title: A qualitative study on clinicians' perceptions about the implementation of a population risk stratification tool in primary care practice of the Basque health service.
abstract: BACKGROUND
  A prospective Population Risk Stratification (PRS) tool was first introduced in the public Basque Health Service in 2011, at the level of its several Primary Care (PC) practices. This paper aims at exploring the new tool's implementation process, as experienced by its potential adopters/users, ie. PC clinicians (doctors and nurses). Findings could help guide future PRS implementation strategies.
  
  
  METHODS
  Three focus groups exploring clinicians' opinions and experiences related to the PRS tool and its implementation in their daily practice were conducted. A purposive sample of 12 General Practitioners and 11 PC nurses participated in the groups. Discussions were digitally recorded, transcribed verbatim and analysed by two independent researchers using thematic analysis based on Graham et al.'s Knowledge Translation Theory.
  
  
  RESULTS
  Exploring PC clinicians' experience with the new PRS tool, allowed us to identify certain elements working as barriers and facilitators in its implementation process. This series of closely interrelated elements, which emerged as relevant in building up the complex implementation process of the new tool, as experienced by the clinicians, can be grouped into four domains: 1) clinicians' characteristics as potential adopters, 2) clinicians' perceptions of their practice settings where PRS is to implemented, 3) clinicians' perceptions of the tool, and 4) the implementation strategy used by the PRS promoter.
  
  
  CONCLUSIONS
  Lessons from the implementation process under study point at the need to frame the implementation of a new PRS tool within a wider strategy encouraging PC clinicians to orientate their daily practice towards a population health approach. The PRS tool could also improve the perceived utility by its potential adopters, by bringing it closer to the clinicians' needs and practice, and allowing it to become context-sensitive. This would require clinicians being involved from the earliest phases of conceptualisation, design and implementation of the new tool, and mounting efforts to improve communication between clinicians and tool promoters.Graham et al.'s Knowledge Translation Theory proved a suitable framework to explore the implementation process of a new PRS tool in the public Basque Health Service's PC practice, and hence to identify implementation barriers and facilitators as experienced by the clinicians.
authors.forename: Regina
authors.initials: R
authors.lastname: Sauto Arce
authors.forename: Amaia Saenz
authors.initials: AS
authors.lastname: De Ormijana
authors.forename: Juan F
authors.initials: JF
authors.lastname: Orueta
authors.forename: Marie-Pierre
authors.initials: MP
authors.lastname: Gagnon
authors.affiliation: O + berri, Basque Institute for Healthcare Innovation, Torre del BEC, Ronda de Azkue, 1, 48902 Barakaldo, Bizkaia, Spain. nuno@bioef.org.
authors.forename: Roberto
authors.initials: R
authors.lastname: Nuño-Solinís
mesh_terms: D057179:Advanced Practice Nursing; D001291:Attitude of Health Personnel; D005260:Female; D017144:Focus Groups; D058005:General Practitioners; D006801:Humans; D008297:Male; D011320:Primary Health Care / Q000379:methods*; D036301:Qualitative Research; D018570:Risk Assessment / Q000379:methods*; D013030:Spain