to do. And here we are sending them a letter saying, “your patient has had a hip fracture and this is some of the things that we have done. We’ve started this medication; we are doing these investigations”, to help them out because they may not often be comfortable with orthopedic care or osteoporosis management (Site 1, Participant 1). When they were sent back to their community living arrangement there was a plan of care for the primary care provider to understand what the therapy was to continue on in their future (Site 2, Participant 2). The care that is provided to the patients will be passed on to their primary care physician to ensure seamless care and treatment of patients with osteoporosis (Site 2, Participant 4). Whatever we do initially whether that’s starting therapy in hospital or sending patients home with a prescription…we send a letter to their GP [general practitioner] and then also at 3, 6, 9 and 12 months. We’ll also send another letter to their GP and just let them know what we have done and the plan is that at 3 months we’ll do a Vit D level as well as a bone mineral density test if they have not had one in the last couple of years. And those two a copy of those will go to their GP (Site 2, Participant 5). We’ve done a year of this focused work of getting [patients] on the right trajectory. Now we do a hand off to primary care saying this patient now has a detailed care plan. It’s really now under primary care accountability to manage that chronic disease and manage that osteoporosis similar to how they have managed their diabetes or cardio vascular health or any other chronic disease situation…the FLS is really designed to be that transition period (Provincial Stakeholder, Participant 2).
	Expanded scope beyond 3i model	My role is basically to help assess and guide therapeutic plan with regards to these patients post hip fractures, especially with their osteoporosis care, medications to address that. As well as flagging any geriatric syndromes…from my geriatric point of view is our success rate with getting these people into other services (Site 1, Participant 3). They’re [FLS physician and clinical nurse] reviewing not just the patient’s bone health, but just overall medical history and providing suggestions and recommendations. And if the patient does not require a full geriatric assessment he [FLS physician] will provide those suggestions - perhaps outpatient geriatric referral’, ‘perhaps rehab referral’ or ‘perhaps a day program referral’ for PT in the community. So he would provide some of those suggestions or if he had to catch the patient who is having ongoing delirium post-operatively, he can provide some preliminary recommendations, not involving the patient geriatric consult service but he’s able to try some suggestions on delirium management. So looking at the bone health and also looking at overall the patients’ health (Site 1, Participant 11). The other piece about the FLS service is beyond the osteoporosis management which is also identifying patients with reoccurring falls. So especially in the 65 [years old] and above. Identifying geriatrics syndrome, in cognitive impairment, delirium, dementia, depression or poly pharmacy…the experience in [name of beta site city] certainly has been, you know, not just identification of osteoporosis and treatment but also looking at all that complex medical problems from the pharmacy. And were seeing the same thing in [name of second site city] (Site 2, Participant 6). We decided to make ours a little bit broader in the sense that we did not want it just to be a medication type program. We also wanted to include some aspects of geriatric care because of the model that we developed and we were using care of the elderly physicians. So that was another piece to it. So we expanded the scope to include having physicians to start to identify those underlined geriatric syndromes that may be contributing to the fall initially. And then we also obviously deal with the osteoporosis medication and treatment piece of it but there is that added geriatric component (Provincial Stakeholder, Participant 1).
Aligned with organizational values	Providing patient-centered care	From the first day they realized that this could not be a cookie cutter approach. Not everyone was going to go on medication, not everyone wants to go on medication…You need to make sure that they are first educated and aware of their options. So I think that it’s wonderful why the FLS goes for a year. Because sometimes at the point of care, surgery, people aren’t ready to make some of these decisions. Maybe at 3 or 6 or 9 months down the road, when they are a little bit back to their normal self, maybe they can make some of these decisions (Site 1, Participant 1). It certainly helps to provide that greater education for patients so that then they can make informed decisions; patients and families and then their wants. We are also having to be patient centered, so giving them the options with the risks and benefits and then respecting whichever choice they choose to make (Site 1, Participant 4). We are still trying to ultimately preserve lives but then respect decisions of the patients themselves (Site 1, Participant 10) For me the FLS really aligns well with that because it is still patient centered (Site 2, Participant 1). I mean the rule of the [name of hospital] again that saying, “If it’s good for the patient, if its patient centered if it will improve patient care” we’ll buy into it (Site 2, Participant 6). The model of the program, it’s about encouraging patients to participate in osteoporosis care and prevention. To accept resources in the community. But there are certain situations – we are always balancing things off - the financial picture of the patient, their ability to access services in the future, and their ability to pay for medication. And work with the patient to come up with the best game plan for the patient that incorporates that information…you cannot force a patient to take a medication. That takes away their preference. You can provide the information and the supports available for the best courses of treatment (Site 2, Participant 7).
	Collaborative or multi-disciplinary approach to providing care	Again the culture of our multidisciplinary approach and the very high likelihood that this is an intervention that we can do and make a difference for people (Site 1, Participant 7). We are very collaborative multidisciplinary team including rehab, PT, OT, the transition coordinator, pharmacy, the clinical associate/physician, and our FLS [clinical nurse]. We work together collaboratively to try to make sure that we are placing not just fractured hip patients but all of our patients on the right [path of care] (Site 1, Participant 9). There was a little bit of a [barrier] in terms of not crossing into people’s territories. But a wonderful collaborative relationship happened a lot with geriatric medicine. It’s amazing. I mean, we see notes from geriatrics saying, “FLS to recommend osteoporosis management” and I smiled when I first saw that (Site 2, Participant 6).
Evidence-based but adapted or tailored	Evidence-based model adapted to Alberta context	It’s encouraged in other guidelines like the NICE guidelines in the UK. It’s considered best practice as far as having it in your post-op post hip fracture care. So just for all the reasons as far as consensus amongst even the British orthopaedic and geriatrics societies have agreed upon this as the gold standard of treatment. So it’s one of the initiatives that seem to be an accepted standard in hip fracture care (Site 1, Participant 3). It’s specifically addressing the fact that this is a recommended guideline research evidenced based therapy that should be administered to most of the patients (Site 2, Participant 2). The evidence base for this program is very strong. We are not testing an unproven method here. We’re actually applying strong evidence that we know works. So this is one of those few areas in health care where there’s not a lot of controversy and not a lot of dispute over the value of this program. That’s a very unique situation. Most of our programs, they are far greyer in terms of the economic and quality of impact on health service delivery. Here we have got pretty cut and dried strong evidence based, a lot of that evidence also is made in Alberta. We’ve got lots of research history in this area here in Alberta (Provincial Stakeholder, Participant 2). Clinicians in the fragility and stability group have been excellent in getting this going. And this includes clinicians that extend past [this group], such as other physicians in the osteoporosis clinic. They have come together to provide knowledge…so that we could pick their brains as to what is important to put in [our] FLS. What is important to send to family physicians? I do not think we would have come up with all the different algorithms and tools that we are currently using in the FLS. I think having broad representation from people across the province, whether they are directly involved or not, has been just so important for this project (Site 1, Participant 1). They had a committee with of a lot of experience and education getting behind them. “Ok, here you go. These are all the specs we want you to include”. They developed their algorithms and then double checked it with all the medical guidelines and then proceeded with it (Site 2, Participant 2).
	H-FLS tailored to site-level contexts	This is a programme that was started up for the FLS in [name of beta site], so we literally took their template. Adjusted a few things for [name of city of second site] (Site 2, Participant 6). A little bit of negotiation, in terms of here’s what we are doing, how does it fit into your model? Because, you know, each of the sites is different…I really relied on those site leads to tell me what makes sense at their hospital site (Provincial Stakeholder, Participant 1). I suppose it’s then how even a unit runs, so when they do their rounds, when’s a good time to talk with the multidisciplinary team. Each site is so different and so that will be important going forward, is knowing what are their routines so that you can kind of almost again build yourself into their routine without disrupting it too much. Because, you know, you want it to be an add-on service; you do not want to be a hindrance to anything that they are doing (Site 1, Participant 1). The advice I would have for [new sites] is you have the model, you have the goal, you know what you want to achieve but it can look slightly different on how it unfolds at your particular site. So the first step is just doing a deep dive into your area, reviewing the resources that are available, reviewing who would interact with the clinic and just kind of defining slightly how it’s going to look at your site. Because it can look different. We’ve got the base model, the same goals we want to achieve but it can look different and probably will look different in your particular area. And I think if you looked at the three places that are set up now achieving the same goal, you can say it’s fulfilled the 3i model however things do look a little bit different between the three centres so far (Site 2, Participant 7).
Theme 3—Evidence of facilitated learning, not merely monitoring implementation
Willingness to share and accept lessons learned	During implementation	The general structure, how the 3i model was rolled out, I think [it] went through a couple of modifications at the [name of beta site]. And that’s just learning from learning. So it was easier for us being the second team to go because they had already ironed out a couple of kinks (Site 2, Participant 7). We have learnt so much from [city of beta site] already so we had worked with [beta site] to figure out a medical algorithm to figure out the work sheet and [name of FLS nurse], who’s the nurse up in [name of city] she’s hugely supportive and had lots of really good tips for me for when I started. And when I started I could call her and say, “Ah, what do you do for this or that” and so lots of support that way (Site 2, Participant 5). This is a programme that was started up for the FLS in [city of beta site], so we literally took their template. Adjusted a few things for [city of 2nd site]. So, we learned from their mistakes, their good areas. We kind of learned from those. We learned from their successes, so that’s why I think we did well...they shared what worked well, what did not work well and what we should not do (Site 1, Participant 6).
	To inform spread	I am the only nurse in [city of beta site] who knows this program so, you know, it’s a great opportunity to mentor new people (Site 1, Participant 1). Draw on our site to help promote that program in other sites as well (Site 1, Participant 2). When I do orientation and when I do think about what to tell new people that start, it’s like, you know, assessments are so important. And just the knowledge that I now know about the medications, I tell the new nurses rather than them having to figure it out for themselves (Site 2, Participant 5).
Establishment of a provincial steering committee to facilitate learning in addition to monitoring implementation of the H-FLS across the province		I think that mere fact that it was a staged roll out and they were looking at tools that were used in Alberta for several months but had been tweaked and revised based on learnings as the program matured. But the planning steps for that second site were probably half the time, half the energy level of what the original initial sites were. And as we roll out to [name of city] as a 3rd site, I’m seeing already that they are starting on step 3 not step 1. So it’s really reducing the planning stage. And that definitely contributes to simplifying implementation….We’re walking in with a tool kit ready to go turnkey implementation almost. You take it, you turn it to your needs and go forward. That has defiantly simplified the approach greatly (Provincial Stakeholder, Participant 2). A provincial FLS meeting twice a year and it’s that chance to get everyone together, say what’s going at your site, and we learned a lot from those (Provincial Stakeholder, Participant 1. There’s now been developed an FLS committee province-wide. So now we have other peers to run through decision-making with, and there are lots of decisions where we decide, okay, we are going to make this standardized between the teams. So that helps, having colleagues. Also, some of the local resources for osteoporosis care, but it’s hard to program, like, the nuts and bolts (Site 1, Participant 3). Thanks to [name of ABJHI PM] and her organization ability is meeting regularly as a provincial group. So, I think it’s about every six months that we meet. And it gives us a time to really look at things like our medical algorithm, our processes, our letters, and just have a really frank discussion with the players in the FLS to see, you know, what’s working well, what needs, to be tweaked, what are your challenges. So, I think ongoing support within the group (Site 2, Participant 5).