Table 1 Enablers and barriers discussed during interviews

Knowledge

Regular communication on value of patient reported outcome measures (PROMs) from hospital-level leadership, corporate-level leadership and the private health information network (PHIN)*

Poor awareness that collection and reporting of PROMs is mandated by the Competition and Markets Authority (CMA)

Poor awareness that collection of PROMs extends beyond knee and hip replacement

Skills

Training opportunities on skills required for collection, submission or interpretation of PROMs

Limited skills for hospital managers in interpreting PROMs data

Social/ professional role and identity

Designating responsibility for the PROMs collection and submission process to an individual or individuals, ie pre-operative administrators or clinical nurse specialists

Limited or no involvement of hospital consultants in development of processes for collection, submission and reviewing of PROMs*

Not recognized by some hospital consultants that it was their responsibility to encourage the use of PROMs

Belief about capabilities

Embedding PROMs into patient pathways through policies and procedures

Incorporating PROMs within pre-operative assessment documentation

Designated drop-off points for completed PROMs forms

Absence of dedicated personnel or processes in place for PROMs collection*

Absence of forum to review and act on PROMs data*

Optimism

Adequate volumes of procedures

Benchmarking performance against other hospital consultants

Use of validated PROMs instruments

Appropriate case-mix adjustment when reporting PROMs data*

Absence of clear indication for certain PROMs instruments

Perception of inconclusive or mixed evidence regarding value of specific PROMs instruments

Absence of feedback mechanisms for PROMs data*

Belief about Consequences

Regular feedback and discussion of PROMs data at clinical meetings*

Greater role for insurers in accessing and reviewing PROMs data to guide patient decisions

Perception that PROMs are a reporting requirement rather than beneficial for quality improvement

Absence of feedback mechanisms for PROMs data*

Poor public awareness about PROMs

Reinforcement

Routine benchmarking of hospital performance in terms of PROMs response rates

Regular reminders through newsletters, meetings, or information boards on wards

CMA and/or PHIN holding hospitals accountable that do not collect or report PROMs

Poor awareness among hospital consultants of reinforcement mechanisms for PROMs

Intentions

Developing a corporate-level or hospital-level strategy to improve PROMs uptake

Involvement of hospital consultants in development of strategies to improve response rates*

Absence of direction from corporate level leadership regarding value and importance of PROMs*

Goals

Setting hospital-level targets for PROMs participation and completion rates*

Setting a target in isolation without actions to improve awareness, train staff and feedback data

Memory, attention and decision processes

Ensuring staff have the right tools to aid communication with patients such as patient information leaflets

Allowing patients to choose whether to complete PROMs forms in outpatient clinics or later via post or electronically

Patients experiencing “form-fatigue” when overwhelmed with forms to complete in outpatient clinics

Complexity of processes involved in identifying eligible patients, data protection and submitting data

Environmental context and resources

Designing patient pathways whereby the collection of PROMs becomes a by-product of care

Emphasising the value of PROMs to demonstrate quality of care as a hospital marketing strategy

Limited capacity within governance teams to monitor compliance with processes involved in collection, submission or reviewing of PROMs

Social influences

Commitment from hospital and corporate level leadership to improve PROMs uptake*

Developing a long-term strategy to improve PROMs uptake rather than “one-off” initiatives

Avoiding a blame culture for hospital consultants with lower than average PROMs scores*

Limited support for PROMs from hospital consultants, particularly if perceived as solely a monitoring exercise

Different approaches to PROMs in the NHS across the four countries of the UK

Emotion

Confidence that data is not misleading through appropriate case-mix adjustment, and caveats that acknowledge limitations in data

Reporting at hospital-site level rather than individual hospital consultant level

Misleading data if not representative of breadth of practice across NHS and independent health sector or complexity of patients

Behavioural Regulation

Reviewing PROMs data at clinical or governance meetings*

Greater emphasis on PROMs within hospital consultant appraisal and revalidation

Absence of awareness among hospital consultants of mechanisms to monitor compliance with processes involved in PROMs