Implementing culturally competent transplant care and implications for reducing health disparities: A prospective qualitative study

Abstract Background Despite available evidence‐based interventions that decrease health disparities, these interventions are often not implemented. Northwestern Medicine's® Hispanic Kidney Transplant Program (HKTP) is a culturally and linguistically competent intervention designed to reduce disparities in living donor kidney transplantation (LDKT) among Hispanics/Latinos. The HKTP was introduced in two transplant programs in 2016 to evaluate its effectiveness. Objective This study assessed barriers and facilitators to HKTP implementation preparation. Methods Interviews and group discussions were conducted with transplant stakeholders (ie administrators, nurses, physicians) during implementation preparation. The Consolidated Framework for Implementation Research (CFIR) guided interview design and qualitative analysis. Results Forty‐four stakeholders participated in 24 interviews and/or 27 group discussions. New factors, not found in previous implementation preparation research in health‐care settings, emerged as facilitators and barriers to the implementation of culturally competent care. Implementation facilitators included: stakeholders’ focus on a moral imperative to implement the HKTP, personal motivations related to their Hispanic heritage, and perceptions of Hispanic patients’ transplant education needs. Implementation barriers included: stakeholders’ perceptions that Hispanics’ health insurance payer mix would negatively impact revenue, a lack of knowledge about LDKT disparities and patient data disaggregated by ethnicity/race, and a perception that the family discussion component was immoral because of the possibility of coercion. Discussion and Conclusions Our study identified novel barriers and facilitators to the implementation preparation of a culturally competent care intervention. Healthcare administrators can facilitate organizations’ implementation of culturally competent care interventions by understanding factors challenging care delivery processes and raising clinical team awareness of disparities in LDKT.


| INTRODUC TI ON
Health disparities persist as a significant public health problem, 1 despite the availability of effective evidence-based interventions, 2 including culturally competent and adapted interventions, 3,4 because these interventions are not widely implemented or not delivered as intended (ie with fidelity). For example, ethnic/racial disparities in access to living donor kidney transplantation (LDKT) have increased in the last decade. 5 Hispanics/Latinxs waitlisted for kidney transplant received significantly fewer LDKTs than waitlisted non-Hispanic Whites in 2019: 5.0% versus 12.2%. 6 Because LDKT offers longer kidney graft and patient survival than deceased donor kidney transplantation, 7 LDKT disparities may magnify ethnic/racial disparities in transplant outcomes. 8 Northwestern Medicine's ® Hispanic Kidney Transplant Program (HKTP) was established in 2006 to provide culturally competent and linguistically congruent care to Hispanic/Latinx patients and their families seeking evaluation for kidney transplantation. Cultural competency refers to: 'A set of values, principles, behaviours, attitudes, policies and structures that enable organizations and individuals to work effectively in cross-cultural situations'. 9 The HKTP addresses recipient-donor, health-care provider, and health system factors known to contribute to lower rates of LDKT in ethnic/racial groups, 10 including lack of knowledge, cultural and religious beliefs about transplantation, lack of bilingual staff at dialysis facilities and transplant programmes, and lack of culturally competent care. 11 The HKTP was associated with a 74% increase of Hispanics receiving LDKTs and 70% decrease in the proportion of Hispanic LDKTs to non-Hispanic white LDKTs. 12 One factor contributing to ongoing disparities is that organizations often encounter considerable barriers to carrying out interventions. 13 Although many culturally competent care interventions have been put into effect across clinical conditions, 3 and some have evaluated the barriers and facilitators to their implementation, few have directly evaluated their implementation and/ or used an implementation science theoretical framework to guide their implementation evaluation. 14,15 Such trends have been attributed, in part, to the implicit focus of equity in implementation and dissemination research. 16 Further, few interventions are multilevel, that is, directed at more than patient, provider, system, social, policy or environmental levels of influence on health necessary for reducing health disparities. 17 Moreover, few interventions aim to change clinical microsystems, 18,19 or small groups of people who routinely work together to provide health care to patients. 2 Thus, little is known about how system factors (eg healthcare teams, hospitals, health systems) affect implementation of interventions to reduce racial/ethnic health disparities in access to care. 18,20 The purpose of this study was to identify the facilitators and barriers of HKTP pre-implementation. Implementation research scholars recommend evaluating the barriers and facilitators to putting the intervention into effect in the preparation phase to ensure the validity of the observations. 21 'Implementation preparation' (or 'pre-implementation') research occurs after an organization's leadership has decided to adopt an intervention but before it is carried out. 22 The preparation phase also includes undertaking 'implementation strategies', which are 'methods or techniques used to enhance the adoption, implementation and sustainability of a clinical programme or practice', 23 such as training stakeholders about the intervention and further assessing organizational needs for adaptation. The preparation phase is valuable for increasing intervention adoption and fidelity. 24,25 Implementation research examines 'methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services'. 26 Implementation research aims to shed light on the gap between expected outcomes based on scientific and clinical evidence, and outcomes experienced by healthcare organizations in their implementation of those recommendations.
The Consolidated Framework for Implementation Research (CFIR) 27 guided the study's implementation design and evaluation. 11 CFIR is a meta-theoretical framework compiled from 19 frameworks; it includes 39 constructs in 5 domains-intervention characteristics, organizational inner setting, characteristics of individuals, outer setting, and process. 21 CFIR can be used as a data collection or analysis that the family discussion component was immoral because of the possibility of coercion.

Discussion and Conclusions:
Our study identified novel barriers and facilitators to the implementation preparation of a culturally competent care intervention. Healthcare administrators can facilitate organizations' implementation of culturally competent care interventions by understanding factors challenging care delivery processes and raising clinical team awareness of disparities in LDKT.

K E Y W O R D S
consolidated framework for implementation research, health disparities, healthcare administrator, Hispanic/Latinx, implementation science, living kidney donation tool in any stage of the implementation (eg preparation, executing, reflecting).
Few studies to date have used CFIR (or other implementation science frameworks) to examine barriers and facilitators to interventions in healthcare settings during the preparation stage. 14,21 Intervention characteristics identified as facilitators include the following: strength of evidence 28 and relative advantage over existing practice, 29,30 adaptability, 28 trialability 28,29 and design quality and packaging. 31 The primary intervention characteristic barrier found in prior research is complexity. 28,29,32 Outer setting characteristics enabling intervention implementation in healthcare settings include the following: relationships between the healthcare organization and other organizations 31 and the presence of best practice examples in other healthcare organizations. 28 No outer setting barriers have been identified in CFIR research in the preparation phase. Inner setting characteristics identified as facilitators in healthcare settings include the following: readiness for the implementation, 30 particularly having sufficient resources to implement the intervention, 29 the nature and quality of teamwork 31 and communicated leadership commitment. 28 Inner setting characteristics identified as barriers to interventions were: competing organizational priorities 29,31 and perceived lack of compatibility with existing work routines and technology systems. 32 Characteristics of individuals identified as facilitators in healthcare settings include the following: knowledge and beliefs about the intervention, 28 self-efficacy 29 and a sense of belonging among the staff. 31 Individual characteristic barriers include the following: resistance to new routines, 28 limited knowledge or negative attitudes about the intervention, 30,32,33 and turnover. 29 The only process factor identified as a facilitator was a stepwise rollout. 28 A systematic review of interventions that used no or other theoretical frameworks identified an additional barrier not mentioned in CFIR research: safety/legal and ethical concerns in the context of patient confidentiality, legal restrictions, and fear of litigation. 34 Although prior research revealed common facilitators and barriers to implementing interventions to improve health outcomes across the population in healthcare settings, unique facilitators and barriers may arise upon implementing culturally competent care interventions designed to reduce racial/ethnic inequity. Many studies have examined facilitators and barriers to the implementation of culturally competent care interventions. 14,15,[35][36][37][38] However, few of these studies highlight the unique factors relating to the implementation of culturally competent care, and/or use implementation science theoretical frameworks or models to guide study design and/or situate findings within implementation research. 14,15 Unique facilitators identified included the following: a recognition of the changing demographics of the client population, the medical center's explicit commitment to diversity, past experience with multicultural interventions, and a shared commitment to serve underserved populations. However, the barriers to implementing culturally competent care were consistent with those in previous research on other types of interventions in healthcare organizations.

| The culturally competent transplant care intervention
The HKTP provides patients care under the same standards but utilizes different care delivery processes compared with patients receiving transplant education and evaluation in English. The HKTP intervention entails 16 key components, which map directly to the National Quality Forum's Framework for Measuring and Reporting Cultural Competency, as described 11 12 Both hospitals were non-profit. Site A was a regional based academic affiliated medical center that had a large-sized 1,000-bed hospital with a level one trauma center. Site B is part of a national academic medical center that had a medium-sized 300-bed hospital with no trauma center. Implementation preparation spanned from

| Data collection
The study Co-Principal Investigators (EJG, JCC) conducted site visits in May 2016 to identify stakeholder, operational, and centerlevel barriers and facilitators to HKTP implementation; clarify the protocol; and troubleshoot ways to accommodate the intervention into each institutional setting. Site Principal Investigators recruited stakeholders for the initial group meeting.
In-person group unstructured discussions were led by the Co-Principal Investigators to clarify the study protocol, assess progress on intervention implementation preparation strategies using a checklist and brainstorm ways to accommodate the intervention. In-depth semi-structured interviews were conducted with transplant stake-

| Data analysis
Audio-recordings were transcribed, and transcriptions were analysed for themes using the constant comparative, 41  Discrepancies between coders were resolved through arbitration by one team member (EJG). Recoded transcripts were uploaded into qualitative analysis software (MAXQDA v.12). Table 1 lists the codes by CFIR domain.
Text segments for each code were then independently reviewed by two team members to create a code summary. Each summary was developed by comparing segments and grouping together similar ideas to identify emergent patterns and themes, and comparing themes in one code summary to themes in other code summaries. 43 We also compared and contrasted themes by study sites to see if codes were common to both sites or idiosyncratic to one site, we focused our analysis on themes common to both sites. Next, the research team reviewed all codes to see whether they mapped to CFIR; codes that did not map onto CFIR revealed new factors related to the implementation preparation of culturally competent care interventions. The research team met in groups of 2-4 people

| Common health-care organization factors influencing HKTP implementation
The HKTP intervention encountered facilitators and barriers common to research on implementing interventions into healthcare settings. 34 These results correspond to two CFIR domains: intervention characteristics and the inner setting. Illustrative, representative quotations documenting these results are presented below and in greater depth in the Appendix 1.

| Intervention characteristics
Stakeholders at both sites reported that they perceived that the HKTP would benefit their current transplant program by increasing Hispanic LDKT rates and improving their program's quality of care.

| Tensions over implementing the culturally competent care intervention
New factors, not commonly found to influence the implementation preparation of interventions in healthcare settings, arose in the HKTP implementation preparation phase.

| Facilitator 1: Equity
Stakeholders perceived the HKTP as the morally 'right thing to do' and appreciated how the HKTP enabled their institutions to provide equitable care to the Hispanic population. Stakeholders recognized that the Hispanic community comprises an underserved population and considered increasing services to this population important.
One stakeholder stated: [A]nybody who is a healthcare provider wants to make sure, I believe, that the patient population is able to receive healthcare in an equitable way, and certainly assist with that…. I can tell you that for us, we want to do the right thing, and if there are patients out there who aren't able to access health care because we're just not mindful of that, then this is the right thing to do.
(A10)   A few stakeholders voiced another moral concern that HKTP's focus on Hispanics could compromise patient care for non-Hispanics. They feared that the HKTP could create 'resentment' among other minority patients who do not have a culturally competent program catered to their needs.

| Summary
Our study advances knowledge of the implementation of culturally competent care interventions, and thereby extends the field of implementation research. Our study is consistent with other studies using CFIR to guide study design, but is relatively novel in assessing providers' barriers and facilitators to intervention implementation during the preparation phase to explain adaptations in the implementation period. 21 Most studies of culturally competent interventions examine intervention efficacy, but not its implementation. Our study contributes to scant research 14,15 using implementation science to evaluate the barriers and facilitators to the implementation of a culturally competent care intervention. Unlike many culturally competent interventions that focus on the patient-provider interaction, our study intervened on multiple-levels beyond the patient-provider interaction (ie outreach, marketing, clinic education, scheduling processes). Thus, we identified a more holistic set of barriers and facilitators involved in implementing a culturally competent care intervention, thereby advancing implementation research designed to increase health equity. 16 We identified several novel facilitators and barriers to the implementation preparation of a culturally competent care intervention targeting the Hispanic patient population not identified in previous CFIR research on healthcare settings.

| Comparison with existing literature
Some of these themes are consistent with research directly evaluating barriers and facilitators to the implementation of culturally competent care in healthcare settings. 14 receive the care they need to achieve the same healthcare results. 54 We recommend that healthcare leaders understand and articulate to their teams that institutions should strive for equity in outcomes, as opposed to equality in care delivery processes, to foster culturally competent care.

| Implications for research and clinical practice
We recommend several strategies to facilitate the implementation of the HKTP or other culturally competent care interventions in healthcare institutions (Table 2). During the implementation preparation phase, transplant healthcare administrators should leverage their knowledge of hospital operations and access to patient-level data to identify optimal ways to accommodate the intervention within the institution, and conversely, to adjust the institutional infrastructure to accommodate the intervention. Accordingly, they should plan for and monitor costs and reimbursements associated with the intervention. Healthcare leadership should also analyze patient outcomes data by racial/ethnic groups to identify potential disparities and use these data to set program goals for improving

| Strengths and limitations
A strength of this study is that it was conducted in multiple sites, contributing to transferability of study findings. Another strength is the use of the implementation science theoretical framework, CFIR, to guide analysis of the implementation preparation process.
A study limitation is that participants' statements or perceptions may not reflect actual behaviours. Although our results may be transferrable to academic, non-profit hospitals, results may differ in community hospitals and/or hospitals in other US geographic regions. Study findings may reflect US experiences in implementing culturally competent care interventions highlighted by its market-based system that may not arise in countries with a single payer system. A social desirability bias may have softened stakeholders' concerns because grant funding supported HKTP implementation. We used measures to control for social bias including informing participants that their input would be analysed in aggregate and contribute to a better understanding of how to implement the HKTP and deliver culturally sensitive care for Hispanic patients in the future. Perceived barriers may not have prevented implementation.

| CON CLUS ION
Our study identified novel barriers and facilitators unique to the implementation preparation of a culturally competent care intervention that reflect implicit biases about delivering care to cultural groups. Our findings may enable healthcare organizations to more effectively implement the HKTP and other culturally competent care interventions in the future.

ACK N OWLED G EM ENTS
We thank the stakeholders from both study sites for participating in interviews and implementing the HKTP intervention. We also thank Andrew Wang for his research assistance. An earlier version of this manuscript was presented at the Université de Montréal. CRCHUM.  'I think the history of what we believe is always the right thing to do for the right reason, which I think everybody thinks this is the right thing to do, it's a need that we have, which is how we always decide how to do things, we looked at the needs and various to-dos: does your patient need to do it? And, is it the best thing for the patient? I think one thing you'll see about our organization and our culture really is that we like to pride ourselves, and I think we do on being a patient-centered organization. special per se or the thoroughness of it or the quality of care with the education and research backing it up, it will just bring that full range of culture and care to the Hispanic population instead of just a fraction of it, you know, by using interpreters or just having written information duplicated but not having that access to a Spanish speaking provider. So they are not getting the full experience, I guess, I would say, currently, because of that, but if they did, then it would be great'. (B13) 'I think that it can, yeah, I think so, I think that it's going to increase Hispanic kidney transplant and I think that in itself will increase living donor kidney transplant, so I think that's an advantage'. (A10) Changing Roles of Physicians and Nurses 'I will just mention this, it seemed odd to me, not odd, but I understand the concept, but having the physicians, do all the teaching, I have a little bit of anxiety with that, because I don't, I think there are things that our physicians won't know about, won't teach as well, and know, different physicians are different, there are some physicians that are excellent teachers and others are not and so, not that it can't happen, but I feel strongly, like I want to listen, participate, I feel like I need to have my hands on that a little bit more than, "Sure you just go teach!"' (A10) [S]omething like this, I think offers us the opportunity to not only focus on underserved population but also I think will enhance or change some of our thinking related to all populations, as part of being able to think outside of the box. Having a physician or surgeon teach a class is so far-fetched from anything anybody, you know, it's always, relegated to the lowest clinical provider'. (B16) A PPE N D I X 1 (Continued) (Continues)