KanSurvive: Testing a Model for Improving Cancer Survivorship Care in Rural Practice
Phase: NA
Conditions: Breast Cancer, Colorectal Cancer, Lung Cancer, Prostate Cancer
Sponsor: University of Kansas Medical Center

Cover Page 
IRB Approval: September 9, 2020 
NCT04763824 
Protocol and Statistical Analysis Plan 
Study Title: KANSURVIVE: TESTING A MODEL FOR IMPROVING CANCER 
SURVIVORSHIP CARE IN RURAL PRACTICE 
Principal Investigator: JENNIFER KLEMP, PHD, MPH AND ALLEN GREINER, MD, 
MPH 
Co-Investigator(s): EDWARD ELLERBECK, MD, MPH, CHRISTIE BEFORT, PHD, 
EVE-LYNN NELSON, PHD, ANNE O’DEA, MD 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
University of Kansas Medical Center  
RESEARCH PROTOCOL INVOLVING HUMAN SUBJECTS  
 
Version date: 7APRIL2021 
 
 
Principal Investigator: JENNIFER KLEMP, PHD, MPH AND ALLEN GREINER, MD, MPH 
Study Title: KANSURVIVE: TESTING A MODEL FOR IMPROVING CANCER SURVIVORSHIP CARE IN 
RURAL PRACTICE 
 
Co- Investigator(s): EDWARD ELLERBECK, MD, MPH, CHRISTIE BEFORT, PHD, EVE-LYNN NELSON, PHD, ANNE 
O’DEA, MD 
 
 
   Purpose, Background and Rationale 
A. Specific Aim and Hypotheses  
 
While evidence-based practice (EBP) guidelines exist (1) for cancer survivorship care, implementation in rural 
practices has fallen short. Approximately 72.5% of Kansas cancer survivors who have completed their cancer 
treatment receive a majority of their health care from Primary Care Providers (2), yet these providers describe a 
lack of basic awareness of risk-based surveillance, effects of cancer treatment and their management, as well 
as inadequate resources, and growing administrative demands 
as reasons for not working to improve survivorship care (3). These factors may also prevent shared care 
management of cancer survivors between primary care and rural oncology care providers. There is a pressing 
need to understand primary care practice capacity to implement guideline informed management and follow-up 
for cancer survivors in the acute and extended phases of care. (4) To address this need, we adapted an in-clinic 
4 session cancer survivorship educational curriculum, which resulted in change in knowledge but not in practice 
(5). We then piloted an updated in-person curriculum plus basic practice facilitation training model in seven 
primary care practices across Kansas to establish feasibility and acceptability within our network. Our program 
adaptation (KanSurvive) was also based on needs identified during focus groups (3) with rural practice providers 
and staff and included help with formal identification of survivors within the practice, ability to access and 
incorporate evidence-based practice (EBP) guidelines in care management, and for a more comprehensive 
understanding of the risks of cancer treatment. However, participants in KanSurvive reported interest in receiving 
more case-based examples, access to survivorship specialists, and ongoing quality improvement (QI) support 
to implement EBP guidelines in hectic rural practices. (3) The Project Extension for Community Healthcare 
Outcomes (ECHO), (6), provides a telementoring approach that addresses many of the limitations that we 
encountered with our preliminary work. Through an interactive “community of practice” and case-based learning, 
ECHO includes identification and support of practice-champions; sharing “how-to”/workflow lessons across rural 
practices; reinforcement of KanSurvive QI and electronic health record (EHR) processes; ongoing facilitation 
using checklists; and ongoing support from survivorship experts and rural provider peers. Thus, we propose to 
blend our in-person curriculum ad practice facilitation with ECHO telementoring to increase the “dose” of 
implementation support, lead to a sustainable “community of practice” and promote better adoption of EBPs. In 
this project, we will recruit 20 rural primary care practices to participate in a delayed intervention-controlled trial. 
We will start by conducting more formal and structured work flow evaluations to better identify specific gaps in 
processes of care while assessing what on-going training is needed for adoption of high-quality cancer 
survivorship care in rural practice. These will be incorporated into the ECHO sessions (Aim 1). We will then test 
the effectiveness of the novel KanSurvive-ECHO intervention (Aim2) and finally identify barriers and facilitators 
to implementation of KanSurvive-ECHO (Aim 3). Specific Aim 1. Formally assess gaps in processes of care and 
additional training needed to result in actual adoption of high-quality care for acute and chronic survivors of 
breast, colorectal, lung, and prostate cancer in 20 rural primary care practices. Utilize this formative information 
to further refine the KanSurvive-ECHO. 
Specific Aim 2. Evaluate the effectiveness of KanSurvive-ECHO for enhancing evidence-based survivorship care 
for rural breast, colorectal, lung, and prostate cancer survivors. Hypothesis: Compared to delayed intervention 
control, rural primary care practices randomized to KanSurvive-ECHO will demonstrate greater concordance 
with evidence-based survivorship care guidelines as measured by a composition score determined by change 
in EHR documentation consistent with guideline concordant care. 

 
Specific Aim 3: Utilizing the Integrated Promoting Action on Research Implementation in Health Services (i-
PARIHS) framework (6) describe key facilitators and barriers to implementation of KanSurvive-ECHO including 
innovation, recipients, context, and facilitation. This novel project will provide a model for development of a 
community of practice using practice facilitation and Project ECHO to improve the management and follow-up of 
cancer survivors in the acute and extended phases of cancer survivorship. 
 
B. Background and Significance 
Access to Acute and Extended Survivorship Care in Rural Cancer Survivors: In Kansas (82,279 miles2 and the 
15th  “largest” state by area), 26% of the population lives in designated rural counties, and the rural population is 
spread out over 99% of the land area. Multiple factors such as limited availability of cancer treatments and 
providers, distance and transportation, financial issues and insurance status, and cultural and language barriers 
in rural Kansas impact the quality of cancer care and produce rural/urban cancer disparities. Many cancer 
patients living in rural areas go undiagnosed or are diagnosed with late stage disease, often due to difficulties 
accessing specialty oncology care services.(1, 2) Accessing cancer care is a more involved process for rural 
patients, who may have to drive significant distances or wait for oncology care teams to travel to their community 
hospital on an infrequent basis (monthly or bi-monthly).(3) Outreach to rural communities over the last twenty 
years has kept patients closer to home, with an increase in the rate of chemotherapy administration among rural 
patients from 10% to 24% (Ward MM, Ullrich F, Matthews K, et al). However, intermittent availability of visiting 
oncologists, limited teleoncology adoption due to reimbursement gaps, and lack of access to the full 
interprofessional oncology care team may not meet the needs of all cancer patients, may lead to treatment 
delays, and puts more of the day-to-day patient care on locally 
available primary care teams.(3, 4) On the upside, there has been 
a significant increase in the overall number of cancer survivors 
living with and through their disease, but many have more than 
one primary cancer (Figure 1),(5, 6) and approximately 72.5% of 
cancer survivors in Kansas who have completed their cancer 
treatment receive a majority of their health care from Primary Care 
Providers (5), thus increasing the importance of rural primary care 
providers engaging in the acute (during treatment) and extended 
phases (post-treatment) of survivorship care. (7, 8) 
                                                                                                      
A1. Gaps in Knowledge, Attitudes, and Practice: Primary care providers may not feel adequately prepared or 
informed to handle survivorship needs, (7, 9, 10) particularly in rural settings with limited access to oncology 
colleagues. Preliminary data suggests that cancer survivors in these settings are not receiving appropriate 
guideline-based services, are less likely to participate in clinical trials, and have overall worse survival outcomes. 
For instance, in a large CMS population of women within 10-years of a breast cancer diagnosis, screening 
mammography rates dip to almost 60%. (11) Rural primary care practices have limited capacity and few 
incentives to implement guideline concordant cancer survivorship care. It is also unclear whether practices are 
aware of survivorship care deficiencies and if they have received survivorship care plans (treatment summary 
plus follow-up recommendations) from oncology providers. Even in the most innovative practices, survivorship 
care is unlikely to be incorporated into routine follow-up care unless it is recognized as a distinct clinical category 
and is supported by a functional information systems infrastructure. (12) 
A2. Importance of an implementation and dissemination framework to guide all study activities. Applying research 
advances to address the needs of cancer survivors in real world settings is complex. Because primary care 
practices have few incentives to prioritize cancer survivorship care, improving outcomes for these patients may 
be difficult to achieve. There are few investigations of the impact of implementation strategies on the uptake of 
evidence-based practices (EBPs) by primary care providers managing cancer survivors. Our project seeks to 
fully understand these difficulties across rural settings and includes both formative and intervention effectiveness 
testing activities. We propose a two-phase approach to developing and testing implementation strategies to 
support uptake of EBPs for cancer survivorship. During all phases of the project, data collection and analysis will 
be guided by an implementation and dissemination framework. This will allow us to systematically address “which 
practices and why” the KanSurvive intervention has influence. During recent decades as practice facilitation and 
other quality improvement strategies have been deployed to improve outcomes in primary care, scholars have 
found the need to more closely analyze how practices think, act and organize improvement efforts. (13) Clearly, 
practices and health care systems are complex systems that may have many reasons for adopting or not 
adopting research advances or evidence-based guidelines. Facilitators and barriers to adoption are important 
but a more holistic framework may be crucial to evaluation in such settings. The Integrated Promoting Action on 
Research Implementation in Health Services (i-PARIHS) framework will guide both the formative and intervention 
Figure 1: Cancers in Kansas Survivors 

 
effectiveness components of our project (14). Within the i-PARIHS framework there are four core components 
of successful implementation. We adapted Harvey & Kitson’s framework to include Project ECHO (Figure 2). 
Key elements include: innovation, recipients (individual and collective), context (inner and outer), and facilitation. 
 
According to the i-PARIHS developers (14), 
the more positively the components of an 
intervention affect each domain, the more 
likely primary care practices are to routinize 
a new and improved way of delivering care, 
such as EBP. To be effective, practice- 
improvement projects must make rational 
changes to workflows and explain to users 
their benefits and purposes. The facilitation 
process must convince recipients that 
alterations will deliver innovation while 
tending to the internal and external context 
of the practices. Facilitation strives to 
minimize not only internal and external 
barriers to adoption of new systems of care 
but also the effects of these systems on 
users’ roles and responsibilities. Qualitative 
assessments have indicated that complex 
interventions become routine practice when they are perceived to improve patient-provider interactions and care-
team interactions. (15) Our formative activities will help us better understand the four components of i-PARIHS as 
they pertain to cancer survivorship care improvement and these key interactions. They will also help us further 
refine our intervention to maximize its positive influence on the four i-PARIHS components. Throughout the study, 
we will use an i-PARIHS guided process evaluation to determine how well our intervention is succeeding or failing. 
This process evaluation will help us understand which intervention components are working well, as well as the 
implementation facilitators and barriers that practices experience as they attempt to alter survivorship care. We 
posit that with a successful intervention, implementation occurs when practice facilitation leads to the 
acceptance and deployment of an innovation that fulfils recipients’ needs and is tailored to the specific context 
of the practice. The process evaluation will use observational and interview data to examine these four 
components, adapting the intervention as necessary. Process evaluation questions will be developed based on 
prior i-PARIHS structured interventions. (16, 17) 
 
Practice facilitation. Through more intensive practice facilitation onsite and through ECHO activities, we aim to 
improve care delivery by creating an ongoing, trusting relationship between all practice staff and an expert 
facilitator who will help clinic staff redesign workflows and improve quality.(18) This promotes a clinical culture 
of learning, consensus building, goal setting, quality improvement, and achievement, as demonstrated by the 
Institute for Healthcare Improvement’s Learning Collaborative Breakthrough Series,(19) (20). One study using 
similar methods, the EPIC cluster randomized trial, used a practice facilitation intervention to produce a 100% 
increase in diabetic patient foot examinations, compared to a 33% increase in a control arm, which used self- 
directed provider education for quality improvement.(21) Rural clinics in this study will use brief plan-do-study- 
act cycles, to improve clinic and provider adherence to cancer survivorship care guidelines. The steps involved 
include: 1) practice-level discussion until reaching consensus on a specific, measurable, quality-improvement 
goals for using electronic health records (EHRs) to improve survivorship care clinical performance; 2) identifying 
barriers to implementation in achieving the goal; 3) selecting one or more changes to improve the status quo in 
survivorship care; 4) instituting these changes; and 5) measuring change in provider and clinic performance via 
assessments of EHR change for cancer survivors in the practice. In successive cycles, practice staff will 
brainstorm ways to overcome emerging barriers to achieving plan-do-study-act goals. We will support this 
process using visiting practice facilitators assigned to rural primary care practices. Facilitators will be trained and 
certified using the University of Buffalo Practice Facilitator online training program (22) and will be selected and 
assigned based on previous experience working with rural teams. Practice facilitators will in turn train practice 
staff to use a consistent approach for quality improvement work and workflow redesign. Facilitators will 
communicate at least weekly with a clinic-designated nurse or practice manager in each rural study practice (the 
Practice Champion), and at least monthly with a clinic physician designated as the Practice Lead. The role of the 
Practice Champion and Lead will be to legitimize the intervention in their clinics, assist with training/orientation 
of other clinicians and clinic staff, and ensure response to facilitators and EHR data being fed back to practices. 
The Facilitator will aim to maximize inter-professional impact by coaching Practice Champions and Leads to use 
a team-building, collaborative approach adapted to the organizational context of each practice. Facilitators will 
Figure 2: Project ECHO 

 
not provide clinical care directly but will coach the Practice Champion and other practice staff (the “Practice 
Improvement Team”) to solve problems and build improvement into routine clinical operations. 
Prior studies have shown that practice improvement teams are able to effectively recruit others to take part in IT-
related quality-improvement projects. (23) 
A4. Building an ongoing “community of practice.” Practice facilitation does not utilize approaches that leverage 
practice-to-practice interaction, resulting in inefficiencies and missed shared learning opportunities. Practices 
work in isolation with facilitators to make change. Opportunities for co-learning, sharing best practices between 
peers and benchmarking may be missed when practices work to make improvements in isolation. A “community 
of practice” is a group of practices working in some joint fashion to improve the care they deliver. They work as 
a group to help each other and proceed through improvement cycles together. The Project Extension for 
Community Healthcare Outcomes (ECHO) telehealth approach was developed as a virtual method for 
developing a community of practice for rural practice groups. The model expands primary care provider (PCP) 
capacity to manage complex diseases by sharing knowledge, disseminating best practices, and building a 
community of practice. Project ECHO originated when Arora, et al. (24) completed a randomized trial showing 
rural primary care physicians were able to launch hepatitis C treatment programs and achieve the same 
outcomes as academic center-based hepatologists. This work demonstrated ECHO's ability to support practice 
change and best practice adoption in rural primary care. In 2016, Zhou et al., (25) completed a systematic review 
of 39 studies, which addressed 17 different medical conditions and found that these studies support the ECHO 
model's effectiveness in improving the knowledge (n = 4) and self-efficacy of participating PCPs (n = 8), as well 
as changes in provider behavior (n = 1), improved patient outcomes (n = 7), and cost-effectiveness (n = 2). 
Project ECHO’s mission is to democratize knowledge and decrease health disparities across underserved 
populations. (26) A facilitator assists throughout ECHO sessions by advancing engaged discussion between the 
hub team and spokes and between spoke sites. The ECHO model has been extended to include additional health 
care expertise on the specialist team at the hub site in order to support primary care practice needs, including 
expertise/supports across quality improvement, health information technology, and patient-centered care/health 
literacy support. Serhal et al. (27) describe the educational theory supporting ECHO, summarizing “the ECHO 
model uses both situational and social cognitive learning theories and enables participating primary care 
practices to identify learning gaps (cognitive dissonance) and reflect critically on their learning process.(24, 27-
29) Project ECHO allows for problem-centered learning to occur in the clinical context where new knowledge will 
be applied; promotes interprofessional collaboration among participants; models best-practice care; supports 
learners to feel that they are benefiting and improving self-efficacy; and allows participants to receive positive 
feedback and reinforcement from clinical opinion leaders.” The Project ECHO model (University of New Mexico 
figure below) has rapidly expanded in recent years, with over 140 international ECHO projects covering a range 
of chronic diseases (hepatitis C, HIV/AIDS prevention, behavioral health and addiction medicine, chronic pain 
management among others). 
Through regularly scheduled virtual clinics (Figure 3), Project ECHO creates 
a supportive community network where rural primary care teams can 
connect with specialists and with other providers practicing in similar settings 
via multipoint video technology to discuss best practices in care and 
complex cases managed within their practice. This multifaceted knowledge 
and capacity-building intervention includes three components: a didactic 
lecture delivered by a member of the hub team (based on curriculum 
developed from guidelines, best practices, and/or a needs assessment); 
recommendations for case management (telementoring) offered by the 
community in response to anonymized clinical cases presented by spoke 
sites; and in some cases, review and reinforcement of practice quality 
improvement approaches in implementing best practices. Low-cost, user- 
friendly ECHO technology (secure Zoom videoconferencing) leverages 
scarce healthcare resources. The ECHO model is not “telemedicine” where  
the specialist assumes the care of the patient, but instead a guided practice 
model where the primary care practice team retains responsibility for managing the patient following national 
guidelines and best practices. 
There is growing interest in cancer-related ECHO topics, including cancer survivorship. (30) ECHO programs 
have been deployed to improve cancer screening in underserved areas (30, 31) and to advance cervical cancer 
prevention and treatment. (32) Cancer survivorship care in primary care meets ECHO criteria as there is an 
extensive gap between existing cancer survivorship guidelines and community practice, particularly in rural 
areas. There are large numbers of survivors seen in primary care and primary care professional guidelines 
encourage management in the primary care setting. There are improved health outcomes for patients with 
Figure 3: ECHO Clinic 

 
survivorship best practices and evolving treatment strategies that require periodic practice updates. Finally, 
cancer survivorship has high societal impact in terms of symptom burden, quality of life, (33) and health care 
expenditures. 
We identified Project ECHO as an implementation strategy to build a community of practice around survivorship 
care improvement and enhance our onsite KanSurvive practice facilitation strategies. We believe this approach 
and its comingling of primary and specialty care providers will also strengthen relationships and communication 
between primary and oncology care teams as they both engage in ECHO activities. 
1. Innovation 
This project builds from pilot work highlighting the common themes and opportunities for managing rural cancer 
survivors from diagnosis through the lifespan using a collaborative model between primary care and cancer care 
teams. This project will include: (a) an examination of current patterns of care in managing patients from the time 
of diagnosis of the cancer through their life span, (b) the delivery of a unique intervention combining education, 
practice facilitation, and tele-mentoring with ECHO, aimed at increasing evidence-based practice, and (c) and 
evaluation to identify key elements of practice change that could be used on a larger scale for widespread 
dissemination. This multi-system intervention is innovative as it has been informed by rural primary care 
providers, cancer care teams, survivors and advocates, and subject matter experts to address established 
barriers in rural cancer care delivery. Use of low-cost telehealth technology and engaging interactive ECHO 
content will provide innovative means to develop a community of practice that supports initial and long-term 
learning and mentoring. Though there are unique challenges to addressing the survivorship care needs of rural 
cancer survivors, the combination of practice facilitation and ECHO support adoption of quality improvement 
processes and problem-solving skills to advance ongoing implementation of cancer survivorship guidelines and 
updates across the breast, colorectal, lung, and prostate survivor guidelines. 
 
 D. Preliminary Studies and Investigators 
Preliminary Studies and Previous Experience: The study team is comprised of investigators who have 
collaborated on pilot and large-scale projects and form a multi-disciplinary team with complementary skills 
including: medical oncology, primary care, preventive medicine and public health, tele-health, biostatistics, 
behavioral health, and implementation science, with a strong focus in rural communities.  
 
 
 
The Co-PIs bridge the strengths of primary care, cancer control and rural health (Dr. Greiner) along with cancer 
survivorship, genetics, practice facilitation, and certification in Project ECHO (Extension for Community Healthcare 
Outcomes) (Drs. Klemp and Nelson). Dr. Greiner is a family medicine physician-scientist who has engaged PCPs 
in rural Kansas in preventive health research for the past 15 years; and has been the lead or co-investigator on 4 
NIH R01 trials and a NIH Community Networks Program Center (U54) targeting enrollment of rural minorities into 
clinical trials. (34-37) He is the Director of Kansas Patients and Providers Engaged in Prevention Research 
(KPPEPR) network, a rural practice-based research network. Dr. Klemp is a clinical-researcher in clinical health 
psychology and cancer genetics; she has worked with rural oncology practices for more than 15 years delivering 
tele-health cancer genetic consultation and practice and practice transformation; and is the Director of Cancer 
Survivorship, at KUCC. She has led or been an integral team science member of a CDC Survivorship Award, two 
NCI RO1’s, and other peer-reviewed work focused on risk and late effects in cancer survivors. Drs. Klemp and 
Greiner are currently collaborating on the delivery of a cancer survivorship training and practice facilitation pilot 
program in seven primary care practices across Kansas (CDC15-1501). Drs. Greiner (Co-PI), Befort (Co-PI), and 
Ellerbeck (Co-I) have just launched a P30 Rural Supplement, “Developing Cancer Control Research Capacity in 
Kansas Rural Primary Care Networks”, which will inform this proposal with regards to EHR and data sharing 
capabilities among primary care practices across Kansas. Drs. Greiner (Co-I), Befort (PI), and Ellerbeck (Co-I), 
also collaborate on a large pragmatic PCORI trial testing practice change to facilitate weight loss in 21 KPPEPR 
practices (OB-1402-09413). Dr. Befort is a health psychologist who has led efforts to expand our rural primary 
care clinical research toward pragmatic effectiveness-implementation trials wherein local clinic personnel are 
trained to implement interventions in their local practice as well as serve as research personnel who consent 
patients and collect data.(38) Dr. Ellerbeck is a primary care physician-scientist with 25 years of experience 
conducting healthcare delivery research in rural primary care practices including two NIH R01 trials. Dr. O’Dea is 
a medical oncologist who established a successful rural oncology practice at Hays Med, Hays, KS, and recently 
returned to KUCC, still providing 2nd opinion consultation across the state via telemedicine. She is a busy 
oncologist and serves as a national thought leader in treating women with breast cancer and is the Medical 

 
Director of Breast Cancer Survivorship. She has collaborated with Drs. Klemp and Befort for the past 10-year 
focused on major survivorship issues including genetic and weight control. (39-41) Dr. Nelson has researched 
and delivered telehealth services in Kansas for almost 20 years. She is a national telemedicine fellow, directs 
telehealth research at the University of Kansas 
Medical Center, and is PI for the federally funded 
tri-state Heartland Telehealth Resource Center. 
She and her team pioneered ECHO in Kansas and 
have developed eleven Project ECHO initiatives 
across Kansas based on unmet needs of high-risk 
populations (ADHD, Airways, Asthma, Autism, 
Back to School, Epilepsy, Opioid Use Disorder, 
Pain 
Management, 
Pediatric 
Psychopharmacology, 
Problem 
Behaviors, 
Pulmonary 
Fibrosis), 
spanning 
over 
200 
participating sites across all regions in Kansas 
(Figure 4). (42-47) Consultant, Dr. Reddy, is 
hematologist/oncologist with over 20 years’ 
experience in rural oncology as a partner with 
Cancer Center of Kansas with 21 locations across 
the state of Kansas. He has done both oncology and bone marrow transplant fellowships’ and has expertise in 
cancer survivorship. He has collaborated with Dr. Klemp since 2006 on implementing cancer genetics and 
survivorship programs via telemedicine across Kansas along with research in symptom management of breast 
cancer survivors. (48)  
 
Preliminary Assessment and Practice Facilitation/Educational Pilot (KanSurvive): Our team has conducted pilot 
work to establish the need, feasibility, and acceptability across the state-wide practice based primary care and 
oncology research networks to inform the current proposal (CDC15-1501). 
 
Understanding current practice and management of cancer survivors by primary care and oncology care teams. 
The Midwest Cancer Alliance (MCA), the outreach arm of The University of Kansas Cancer Center (KUCC), and 
Kansas Patients and Providers Engaged in Prevention Research (KPPEPR), completed semi- structured 
interviews and focus groups in rural primary care and oncology practices across Kansas in 2016-17. Qualitative 
methods were used to obtain in-depth information regarding providers’ beliefs, current practices and barriers 
related to cancer survivorship care so that future interventions could be tailored to this population of providers in 
rural Kansas. Focus groups were audio-taped and transcripts were produced. Qualitative analysis was 
conducted by independent reviewers using an iterative process to reach consensus on primary themes and 
definitions. Thematic categories were identified and recorded. Transcripts were then reread by each team 
member to assure thematic fit for all focus group content. Triangulation and consensus were used throughout 
the analysis phase to maximize trustworthiness of findings. Primary care and oncology teams face similar cross- 
cutting barriers in caring for cancer survivors including: educational gaps; communication of history, treatment 
and recommendations; EHR integration; and lack of resources, highlighted in table 1. Based on the complex 
needs of cancer survivors and the complexity of health care delivery, an organized approach is needed to align 
survivorship care delivery across settings. (49) 
    Table 1: Cross-Cutting Themes
 Figure 5: 
Map of 
Focus 
Group 
Locations:     
KanSurvive 
1.1.a. 
Test the feasibility and acceptability of a survivorship 
care educational and practice facilitation intervention. The 
KanSurvive Pilot Intervention was undertaken to establish 
Figure 4: Kansas ECHO Clinic Sites 

 
feasibility and acceptability within our network. Klemp, Greiner, and team adapted materials (50) for a pilot project 
to use practice facilitation to deliver in-person content on EBP survivorship care guidelines for acute and 
extended cancer survivorship care in rural primary care (CDC15-1501). The team worked with rural primary care 
providers and oncologists to develop a series of patient case summaries for colon, breast, and   prostate cancer, 
as well as for an adult survivor of childhood cancer. Patient cases were then merged with appropriate content 
for delivery during practice facilitation sessions. The curriculum was informed by findings from the focus groups 
conducted in 2016-2017 (49) and reviewed by Kansas cancer survivors and advisors (Patient and Investigator 
Voices Organizing Together or PIVOT) (Figure 2). Seven rural primary care practices (Figure 5) completed 4 
hours (1 hour per session) of on-site practice facilitation + cancer survivorship training. Practice facilitation was 
delivered by an oncology nurse/navigator with >25 years of experience and community health Physician 
Assistant (PA). Sessions included skills for identifying survivors within the practice, where to find EBP guidelines, 
and reviewing common causes and management of acute and extended survivorship issues. Facilitation 
activities 
also 
provided 
access 
to 
additional 
local, 
regional, 
and 
national 
web 
resources 
(http://kscancerpartnership.org ), though a collaboration with the Kansas Cancer Partnership and the Kansas 
Department of Health and Environment (CDC15-1501). Follow-up data collection has recently been completed 
and we identified that participating rural primary care practices reported high satisfaction with the approach and 
knowledge gains, but challenges in translating knowledge into practice. They reported benefiting from the onsite 
practice facilitation but the majority felt they would like additional facilitation and other support over a longer 
period of time due to the complexity of the practice change needed to implement cancer survivorship guidelines 
across breast, colorectal, lung, and prostate cancer. Participants liked “real life” examples from the facilitators. 
They were interested in talking with other rural practices about how they worked through challenges in putting 
EBP guidelines into practice in very busy, often low-resource settings. Participants asked for consultation and 
ways to increase communication with survivorship experts in order to support specific patients in their practices. 
Finally, practices had needs for quality improvement strategies with limited trained staff and strategies to extract 
and utilize their own cancer survivor data. Since most practices reported rarely seeing “survivorship care plans” 
(or post treatment plans from oncologists), they were interested in easy tools and resources for moving their care 
processes in line with survivorship guidelines. Throughout the pilot intervention and focus groups, the need for 
role delineation and improved communication between primary care and cancer care teams was evident. 
 
Approach: Research Design will include observational research plus pilot testing of the KanSurvive- 
ECHO intervention 
Conceptual Framework: Informed by the Integrated Promoting Action on Research Implementation in Health 
Services (i-PARIHS) implementation framework, the KanSurvive intervention will target EBP improvement in rural 
primary care. Our recent pilot work using an updated 4-session case-based curriculum relied on utilization of 
practice facilitators providing on-site training to rural primary care teams. This project will expand to move beyond 
traditional training models, to a hands-on practice re-organization. Additional formative data collection with site 
visits and practice observation will inform final refinement of the KanSurvive ECHO Intervention. The delayed 
intervention control and KanSurvive-ECHO practices will be compared on outcomes specified by the RE-AIM 
evaluation framework (e.g., Reach, Effectiveness, Adoption, Implementation fidelity and acceptability, and 
Maintenance after 6 months). 
Study Design: Using a Hybrid Type II study design, (51) the proposed study includes a three-aim plan for further 
assessing the rural practice environment and refining the KanSurvive-ECHO intervention (Aim 1), testing the 
effectiveness of KanSurvive-ECHO (Aim 2), and describing key facilitators and barriers to adoption of 
KanSurvive-ECHO intervention components in rural primary care (Aim 3). We will recruit 20 rural (defined using 
RUCA-UR codes) primary care practices from the KPEPPER network for a delayed intervention control trial. 
 
Target population: The project will recruit rural-dwelling cancer survivors and KPPEPR primary care practices 
that care for these patients. The 2016 estimates for The University of Kansas Cancer Center (KUCC) catchment 
area, were for 22,000 people with a cancer diagnosis, and more than 8,500 cancer deaths. (52) The catchment 
area, includes 123 counties in Kansas and western Missouri (78%) are either classified as rural or frontier 
counties, with a total population of 4.4 million. Utilizing the 2010 Rural Urban Commuting Areas (RUCA) the data 
demonstrates that the KUCC catchment area includes a high percentage of individuals residing in rural 
communities with RUCA categories 4-10. The rural counties (RUCC 4-9) in our project area have a range of 
percent individuals in poverty from 7.5 to 22.3% and has a slightly higher percentage of those without health 
insurance at 11.74%.(53, 54) The poverty threshold in 2017 for a household with one adult under 65 years of 
age was $12,752 and for two adults with two children was $24,782.(53) 

 
Recruitment of sites 
Rural Primary Care Clinics: We have experience recruiting rural primary care clinics across all of rural Kansas. 
The Kansas Patients and Providers Engaged in Prevention Research (KPPEPR) network is a practice-based 
research network that has served as host to four previous NIH R01-funded trials. The Board of the network has 
unanimously agreed to support this project, (see letter of support). They have advised us that they believe we 
will have no difficulty recruiting the twenty practices needed for this study. We will identify clinics that care for an 
average of 200 patients that are survivors of breast, colon, lung or prostate cancer. This volume will allow 
participating practices to observe meaningful changes in patient survivorship care implementation and outcomes. 
From our pilot work, primary care providers described sending almost all (~95%) of their newly diagnosed cancer 
patients to the same, local oncology providers/practices. Currently, no EHR-based mechanisms are in place in 
any of the pilot practices we have worked with to systematically identify cancer survivors or to guide survivorship 
care through best practice alerts, orders sets, health maintenance modules or other tools. However, an improved 
understanding of the capacity of the participating primary care clinics will be informed by a recently awarded 
rural supplement to the KUCC cancer center P30 (Greiner & Befort, co-leads). Data from all participating clinics 
will be extracted from EHRs by an “honest broker” who will utilize a consistent algorithm across all EMR systems 
to record evidence of guideline concordant survivorship care. We anticipate receiving a HIPAA waiver to allow 
such data abstraction without consenting individual patients. 
 
Planning and engagement 
Phase 1 In order to address the cross-cutting implementation barriers in caring for cancer survivors identified in 
the pilot, (55) we propose to formally describe care gaps, infrastructure needs and processes of care for acute 
and chronic cancer survivorship in rural primary care focusing on breast, colorectal, lung, and prostate cancer 
survivors and utilize this formative information to further refine the KanSurvive intervention, including the practice 
facilitation and Project ECHO approaches. 
The Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will 
guide (Harvey & Kitson, (14) the discovery of capacity for implementing the EBP for cancer survivors and further 
refining the KanSurvive practice facilitation strategies. i-PARIHS posits that core components of successful 
implementation are innovation, recipients (individual and collective), context (inner and outer), and facilitation. 
Successful implementation takes place when facilitation (i.e., KanSurvive) promotes the acceptance and use of 
an innovation (i.e.,EBPs) based on recipients’ needs (i.e., primary care and cancer care teams see improving 
survivorship care as important) and on the nature of the implementation context (i.e., unique external and internal 
features of rural primary care ). We will also use concepts from this framework to identify facilitators/barriers to 
implementation of KanSurvive ECHO (Aim 3). Definitions and associated evaluation questions will be drawn 
from the i-PARIHS developers (14, 16) as well as informed by the PARIHS implementation guide (Table 2). (17) 
 
Table 2 
I-PARIHS DOMAINS TO INFORM PRE-TRIAL (Aim 1) 
and POST-TRIAL (Aim 3) EVALUATION 
i-PARIHS 
Domain 
i-PARIHS Subdomains 
Informant(s) 
Measurement 
Innovation 
Underlying knowledge sources 
Rural primary 
A mixed methods 
Clarity 
care and 
approach will be used 
Degree of fit with existing practice and values 
oncology 
across domains 
(compatibility or contestability) 
practices: 
including: 
Usability 
leadership 
Relative advantage 
and team 
Semi-structured 
Trialability 
members 
Interviews  informed by 
Observable results 
Harvey & Kitson (56) as 
Recipients 
Motivation 
Values and beliefs 
Goals 
Skills and knowledge 
Time, resources, support 
Local opinion leaders 
Collaboration and teamwork 
Existing networks 
Power and authority 
Presence of boundaries 
 
Rural ACO 
well as related 
leaders and 
implementation 
transformation domains from the CFIR 
specialists 
interview guide and 
consistent with Stettler 
Subject 
et al.(17) 
Matter 
Experts 
Practice environment 
checklist 
Organizational Change 

 
Context 
Local level: 
Formal and informal leadership support 
Culture 
Past experience of innovation and change 
Mechanisms for embedding change 
Evaluation and feedback processes 
Learning environment 
Organizational level: 
Organizational priorities 
Manager(57) 
 
Senior leadership and management support 
Culture 
Structure and systems 
History of innovation and change 
Absorptive capacity 
Learning networks 
External health system level: 
Policy drivers and priorities 
Incentives and mandates 
Regulatory frameworks 
Environmental (in)stability 
Inter-organizational networks and relationships 
Facilitation 
On-Site Purpose, external and/or internal role 
Expectations and activities 
Skills and attributes of facilitators 
Facilitators 
Rural primary 
care and 
oncology 
practices 
ECHO expert 
panels 
Practice Environment 
Checklist 
Facilitator logs 
Acceptability, 
Feasibility, & Fidelity 
ratings 
ECHO 
Telehealth 
 
With enrolled study sites will complete an assessment of baseline organizational characteristics informed by the 
i-PARIHS framework. Semi-structured interviews will be completed with clinical and administrative key 
informants to further assist in identifying potential barriers and facilitators to implementing cancer survivorship 
guidelines and the KanSurvive intervention, focused on organizational processes and workflow. Based on the 
revised questions from the pilot, practice teams will complete interviews to inform the I-PARIHS domains 
(innovation, recipients, and context). This information will in turn inform KanSurvive content and implementation 
strategy modification. Organizational readiness to change will be assessed using the interview guides and the 
Organizational Change Manager survey, a validated readiness tool. (57) 
 
Data collection:  
1.) Key informant interviews. We will conduct key informant interviews with the following: a) Rural primary care 
practice providers, managers, nursing and staff members; b) Rural Oncology practice providers, managers, 
nursing and staff members; c) Rural Accountable Care organization leaders and practice transformation 
specialists (also involved in P30 Rural Supplement); d) Subject matter experts including the ECHO expert 
panelists; and e) Rural cancer survivors. We will use a semi-structured interview guide organized by i-PARIHS 
constructs. This includes gaining input on workflow mapping, processes of care and any ongoing quality 
improvement efforts. Drs. Klemp and Greiner will recruit key informants and conduct interviews alongside the 
project manager. 2.) Baseline study site assessment. Using direct observation and on-site data collection the 
project manager will gather data on practice-level variables that impact the implementation of EBP, including 
number of FTE staff, turnover rates, clinic volume, policies and systems, and technology use (EHR and 
telehealth). We will develop and use a practice environment checklist to inventory current policies, workflows, 
and staff roles and responsibilities in relation to cancer survivorship. Fieldnotes and schematics will be recorded 
and kept for team analysis. Practice personnel will also complete the Organizational Change Manager 
(Gustafson et al., 2003), a validated 60-item readiness measure with 15 domains that complement many i- 
PARIHS subdomains. 

 
 
Data analysis:  
1.) Key informant interview analysis. Key informant interviews will be audio-taped and transcribed. 
Qualitative analysis will be conducted by independent reviewers using an iterative process to reach 
consensus on primary themes and definitions. Thematic categories will be identified and recorded. 
Transcripts will then be reread by each team member to assure thematic fit for all key informant content. 
Triangulation and consensus will be used throughout the analysis phase to maximize trustworthiness of 
findings. 2.) The baseline study site assessment information will be tabulated and summarized per practice, 
including general descriptive information on staff, patient volumes, policies and technology use. Workflows 
and schematics will be mapped. Site summary data will be merged with organizational readiness measures 
to characterize practices in relation to peers. 
Intervention refinement: The research team will work to review Phase 1 data with participating practice 
leads and champions, Rural ACO leaders and transformation specialists, regional content experts, and the 
KPPEPR Board to come up with a set of 4-8 major recommendations for intervention. They will then review 
previously developed pilot KanSurvive materials and suggest refinements based on these major 
recommendations. The research team and staff will utilize these suggestions to refine and finalize the 
KanSurvive intervention for Phase 2 (See Figure 6, Suggested study schema). 
4.6 Phase 2: Implementation of the cluster-randomized controlled trial, with delayed start control 
arm Figure 6:  Suggested Study Schema 
Practice Facilitation. Due to the complexity of translating evidence-based guidelines into practice, 
significant gaps continue to exist between research evidence and practice.(58, 59) Knowledge is rarely 
sufficient to support the adoption of EBP behavior,(60, 61) with didactic education or passive dissemination 
strategies largely ineffective. Practice facilitation has emerged as an effective practice change approach 
and will be a key implementation strategy in the proposed study. Taken literally, facilitation means “to make 
easier”. (56, 62)Practice facilitation is broadly defined as “a supportive service provided to a primary care 
practice by a trained individual or team of individuals. (63)These individuals use a range of organizational 
development, project management, quality improvement (QI), and practice improvement approaches and 
methods to build the internal capacity of a practice to help it engage in improvement activities over time and 
support it in reaching incremental and transformative improvement goals. This support may be provided 
onsite, virtually (through phone conferences and Webinars), or through a combination of onsite and virtual 
visits” (AHRQ, https://pcmh.ahrq.gov/page/practice-facilitation). Practice facilitators, also known as practice 
coaches or quality improvement coaches, are specially trained individuals who help practices engage in 
implementing guidelines and developing capacity for continuous quality improvement. (18) 
Baskerville, Liddy, & Hogg (64) completed a systematic review and meta-analysis showing primary care 
practices are 2.76 (95% CI, 2.18–3.43) times more likely to adopt evidence-based guidelines through 
practice facilitation. Consistent with the strategies used in KanSurvive practice facilitation, all the systematic 
review studies included audit with feedback, practice consensus building, and goal setting as key 
components, as well as basing the change approach on the system level and the organization change on 
common quality improvement tools, such as plan-do-study-act. Many also incorporated collaborative 
meetings, most using resource intensive onsite meetings and a handful utilizing virtual meetings. We 
considered options including increasing onsite facilitation, but this proved cost prohibitive in terms of travel 
and time as facilitators traveled 2- 8 hours one-way in order to meet with practices. There was repetition with 
some training needs across practices which lends itself to group training. In addition, facilitators noted 
common process challenges across many sites and sought additional ways to share these “lessons 

 
 
learned” across sites. The combined KansSurvive-ECHO and enhanced facilitation approach provides 
greater exposure to implementation strategies from the Expert Recommendations for Implementing 
Change (ERIC) project,(65) both in terms of number of strategies and duration of the strategies. 
The Project ECHO telementoring approach was identified as an implementation strategy to enhance the 
onsite practice facilitation strategies. We anticipate that the blend of in-person and telehealth strategies will 
address barriers around cost and scalability. The increased dose of facilitation provided through ECHO will 
provide repetition of key principles and will develop a community of practice. ECHO benefits are associated 
with social learning theory, with participants learning from the expert panel and from one another. ECHO 
sessions will include brief practice updates as well as de-identified cases related to both guideline content 
and “how to” processes for clinic adoption and sustained use. De-identified quality improvement information 
will also be shared. 
In this study we will use a delayed intervention control arm design to evaluate the effectiveness of a 
combined practice facilitation (KanSurvive) plus Project ECHO improvement model for improving 
survivorship care in rural primary care practice. Our group has used validated implementation frameworks, 
such as Damschroder’s (2009) Consolidated Framework for Implementation Research (CFIR) and Proctor’s 
(2011) taxonomy of implementation outcomes to (1) create a set of questions to assess organizational 
readiness and suitability for ECHO and (2) provide those who commit to Project ECHO with a checklist 
to support successful implementation. Using adaptations of I-PARIHS and CFIR constructs, we created 
ECHO-specific organizational readiness questions, as well as a process guide for implementation. Each 
consideration was mapped onto Proctor’s (2011) implementation outcomes, and questions relating to the 
constructs were developed and reviewed for clarity. The Preimplementation list included 20 questions; most 
questions fall within Proctor’s (2001) implementation outcome domains of “Appropriateness” and 
“Acceptability.” The Process Checklist is a 26-item checklist to help launch an ECHO project; items map 
onto the constructs of Planning, Engaging, Executing, Reflecting, and Evaluating. Given that fidelity to the 
ECHO model is associated with robust outcomes, effective implementation is critical. These tools will 
enable practices to work through key considerations as they implement KanSurvive plus Project ECHO. 
Evaluation:  RE-AIM (66) 
1. Reach measured as %Expressed Interest /%Enrolled. As a marker of reach, participation rates will be 
calculated as the total number of rural primary care practices who express interest in the program divided 
by the total number of rural primary care sites eligible. Percent enrolled will be calculated as the total 
number of rural primary care practices who complete enrollment procedures divided by the total number of 
rural primary care practices who expressed interest. Structured Interviews with Non-participants. Structured 
interviews will focus on identifying the barriers associated with lack of participation in KanSurvive-ECHO, 
as well as facilitators/solutions to these barriers. 
2. Effectiveness will be measured as % change in electronic health record evidence of guideline concordant 
care from pre- to 6-months post- KanSurvive-ECHO in intervention versus delayed intervention control 
practices. Using baseline EHR assessments in charts of cancer survivors identified from hospital registries 
we will compare the pre- and post- percentages of these survivors with best practice alerts, orders sets, 
health maintenance modules or other tools that notate specific survivorship care services that they should 
be receiving to meet guidelines (Table 3) (67-74) 
3. Adoption will be measured by calculating the representativeness of the participating rural primary care 
practices. Specifically, participating rural primary are practices will be measured on their size and their 
patient panels and will be compared as a group to the overall data that is available for all rural primary care 
practices in the state of Kansas on these key variables to assess for the representativeness of participating 
practices. 
4. Implementation Consistency: In addition to project feasibility and acceptability, we will assess facilitators 
and barriers to KanSurvive adoption using the i-PARIHS framework (Aim 3). Fidelity: We will refine 
KanSurvive fidelity assessment consistent with Schoenwald et al.(55): (1) identifying relevant components 
for monitoring across practice facilitation and ECHO components (e.g., specificity, necessity, degree of 
precision), (2) determining who would provide the ratings, (3) obtaining the ratings, and (4) creating a 
summary score for the ratings. We will monitor fidelity to the KanSurvive components, with checklists 
associated with practice facilitation from multiple perspectives (e.g., participating practice teams, 
facilitators, ECHO subject matter experts). Attendance and Participation. Percent attendance will be 

 
 
calculated for each rural primary care practice as the percent of practice facilitation and ECHO sessions 
attended divided by the total number of sessions offered. For both groups’ participation the amount of 
between session work completed (as a percent). 
5. Maintenance: Our experienced team will conduct structured interviews with participating rural primary 
care practices to assess their ability to sustain key components of the KanSurvive ECHO program over 
time and maintain effects at 6-months, including policies and procedures to support the cancer survivorship 
guidelines. Identification of cancer survivors with breast, lung, colon and prostate cancer. In order to identify 
survivors under the care of a particular PCP, we will engage the local/affiliated hospital’s tumor registry. A 
list of all primary care providers participating in the intervention will be compiled using several key fields: 
“following doctor” (primary care provider) and the type of cancer (breast, colon, lung, and prostate cancer). 
This PCP list will be given to local hospitals, which will run a report to identify all cancer survivors with breast, 
lung, colon and prostate cancer affiliated with the “following doctor”. Additional variables from the tumor 
registry will include demographics, stage, treatment, treating oncologist. Each primary care provider 
participating in the intervention will receive their list of affiliated patients. (75) 
 
Data extraction will be completed by an “honest broker” who will utilize a consistent algorithm across all 
EMR systems to record evidence of guideline concordant survivorship care through a HIPAA waiver to allow 
such data abstraction without consenting individual patients. Medical record extraction is considered the 
“gold standard” and will be the primary objective data source for this trial. Practice-level data gathered from 
participating practices will be recorded directly into a secure KUMC REDCap database which requires 
username and password verification. Only designated research staff will have access to research 
information. The data collection survey tool built in REDCap will be pilot tested internally and modified as 
needed to ensure clarity for the data collector.  
 
  Table 3: Measure change in EHR documentation Concordant with Evidence-based Cancer Screening by Diagnosis 
 
Limitations and strengths to EHR data are inherent to this type of project. There will be cancer survivors 
missed by the method of using local hospital registries, however, >95% of referrals from our focus group 
primary care providers are to the same oncologist/practices (49), thus keeping missing cancer survivors to 
a minimum. Use of a trained honest broker for data extraction will reduce the confounder of a lack of 
familiarity with EHR and where to find documentation within the EHR also will eliminate potential bias within 
the practice and patient population.  
Study Timeline 
Phase/Activity 
Year 1 
Year 2 
Year 3 
Year 4 
Year 5 
4.9 Dissemination and Future Plans: 
Using the i-PARIHS and RE-AIM 
frameworks for evaluation, relevant 
findings will be submitted for abstract 
(poster or presentation) at regional and 
national meetings and to peer reviewed

 
 
Patient & advisory 
board engagement 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Phase 1 
x 
x 
x 
Site recruitment 
x 
x 
Workflow analysis 
x 
x 
Assess practice & 
EHR capabilities + 
P30 rural supp 
x 
x 
Explore facilitators & 
barriers of successful 
process 
x 
x 
x 
x 
Finalize intervention 
& assessment tools 
x 
x 
Phase 2 
x 
x 
x 
x 
x 
x 
x 
Intervention 
x 
x 
x 
x 
Wave 1 
x 
x 
x 
Wave 2 
x 
x 
x 
Data extraction 
x 
x 
Evaluation 
x 
x 
Data analysis, 
Dissemination 
x 
x 
Identify opportunities- 
sustain community of 
practice 
x 
x 
 
Location where study will be performed: The study will be performed at KUMC sites. Research staff are 
located in 2330 Shawnee Mission, Parkway, Westwood, Kansas 66205. Additionally, the rest of the 
research staff is being supported by the Masonic Cancer Alliance (MCA) located in 4350 Shawnee Mission 
Pkwy, Fairway, KS 66205. Other study activities will be completed online through Project ECHO.  
 
Collaboration (with another institution, if applicable): The MCA will provide research support to 
complete various phases of the protocol.  
Personnel who will conduct the study, including: The sponsor and principal investigators for the study 
are Jennifer Klemp, PhD, MPH and Allan Greiner, MD, MPH.  
 
Assessment of Subject Safety and Development of a Data and Safety Monitoring Plan:  
Since this study does not involve any therapeutic intervention we do not anticipate the need for any safety 
monitoring.   
 
Informed consent process and timing of obtaining of consent: Participating clinics will provide verbal 
consent to confirm they will participate in the project.   
Alternatives to Participation: any of the recruited clinics will the option to participate or not as the study 
is completely voluntary.   
Costs to Subjects: Participating clinics will not incur any cost while in the project. Participating clinics will 
get a total of $1,500 as compensation for their time and participation.  
Publication Plan: Results will be published as deemed appropriate by the investigators Drs. Klemp and 
Greiner. 
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ANALYSES 
 
Quantitative Data:  
• Differences in cancer survivorship performance indicators before and after 
intervention were assessed using Chi-square or Fisher Exact tests.  
• Clinical characteristics are summarized with frequencies and percentages. 
• Demographic and patient characteristics are summarized descriptively with 
respect to frequencies and percentages for categorical variables, and mean, 
standard deviation, median, minimum and maximum for continuous variables. 
• Differences in surveillance rates by tumor types before and after intervention 
were assessed using Fisher Exact tests.  
• Statistical tests were considered significant if p<0.05.    
  
Qualitative Data:  
• Interview notes, transcripts of practice facilitation meetings, and field records 
were compiled and analyzed using the i-PARIHS framework to evaluate barriers 
and facilitators to implementation.  
• A thematic network analysis was employed by first noting initial impressions. 
• Transcripts were independently reviewed line-by-line and preliminary codes were 
applied to relevant passages.  
• A coding framework was developed with clear code descriptions, organizing data 
into themes and sub-themes.  
• This framework was systematically applied to all transcripts using Dedoose 
software to ensure consistent and meaningful codes across the dataset.