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Serious Illness Care Programme—contextual factors and implementation strategies: a qualitative study
  1. Joanna Paladino1,
  2. Justin Sanders1,2,
  3. Laurel B Kilpatrick3,
  4. Ramya Prabhakar4,
  5. Pallavi Kumar5,
  6. Nina O'Connor5,
  7. Brigitte Durieux6,
  8. Erik K Fromme1,6,
  9. Evan Benjamin1 and
  10. Suzanne Mitchell1,7
  1. 1 Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
  2. 2 Family Medicine, Palliative Care, McGill University, Montreal, Québec, Canada
  3. 3 Division of Supportive and Palliative Care, Baylor Scott and White Health, Temple, Texas, USA
  4. 4 Atrius Health, Newton, Massachusetts, USA
  5. 5 Penn Medicine, Philadelphia, Pennsylvania, USA
  6. 6 Dana-Farber Cancer Institute, Boston, Massachusetts, USA
  7. 7 UMass Memorial Health Care, Worcester, Massachusetts, USA
  1. Correspondence to Dr. Joanna Paladino, Ariadne Labs, Boston, Massachusetts, USA; jpaladino{at}


Objectives The Serious Illness Care Programme (SICP) is a multicomponent evidence-based intervention that improves communication about patients’ values and goals in serious illness. We aim to characterise implementation strategies for programme delivery and the contextual factors that influence implementation in three ‘real-world’ health system SICP initiatives.

Methods We employed a qualitative thematic framework analysis of field notes collected during the first 1.5 years of implementation and a fidelity survey.

Results Analysis revealed empiric evidence about implementation and institutional context. All teams successfully implemented clinician training and an electronic health record (EHR) template for documentation of serious illness conversations. When training was used as the primary strategy to engage clinicians, however, clinician receptivity to the programme and adoption of conversations remained limited due to clinical culture-related barriers (eg, clinicians’ attitudes, motivations and practice environment). Visible leadership involvement, champion facilitation and automated EHR-based data feedback on documented conversations appeared to improve adoption. Implementing these strategies depended on contextual factors, including leadership support at the specialty level, champion resources and capacity, and EHR capabilities.

Conclusions Health systems need multifaceted implementation strategies to move beyond the limited impact of clinician training in driving improvement in serious illness conversations. These include EHR-based data feedback, involvement of specialty leaders to message the programme and align incentives, and local champions to problem-solve frontline challenges longitudinally. Implementation of these strategies depended on a favourable institutional context. Greater attention to the influence of contextual factors and implementation strategies may enable sustained improvements in serious illness conversations at scale.

  • Communication
  • End of life care
  • Service evaluation

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information. N/A.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information. N/A.

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  • Contributors JP: guarantor, conceptualisation, planning, methodology, data collection, analysis, data curation, writing—original draft, writing—review and editing, and reporting. JS: conceptualisation, planning, methodology, analysis, writing—review and editing. LBK: planning, data collection, analysis and writing—review and editing. NO'C, PK and RP: planning, data collection, analysis and writing—review and editing. BD: planning, data curation, analysis, project administration and writing—review and editing. EKF and EB: methodology, analysis, supervision and writing—review and editing. SM: conceptualisation, planning, methodology, analysis, supervision, writing—review and editing, and reporting. All authors have contributed to the design, analysis and writing of the manuscript.

  • Funding This work was supported by the Cambia Health Foundation through the Sojourns Scholar Leadership Programme awarded to JP.

  • Disclaimer The funder did not contribute to the design, analysis or writing of this manuscript.

  • Competing interests SM holds equity in See Yourself Health LLC, a digital health platform for diabetes education. She also has delivered workshops on relationship-centred care sponsored by Merck and Co, for which no product promotion is permitted.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.