Focus Group conducted at the National
Association of Community Health Center
(NACHC) Conference
Preliminary Findings
Oct 5th, 2011
FQHC Qualitative Inquiry Subgroup
Maria E. Fernandez, PhD
Associate Professor of Health Promotion and Behavioral Sciences
University Of Texas Health Science Center at Houston
School of Public Health
Outline
1. Development of Focus Group Guide
2. Focus group guide overview
3. Participants
4. Major practice changes
5. Preliminary analysis based on CFIR
6. Summary
7. Next steps
Focus Group Guide Development
 Qualitative Inquiry Subgroup (QIS) members met several
times and drafted the guide
o Appreciative Inquiry questions—Dr. Betsy Risendal
o CFIR Questions—Dr. Michelle Kegler
o Implementation process and characteristics questions—Dr. Maria
Fernandez and Glenna Dawson
 FQHC Workgroup provided feedback
 External feedback from Dr. Kurt Stange and Dr. Bryan
Weiner
Focus Group Guide Overview
Part I: Example of successful practice changes
Part II: Explore evidence-based cancer
prevention and control strategy (Example: Tobacco
Cessation: Ask-Advise-Refer)
Part III: Inner setting—organizational
characteristics and readiness for
implementation
Part IV: Other domains of CFIR—intervention
characteristics and outer settings
Participants
Facilitator: Glenna Dawson
Observers: Dr. Michelle Kegler, Dr. Vicki
Young, and Michelle Proser
Focus group participants
o2 male and 2 female
oAll are Medical Directors/ Chief Medical Officers
oFrom South Carolina, Georgia and Texas
oCHCs range in size from 5 to 12 sites
Major Practice Change
Electronic Medical Records (EMR)
Patient-Centered Medical Home (PCMH)
Cancer control practice
oCRC screening initiative with navigator program
oPSA tests and media campaign
oBreast and cervical cancer screening and follow up
Ask-Advise-Refer
Other: Vitamin D deficiency test
Preliminary Analysis Based on Consolidated
Framework for Implementation Research
(CFIR)
Domain 1: Implementation Characteristics
Domain 2: Inner Setting
Domain 3: Outer Setting
Domain 4: Characteristics of Individuals
Domain 5: Process of Implementation
Domain1: Intervention Characteristics
Constructs
Emerging Themes
Evidence Strength and
Quality
--Providers need “intervention that work” and
“good evidence”
Complexity
--EMR implementation is overwhelming
--Change is not easy
Design quality and
packaging
--The EMR systems have “glitches” that make
implementation difficult
“The files don’t talk to each other, it doesn’t come up……It
is a great surprise to our CEOs given that we paid all this
money……”
--The more automatic, the better
Cost
--Cost of intervention sometimes affects the
decisions to adopt practice change
“At the end of the day, it wasn’t economically feasible for the
amount of cancer they were finding in routine
screening……it just didn’t pay for itself”
Domain 2: Inner Setting
Constructs
Structural
Characteristics
Emerging Themes
--The CMOs usually make the decision to change
“I (the CMO) have to be the person to push it, to let folks know that it’s
an issue, it’s a concern and to push it.”
“I think the decision probably rests with the CMO most commonly though
you get buy-in from our whole team......”
--For some CHC, decision is made by the CEO
--Whether or not services are offered at the clinic
Networks and
Communication
s (within the
organization)
--Team work is very important
--Agreement among CEO, CMO, CFO, and COO are
essential
“The partnership between, what I called the 4Cs really is just
essential……they have to be on the same page, or at least on the same
chapter of the book.”
Domain 2: Inner Setting (Cont.)
Construct—
Implementation
Climate
Emerging Themes
Tension for
Change
--CMO and board members think it urgent to change to meet the
goals
Compatibility
--Evidence will be ignored if it does not fit the values of an
organization and its providers
“Unless you are growing and changing and transforming, the four goals
of NACHC right now, we are not being able to survive”
“I don’t know a provider out there that does that…You know if it doesn’t
fit the values of the society. I don’t care how much evidence you got as
‘evidence’. Like that recommendation, it was completely ignored.”
Relative Priority
--Sometimes the importance of doing the intervention outweighs
cost concerns
Organizational
incentives and
rewards
--Financial reward for staff improve clinical outcomes
--Good performance and outcome galvanize people to change
Goals and
feedback
--Showing staff the outcomes (how well they are doing) and
goals motivate them to change
Domain 2: Inner Setting (Cont.)
Construct—
Readiness for
Implementation
Leadership
Engagement
Emerging Themes
--Leadership is key to change
“Without good leadership, there is no change……each
organization needs a leadership team that’s one that embraces
change”
--CMOs are confident to adopt changes
“Confident (to adopt) as long as there is some good evidence
behind it”
“We are change-ready organizations. Most of us”
Access to
information and
knowledge
--CHCs are in need of the “right tool” to implement
change
“It’s got all the evidence, all the research, it’s all there…I think it’ll
be a great job for academics, to give us a tool and let us roll them
out”
--Providers need to put change into daily work load
“So we’ve got to figure out ways to put that into your work
load…and the doc’s got to remember all this…”
Domain 3: Outer Setting
Constructs
Emerging Themes
Patient needs and
resources
--Cancer survivors provide deep community support
--Listening to the patients is important
Cosmopolitanism
--Help from outside agency is essential, especially
academic institutions
Peer pressure
--Motivated to join the movement (of practice change)
External policies and --Making PCMH a national focus makes it easier for
CHCs to change
incentives
“But I think that it’s this national focus, where you get everybody kind of
locked in behind it makes it a lot easier to change because we are not in
isolation.”
--PCAs and NACHC translate the national vision down
to health centers, which help CHCs to change
“I think it extraordinary important is the role of PCAs & NACHC…
they’ve been able to develop a visionary role that, then translates
down…so it’s extraordinary to have kind of a national vision, an then
translate down to health centers”
--IRB approval is one of the biggest hurdles
Domain 4: Characteristics of Individuals
Construct
Emerging Themes
Knowledge and --EMR is perceived as very difficult to
beliefs about
implement by the CMO
the Intervention “We’ve got to go second round of EMR, I mean it’s
driving me nuts to have to take it”
--Some providers are not willing to implement
Ask-Advise-Refer because of poor patient
response
“So now our providers do not want to do it. If I ask my
patients “do you smoke”, and I get these eyes rolled over
to the back to my head, reckless I am not here to lecture
you.”
Domain 5: Process of Implementation
Constructs
Planning
Emerging Themes
--Practice change needs strategic planning
“It turns out that transformation requires some organizational strategic
planning, say, who’s involved, who has the buy-in, and how can we
make it happen.”
Engaging
--Need to prepare staff for change
--Need a whole implementation team
--Community outreach department brings in projects to
engage providers
Executing
-- Process measures are needed
“In the whole continuum of CRC screening, there’s a lot of process
measures that need to be implemented. We went through a series of
about seven different using actually pre-med student recruits……”
--Writing protocols help with implementation
Reflecting
and
evaluation
--Rapid feedback is very important
“And we did a rapid return, and our control rates went up. But it was
that rapid evaluation, which is real important. Because if you do
something, you want to know if it works.”
Summary
Findings fit well within CFIR constructs
Connections and partnerships with academics
are very important for CHCs’ practice change
Federal regulation and national visionary goals
drive changes
CHCs are willing to change given the right tool
to implement changes
Next Steps
Appreciative Inquiry during an “Intensive
workshop” at the 21st Annual Midwest Stream
Farmworker Health Forum
oNov 10th –12th, 2011; Albuquerque, NM
oThree hours (180 min) available
oAttendants include: Medical directors, mid-level
managers, frontline workers (health educators, lay
health workers, etc.)
Discussion
How shall we approach this “intensive
workshop”?
oPure Appreciative Inquiry?
oFocus on certain constructs?
What shall we provide for the attendants?