Presentation
PS9 - Mapping Sustainability Strategies From Implementation Science to Human Factors Work System Redesign Domains: Secondary Analysis From the Cancer Center Cessation Initiative (C3I)
SessionPoster Session 2
DescriptionBackground:
Tobacco is the leading cause of preventable cancer with 40% of cancer diagnoses in the United States being attributed to tobacco use (Islami et al., 2018). Furthermore, continued smoking after cancer diagnosis is associated with significant increases in cancer-specific mortality, and all-cause mortality (Wang et al., 2019). As such, the National Cancer Institute (NCI) launched the Cancer Center Cessation Initiative (C3I) with the goal of supporting cancer centers in building and implementing sustainable tobacco cessation treatment programs to promote tobacco cessation among their current patients.
Starting in late 2017, 52 cancer centers were selected to receive two years of funding to initiate or expand tobacco cessation treatment programs. At its core, C3I is an implementation effort, integrating evidence-based tobacco dependence treatment into cancer care workflows and utilizing electronic health record technology to facilitate that integration (Croyle et al., 2019). Thus far, C3I-funded sites have collectively delivered tobacco cessation treatment to more than 50,000 patients with cancer who smoke, and more than doubled overall patient reach. While the C3I-funded tobacco cessation programs have been shown to be effective, little is known about strategies to sustain them in the long term.
These cancer center work systems present unique challenges related to organizational sustainability. Existing frameworks including the systems engineering initiative for patient safety (SEIPS), capture the need for ongoing adaptations to sustain work system outcomes as environments change (Carayon et al., 2006; Holden et al., 2013). However, specific strategies to support sustainability have yet to be generated.
Recent developments in the field of Implementation Science related to sustainability include sustainability determinants (barriers and facilitators to sustainability) frameworks such as the Clinical Sustainability Assessment Tool (CSAT) and Program Sustainability Assessment Tool (PSAT). The CSAT and PSAT are validated instruments for evaluating the sustainability capacity of a clinical practice. This large national study within cancer cessation programs presents the opportunity to leverage expert opinions on sustainability guided both by the SEIPS model and these validated instruments.
The purpose of this study was to develop a taxonomy of sustainability strategies to address the needs of these unique work systems. To achieve this goal, we leveraged the expertise of individuals who were involved in the initial development of the tobacco cessation programs across a variety of roles and sites. By focusing first on the CSAT domains of sustainability, then reframing these strategies around work system needs, we aimed to support sustainable tobacco cessation programs with expert-endorsed sustainability strategies.
Approach:
In this secondary data analysis study, sustainability strategies developed using a user-centered co-design process described below were deductively coded using the systems engineering initiative for patient safety (SEIPS) 2.0 framework. Experienced qualitative researchers dual-coded all strategies as one or more SEIPS 2.0 elements.
The process by which the sustainability strategies data used in this secondary analysis were generated was reported elsewhere and is summarized as follows. A multidisciplinary team of researchers, clinicians, and cancer center administrators came together to form the Sustainability Working Group (SWG) (C3I Coordinating Center and Expert Advisory Panel, 2021). In accordance with the Delphi approach, 22 experts representing 16 institutions engaged in iterative conversations across multiple rounds to develop, adapt, and reach consensus on strategies for the sustainment of existing tobacco cessation programs. Strategy development followed an iterative process consisting of 7 1-hour long sessions across 4 phases: ideation, sorting, refinement, and group and individual ranking. The ideation phase consisted of 3 sessions. This process was organized by the CSAT domains to explicitly target sustainability-focused strategies. This was followed by 2 sessions of sorting strategies into their corresponding CSAT domains. Next, the SWG spent 2 sessions revising and refining the list of strategies. The revised strategy list was reviewed by the group to reach consensus on importance and feasibility ratings for each strategy. Following the strategy development process, individual SWG members were invited to review the group consensus scores and further provide their input by assigning new scores in a Qualtrics survey, informed by their expertise and the group scores. Next, the survey was sent out to all C3I-funded sites with a request to share the survey with individuals in a variety of roles at each site.
Results:
The deductive analysis guided by SEIPS allowed for organization of sustainability strategies by which work system component they targeted or leveraged: 27 were related to the “organization” component of the work system, 18 were related to “tools & technology,” 13 were related to “external environment,” 10 were related to “person,” and 1 was related to “tasks.” Paired with the results from the Delphi approach, there were 10 consensus organization sustainability strategies, 8 consensus tools & technology sustainability strategies, 5 consensus external environment sustainability strategies, and 2 consensus person(s) sustainability strategies. No consensus strategies were identified targeting the task or internal environment components of the work system.
High consensus on importance and feasibility of strategies did not necessarily indicate these strategies were important and feasible. Using the overall average importance and feasibility scores, 15 consensus sustainability strategies were both high importance and high feasibility, 4 were high importance and low feasibility, 1 was low importance and high feasibility, and 4 were low importance and low feasibility. Additionally, most high importance and high feasibility sustainability strategies were mapped to the organization work system component.
Discussion:
Organization-centered strategies tended to be viewed as higher importance and higher feasibility than strategies targeting other work system components. Consensus was established in mostly high importance, high feasibility sustainability strategies, lower importance and feasibility strategies tended to see more disagreement on importance or feasibility scores or both. Consensus strategies for sustainability that target the task and internal environment components of the SEIPS model were not identified in this study, but these gaps reflect the nature of the C3I program, and the individuals involved with the SWG (C3I Coordinating Center and Expert Advisory Panel, 2021; Carayon et al., 2006). Future work will explore patient-generated strategies and the application of these strategies to similar programs planning for sustainability.
References:
C3I Coordinating Center and Expert Advisory Panel. (2021). Introduction to the Cancer Center Cessation Initiative Working Groups: Improving Oncology Care and Outcomes by Including Tobacco Treatment. Journal of the National Comprehensive Cancer Network, 19(Suppl_1), S1–S3. https://doi.org/10.6004/jnccn.2021.7095
Carayon, P., Hundt, A. S., Karsh, B., Gurses, A. P., Alvarado, C. J., Smith, M., & Brennan, P. F. (2006). Work system design for patient safety: The SEIPS model. Quality & Safety in Health Care, 15(Suppl 1), i50–i58. https://doi.org/10.1136/qshc.2005.015842
Croyle, R., Morgan, G., & Fiore, M. (2019). Addressing a Core Gap in Cancer Care: The NCI Cancer MoonshotSM Initiative to Help Oncology Patients Stop Smoking. The New England Journal of Medicine, 380(6), 512–515. https://doi.org/10.1056/NEJMp1813913
Holden, R. J., Carayon, P., Gurses, A. P., Hoonakker, P., Hundt, A. S., Ozok, A. A., & Rivera-Rodriguez, A. J. (2013). SEIPS 2.0: A human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics, 56(11). https://doi.org/10.1080/00140139.2013.838643
Islami, F., Goding Sauer, A., Miller, K. D., Siegel, R. L., Fedewa, S. A., Jacobs, E. J., McCullough, M. L., Patel, A. V., Ma, J., Soerjomataram, I., Flanders, W. D., Brawley, O. W., Gapstur, S. M., & Jemal, A. (2018). Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States. CA: A Cancer Journal for Clinicians, 68(1), 31–54. https://doi.org/10.3322/caac.21440
Wang, Y., Tao, H., Paxton, R. J., Wang, J., Mubarik, S., Jia, Y., Wang, W., & Yu, C. (2019). Post-diagnosis smoking and risk of cardiovascular, cancer, and all-cause mortality in survivors of 10 adult cancers: A prospective cohort study. American Journal of Cancer Research, 9(11), 2493–2514.
Tobacco is the leading cause of preventable cancer with 40% of cancer diagnoses in the United States being attributed to tobacco use (Islami et al., 2018). Furthermore, continued smoking after cancer diagnosis is associated with significant increases in cancer-specific mortality, and all-cause mortality (Wang et al., 2019). As such, the National Cancer Institute (NCI) launched the Cancer Center Cessation Initiative (C3I) with the goal of supporting cancer centers in building and implementing sustainable tobacco cessation treatment programs to promote tobacco cessation among their current patients.
Starting in late 2017, 52 cancer centers were selected to receive two years of funding to initiate or expand tobacco cessation treatment programs. At its core, C3I is an implementation effort, integrating evidence-based tobacco dependence treatment into cancer care workflows and utilizing electronic health record technology to facilitate that integration (Croyle et al., 2019). Thus far, C3I-funded sites have collectively delivered tobacco cessation treatment to more than 50,000 patients with cancer who smoke, and more than doubled overall patient reach. While the C3I-funded tobacco cessation programs have been shown to be effective, little is known about strategies to sustain them in the long term.
These cancer center work systems present unique challenges related to organizational sustainability. Existing frameworks including the systems engineering initiative for patient safety (SEIPS), capture the need for ongoing adaptations to sustain work system outcomes as environments change (Carayon et al., 2006; Holden et al., 2013). However, specific strategies to support sustainability have yet to be generated.
Recent developments in the field of Implementation Science related to sustainability include sustainability determinants (barriers and facilitators to sustainability) frameworks such as the Clinical Sustainability Assessment Tool (CSAT) and Program Sustainability Assessment Tool (PSAT). The CSAT and PSAT are validated instruments for evaluating the sustainability capacity of a clinical practice. This large national study within cancer cessation programs presents the opportunity to leverage expert opinions on sustainability guided both by the SEIPS model and these validated instruments.
The purpose of this study was to develop a taxonomy of sustainability strategies to address the needs of these unique work systems. To achieve this goal, we leveraged the expertise of individuals who were involved in the initial development of the tobacco cessation programs across a variety of roles and sites. By focusing first on the CSAT domains of sustainability, then reframing these strategies around work system needs, we aimed to support sustainable tobacco cessation programs with expert-endorsed sustainability strategies.
Approach:
In this secondary data analysis study, sustainability strategies developed using a user-centered co-design process described below were deductively coded using the systems engineering initiative for patient safety (SEIPS) 2.0 framework. Experienced qualitative researchers dual-coded all strategies as one or more SEIPS 2.0 elements.
The process by which the sustainability strategies data used in this secondary analysis were generated was reported elsewhere and is summarized as follows. A multidisciplinary team of researchers, clinicians, and cancer center administrators came together to form the Sustainability Working Group (SWG) (C3I Coordinating Center and Expert Advisory Panel, 2021). In accordance with the Delphi approach, 22 experts representing 16 institutions engaged in iterative conversations across multiple rounds to develop, adapt, and reach consensus on strategies for the sustainment of existing tobacco cessation programs. Strategy development followed an iterative process consisting of 7 1-hour long sessions across 4 phases: ideation, sorting, refinement, and group and individual ranking. The ideation phase consisted of 3 sessions. This process was organized by the CSAT domains to explicitly target sustainability-focused strategies. This was followed by 2 sessions of sorting strategies into their corresponding CSAT domains. Next, the SWG spent 2 sessions revising and refining the list of strategies. The revised strategy list was reviewed by the group to reach consensus on importance and feasibility ratings for each strategy. Following the strategy development process, individual SWG members were invited to review the group consensus scores and further provide their input by assigning new scores in a Qualtrics survey, informed by their expertise and the group scores. Next, the survey was sent out to all C3I-funded sites with a request to share the survey with individuals in a variety of roles at each site.
Results:
The deductive analysis guided by SEIPS allowed for organization of sustainability strategies by which work system component they targeted or leveraged: 27 were related to the “organization” component of the work system, 18 were related to “tools & technology,” 13 were related to “external environment,” 10 were related to “person,” and 1 was related to “tasks.” Paired with the results from the Delphi approach, there were 10 consensus organization sustainability strategies, 8 consensus tools & technology sustainability strategies, 5 consensus external environment sustainability strategies, and 2 consensus person(s) sustainability strategies. No consensus strategies were identified targeting the task or internal environment components of the work system.
High consensus on importance and feasibility of strategies did not necessarily indicate these strategies were important and feasible. Using the overall average importance and feasibility scores, 15 consensus sustainability strategies were both high importance and high feasibility, 4 were high importance and low feasibility, 1 was low importance and high feasibility, and 4 were low importance and low feasibility. Additionally, most high importance and high feasibility sustainability strategies were mapped to the organization work system component.
Discussion:
Organization-centered strategies tended to be viewed as higher importance and higher feasibility than strategies targeting other work system components. Consensus was established in mostly high importance, high feasibility sustainability strategies, lower importance and feasibility strategies tended to see more disagreement on importance or feasibility scores or both. Consensus strategies for sustainability that target the task and internal environment components of the SEIPS model were not identified in this study, but these gaps reflect the nature of the C3I program, and the individuals involved with the SWG (C3I Coordinating Center and Expert Advisory Panel, 2021; Carayon et al., 2006). Future work will explore patient-generated strategies and the application of these strategies to similar programs planning for sustainability.
References:
C3I Coordinating Center and Expert Advisory Panel. (2021). Introduction to the Cancer Center Cessation Initiative Working Groups: Improving Oncology Care and Outcomes by Including Tobacco Treatment. Journal of the National Comprehensive Cancer Network, 19(Suppl_1), S1–S3. https://doi.org/10.6004/jnccn.2021.7095
Carayon, P., Hundt, A. S., Karsh, B., Gurses, A. P., Alvarado, C. J., Smith, M., & Brennan, P. F. (2006). Work system design for patient safety: The SEIPS model. Quality & Safety in Health Care, 15(Suppl 1), i50–i58. https://doi.org/10.1136/qshc.2005.015842
Croyle, R., Morgan, G., & Fiore, M. (2019). Addressing a Core Gap in Cancer Care: The NCI Cancer MoonshotSM Initiative to Help Oncology Patients Stop Smoking. The New England Journal of Medicine, 380(6), 512–515. https://doi.org/10.1056/NEJMp1813913
Holden, R. J., Carayon, P., Gurses, A. P., Hoonakker, P., Hundt, A. S., Ozok, A. A., & Rivera-Rodriguez, A. J. (2013). SEIPS 2.0: A human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics, 56(11). https://doi.org/10.1080/00140139.2013.838643
Islami, F., Goding Sauer, A., Miller, K. D., Siegel, R. L., Fedewa, S. A., Jacobs, E. J., McCullough, M. L., Patel, A. V., Ma, J., Soerjomataram, I., Flanders, W. D., Brawley, O. W., Gapstur, S. M., & Jemal, A. (2018). Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States. CA: A Cancer Journal for Clinicians, 68(1), 31–54. https://doi.org/10.3322/caac.21440
Wang, Y., Tao, H., Paxton, R. J., Wang, J., Mubarik, S., Jia, Y., Wang, W., & Yu, C. (2019). Post-diagnosis smoking and risk of cardiovascular, cancer, and all-cause mortality in survivors of 10 adult cancers: A prospective cohort study. American Journal of Cancer Research, 9(11), 2493–2514.
Event Type
Poster Presentation
TimeTuesday, April 14:45pm - 6:15pm EDT
LocationFrontenac Foyer