title: Implementation challenges and successes of a population-based colorectal cancer screening program: a qualitative study of stakeholder perspectives.
abstract: BACKGROUND
  Few studies describe system-level challenges or facilitators to implementing population-based colorectal cancer (CRC) screening outreach programs. Our qualitative study explored viewpoints of multilevel stakeholders before, during, and after implementation of a centralized outreach program. Program implementation was part of a broader quality-improvement initiative.
  
  
  METHODS
  During 2008-2010, we conducted semi-structured, open-ended individual interviews and focus groups at Kaiser Permanente Northwest (KPNW), a not-for-profit group model health maintenance organization using the practical robust implementation and sustainability model to explore external and internal barriers to CRC screening. We interviewed 55 stakeholders: 8 health plan leaders, 20 primary care providers, 4 program managers, and 23 endoscopy specialists (15 gastroenterologists, 8 general surgeons), and analyzed interview transcripts to identify common as well as divergent opinions expressed by stakeholders.
  
  
  RESULTS
  The majority of stakeholders at various levels consistently reported that an automated telephone-reminder system to contact patients and coordinate mailing fecal tests alleviated organizational constraints on staff's time and resources. Changing to a single-sample fecal immunochemical test (FIT) lessened patient and provider concerns about feasibility and accuracy of fecal testing. The centralized telephonic outreach program did, however, result in some screening duplication and overuse. Higher rates of FIT completion and a higher proportion of positive results with FIT required more colonoscopies.
  
  
  CONCLUSIONS
  Addressing barriers at multiple levels of a health system by changing the delivery system design to add a centralized outreach program, switching to a more accurate and easier-to-use fecal test, and providing educational and electronic support had both benefits and problematic consequences. Other health care organizations can use our results to understand the complexities of implementing centralized screening programs.
authors.affiliation: Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA. Elizabeth.G.Liles@kp.org.|Northwest Permanente, Kaiser Permanente Northwest, 500 NE Multnomah St, Suite 100, Portland, OR, 97232, USA. Elizabeth.G.Liles@kp.org.
authors.forename: Elizabeth G
authors.initials: EG
authors.lastname: Liles
authors.affiliation: Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA. Jennifer.L.Schneider@kpchr.org.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Schneider
authors.affiliation: Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA. Adrianne.C.Feldstein@kp.org.|Northwest Permanente, Kaiser Permanente Northwest, 500 NE Multnomah St, Suite 100, Portland, OR, 97232, USA. Adrianne.C.Feldstein@kp.org.
authors.forename: Adrianne C
authors.initials: AC
authors.lastname: Feldstein
authors.affiliation: Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA. David.M.Mosen@kpchr.org.
authors.forename: David M
authors.initials: DM
authors.lastname: Mosen
authors.affiliation: Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA. Nancy.Perrin@kpchr.org.
authors.forename: Nancy
authors.initials: N
authors.lastname: Perrin
authors.affiliation: Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA. Ana.G.Rosales@kpchr.org.
authors.forename: Ana Gabriela
authors.initials: AG
authors.lastname: Rosales
authors.affiliation: Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA. David.H.Smith@kpchr.org.
authors.forename: David H
authors.initials: DH
authors.lastname: Smith
mesh_terms: D003113:Colonoscopy / Q000706:statistics & numerical data; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D055088:Early Detection of Cancer / Q000379:methods*; D006801:Humans; D007407:Interviews as Topic; D009780:Occult Blood; D016730:Program Development; D015397:Program Evaluation; D036301:Qualitative Research; D058996:Quality Improvement