Table 3

Qualitative evidence on selected implementation outcomes and contextual factors

Implementation outcomes29 and contextual factorsExemplar quotations
Appropriateness/satisfaction
  • Front-line staff expressed satisfaction that protocol had minimal effect on workload and fit scope of practice

  • Pharmacists appreciated how the pilot study enabled them to improve patient care and collaborate

  • Pharmacists were motivated that structured communication led to improvements in patient outcomes during early phase of pilot

‘There’s plenty of availability in our clinics to do (hand-offs), and since the management of these risk factors is already part of our scope; that’s easy to add in’ (P102)
‘We’re (pharmacy) kind of well-established throughout the facility so (implementing the protocol) has been basically a seamless transition.’ (P102)
‘This was a really good fit with some initiatives that we were trying to kind of break into. Historically, acute care pharmacies and the ambulatory care pharmacists were kind of in silos. Over time, as people start to recognise that these are more integrated activities than what people think, we were looking for opportunities to develop transition in care opportunities.’ (P103)
‘today the patient I said I saw was really exciting, because his last A1C was 10.8, we want less than 7, and today it was 7.7, so he was within like 3 months, so I was like ‘okay so this is a really good referral process’ (P108)
Adoption/feasibility
  • The protocol is an evidence-based tool to support recommendations

  • A relatively low volume of TIA patients makes implementation feasible

  • A change in Veterans Affairs policy requiring medical support assistants to schedule patient visits forced pharmacists to adapt protocol

‘As far as like implementing the protocol, a lot of this stuff it’s kind of how we use it is more of just kind of more an evidence based tool that we can use… It’s utilising the protocol as more evidence that we can use to support any recommendations that we make’ (P101)
‘know right now, (the protocol implementation is) not been a big deal. It’s very easy to accommodate that… You know I get one or two people on a week that I call and it’s not too bad’ (P103)
‘…my initial thoughts is that now pharmacists no longer have scheduling capability, so we rely on other people to schedule our appointments’ (P108)
Fidelity
  • Pharmacists generally have followed guidelines through ‘flowmaps’ and tables according to intended protocol in figure 1

  • Some providers have followed up on recommendations with direct communication on blood pressure management to ensure patient care

‘(INPATIENT PHARMACIST) is using the TIA tool to identify patients, especially inpatients who may have had a TIA. He is either reaching out to (hits table) the primacy care pharmacist or reaching out to the primary pharmacist on the inpatient team… to get the patient scheduled for an appointment before discharge. That’s our goal.’ (P102)
‘She wasn't able to find a pharmacist because the (community-based outpatient clinics) don’t have a pharmacist assigned to them like the outpatient teams here, and so I made a call to the nurse there to try to find out…they were supposed to pick up a blood pressure cuff, and it wasn’t clear to me from the consult or the notes whether that had occurred, and this nurse also had done a post follow-up call, and so when I asked her about it … she said that she would call the patient again’ (P106)
Inner Setting Factors
  • Learning climate: pharmacists tend to be current with recent evidence-based medicine, receive Quality Improvement training have patient communication and motivational interviewing incorporated into their training

  • Culture: the medical facility promotes an ethos of continuous quality improvement across services

‘We embrace the “Lean” model. I think people are very accustomed to those kinds of things. Acute care pharmacists are probably a little more nimble than the ambulatory care pharmacists and just because things in the acute care world change every day.’ (P103)
‘(They) presented compelling data … ‘You know, this is the patient population that we’re missing.’ … We do a lot of process improvement type projects in our department. It’s something that is kind of ingrained into all of us in training.’ (P101)
Intervention characteristics
  • Design quality and packaging and source of intervention: appreciate the range of presentations (algorithm vs table)

  • Intervention source participants discussed their involvement in designing the protocol, viewing it as internally developed and pilot tested

  • Evidence strength and quality

  • Relative advantage: compared with usual care, wide recognition that patient tracking tool enables identification of on-site patients

‘I feel really proud about the protocol, even though my part was small. It was a really good collaborative effort, and I learnt a lot from the way that (PI) approached it, and again, it was very I guess encouraging to see (laughter) a discipline like pharmacy be ready to just jump in on that.’ (P106)
‘I think we were surprised that people thought that we were the group that people thought would be helpful in this … And it was surprised in a good way, not a bad way… like, well, we must be doing something right if they think that we would do a good job at doing this.’(P108)
‘It all looked very well researched and very literature backed--it’s all very concrete with published evidence. So I think from that standpoint, it’s gone well.’ (P101)
‘The real key to it working is that real time report of patients that are in the hospital, and that’s always been kind of a difficult thing.’ (P106)
  • TIA, transient ischaemic attacks.