Adaptation of a cardiovascular quality improvement initiative for worksite health centers: application of the ADAPT-ITT framework

BACKGROUND: Evidence-based quality improvement (QI) interventions and strategies often require adaptation before implementation in new settings. The goal of this study was to describe the adaptation process of QI strategies from an evidence-based cardiovascular initiative, previously tested in community-based primary care clinics, for use in worksite health centers (WHC). Participating WHCs were located at large manufacturing plants. The adapted QI strategies were offered as part of the Healthy Hearts in Manufacturing initiative. METHODS: Our team followed the ADAPT-ITT framework to adapt the QI strategies for twelve randomly selected WHCs. Meetings were held with WHC leaders, and semi-structured interviews were conducted with WHC clinicians and staff to understand current workflows and identify contextual factors that could help or hinder the implementation of the QI strategies. Data were analyzed using qualitative content analysis. Adaptations were then identified and developed by clinical experts and a practice facilitator, with input from an Advisory Panel. Proposed adaptations were shared with WHC leaders and clinicians for feedback before implementation protocols were finalized. RESULTS: Phase 1 (Assessment) showed that manufacturing communities had high rates of heart disease and its risk factors. Four QI interventions from the Million Hearts campaign were selected for implementation using evidence-based QI strategies during Phase 2 (Decision). Phase 3 (Administration) revealed helpful implementation factors, including strong patient-clinician relationships and leadership support, as well as hindering factors, including deficiencies of electronic health records systems, high staff turnover, and poor patient adherence to treatment. These factors informed the Phase 4 (Production) development of implementation materials, for example, tailored blood pressure measurement protocols and patient educational tools. During Phase 5 (Topical experts), clinicians and WHC leaders provided feedback on the adaptations, which were then integrated in Phase 6 (Integration) into a flexible implementation protocol for the practice facilitator. The final phase (Testing) is ongoing. CONCLUSION: This study describes the adaptation process of a primary care cardiovascular QI initiative to meet the unique clinical settings of WHCs. The findings suggest that with contextual adaptation of QI strategies, WHCs have the potential to implement evidence-based interventions to improve cardiovascular care, providing insights for future initiatives in non-traditional clinical care settings.