Table 1.

Barriers and facilitators to Operating Room Black Box implementation at the institutional level according to the consolidated framework for implementation research.

Domain, facilitators and barriers			Additional details
Characteristics of the Operating Room Black Box intervention
	Facilitators
		Adaptability: The platform is a highly adaptable. Its use can be tailored to local needs.	The research team secured grant funding for the purchase of the device. Long term maintenance is expected to be minimal.
		Trialability: The platform is implemented on a small scale (one operating room only) and is easily reversible.	Operation of the system is simple and completely unobtrusive.
		Relative advantage: There is no other existing intervention that could achieve the desired details and minimal intrusiveness offered by the platform.	N/Aa
	Barriers
		Evidence of strength and quality: New technology that lacks supporting evidence on its use to improving patient care.	Each institution has its own rules and structures related to information technology, which limited the team’s ability to draw on the experiences of other centers.
		Costs: There are costs associated with the purchase, installation, and maintenance of the equipment.	Before the approval of the project, there was no way for the research team to estimate costs associated with implementing the Operating Room Black Box at our institution.
Outer setting
	Facilitators
		Patient needs: Improving teamwork has been identified as a sustainable and practical way to promote patient safety.	There was a general positive environment in the outer setting that promotes the use of technology in improving patient care.
		Peer pressure: The platform has been successfully implemented in 4 other hospitals in Ontario.	Evidenced by successful implementation of the Operating Room Black Box nationally and internationally.
		Cosmopolitanism: Collaboration with experienced implementers to share best practices.	The lack of other alternatives to collect the same level of data in such an unobtrusive way also makes the Operating Room Black Box a favorable option.
		External policy and incentives: The concept of Operating Room Black Box supports the CanMEDS Physician Competency Framework.	N/A
Inner setting
	Facilitators
		Culture: Organizational commitment to support research to improve patient care.	Letters of support were received from the Chief Executive Officer and numerous department heads to secure grant funding to purchase the device.
		Readiness for implementation, leadership engagement: Overall strong support and commitment from leadership.	We established our network of support through early engagement with the senior leadership team (1 year prior to funding received).
		Access to knowledge and information: A comprehensive information campaign was in place to inform affected patients and clinicians of the intervention and how it would not affect their care.	Our information campaign included emails, posters, internal website, presentations at rounds, pamphlets, excerpts in internal newsletters, stakeholder meetings, etc.
		Implementation climate: The information campaign also aimed to promote positive momentum toward better practice and care through increased transparency and open discussions. Integration of Operating Room Black Box recording with existing work process. Patient advisors engaged early in the project design.	We have a structured opt-out process, which allows patients and clinicians to decline being recorded at 4 different time points. This strategy aims to increase transparency and to build a trusting relationship. This approach was developed in collaboration with clinician representatives and the Research Ethics Board.
	Barriers
		Readiness for implementation, available resources: Concurrent budget cutting and other competing projects at the institutional level.	Lack of within-institution communication.
		Networks and communications: Lack of a working model between the hospital and research institute for implementation of new technology into clinical practice.	The research institute’s contract office faced many challenges related to the lack of an internal working model to collaborate with the hospital’s contract office and to determine who will be leading the negotiation of the project’s contract component. The Operating Room Black Box involves both research and clinical practice and therefore required approvals from both the Research Ethics Board and hospital administration. However, there was no standard procedure for the research team to follow.
Characteristics and attitudes of clinicians, patients, and senior leadership
	Facilitators
		Knowledge and beliefs about the intervention: Patients are open to the initiative.	Interviews with 15 surgical patients across the hospital’s 3 campuses confirmed support and appreciation for the Operating Room Black Box.
		Individual identification with organization: Shared staff commitment to improve patient safety and care.	Interviews with 17 perioperative clinicians and 9 hospital administrators identified a desire for progress and improving patient care (paper under final peer review). Patient advisors supported implementation.
	Barriers
		Knowledge and beliefs about the intervention: Clinician skepticism regarding the value of new technology and perceived lack of trust in hospital management.	The interviews conducted also revealed that clinicians had many questions and misconceptions related to the use of the technology.
Operating Room Black Box implementation process
	Facilitators
		Engaging: Collaboration with the hospital’s capital project team on the installation.	A peer-to-peer approach in communicating Operating Room Black Box progress was particularly useful.
		Engaging: Use of an information campaign to ensure that all affected patients and clinicians are well informed.	Rather than sending out Operating Room Black Box communications through the research team, we collaborated with project champions and department leaders, who helped distribute Operating Room Black Box–related information.
		Executing: Use of soft launch to stress test the data collection protocol. Standardization of communication process for anticipated patient inquiries.	We believed that people were more responsive and felt more comfortable expressing their questions or concerns to their professional peers than to the research team directly. The research team ensured that any expressed concerns were addressed and that any required opt-out paper work was filled out, hence promoting a positive environment to discuss the Operating Room Black Box with professional peers, while minimizing the extra burden on our project champions.
		Planning and engaging: Kick-off meeting and regular newsletters.	N/A
		Early and ongoing engagement of patient advisors	N/A
		Communication strategy developed and accounted for various audiences.	We created a one-page process flow map and training materials to ensure that key actors and assessors were aware of the “big picture,” and the research team filled in the gaps when questions were raised.
	Barriers
		Planning: Lack of knowledge of administrative process in the hospital. Unawareness of new committees and services that need to be informed of the Operating Room Black Box	N/A
		Executing: Participants are free to opt out from the program, making it impossible to predict participation rate. Implementation limited to some (not all) clinicians, creating multiple workflows for the same process. Hidden costs.	N/A

^aN/A: not applicable.